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.