The Second Law of Thermodynamics and The “Med Check”

On one of my recent posts, a psychiatrist made a very thought-provoking comment.  He/she wrote that they interviewed at a clinic where the psychiatrist saw 20 patients per day and made well over $300,000 per year.  At a different clinic the psychiatrists saw many fewer patients (and, of course, made less money) but, the commenter opined, the patients probably received much better care.

This problem of “med checks” serving as the psychiatrist’s bread-and-butter has been discussed ad nauseum, particularly since the infamous New York Times “Talk Doesn’t Pay” article (see my comments here and here).  It’s almost universally accepted that this style of practice is cold, impersonal, sometimes reckless, and often focuses on symptoms and medications rather than people.  I would add that this approach also makes patient care more disorderly and confusing.  Moreover, minimizing this confusion would require more time and energy than most psychiatric practices currently allow.

I work part-time in one setting where the 15-20 minute “med check” is the standard of care.  Because my own personal strategy is to minimize medication usage in general, I’ve been able to use this time, with most patients, to discuss lifestyle changes or offer brief supportive therapy, keeping the lid (hopefully) on irresponsible prescribing.  However, I frequently get patients who have been seen by other docs, or from other clinics, who come to me with complicated medication regimens or questionable diagnoses, and who almost universally complain that “my last doctor never talked to me, he just pushed drugs,” or “he just kept prescribing medication but never told me what they were for,” or “I had a side effect from one drug so he just added another one to take care of it,” or some combination of the above.

These patients present an interesting dilemma.  On the one hand, they are usually extraordinarily fascinating, often presenting tough diagnostic challenges or complicated biological conundrums that test my knowledge of psychopharmacology.  On the other hand, a 15- or 20-minute “med check” appointment offers me little time or flexibility to do the work necessary to improve their care.

Consider one patient I saw recently.  She’s in her mid-20s and carries diagnoses of “bipolar II” (more about that diagnosis in a future post, if I have the guts to write it) and Asperger syndrome.  She is intelligent, creative, and has a part-time job in an art studio.  She has a boyfriend and a (very) involved mother, but few other social contacts.  She was hospitalized once in her teens for suicidal ideation.  Her major struggles revolve around her limited social life and the associated anxiety.  She’s also on six psychiatric medications: two antipsychotics, two mood stabilizers, a benzodiazepine, and a PRN sleep agent (and an oral contraceptive, whose efficacy is probably inhibited by one of her mood stabilizers—something that she says she was never warned about), and complains of a handful of mild physical symptoms that are most likely medication side effects.  She (and her mother) told me that her last two doctors “never took the time” to answer their questions or engage in discussion, instead “they just gave me drugs and kept asking me to come back in three months.”

What to do with such an individual?  My first wish would be to discontinue all medications, assess her baseline, help to redefine her treatment goals, and identify tools to achieve them.  But remember, I only have 20 minutes.  Even the simplest of maneuvers—e.g., start a gradual taper of one of her medications—would require a detailed explanation of what to expect and how to deal with any difficulties that might arise.  And if I can’t see her for another 2-3 months—or if I have only 13 annual visits with her, as is the case in my Medicaid practice—then this option becomes far more difficult.

As a result, it’s easier to add stuff than to take it away.  It brings to mind the second law of thermodynamics in physics, which (very loosely) says that a system will always develop greater disorder (or randomness, or “entropy”) unless work is done on that system.  Stated from a clinical point of view:  unless we invest more time and energy in our patients, their care will become more scattered, disorganized, and chaotic.

Some of that time and energy can come from a dedicated physician (which will, of course, require the additional investment of money in the form of greater out-of-pocket cost).  Other times, it can come from the patient him- or herself; there are an impressive—and growing—number of websites and books dedicated to helping patients understand their mental illness and what to expect from specific medications or from their discontinuation (for instance, here’s one to which I’ve referred several patients), often written by patients or ex-patients themselves.  But without some external input, I’m afraid the current status quo sets many patients adrift with little or no guidance, direction, or hope.

It’s disheartening to think that psychiatric care has a tendency to make patients’ lives more disorganized and unstable, particularly when most of us entered this field to do the exact opposite.  It’s also discouraging to know that for those patients who do benefit from mental health care, it’s often in spite of, not because of, the psychiatrist’s involvement (something I’ve written about here).  But if our training programs, health care system, and large financial interests like the pharmaceutical companies—not to mention the increasingly narrow expertise of today’s psychiatrists—continue to drive psychiatric care into brief med-management appointments (which, BTW, I find insulting to call “psychiatry,” but that’s an argument for another time), then we must also prepare for the explosion in diagnoses, the overprescription of largely useless (and often damaging) drugs, skyrocketing rates of psychiatric “disability,” and the bastardization that currently passes as psychiatric care.

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29 Responses to The Second Law of Thermodynamics and The “Med Check”

  1. L says:

    “bipolar II” (more about that diagnosis in a future post, if I have the guts to write it)

    Oooh! Oooh! Is that the one where the client gets angry a lot, and angry outbursts are mood swings, right? And mood swings are bipolar, right? So the client has BIPOLAR! Yay! Pass the mood stabilizers!

    Double points if the client actually has borderline personality disorder that your diagnosis will now obfuscate for the next decade.

    Triple points if the client is a child under age 10.

  2. L says:

    N.B.: By “your” I don’t mean YOU, I mean the general you. Well, you know what I mean. D’oh!

  3. Another great post. You really do have a knack for blogging. I agree with you 100%, except to say that even with only 20 minutes, I’d opt for that “gradual taper of one of her medications.” Could you use brief phone contact, if needed, between those too-infrequent visits? You’re in a position to offer such patients tremendous benefit.

    I see a patient who received unnecessary anti-psychotics and mood stabilizers for many years. She’s doing much better now on no meds at all. But the damage was done: She decided not to have children because her “needed” meds risked birth defects. She didn’t want to pass her “biological mental disorder” to her children. Now she’s past child-bearing age and mourns her lost opportunities. What a pity — and she reminds me of the patient you describe. I hope you don’t let this happen to her. And I hope our misguided med-lobbing colleagues come to their senses.

    • Altostrata says:

      I agree with starting to get the patient off the medications. Once they get the knack, patients can follow taper schedules on their own, to conserve those precious 20-minute appointments.

      I suggest one of the antipsychotics to go first. Surely two are not needed unless one wants to assure the eventual development of diabetes.

  4. AA says:

    Steve,

    As one who got on the psych med treadmill hell due to dealing with undiagnosed issues that were similar to AS, this post struck a raw nerve.

    My guess is your patient was put on an antidepressant due to not knowing how to cope with her AS issues. Then she had adverse BP reactions and was automatically deemed bipolar.

    Meanwhile her complaints of mild physical symptoms are only going to get worse. And after several years of this routine, she will have parting gifts that make the cure worse than the disease.

    Steve, I know you’re in a tough position. But you have to make some tough decisions when your residency is up.

    Are you going to be part of the problem and lament there is nothing you can do and just past these people along? Or are you going to find a way to practice psychiatry differently and make a difference in someone’s life.

    I apologize if this seems like a rant. But I am mad as hell (long story) and I don’t want to see anyone else suffer.

  5. Tom says:

    Your clinic allows you 20 minutes for a DIAGNOSTIC EVALUATION? I am sorry but that seems to constitute malpractice. I suggest you quit your job.

    • stevebMD says:

      Tom,

      No, I’m talking about medication follow-up appointments. However, my main point is that, even when a diagnostic evaluation is relatively thorough (unlikely to be the case in some community settings), a patient will only receive one or two of these in his/her lifetime. The rest of that person’s “care” is conducted in 20-minute med-management visits during which the psychiatrist must take into account everything else that has affected that person’s well-being and recovery in the interim. (In the ideal case, that patient is seeing other professionals for therapy, coaching, training, case management, etc., but that means that the 20-minute “med check” is even less relevant, as it often results in just responding to what those other professionals observe and prescribing a med to address it.)

      If, in each patient visit, the psychiatrist’s responsibility is to assess a patient’s progress towards his/her goals, evaluate and treat risk factors for future decompensation, and steer a patient toward recovery, this is impossible in a 15- or 20-minute session, so yes, I would argue that a psychiatrist attempting to do so IS malpractice.

      • LAMMD says:

        Can you not schedule another evaluation session for 40-50 minutes whenever the situation warrants it?

        Can we as psychiatrists determine what sort of session a patient needs rather than try to fit someone into an administrator’s idea of a schedule?

        Or have her back more frequently until you know her case better.

        Gather with colleagues and take a stand with this clinic about how care will be given.

        Psychiatrists can and should show leadership.

      • LAMMD – How right you are.

  6. Jay says:

    Another thought-provoking post. This blog hath become my first go-to while the coffee is brewing.

    Some folks do just fine with brief med checks. I did a chart review recently on one of our long term clients. He is one of the rarities: straight-up schizophrenia with no significant co-morbid conditions. He’s been with us for 12 years and his chart comprises just two volumes. He is ‘stability’ personified. Contrast that with an NGRI client I see who has been with us for less than three years. Her chart comprises four volumes. The interesting thing is that both receive med checks of 30 minutes or less. The first is attributable to stability and a good AFC placement. The second is prone to what I call “major pile-ups at the intersection of Axis II and Axis IV”. Medication is not her solution, and the psychiatrist appropriately defers to therapy as the needed intervention.

    Contrast these two scenarios with a consult I requested recently regarding a 62 year old who has seen some precipitous declines in all functional areas. A whole lot of OCD/anxiety and a CT scan that was negative for stroke. Our psychiatrist went the extra mile, time-wise, and uncovered some patently psychotic features of her depression that were previously unseen. She took the necessary time and did not simply stick to a med-driven algorithim.

  7. aek says:

    If treatment/care is truncated solely due to reimbursement and specifically not as a patient outcome/assessed need/evidence based practice standard, then yes, it’s malpractice. A very rough analogy would be to initiate cardiopulmonary resuscitation and end it arbitrarily at a designated time based on reimbursement instead of patient response, need and outcome.

    Psychiatry seems to have been given a complete and total pass on evidence-based practice and patient outcomes. In the ACO (accountable care organization) model, I don’t even see psychiatry/mental health services mentioned.

    Psychiatry seems to be gravitating to a narrower and narrower practice aimed at using medication/electrical stimulation to suppress outward manifestations of distressing symptoms where those symptoms are perceived as negative by the referrers and/or treaters. There seems to be an almost total disconnect between patients’ needs/wants relative to psychological, cognitive and perceptual distressors and psychiatrists’ approaches to treatment.

    It seems to me that psychiatry is fast transforming itself into 2 camps: neuroscience researchers and not credible, hysterical snake oil salesmen.

    When I read blog posts by most psychiatrists (you are a notable exception to this anecdotal finding, BTW), I know that I will find extreme use of emotive adjectives. There will be a lot of self-congratulatory statements about saving lives and providing effective treatment without any supporting evidence, whatsoever. There will be self contradictions about simultaneously maintaining boundaries, where no physical touching of patients ever occurs alongside of veiled references to needing to manage the iatrogenic diseases resulting from the adverse effects of prescribed medications. How, one wonders, does a psychiatrist “manage” hypertension without physically applying a BP cuff? Or listening to heart sounds? Performing an EKG? Measuring waist to hip ratio?

    Psychiatric practice is long on jargon – psychoeducation, psychopharmacologist – and short on basic evidence-based practice. Psychiatrists are not licensed as pharmacists or pharmacologists, and this theft of the term is misleading and deceitful. Education about symptoms, diseases and their management doesn’t need the prefix “psycho”. The whole message that psychiatry is selling is that they possess unique and specialized knowledge, and that they are educated to apply this specialized knowledge via the social contract, so that they have a code of professional ethics and the ability and resources to self regulate. We all know that this has been and continues to be a falsehood.

    Anyone can measure that at any time by the example you used in this blog post. The treatment ends when the reimbursement does. Not when the patient’s needs are met and the response is satisfactory.

  8. Deer raiding the bird feeder says:

    I would like to hear more about bipolar II, although I can see you don’t want the backlash. I get the impression that some docs don’t think it exists, but I’m not sure I understand correctly.

    I thought bipolar II was supposed to be just like bipolar I, but the mania somewhat milder. My diagnosis keeps switching back and forth between bipolar I, II and NOS and I have no idea why. I used to get classic mania symptoms with euphoria for many weeks at a time, but I did not think I was God, and I wanted 4 hours of sleep a night. Otherwise, it was the classic stuff – starting up businesses, starting a remodeling project in the middle of the night, and so on. I had these “hypomanias” many times thru the years when I was not taking any pills, but I haven’t had any for a long time. Just the cycling depression. So I just don’t get it. My therapist, whom I’ve seen a long time, much more frequently than any psychiatrist, insists it’s bipolar I, but if I can pass for normal during mania (among people who do not know me), then it isn’t full blown mania, right? Or is it, even though I slept around 4 hours a night? Or is there a disconnect because my therapist does not talk to my psychiatrist? She claims she saw me manic (I don’t recall) but the doc never did. Maybe I soft pedal what has happened in the past, because I always assumed it’s bipolar II, so the new doc has no idea? But the old doc had Bipolar NOS too, but she was a 15 min med checker I saw infrequently. Who knows? I think it’s funny that for 20 years now, the diagnosis keeps switching! When I look thru my medical records, the background story that I tell seems consistent.

    I guess I am primarily *curious,* and think this type of stuff makes psychiatry look silly, but really, I just wish treatment had helped.

    • Discomposed says:

      I too would like to see you discuss your opinion on “bipolar” disorder. You stick it in quotes often enough, but rarely expand beyond a few quips here and there. I’m genuinely curious, very interested to hear what you have to say. So somebody with a stick up their backside gets a little uppity, so what? There are likely countless others who will agree with you whom simply don’t/won’t speak up.

      I really hope you’ll expand beyond your passive-aggressive use of quotation marks.

      • stevebMD says:

        Discomposed,

        LOL… yes, I guess the quotes are a little passive-aggressive. And really, my thoughts aren’t radical or “game-changing” (oops, used those darn quotes again) or anything; they’re just, well, thoughtful (I hope). But I need to be wary of those with backsides inhabited by said sticks. I’ll get something out there soon.

  9. Steve, why do you need to have guts to write about bipolar II, which I believe is part of the “bipolar, my ass” spectrum disorder? I write about it all the time:

    http://davidmallenmd.blogspot.com/2011/02/stupid-study-and-even-stupider-headline.html

    http://davidmallenmd.blogspot.com/2010/07/counting-symptoms-that-dont-count.html

    http://davidmallenmd.blogspot.com/2011/08/more-bipolar-disease-mongering-in.html

    We are a shortage specialty. The only reason we let ourselves get into these bad practice situations and accept meager remuneration for doing the right thing is that we accept it.

  10. Andy says:

    Hi,
    I enjoyed your blog and was disturbed by the complex meds regime your ?BPAD2 patient was on. However, I would like to suggest that the first step should be to review the history, to decide whether or not the diagnosis is correct, rather than stopping the meds. I often encounter the view that “unless I have seen mania I don’t believe it” This approach neglects the wealth of info available from your patient as well as potentially putting them through an episode with all sorts of potentially damaging consequences.
    All the best,
    Andy

    • stevebMD says:

      Andy,

      Thanks, you are exactly right. And your alternative is, I agree, more acceptable than subjecting her to “potentially damaging consequences” of all sorts. But the alternative leads us right back to the heart of my argument, which is that to “review the history” and determine an accurate diagnosis, requires more than what 20 minutes offers.

      The name “med check” is very apropos. It’s decidedly not a “person check.”

  11. Hawkeye says:

    I am a bipolar imperialist. Please write about bipolar II. The existance of such a possible diagnosis was hidden from my family for years by a prestegous academic institution. When finally made and treatment begun, simple mood stabilizer monotherapy, a miricle occured and has continued, for years.
    The issue is not diagnosis, but treatment. When all else fails, try moodstaiblizers and remove the most important drug commonly used–alcohol.
    People’s lives are being destroyed by arcne Platonic deabates about diagnosis. Today my doctor called me a “sports car.” That’s as good as bipolar II.
    I a lot of thoughtful folks now think that affective disorders are about glutamate/gaba, that is excitation/quiesence.

  12. Suedehead says:

    this is absolutely my favorite psych blog. please never stop.

  13. Ross says:

    Practicing community MHC psychiatrist here. This post is spot on. Good job!

  14. Kevin Nasky, DO says:

    The only important question here is: are psychiatrists willing to make less money in order to spend more time with patients? The answer, of course, is a resounding “no.” Not sure what the answer is. Perhaps we should have nurses or mental health care educators do the time intensive work of explaining things to patients (for example, walking a patient through a complex taper). As a med student, I rotated with an endocrinologist that had a wonderful nurse who spent lots of time with patients (especially newly diagnosed diabetics) in a health educator role. Perhaps psychiatrists should look into this. Remember, if psychiatrists all start spending more time with patients, it won’t just be the psychiatrists who suffer (financially). Psychiatrists are already a scarce resource in most places. If you think about it this way, there are only so many of psychiatrist-hours out there, right? If each psychiatrist increases time with patients from 20 to 30 minutes, you’re going to reduce overall psychiatrist availability, which will reduce access all around. We have to take a deep breath, and make some decisions about the best way to utilize our unique set of skills and education.

    • You make a thoughtful point, but in actuality most psychiatrists, or at least most I know personally, trade some income for better patient care. The answer is hardly a “resounding no”, although I wish the “yes” were louder. It’s a problem of where to draw the line, and I’m all for drawing it on the side of compassion.

      The “scarce resource” argument doesn’t sit well with me though. All American physicians could abandon our practices, and instead assist with public health efforts in the 3rd world. We’d surely save more lives and relieve more suffering. However, the duty of a doctor is to help individual patients, not save the world in general (even if as world citizens, we should strive to do that too). Treating individual patients with safe, effective, sensitive care should be an unambiguous goal for individual practitioners and for our profession. Certainly, nurses or mental health educators could fill time-intensive roles in some practices. But there’s also an ongoing role for us psychiatrists to take the time to do a good job. As I see it, resource scarcity isn’t a good rationale to do otherwise except in extreme circumstances (on the battlefield, only psychiatrist in 100 mi, etc). If we don’t uphold our own professional standards, we only have ourselves to blame.

      • Altostrata says:

        I can’t see psychiatry as a scarce resource, either. The pharma-sponsored campaigns to “destigmatize mental health” and “make treatment available to all” have put any MD (or PA) in the role of psychiatrist in arbitrarily diagnosing and throwing prescriptions at patients.

        The 20-minute med check is perfectly suited to pharmaceutical psychiatry — all you need to do is match drugs to symptoms, why would you need to go into history? (And, as Dr. Steve says, adding drugs is much more convenient than reducing them.) To respond to demand generated by advertising and public relations, what you need is an assembly line, not a concerned, knowledgeable specialist.

        To differentiate themselves from assembly-line psychiatry, which can be done by anybody, real psychiatrists need to show they can provide better care than all the other MDs doing the same job. They have to demonstrate their value-add.

        Here’s the rub: To do this, real psychiatrists are going to have to explain what’s wrong with assembly-line psychiatry: the misdiagnosis and overprescription, the lack of monitoring, the unrecognized adverse effects. They need to swim against the current. They need to become advocates for patients, not psychiatry.

        Can real psychiatrists get their professional organizations to take the position of patient advocacy? Can the field go to war against assembly-line psychiatry and GP psychiatry and pharmapsychiatry?

        I know doctors hate to organize, but if real psychiatrists want to change the writing on the wall, they’ll have to do something to make a larger impact on their own profession.

        PS One area where real psychiatrists can demonstrate a value-add is by untangling polypharmacy generated by the assembly line. Basically, you’d be trying to correct all the other doctors’ mistakes. There’s a real need for this, but wouldn’t you rather change the system than be relegated to clean-up?

      • Yes Altostrata, I agree. And this is my cue to mention my recent post on commodity psychiatry: http://blog.stevenreidbordmd.com/?p=535

      • Altostrata says:

        Good blog post, Dr. R.

        I have no doubt warm person-to-person psychiatry provides more benefit to the patient than machine-like commodity psychiatry.

        How can warm psychiatrists make this point to the rest of medicine and the public?

    • Altostrata says:

      In an era of diminished financial expectations for so many, why shouldn’t psychiatrists face reality? Your jobs have been outsourced to GPs.

      Take less compensation and differentiate yourself by providing a higher quality of care.

  15. Mara says:

    Hey, I don’t normally do this (ask really off topic questions), but you seem like you’re into alternative solutions and not selling out to Pharma. I wanted to know what you think of St. John’s Wort. When people would tell me about it when I was growing up, I used to think the antidepressant effects were probably just placebo. But I went on wikipedia, cuz I was thinking of trying it, and it’s a lot more legit than I originally thought ten years ago. It’s prescribed all the time in Germany, and Ireland considers it a real antidepressant as well. You can’t even get it OTC in Ireland

    What do you think about it? If you know anything about it at all.

  16. rtherenegood1sleft says:

    My holy grail as a patient – to find a caring, ethical psychiatrist who knows what the hell they are doing, and who takes more than ten minutes to figure out what to do and to follow up. My first doc was about the best I had in any specialty because that person took the time and cared enough. As I go to a c linic, but am not non medicaid, the next one was ugh! I resisted going to her based on a gut feeling I had when I saw her and finally caved, under pressure from my pcp. She was as I thought, and I was planning to quit. She made me go up on a med that just got new warnings at higher doses. Patients… educate yourselves. Read about meds. Check it out w/ your doctor. From here on out I won’t go to any psychiatrist I don’t like or who doesn’t hear me. I’d rather be stark raving mad, thanks.

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