Sunday, August 30, 2009

How Many Patients Per Hour?

Psychiatrist and former podcast guest Dr. Mark Komrad asks:

As Chairman of Ethics at Sheppard Pratt I have been approached with a question that seems to stand at the border between ethics and "practice guidelines." The question is: "What is the maximum number of patients that a psychiatrist can/should see in an hour to be safe and effective?" In other words, the concern is about certain psychiatrists who are starting to see 8, 9, even as many as 12 patients in an hour (these would average to 7.5-10 min per patient if no breaks). This is an entirely new level of caseload that is emerging, and the question came to me "at what point does it start to become unethical or bad practice." I find this difficult to answer, but thought it a good question to submit for discussion on this list. Afterall, if memory servies, I read somewhere that the typical Primary Care doc is gives each patient an average of 8.5 minutes. Is it possible to do psychiatry with that kind of average time per encounter? Your thoughts?


Unknown said...

No. that is a medication mill pure and simple. you have to start your interview while walking the patient in from the waiting room just to get everything in that you need to get in. ridiculous.

Aqua said...

My boyfriend's psychiatrist sees him for 10 minutes a month. She has no time to listen, or review what he said last week. When he told her he was still extremely depressed she had no time to as why, or to listen...she just increased his antidepressant.

When that caused difficulty orgasming, she had time to say, "yes, that is a side effect of Celexa" time to discuss a plan, or how to fix it, or a new medication.

To top it off his psychiatrist and therapist make him meet them together...a sort of panel interview. It scares him when they are both in the room.

You may think, "well he has a therapist...but all she ever does is tell him not to do whatever it is he does. She never listens, just tells.

Everyone might be thinking "get a new pdoc and therapist...It is pretty much impossible to find a psychiatrist in Vancouver. People wait for eons.

BTW...this note too more than 10 minutes to write

Anonymous said...

the obvious answer, of course, is no. but i'd like to toss in the caveat that there are times when an appointment can necessitate 8.5 minutes, and not really any longer. when i was stabilized on meds for severe, treatment-resistant depression, for over two years, i met with my psychiatrist every 3-4 months with a 2-3 minute phone call check-in a few times in between. the appointment needed about 10 minutes, though we sometimes sat longer, just chatting. on the flip side, for the years before and after that lovely 2 year period of stabilization, there were periods where my psychiatrist requested to meet with me biweekly, and sometimes weekly, and those sessions took a half hour to an hour.

is seeing patients routinely for less then ten minutes a good, or ethical, or practical, or positive idea? absolutely not.
but do all med. management appointments need half hour appointments? nope, definitely not.

problem, of course, is that you can't predict beforehand which it will be.

The Crazy Music Lady said...

The question that this raises for me is what type of treatment are we talking about? Inpatient, outpatient, medication management, actual hands on therapy, stabilization? Pure medication management, I could see that working for. A sort of check up see how things are going in inpatient hospitalization where a diverse range of other therapies are offered, yes. Anything else? I don't think quality of care would be adequate.

Rach said...

What about the interplay between bichemical and environmental factors in psychiatric illness?
Shouldn't the psychiatrist spend time inquiring about a patient's lifestyle or other stressors that might effect medication efficacy?

Anonymous said...

I am a psychiatrist. In my experience, a minimum requirement for good patient care is thorough assessment through out the treatment process. Thorough, meaningful assessment cannot be done in a 10 minute appointment. I refer to the comment by Aqua to illustrate how a person is reduced to symptoms and chemicals when forced into a ten minute box. We would not want that kind of treatment for ourselves or our friends or family.

Call me old fashioned, but I wish my colleagues would resist the push to shorter and shorter visits because it hurts everyone, most of all the patients and the field of psychiatry. I am sure that surgeons could strive for shorter and shorter times in the operating room. They could possibly do 3 bypass surgeries in one day instead of two and make 50% more income (I am making these numbers up for the purpose of my argument.) But would we all be served by rushing a surgical procedure? Are we served by rushing our psychiatric appointments? Can we not make a good enough income seeing three people per hour?

Anonymous said...

Maybe the way to phrase that is, which patients would that work for? With my primary care doc and gynecologist, there are routine matters and simple questions that can be addressed in under ten minutes. As long as I have only one simple question (or none at all), it's fine.

With my psychiatrist, well, it's not simple. I find it virtually impossible to condense how I've been doing over the last month into 15 minutes (and I've only had to do so once). Why? Because I need to cover any significant events, generally what we're doing in therapy, and also bring up any questions that I may have come up with in the interim (rarely related to meds). He may or may not have talked to my therapist in the interim, and even if he has, I suspect they compare notes on what I say. A 30-minute appointment (25-ish of face time) every four weeks is generally adequate these days because I'm making noticeable progress and my life has become less chaotic. He rarely changes my meds, but it would be unfair to conclude that because of that, our appointments could be shortened with no loss of care.

I think he is able to be more conservative about the meds and change things slowly if at all because he has time to sort out which symptoms are situational and which are episodic. He doesn't chase the symptoms with meds.

He was also the first one to get the diagnosis/es right. And he was eventually able to get me to start exercising and to maintain the habit.

I did have one psychiatrist (my second) whose first appointment with me was 15 minutes. So at the next appointment, I asked how to get off my antidepressant. He advised against it, but since he didn't know me and tried to use what seemed like scare tactics ("It might not work the next time you start using it") I ignored him and went ahead.

Speaking of your podcast, are you guys going to record any more episodes? I discovered it recently and am enjoying catching up on old episodes.

Mindful said...

I am fortunate that my psych schedules appointments in 30 min blocks. I am now at the stage where I se him every 8 weeks and it is ample time to do what needs to be done. It seems luxurious compared to the time blocks proposed in the post. Even my primary care doc sees me for 15 minutes. From a consumer's point of view, I can't see how a pysch appointment can be conducted in 10 mins unless it is only for a med review.

mysadalterego said...

I'm pro-moving psychiatry into the normative area of the medical world...that said, I don't think ANY medical appointment should be less than 15 minutes. Just because HMOs and bad systems make that the norm doesn't mean it's good practice...ever. As the anonymous who is a psychiatrist points out, five minutes is also not enough to explain a surgical procedure and get consent. Why pick on psychiatrists when everyone is doing it?

For med management, or anything that isn't formal therapy, why not 15-20 minutes?

Sure, everyone wants more time with their doctor, and psych patients even more often, but from the doctor's side, that just isn't practical. As much as I'm for patient-centered, biopsychosocial medicine (and believe it or not, I very much am), when people come in for too long and share too much, they often develop unrealistic expectations about what doctors can fix for them.

Is it ok to go to your family doctor and she never hears that your mother just died because of the structure of a five minute appointment? No. Can she be there for full sob sessions and sharing your grief and helping you figure out how to arrange the family dynamics after? Also, no.

Psychiatrists get themselves into a lot of trouble by giving the impression that they can fix peoples' lives, make them happy, fix social situations. They can't, and they need to be honest with people about that, and these long involved meetings give a mixed message.

And whatever people say about interaction between biological and social factors - well, that's true in ANY medical field.

Sunny CA said...

Reading this makes me feel very lucky and happy that my psychiatrist sees me for 50 minutes a week. I am also happy that he suggested I go off the medications I was on when I started seeing him. That gave me back my life since I was a robot devoid of emotions on the meds.

I wonder how many people currently managed on psych medications would be better off with a psychiatrist who concentrates on psychotherapy rather than pharmaceuticals?

MySadAlterEgo: My psychiatrist has never given me the impression that he can fix lives, make people happy, and fix social situations. He helps to shine a light into the dark corners of my existence, and points out what I do not see regarding my behavior and ways of interacting. Any changes that are made are done by me and the decision to do so comes from me. He provides emotional support and encouragement.

Anonymous said...

It usually takes my hairdresser 50 minutes to cut my hair. Once, she did it in 30 minutes. I didn't think my hair looked as good, although everyone at work said it was the best haircut I ever had. I still wasn't convinced.

Once I took my car to get the oil changed and they did it in 15 minutes instead of the usual hour! I know they didn't do a good job!!!!

Katyusha said...

Of course 10 minutes is inadequate to manage medications, listen to the patient's concerns, respond thoughtfully, etc. And that's even when the patient is getting therapy from another practitioner. The question is: Compared to what? Compared to no care at all?

I can imagine in severely underserved communities, 10 minutes with a psychiatrist is the best you're going to get. When going without meds is not an option, 10 minutes is life-saving.

Anonymous said...

I had a 10-minute psychiatrist my first go-round. When I told her my therapist had changed his diagnosis (significantly), she didn't ask why, she just changed hers. Blind acceptance, without discussing it with me or the therapist. When I reported problems functioning despite the medication, she didn't have much to offer, so I struggled on for months before it occurred to me that I could have better care. I felt like I was just a check to her.

My new psychiatrist prescribed different meds and though I see him every 3 months now, he spends a half hour with me. I don't feel rushed and I don't feel faceless anymore, thank god.

Anonymous said...

Seems to me that 2-3 medications only patients an hour is probably 'good enough' for docs and clients. For a client with a lot of 'stuff'increasing frequency of visits would be a way to get more time. I see a private pay psych MD and submit to insurance myself. She does 30 minute appts.(25 min of face time.) In a nonprofit agency I know of, clients are booked every 15 min for MD/psychRN, for a 3-4 hour block of time. (No shows are a real problem so no breaks are planned..if everyone DOES show up, the prescriber is lucky to get a chance to use the rest room!)
As a nurse, I think you need at least 15 minutes of face time to assess a client on ALL settings who is reporting to be STABLE - unless there is only ONE diagnosis/issue. Almost all adults, psych or not, have more than one concern beyond health maintenance issues.

Dinah said...

So people are commenting about 10-15 minute med checks versus longer sessions. What about the 8-12 patient/hour (hmm 5-7.5 minutes/patient)....
I can't logistically wrap myself around that one--I'm not sure I could get people to walk in and out of the office that fast and I'd need a much larger waiting room.... Seems like the work to keep people that focused and talking fast enough would be absolutely exhausting (and writing notes...oy!)
This sounds like a completely vacant work life....
Does anyone see a doctor who works at this pace?
I've worked in several clinics, none have expected a doctor to see more than 2-3 patient/hour.

Rach said...

Dinah, you make an interesting point about needing a larger waiting room.
Any psychiatrist who gives a damn (i hope) would spend some time worrying about the privacy of their patients.
If my shrink saw that many patients in an hour, I'm sure I'd eventually run into someone I knew/worked for/taught... which would only make the situation more uncomfortable.

Sunny CA said...

I had a 10-minute shrink before my 50-minute psychiatrist and he had 2 doors from the hallway. One was labeled and led to the waiting room and the other led from the office to the hallway alongside the waiting room, separated by a wall. One out. One in. There were signs with instructions for new patients, plus forms to fill out,
I think that 5-7.5 minute appointments border on malpractice. Unless this is emergency care in a disaster zone, this should not be considered.

Doc said...

Good topic!
The amount of time often depends on the type of patient being seen. I schedule 25-30 minutes for most patients, and provide rudimentary supportive psychotherapy. I still have a few 50 minute patients. Those who are excessively stable (e.g. adult ADHD patients needing monthly Ritalin refills,) or those with severe neuropsychiatric needs (e.g. group home patients with mental retardation, stable, but with routine needed follow-up) can take less time.

Most evidence based results agree with a combination of medications and therapy for many psychiatric conditions. Often, the time may be spent more in psychoeducation (e.g talking with family care-givers for a neuropsychiatric patient).

As I like to tell the residents I teach at the local program, what is the difference between you and a primary care doctor with a good psychopharmacology textbook? Nothing, if you we not grasp the importance (and spend the time on) the biopsychosocial model.

William said...

I would agree with most that 7.5-10min per patient is grossly inadequate in many cases, it is possible that some cases (as Anonymous notes below,) might literally be that simple and stable - but otherwise, no.

Even if you are only managing meds, I would submit that most psychiatric cases require more than 10min of assessment and thought. Psychopharmacology is just not that simple most of the time, never mind that most of the time ONLY pscyhopharmacology just isn't going to get your patient better ...

SteveBMD said...

I work in a busy community mental health clinic in a large city. I have difficulty seeing more than 12-15 patients per day (medication mgmt only), but one of my colleagues boasts that he can see 40+ in each day. His personal "best" was 47 in a day, including 7 new patients! He alleges that he can diagnose people "when they walk through the door."

Anonymous said...

"So people are commenting about 10-15 minute med checks versus longer sessions. What about the 8-12 patient/hour?"

For me, my ten-minute visits dwindled quickly to half that. I felt like if all I was there for was to get a PX, then I wouldn't waste time talking.

Unknown said...

Wow, 8-12 patients an hour! It takes me 5 minutes just for the patient to settle into the chair and feel warmed up and ready to talk!

I see patients for either 25 minute 50 minute follow ups. Depends on, well a lot of factors.

Had the 25 minute versus 45 minute session pro and con talk with another psychiatrist recently. That doc sees all her patients "therapy" and "medication" (artificial division IMO) for 45 minutes.

I argued, how can anyone really get a full 45 minutes if you run on time? Seems that everyone gets more like 40 minutes.

Guess it was a luxurious debate to be able to have. Our patients still get nice relatively long sessions.

Midwife with a Knife said...

That's an interesting question. When I was a fellow, I saw up to ~70 (very occaisionally more than that) in a 10 hour day (9am-7pm) high risk ob patients per day in clinic. That volume wasn't determined by the desire to see more patients to make more money but to try to address everybody's needs.

And it sucked for me and for the residents and for the patients. I'm not sure that psychiatry is so unlike anything else, that unless you actually sit with the patients for a few minutes, it really is hard or impossible to figure out how they're really doing or what's really going on. Other wise, it becomes a game of, "Hey, how're you doing? Fine, ok, let me check your cervix. You're outta here by bye!". Not great medical care, really.

Child Psych said...

This reminds me of a Gary Larson Far Side cartoon. There's a psychiatrist, a patient on the couch, a pad of numbers on the wall (like you take to be served at the deli) and the psychiatrist says "Stop whining and get on with your life! Next!" -- Seems like the only practical model for a 5 minute appointment. Likely to be unsatisfactory to all involved.

NotNormal said...

It's a funny thing.

Sessions with my Psychiatrist last from 10 to 30 minutes. It starts with "So, how are you doing" and ends when I have nothing else to tell her.

If I was forced into a 10 minute visit, I would most certainly just ask for prescription renewals and say everything is just fine.

I hate being bipolar, I hate having to think about it and I would like nothing better than an excuse to pretend like I need not take it seriously. A doctor who treated me like a slab of meat with a health insurance card would make that easy.

Am I just one of the lucky ones?

Scream said...

If my pdoc only saw me for 5 minutes at I time I'd feel like a piece of meat and I'd probably start stalking him.

moviedoc said...

If you get 7.5 when you divide 60 by 12, it's probably unethical purely on the basis that a psychiatrist should have at least 4th grade arithmetic skills.

Seriously, you have to look at what goes on during each visit, not some calculated average duration. Also consider whether the patients will tolerate such short visits (and whether they have a choice) and whether there's time to write adequate notes.

Anonymous said...

My now-ex-shrink (who has expensive tastes) shovels them in and out. I had a brief med appointment, which I thought was at X time. When I arrived at X time (despite slow traffic and a long commute), he said I was 10 mins. late and so had to pay a missed-appointment fee--but that he'd write my Rx as a "courtesy" anyway, even though his next appointment was waiting.

Apparently, I'd misremembered the time, which is a common symptom of my disorder, not some sublimated resistance against taking care of business. I haven't checked my phone messages, but I could have sworn that X time was the correct one.

Worse, I also had two crucial pieces of relevant information to convey to him, but he was more interested in running my credit card and setting up the next appointment--no "hi, how are you," etc. He acted as if I were annoying him by standing there waiting for my receipt.

After I left, I realized that, if he didn't schedule patients every 10 mins., as he said when I inquired about the time discrepancy, then I'd still had at least 5 (if not 7.5) mins. of my own available. Huh?

And hadn't I stood there 5-10 mins. while he ran his payment through? With the door open for the other patient to hear? And couldn't he have at least talked while taking my money for the appointment I was simultaneously at and not-at? And couldn't he at least feign polite conversation?

I called his scheduler and cancelled my future appointments (and I was steamed at the time).

Several days later, I got a longish and condescending letter from the doc, suddenly advancing the time I'd arrived by ANOTHER 10 mins., claiming that I'd made him late for his next appointment and that he thought I was "ambivalent about my treatment" because I'd missed a couple of appointments over the years (I live 40 mins. away and am in graduate school). He also presumed to recommend a couple of referrals without bothering to ask whether I'd wanted any (although he was correct in assuming that I was done with him).

Fortunately, I found a clinic where I don't have to pay $90-120 or more for a ten-minute curt series of "uh-huh"'s over maintenance meds, and where the doctor listened to the other medical issues that may be affecting my treatment. That's money in my family's pocket instead of Dr. No's--and less illness and weirdness in my life.

Unknown said...

My new psych. due to my old one retiring, has her prescription pad out with pen in hand before I even sit down. She sidetracks any thing I might want to say just by asking the same question for a year now. How are you doing with your meds.? Before I could say anything substantial, like " I really feel like dying and tried it last month" my scripts are written and I'm being rushed out 5 minutes tops. She never once in a year asked me some basic questions like... hows your sleep, appetite and do you feel like harming yourself or others. My psych. history on my first visit detailed some episodes of self harm and suicide attempts. I miss my old Doc. It was very difficult to even find her. I feel lost and alone.