Crossroads for young psychiatrists.

Abstract

F OR MANY YEARS there has been a (lichotomy in the practice of psychiatry-institutional versus private practice. Today, however, the changes taking place in mental hospitals, the increasing number of inpatient and outpatient psychiatric services in genera! hospitals, and the emphasis on bringing psychiatry and the psychiatric patient into the community all are serving to blur the distinction between private and institutional practice. Moreover, an increasing number of psychiatrists are accepting part-time appointments in a variety of institutional settings. At the same time it is becoming i ncreasingly common for full-time institutional psychiatrists to do some private practice. We must continue to make the distinction less definite, so that it will no longer be necessary for a young psychiatrist to choose between private and institutional practice. In the meantime, however, conflict still exists, much of it a matter of attitudes and values. There are prejudices against institutional practice. One is the frequently expressed idea that those who can, do private practice, and those who can’t, are relegated to institutional work. Nobody who has gone from private psychiatry to an institution escapes comments based on this prejudice. There are several rcaSons for its persistence. One is the belief that one cannot practice dynamic psychiatry with large numbers of patients; another is the discrepancy between what one can earn in private practice and the salaries paid by most institutions. It is important for us to recognize fully the conflict a young doctor faces so that we can point objectively to the respective advantages and disadvantages of private and institutional prac. tice. Obviously, they can be equally demanding, and both can attract cornpetent and incompetent practitioners alike. The primary purpose of both types of practice is care of patients. Of necessity, however, caring for patients in an institution calls for a structured organization, defined lines of authority, fairly complicated relationships between professional and nonprofessional personnel, and at least some red tape. In this kind of practice the psychiatrist must always be aware of the institution and its needs. In return, however, he has constant valuable opportunities to consult with practitioners of various disciplines, and to check his professional opinions with other psychiatrists, thereby clarifying his thinking and developing his ability to communicate that thinking to others. A good institution encourages him and gives him time to develop and test new concepts. The private psychiatrist, too, has responsibilities toward his professional associates, national and local organizations, and also the schools or hospitals where he teaches. The impact of these responsibilities on patient-care is in. direct, of course. In private practice the psychiatrist needs to consider only what is of primary benefit to each patient individually without being concerned about institutional needs. He can fully explore various areas of special need or interest, taking into account only the financial and emotional resources of the patient and himself. He can have as much or as little cornmunication as he wishes with other individuals and disciplines.