In the Year 2099...

— Steven S. Sharfstein, MD —

Archives Gen. of Psychiatry - Vol. 56 No. 12 - December 1999

In the year 2099, all physicians will be employees of 1 of 4 major health care corporations.

These corporations, vertically and horizontally integrated comprehensive systems of care, will be publicly traded for-profit corporations that will compete for patients and contracts across the United States.

All Americans will be enrolled through a government-financed, universal single plan of care, as employer-based health insurance will have disappeared 50 years earlier.

Americans will be able to choose which health care system they wish to join during an annual “open season” and will be able to select their primary and specialty care physicians.

These corporate plans will compete with each other for access and choice as well as quality with “report cards” being regularly produced by the various state agencies that are charged with assuring accountability of health care within their jurisdictions.

Many of the services will be provided directly in the home or the workplace through a broad and interactive telemedicine capacity since virtually every American will be “online” for their health care and other purposes.

The home personal computer will receive instantaneously the latest in the science and art of the practice of medicine. High-tech health centers, so-called hospitals in an earlier age, will provide the sophisticated gene therapy, organ transplantation, and biomedical engineering that will be available to all in need. Approximately 33% of the gross national product will be spent on health care.

Americans will live to an average age of 105 years. It would not be unusual to find some individuals still living at age 130 to 140 years.

Most Americans at this age will have had their organs replaced by either genetically programmed animal organs or harvested organs from special banks. However, the brain will be the only irreplaceable organ.

Psychiatrists will be primarily involved in the interface of brain and behavior as they have been for 200 years. In the year 2099, an expanded specialty of psychiatric physicians will be certified in 1 of 4 major categories of practice.

These certifications will be in neuroscience, medical psychiatry, psychotherapy, and social psychiatry.

In the year 2099, the neuroscientist psychiatrist will combine the MD with a PhD and be the most highly specialized and, therefore, the most highly compensated (again through a salary) psychiatrist/clinician-scientist.

The neuroscientist psychiatrist will be expert on the human genome, sophisticated brain imaging and mapping, the differential use of neurochemicals, the application of high technology such as magnetic fields for the treatment of mental illness.

Super computers programmed with the entire sequence of the human genome and the different functions of the parts of the brain will rapidly provide a differential anatomical and neurochemical diagnosis for the full range of mental illness as well as “normal” human experience and behaviors.

There will be logarithms or practice guidelines for biological and nonbiological interventions. Many of the neurochemicals will be available over the counter at local pharmacies or health food stores. Prescription drugs will be introduced through high-tech delivery systems directly into the brain.

The psychiatric hospital will no longer exist.

“Hospitalization” (a term of the past) for the purpose of crisis stabilization and safety will occur in small, highly staffed, specialized, intermediate care facilities.

In the year 2099, the medical psychiatrist will most resemble the late 20th century psychiatrist through the subspecialties of geriatrics, adult, child and adolescent, and substance abuse.

The medical psychiatrist will be most closely affiliated with other medical colleagues with many having board certification in not only psychiatry, but also in other areas of medicine.

Geriatrics will be the specialty for the treatment of the very old. Since Alzheimer disease and dementias will have been cured for over 50 years, the constant renewal of the brain will occur in consultation with the neuroscientist psychiatrist.

Similarly, the child psychiatrist will work with the neuroscientist psychiatrist in early preventive interventions at the intrauterine level, with genetic abnormalities being corrected well before birth.

Substance abuse will continue to be a major human affliction with the medical psychiatrist providing primary treatment and care in a society where criminalization for illicit drug use will have been abolished.

The doctor of medical psychiatry will also be competent to attend to the general medical needs of his or her patients except when highly specialized care is required.

This will be a very popular area of specialization for physicians, with more than 20% of all American medical graduates specializing in medical psychiatry.

In the year 2099, psychotherapy psychiatrists will combine the MD with degrees in psychology, education, religion, and the humanities.

The psychotherapist will work in one-to-one and group settings on the age-old human problems of individuation and separation, grief and loss, insight, and self-actualization.

In the ultramechanical age of the year 2099, this high-touch human interaction will be very popular with more than 50% of the population having had the experience of psychotherapy and benefitting from it. In the year 2099, the social psychiatrist will combine the MD degree with a degree in sociology, criminology (PhD), and/or a law degree.

The social psychiatrist will focus on the social control issues of the day. Forensic prisons will be the one remaining area of government-sponsored treatment (in contrast to single-source government funding for all of health care).

These prisons will dominate the criminal justice system with interventions in an effort to reduce criminal behavior.

The social psychiatrist, in addition to salaried employment in the forensic arena, will be in high demand in various community locations, such as workplaces and schools. Managed care will not exist in the year 2099.

It will be perceived as a regrettable experiment of the late 20th century that ended in the very first part of the 21st century.

The universal single-payor system of care eliminated not only the insurance industry, but also the high cost, intrusive middle managers of carve-out behavioral health care companies, allowing a rediscovery of the physician-patient relationship.

Human progress comes in many forms. In the year 2099, medicine and psychiatry will have made advances that make the prior 200 years of psychiatric care seem crude, quaint, and in some ways absurd.

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