Saturday, May 08, 2010

Why Am I Asking All These Questions?

I'm reading a book where the shrinky author starts off with a revelation: it's not the best care to see patients for a 50 minute evaluation, start a medication, have them come back in a month for a 15 minute med check, and refer them to a social worker for psychotherapy. It does sound like a good way to make a lot of money. If you aren't totally exhausted, overwhelmed with the phone calls and paperwork you must have seeing that huge a case load, and are someone who is gratified from this type of work, then it's cool by me. It's not what I want to do.

The author trained at about the same time as I did, and trained at an institution with a biological orientation, like the one I trained out. He talks about this kind of care as though it's standard and the usual and expected. I've never heard this as standard, and in my private practice, I see new patients for 2 hours, and want people to come back weekly for 50 minute sessions until -- they are no longer symptomatic, or they've gotten what they want out of the treatment. Some people come into treatment without symptom---their old shrink moved or died, and they just want a script and someone to rely on if they get sick. I don't insist they come every week, but I'll ask them to come more frequently than they are used to coming for a little while until I feel like I know them. Some people can't afford weekly psychotherapy or find it to be a burden, and I often respect their wishes to come less frequently, unless their illness is destroying their ability to function, in which case I think they need to come weekly. I don't see anyone more than once a week (unless there is an emergency) routinely, and I never seem to have patients who come requesting twice weekly therapy sessions. Almost everyone comes for the full 50 minute session. A few people who just aren't talkers come for half hour sessions.

I've worked in a number of community mental health centers. I know some clinics have huge caseloads and a full-time doc may have 500-1000 patients. I've never worked anywhere like this. Most of the clinics I've worked in have left the frequency of visits up to the doc, though certainly there is a clinic tone. In one clinic I worked in, most patients saw the doc once a month, where I work now, it's once every three months for patients who are stable. The therapist attends those sessions, and they may be quite brief....many of the patients don't seem to want to talk, and the paperwork burden imposed by the regulatory agencies are very heavy. Still, the standard at all the clinics I've worked in is 2 patients an hour. The no show rate is high, and sometimes a 3rd patient may be squeezed into the schedule if there is a scheduling problem.
My record is 15 patients in one day, and this was while I was volunteering at a clinic in Louisiana after Katrina, and the clinic had no full time doctors and a huge demand. It was 15 patients I'd never seen before, some were quite troubled, and it was a tiring day for me. So my hat goes off to those docs who see 4-6 patients an hour. I couldn't do it.

So what is the standard? I thought I'd ask. Of our readers, it looks like many see their psychiatrists weekly and many see them for 50 minute sessions. Just thought I'd ask. Thank you for taking my surveys and please do add your comments.


Lisa G said...

I found the way you work interesting. I've never had the opportunity to work with a pyschiatrist in the manner you describe. It would be nice. I've been stuck with the "first visit 50 minutes, follow up med checks 15 minutes" model. So far, it's been ok, and I've been able to manage my bipolar disorder with that model. I've also been able to get longer appointments when I'm in crisis or I just feel I need them, but they're definitely not the norm. Are you going to post the survey results?

Dinah said...

The results for each survey can be seen at any time by pressing "View Results"...many fewer answers to How Long and How Frequently, then to Why---but I'm presuming this is because I asked only about psychiatrists in those surveys, and for Why Do You See a Shrink, I left it open to all Shrinky versions.

Crissy said...

I've had experience with psychiatrists (clinic and private practice)who only see patients for 15 minute appointments. I never felt like the docs or staff got to really know me, therefore I didn't necessarily trust their judgment. I have friends who see a psychiatrist and their visits are also these short, med management type appointments with anything more being left for them to discuss with their therapist. I've found the only way I can see a psychiatrist (as opposed to a therapist) for 50-minute appointments is to see one who does not accept insurance and I have to pay in full out of pocket. It's very expensive, especially at times when I'm not as stable and require more frequent visits. But I've been seeing this same doctor or 7 or 8 years and fortunately he works with me when I have trouble paying my entire bill at one time.

Anonymous said...

The model that the author describes is basically what most insurance companies will pay for. So that's what people do.

In my case, I found a psychiatrist that I liked very much but other than the long (almost 2 hours) first visit, she could only see me 15 minutes a week for a med check. Any more than that and the insurance company considers it "therapy" and won't cover it.

She told me she had over 700 patients.

It was a pity. I never found a social worker I liked as much as her and eventually abandoned meds and therapy altogether.

Aqua said...

Hi Dinah,
I am finding the stats very interesting. Makes me feel like maybe I am not more needy than other people. Seems others see their pdocs for similar lengths and periods of time.

One thing...You mentioned, "...where I work now, it's once every three months for patients who are stable. The therapist attends those sessions, and they may be quite brief....many of the patients don't seem to want to talk"

My boyfriend goes to sessions very similar to this. He despereately NEEDS to talk, but he says he is overwhelmed by having two drs/therapists in the room with him.

I get that. Having two people, especially people I would perceive as authority figures would make me shut down. Maybe that's why people don't talk? I know for my boyfriend he doesn't even feel comfortable bringing up how he would rather just see the psychiatrist.

synergesta said...

Dinah,I am a female psychiatrist in solo private practice in an urban environment and my practice is almost exactly like yours! It is very encouraging to read your blog and listen to the podcasts. I constantly struggle with time-management issues but otherwise am happy with my current set up. About once a year, when I need to pay taxes and put away $ in a SEP IRA and am flat broke and the malpractice bill and kid's college tuition bill come, I wonder whether I am "crazy" to do this. Then I sigh,think about my patients and my down-time activities (listening to podcasts, surfing the web, books on CD, all manner of hulu-type addictions, just walking around my city...) and I realize that though there is a price, I might just be "sane", or "sane enough..."

moviedoc said...

The good thing about private practice is how it works is completely up to my patients and myself. I have stopped doing psychotherapy, but few of my patients want psychotherapy, and only rarely to I think they need it when they think they don't. Visits last between 5' and 20' or more depending on what is needed. Same low fee for all. Stable pts. may have contact is infrequently as 4/year. Buprenorphine maintenance requires monthly visits. In other cases I ask the patient when they want to come back, knowing we can always move the appointment up or touch bases by phone if need be. For most patients every other contact can be via Skype.

Dinah said...

Moody Mommy--I think you're probably right that the only way to see a psychiatrist for psychotherapy is to go out of network.
Merope 3: that's a lot of patients
Aqua: yes, I think that is probably much of it. The patients meet alone with the therapists for therapy. They often refer to their social worker therapists as "dr." There is not an option to see just a psychiatrist-- the clinic paperwork burdens are too much. Also, there are doctors such as me, only there half a day a week, and so the patients need a full-time person to coordinate their care and be available for emergencies.
synergesta: nice to meet you!
moviedoc: we have different types of practices and I don't have any trouble not having internet in the office. In the clinic, I'll use it to look up interactions or doses or some type of information, but overall the distraction factor (email, blog) far outweighs the helpfulness issue. I wish I could have an iPhone, but 3G would be the end of me.

moviedoc said...

Dinah: That was someone else that asked you how you could manage w/out net in office (lockup?), but it could as easily have been me. I have my tablet PC in my lap to take notes by writing, cannot do keyboard with pt. My forms, as you may know, are all on my Web site. I print them, drug info from Web, and order Rx online with pt sitting in front of me. I have no iphone, but the new HTC Evo will have Skypiatry capability (2 cams) AND google voice, so I'm thinking that's my next phone.

Katie said...

i hate to say it, but i think you're basically wrong. psychiatrists who do not take insurance are, i think, more likely to do more then just "med checks" every 1-3 months, depending on stability, but those that do accept insurance do seem to stick to those 3 month med checks routinely. And from a patient perspective? Well, I don't want to meet with them more frequently, because I know perfectly well I'm nothing more then a source of income....and why on earth would I want to spend more time with someone who so clearly sees me as such?

I did see a psychiatrist for a while for therapy and medication; however, that was her training - psychoanalytic. i saw her once a week for 45 minutes ... i also paid an obscene amount of money out of pocket. Aside from the insane cost, that was by far the best model I've experienced - med. management with someone who actually had a clue as to who I was and what was going on with me.

the only insurance-accepting psychiatrist i ever saw more then once a month/every 3 months (depending on stability) was a psychiatrist who was over 70 - ie very old school. With her, when things were not going well, I saw her as often as once a week for a month or two at a time. However, even her standard of care was 1x/month or 1x/3month when stable. With some of these doctors I saw a therapist (psychologist) in tandem. I would say that's still not an idea model, even with the two professionals are willing to be in contact with each other and stay up to date by phone (not in session with me). It's still third-person, and it always made me a little uneasy what was being said without my knowing (yes, I know I could have withdrawn my consent.)

Therapy these days is a pretty lousy field. Unless you're willing to pay about $150-$250/week, the quality you get is not high.

It sucks.

Anonymous said...

In my experience, the model you described in the frist paragraph, Dinah, IS the norm. Seems the pdocs are very stingy with their time and sort of leave it up to the patient to call and ask for more visits if they feel they need it. Why should I have to call? Coming in every 6 weeks would be better than every 12 weeks--even with a therapist who sees you regularly.

Lockup Doc said...

Dinah--in reference to what MovieDoc said, I was the one who had asked how you get by without internet access in the office. I'm still intrigued by the fact that you do manage without it these days, but it sounds like it works for you.

If anyone is interested in answering (or seeing the results of) a few more questions, I have a reader poll on antidepressant use right now:

Bippidee said...

I am rather late with this reply, but here in the UK it is very much of the assessment appointment and then just med checks system if you see an NHS psychiatrist. I have been seeing my psychiatrist once a month lately, but that is only because of meds being changed - she generally sees people every 6 months, or sometimes every 3 months. My appointments with her are usually for between 15 and 30 minutes. I have seen a number of different psychiatrists, and also have many friends who are in the mental health system over here, and this is fairly typical. I don't know anyone who has ever had therapy with their psychiatrist on the NHS. I see a CPN weekly (or twice weekly recently as I have been going through a crisis patch). Again, this is fairly typical - most people with severe/enduring mental health problems (the criteria that one has to meet to be seen by the CMHTs over here) have a CPN or Social Worker and see thema nything between weekly and monthly. Most people only see a psychologist for a specific type of therapy, ie a course of CBT or CAT or DBT etc, rather than general psychotherapy, although I do know some people who have had more ongoing psychotherapy with a psychologist on the NHS, but most treatment is via CPNs or Social Workers. Don't know if this is at all interesting to you, but I just thought a UK perspective might make a change.