Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Tuesday, November 27, 2007
My Other Life
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I work in two different clinics where I see patients just for medication management. Though I've ranted about the wonders of seeing a single psychiatrist for psychotherapy who also can evaluate for, monitor, and adjust medications, the financial reality of the world is that this is not the cheapest way to offer care, and in a setting where 30% of the patients don't keep appointments, it's not practical to schedule a psychiatrist with hour-long therapy sessions. Many patients in clinic populations need case management, help negotiating benefits, and liaison with rehabilitative and vocational services-- things psychiatrists aren't trained to do.
I've said I don't do med checks. I lied. Or rather, when I'm blogging, I tend to think about my private practice, not the clinics. I do med checks. Do I think I'm giving a lower standard of care to people who can't afford to pay me? Yup, sometimes I do. Mostly though, I've come to terms with it because of these issues:
-- The financial reality: given the No show issue and poor reimbursement rates for medicaid and uninsured patients, I am often paid than the clinics are reimbursed.
--Chronically mentally ill patients need a lot of care coordination with other specialists, care providers, supported employment, psychosocial rehab programs-- and they all have forms that need to be filled out. Charts are kept separately and have to be hunted for. Billing issues must be done as well. These things are done best by other mental health folks or secretarial people.
-- Coordination of care and continuity of treatment work best if patients are seen at an outpatient clinic that is affiliated with an inpatient unit and partial hospitalization program.
--Split therapy works best if the psychotherapist is readily available for consultation, and in one clinic where I work, the patients see the therapists and the docs together. Private patient split therapy can be a hassle with regard to communication and with regard to who does which pieces of the patient's care.
-- Many patients I see in the clinic have no interest in psychotherapy and little inclination to offer much information about their lives. I ask about any new things going on in their lives, their sleep, their appetite, their symptoms, do they hear voices, are they suicidal? Any side effects? Are the meds working? Any new medical problems or medications? The patients don't necessarily come with an agenda for introspection.
Posted by Dinah on Tuesday, November 27, 2007
Labels: med management
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I read most of this post, but skimmed some of it because it made me angry.
As a patient, I was never given the opportunity to know why my psychiatrist was only seeing me for 10 or 15 minutes once a month.
Considering the fact that I had three suicide attempts and several hospitalizations, I would have been willing to at least entertain the notion of paying to see psychiatrist out of pocket for psychotherapy.
I just found out a few months ago in a piece I read, that the reason patients get nothing but "med checks" is because of managed care and their desire for patients to get therapy from a cheap provider.
I consider myself to be intelligent, creative and very capable of introspection and insight. No one gave me the opportunity.
Psychiatry countinues to fester through a thin film of secrecy. Don't blame us.
I have been abused by a bad system. I was hospitalized at a place that ended up shut down by the FBI. There were a lot of shady practices, including "paying for patients" and insurance fraud. That's what got them, because, you know, it wasn't the ill treatment of patients, including the controversial "rage therapy" that I am glad I wasn't exposed to. Me and my insurance company were just bled dry. I stayed there 6 weeks and all shrink would say when I questioned him was that if I asked more questions he would have an ambulance take me to the state hospital...
Poor, pitiful you, the caring doc disparaged for choice of specialty. So sad and so sorry.
The sad thing is that as pissed off as I am at you (and by you I mean the 'profession' and my past shrinks) and as much as I hate you.
I NEED YOU.
You're all I have, as sucky as it is. I need you because my primary doc won't prescribe the meds I take. He knows I need a specialist. I have to see you because I am dependent on you for help with sleep, anxiety and the never ending bouts of depression.
I pay, I pray, and I look up to you. But I hate you and will never let you forget how much you fail me every day I feel like crap. Every day I can't be 'normal.'
So, hit the ATM, plunk down $190 and find someone who cares.
I go to a community mental health center and I personally enjoy the quick med checks. If I am doing okay, why do I need the therapy too? With my hectic schedule it is nice knowing that I can be in and out in just a few minutes as opposed to be there a whole hour.
That's why I pay someone else to do my therapy. Ontario's health care system doesn't enable my psychiatrist to do the work he should be doing - which is quality psychotherapy in addition to medication management.
So I go elsewhere. But to each his/her own.
When my psychiatrist was a resident at the clinic where I first started to see him, I wonder if he had any patients that he just did med checks for. At my first appt, I said that I was there because I needed someone to manage my ADD meds....and at the end of the appt, he asked how much I could afford to pay to come see him every week. I was a little surprised by that, but he must've seen he could help me somehow. In reality, my friend was chief resident and she had told him a little about me prior to my going for my first appt as she helped me get started at the clinic and asked him to see me. I just didn't know going into it that he would want to do therapy, too. Now we spend very little time managing meds and a lot of time doing therapy.
The reason why I wonder if he had any patients for just med management though, is because it was a resident's clinic designed for low or no income patients. If he did therapy with each patient he saw through that clinic, then I'm rather glad for that - because I feel like most low income clinics are not designed for psychiatrists to do therapy AND med management for all the reasons you stated in your post. I understand that therapy isn't for everyone, but it makes me sad that people who are poor (for whatever reason) kinda get shafted if they might have wanted therapy but can't afford to pay big bucks for a psychiatrist that does therapy and med management. Though sounds like you at least do a pretty good job of coordinating treatment at the clinic. I think it would be a hassle for me to have to see 2 different people for meds and therapy, but so goes the system...
Hello there Rach - me too!
Fortunately I'm not very sick. That is, as long as I have my meds and get exercise, I can function almost fine. Fine enough to hold a corporate job for almost ten years and get promoted. I have insurance with my job that pays for $500 of psychotherapy a year, or almost seven appointments. Which is almost enough. (I'm stunned to see the rates you guys are used to. When she isn't working in a hospital clinic my therapist has an office in the basement of her home, so her costs for office space are low. So when I need more than seven appointments a year I just pay for them.)
When I see my therapist we talk about practical things, like becoming a landlord and my ambivalence about having tenants. Mostly she tries to get me to get more exercise and some peaceful time for myself, and we talk about how I can do those things in a way that works for me and why it's important.
Mostly I hire her to be an ally. In our first appointment I told her I needed someone to be nice to me. When I'm with someone I trust who's nice to me I can compare and use that relaxed feeling to judge for myself where the rest of my life is out of whack.
When I couldn't pay full rates - before I got that corporate job - I felt like I couldn't shop around and had to be grateful for what I got, even when what I got was not what I needed. Even when the small amount I was paying then was a much higher proportion of my income. (30$ per weekly appointment is charity work for a psychotherapist, even one working out of her own home. But it's huge for someone whose income is, say, $350 a month.) If I were paying someone 30% of my take-home pay today I would expect to be paying for something I needed, not something that someone else thought I would need if I were a better person. But then, I have meds now. I didn't then.
A very long-winded way of saying... Yaay for med checks!
Med checks from someone who cares and is nice to you can go much further than you'd think on the face of it. Therapy from someone who wants to do work that doesn't interest you can make things worse.
But if you need the therapy, not being able to pay and pick and choose is horrible. Just as much in Canada as in the US.
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