Bill,

Rosenberg continued to educate us in psychiatry and it’s approaches of talk therapy and psychiatric medications, comparing it always with the psychologists approach based on counseling and intervention. Interesting, even in naming the treated party. A doctor calls the person patient; a psychologist calls the person treated as client. Rosenberg believes working together both can do the best for many subjects.

Main extensions after you left:

1. General Medical Practitioner’s (Internists, family doctors) prescribing medications for mental illnesses.

2. His interaction with psychologist’s and referrals

3. Medicare reimbursements* and reporting requirements

4. The place for Electro Convulsive Therapy (ECT) in depression.

1. He sees plenty of GP prescribing without talk therapy or psychological follow-up.
Cites the risk here as the different rates of patient physical re-energizing, with positive drug response, and the lagging emotional response. The latter develops slowly and requires weekly or more hand holding with talk therapy. Risk is as patient moves from lethargy to re-energizing he then can act on suicidal thoughts whereas as a lethargic he cannot execute the same thoughts. In Canada with which he joins in annual conferences of some 90 Canadian GP’s and therapists their GP take required talk therapy training and are able to do the follow through counseling after prescription. He believes that works fine.

2. Medicare reimbursements are absurdly low for his geriatric patients. Here is where he needs to flange up with psychologists. He does this both ways with his patients and/or their Clients with referrals. He works with a very narrow number of psychologists/therapists with whom he has a good understanding and feedback. He does a diagnosis. Prescribes medications, provides the therapists with all the rational behind his diagnosis including how he rules out alternate possibilities. That background goes with the prescription to the therapist. He does not prescribe a treatment plan. He leaves that up to the therapist, with which he has rapport.

Without saying it straight out I think he believes the Canadian medical care system of single payer handles this cost work-around better for psychiatrists and GP’s.

3. Medicare requires a “Report” on each patient he sees. This report may take more time to prepare than the time spent with the patient and the visit itself is at already ridiculously low reimbursements. Being a psychiatrist I think makes terse reporting very difficult. I see reports by radiologists and pathologists all the time. Never more than one page. Full of professional terminology unfathomable to a layperson even with a good medical dictionary. The colonoscopy reports use a standard sketch of the intestines and make notes on where lesions or polyps were found their size, number and pathology. Full of professional jargon that even a GP cannot completely fathom. I believe Rosenberg takes his reporting to a storybook of diagnostic path and alternates considered. He overdoes the reporting at least respecting Medicare’s reimbursement that they do not pay for.

I would recommend for him he cite diagnostic codes he considered by number. Indicate the selected one. The interactions with other codes in a vector diagram with direction and magnitude weightings and point to a therapy recommendation. All on one page. The arrows could be pre-printed in a standard array just like the colon.

I charge $200 per hour in forensic consulting, $175 in geriatric cases.

4. I cited biographic cases (Hemingway, Phillip Graham) as persons I learned about inadequate talk therapy and poorly done ECT (both without medications) ending in suicide and a personal case of an elderly woman with very real reasons for life long depression from multiple of her children with institutionalized imbilcilileism, and one son who became a flower child. All the years her husband did everything in the housework she should have been doing, as well as his earning a good living.

He died in a car accident leaving her mentally paralyzed and depressed at an even more intense level. She went to Carrier Clinic, near Princeton where they routinely use ECT as a front line therapy. Thirty days, multiple courses of modern ECT and she regained a working level of sustained capability. I know the family well.

Rosenberg said He respects ECT. He uses it for patients who fall into the 35% of depressions that do not respond to drugs. It is a final choice in his practice. He is aware of its use as a front line first choice therapy. He did not disabuse that practice.

Conclusion

Rosenberg is so considerate in his speaking delivery he may not disabuse anything or anybody.

He continued to answer questions. He advised that denial of treatment by those needing it is a huge problem for loved ones. He counciled persistence, a gentle persistence, not nagging waiting for a receptive moment. Often this is when a person hits “rock bottom”. Be there then, he said to one anxious mother daughter in the attendees.

* Dr. Rosenberg never quantified medicare reimbursements personnaly. A attendee raised this as a problem and mentioned $275/hr in pivate psychiatric practice vs. Medicare’s $50/hr allowance. Dr. Rosenberg did not comment on these rates cited by the attendee but used the point raised to talk about his work-around to the generic issue of inadequate reimbursements to Doctors