There's ways to schedule a day so that those in need of more help can get it, but it involves juggling the system. E.g. putting a patient with that needs more time right after and before other patients that don't need much time, or are more likely not to show up.
But it's juggling, and sometimes you're just unlucky. Sometimes they all show up, and just happen to want your time, putting that patient that you knew needed more time without it.
As for psychotherapy, I do agree we should be on top of it more, but with our healthcare system's spending already out of control, it would be cheaper for us to refer to others. We should still be on top of it because if we don't know psychotherapy, we won't know how to interact and exchange knowledge well with the psychotherapists as a team. We should also be given at least a few patients where we are allowed to be reimbursed for psychotherapy to keep those skills sharp.
IMHO, some things that can improve psychotherapy skills is to emphasize it more on the board exam, there should be an allowance for attendings to get reimbursement for at least a small number of psychotherapy patients, and establishment of better relations with our colleagues in the field such as psychologists.
I've seen some psychiatrists of an opinion that they don't need to know psychotherapy, as if it's beneath them. Even with that mentality, as I wrote above, how are you going to communicate with those that are giving it? There's more than enough data to support that psychotherapy along with medications are more effective than either alone. There are several intricacies with psychotherapy, that unless you know them, you won't know what's going on if for example the DBT therapist is telling you the patient is not doing well on mindfulness skills, the person is likely going to get worse in the next few weeks of therapy before they get better because they're confronting a major issue, or interpreting a column chart for CBT. Kind of like a surgeon, who may not have to do everything in the surgery room, but has to have knowledge of what each person does to communicate relevantly with them, and understand their recommendations.
I've also noticed that psychiatrists doing psychotherapy are much less likely to misdiagnose. I've seen far too many cases where a borderline was diagnosed with bipolar, put on meds for years, and there was no significant improvement, while the patient also happened to gain > 100 lbs of weight. I've also noticed the same with dissociative disorders often misdiagnosed as psychosis or depression, substance-induced disorders misdiagnosed as non-substance-induced, bipolar depression misdiagnosed as depression (and the patient was never screened for bipolar), and a plentiful over-prescribing of benzodiazapines by doctors who never once explained the risk of that medication to their patient, or had a plan to eventually get the patient off of it.
As for Carlat, I highly agree with his article, which is ironic because I very much disagreed with him on the issue of the Oregon bill that would allow psychologists to prescribe.
