Tuesday, September 24, 2013

Should Psychiatrists See Patients?

Today's Wall Street Journal has an article on a new model of psychiatric care: the psychiatrist serves as a consultant to the primary care doctors and the psychotherapist.  The psychiatrist hears about the patient, but if my read is right, the psychiatrist has a large caseload and never actually sees the patients.  

In Getting Mental-Health Care at the Doctor's Office: Providers Take Integrated Approach, With Patient Numbers Set to Jump Under New Law and Psychiatrists in Short Supply,

Melinda Beck writes:

As the consulting psychiatrist for four primary-care practices, Dr. Ratzliff confers weekly with 10 care managers who follow the patients closely, provide counseling and chart their progress in electronic registries. She helps devise treatment plans and suggests changes for those who aren't improving.

"I get to touch so many more lives than I would if I were seeing these patients in person," she said.

I'm speechless.  The article goes on:

In some practices, psychiatrists and psychologists work alongside primary-care providers on cases. In others, primary-care doctors prescribe antidepressants or other medications, and care managers—typically licensed clinical social workers—confer weekly with patients to monitor progress, often using a standardized nine-question depression quiz.
Many care managers also provide cognitive behavioral therapy and other counseling. "The goal is to give patients the skills to approach problems differently," said Jürgen Unützer, a University of Washington psychiatrist, who has helped more than 1,000 clinics nationwide adopt the model.

Many studies have shown that integrated care can reduce patients' depression and cut costs. One University of Washington study of 1,800 patients found that providing a year of integrated care cost $600 a patient but saved an average of $4,000 in lower medical bills over the next four years.

Still, integrated care is a big adjustment for psychiatrists, whose training typically focuses on one-on-one relationships.

It's good that more people are able to get help.  It's good that money is saved and that this is so economical ($600/year for mental health treatment, wow!)  And primary care providers already prescribe for the majority of patients, so adding a therapist and a psychiatrist to consult with may well be an improvement, but shouldn't patients with serious mental illnesses still see a psychiatrist?  


Steven Reidbord MD said...

Quantity or quality, take your pick.
(Or another favorite... ) Fast, Cheap, or Good — choose any two.

Nicola said...

Unnützer, fwiw, is German for "the useless one".

Anonymous said...

Dinah, I am speechless also.

In reading the article, the critics who stated that it provides superficial, cookie-cutter care and relies too heavily on medication are right on target in my opinion. In my opinion, I see this scenario occurring frequently - The doctor who can't figure what is wrong with a patient will decide pretty quickly to blame in on a psychiatric illness since it will be easier to consult with a psychiatrist who is part of the practice. A horrifying scenario for the patient whose primary medical concern will never be addressed.

By the way, I am curious, do physicians who run this type of practice disclose he/she consults with a psychiatrist? I think since that may influence his/her practice, a patient has the right to know that.

moviedoc said...

Isn't this how academic attending psychiatrists work?

Anonymous said...

Isn't this just the next logical step from the 15 minute med check, which became the ten minute med check, which is down to about the 7.5 minute med check? How is this really any different? When mainstream psychiatry reduced patients to checklists of symptoms on which to base prescription of drugs, I think this became almost inevitable. You don't need an M.D. to fill out a checklist and the hands-on stuff like, oh, say talking to a person and trying to understand his or here life in context could be done by professionals who don't charge nearly as much.

jitterbug said...

Personally, I am suspicious of a doctor who doesn't want to see patients. I don't remember playing "doctor" in kindergarten and not seeing "patients." Wasn't that why we all wanted to be doctors when we were little girls and boys? We wanted to play with the stethoscope and hear a heartbeat, take a temperature, feel a forehead for a fever. I would think that would defeat the point of becoming a doctor.

I'm curious about how many psychiatrists would be dissatisfied with this model. How many of them only wanted to consult and how many of them really wanted to work with patients.

Another concern I would have is of "telephone" type of issues. Remember as a kid when everyone would play telephone and by the last person the word or phrase would be totally different. I could see the patient saying something to the LCSW and it gets slightly distorted. Then the patient goes to the GP, talks about med management stuff, and that gets even more distorted. And by the time the psychiatrist gets all of the information, he is getting a giant distortion of information.

Anonymous said...

i get these points, but i also see what the psychiatrist shortage can do to people. when i was let out of the psych ward after a two month or so stay, it still took three months to see a psychiatrist. by that point i had run out of meds and gone off cold turkey. in the end this was a good thing for me, but could have ended tragically.


Joel Hassman, MD said...

Gee, and all those people who have either laughed or insulted me for hypothesizing this PPACA insult is going to ruin psychiatry effectively, I guess I was so wrong.

Doesn't mean there won't be accountability and liability for this role though. Someone has to be found at fault when the treatment fails.

Incredible. And not only will it happen, wait for it, the APA will support it. Aren't you glad you are a member if I am right on this?!

Anonymous said...

I wouldn't like that. How does the psychiatrist do a mental status exam? Does the psychiatrist write, "Someone told me the patient has poor eye contact...." "Rumor has it that the patient has a flat affect..." But, I don't really know any of this, just going on what I heard...

Please tell me they are not diagnosing patients without having examined them.


jesse said...

@Anonymous who asked "By the way, I am curious, do physicians who run this type of practice disclose he/she consults with a psychiatrist? I think since that may influence his/her practice, a patient has the right to know that."

The issue actually is "who is it who makes the decision and takes the responsibility?" If the Consultant actually has authority to direct care then the patient should know that he doctor she sees is not the final authority as to what is prescribed. On the other hand, if it is actually only a consultation, then that does not have to be disclosed any more than any doctor needs to disclose that he sought different opinions, discussed the case with a colleague, read about the issues, and so on. There are medical/legal issues here. Are there ulterior motives that are not disclosed? For instance, is the psychiatric consultant himself under pressure to hold down costs and not recommend anything more expensive than what a schedule allows?

And yes, it is the training hospital model, and yes, the internists have limited knowledge but do most of the prescribing, but still there are very worrisome trends inherent in this. The training model is generally done to high standards of care, while this might have as its sole motivation the lowering of costs.

And as a psychiatrist who is very proud of his profession, I am very concerned that the field is becoming increasingly cookie-cutting and that fewer and fewer psychiatrists actually do psychotherapy as opposed to just prescibing medication.

Dinah said...

Jesse is right on about the role of a consultant. The primary care doctor/nurse therapist/etc is the doctor of record and the psychiatrist is a consultant. I wonder if the psychiatrist even needs malpractice insurance if he isn't responsible for patient care? Presumably, though, if someone is worrisome, he can recommend a face-to-face consult? I know a hospital locally that is doing this, but my impression was that the psychiatrist consulting in the primary care model actually saw the patients.

Training hospital mode: in the first year of training, the new psychiatrist is responsible for the care of inpatients. The attending psychiatrist comes to the floor every morning, hears the nursing report from the night, and briefly sees every patient. The attending also interviews every person when they are admitted. At least this is how is was in the days when I rode my dinosaur to work.

Pseudo-Kristen: in the consultation model here, the psychiatrist isn't doing a mental status exam, but you are exactly right that the consultants recommendations are filtered through the lens of the person presenting the story and, like that childhood game of telephone, things may get lost in the translation.

Anonymous said...


You said, ""The issue actually is "who is it who makes the decision and takes the responsibility?" If the Consultant actually has authority to direct care then the patient should know that he doctor she sees is not the final authority as to what is prescribed. On the other hand, if it is actually only a consultation, then that does not have to be disclosed any more than any doctor needs to disclose that he sought different opinions, discussed the case with a colleague, read about the issues, and so on. There are medical/legal issues here. Are there ulterior motives that are not disclosed? For instance, is the psychiatric consultant himself under pressure to hold down costs and not recommend anything more expensive than what a schedule allows?""

Sorry, I wasn't clear previously. If I know I have a complex medical situation that is going to get easily blown off, I think I have the right to know ahead of time if doctor x has a psychiatrist that he/she regularly consults with because I fear that would influence his/her decision in my situation. Since that psychiatrist is easily accessible as a consultant, it is easier for the doctor to throw an antidepressant at me vs. doing real detective work to find out what the problem is. Of course, this happens even when a psychiatrist isn't accessible as a consultant but I see the potential for abuse to be alot worse when that person is.


jitterbug said...

Like AA, I might also want to know if the GP is cnosulting with a pdoc. I say this because I have had some instances where I was very ill and a GP decided to play psychiatrist and blame it on mental health issues...causing me to be very sick for far longer than was nescessary. They seem to have an attitude of...well, I just wanna make sure it's not a psychiatric problem before I run any tests or make sure it's not a physical problem. It's all very disturbing to me.

Sort of on a side note, I've met people on the internet who say that they have been treated by a pdoc, they then saw a therapist in the same facility, and then were subsequently discharged by both therapist and pdoc. They were unable to find out the reason why. No explanation. That actually happened to me once. I saw a pdoc, he treated me for months, and then I saw a therapist in his facility one time. He was hostile the next time I saw him, even though he used to be friendly. I thought that therapist wasn't really for me, saw another, and then went back to the pdoc. He discharged me during the visit and said that he strongly suspected I have borderline personality disorder. Because they were all in the same group, they had access to each others notes.

I now see a pdoc and therapist who have communicated with each other and do not think I have a personality disorder.

I think consultations can greatly affect treatment. I only saw those therapists once, and it greatly affected how the pdoc perceived me. Thos were much closer to consultations than treatment, bcause they only saw me once.

Joel Hassman, MD said...

Ladies and gentlemen, I present to you the concept of "Respondeat Superior", and include the link for Wikipedia you can copy to the address tab to read:

(by the way, why doesn't this site allow links if provided by defined commenters?)

I defer to the colleague who coauthors here to tell us how much this concept fits in this example raised by Dr Miller, but, I think it does, simply for this reason:

If colleagues come to you for expertise and direction in care, you as the provider of this expertise and clinical insights to consider are making a clinical intervention if accepting this consultation role. You are telling someone of equivalent stature in clinical care how you would treat the patient. How is this different than what goes on in residency programs?

Let's have a moment of brutal candor and honesty, colleagues, how many of your supervisors in your residency training actually saw the patients you presented to these supervisors? I'll take a stab and suggest a 1/3. Maybe a bit higher, but it NEVER was near 100%, not in my training experience at least about 20 plus years ago.

So, if the basic explanation from Wikipedia have merit, why doesn't it fit here? And if it does, why should these "consultants" get a free pass from any accountability or culpability should a negative outcome occur from the suggested treatment recommendation?

Makes one think a bit harder in having your clinical "gonads" sliced further off into one's abdominal cavity, EH?!

Oh, by the way, what I continue to rail about with the growing intrusions by insurers per these authorization "requests" that interfere with clinical care of late. Read one of these forms if interested, I have one at my site back in April or May post that shows how they are asking for clinical information to then render a clinical opinion as to what meds can or cannot be offered to YOUR patient.

I hope a lawyer is reading here!

Anonymous said...

Yeah, I think a lot more would be lost in translation with this kind of plan. It sounds like a crock of you know what.

I just don't understand how a psychiatrist can offer an opinion about treatment for a patient they have not examined. They need to assess the patient.

I think it also kind of makes me sad. I have a bond with my psychiatrist. We're a team. I think patients under the plan discussed in the blog post would be losing out. I like my PCP, too, he's a great doctor who knows a lot of stuff, but he doesn't know as much about psychiatric medications. I don't want to discuss side effects of psychiatric medications with my PCP. I want to talk to the person who knows about it.


Joel Hassman, MD said...

Here is a link regarding the medical relationship to the above Respondeat Superior comment:


Hope it is of interest.

a psychiatrist who learned from veterans said...

I feel that the APA Task Force did something like this with saying that 'antipsychotic meds are overused*.' Thus in all the categories they mentioned, I was particularly concerned re: adolescents being included, this puts us in the position of a sort of presumed 'overuse' if we prescribe them. The Task Force hasn't seen the patient, hasn't presented to me that data, hasn't sent anybody out to examine the patient with me or anything of the sort. I don't object to warning labels or side effect information being given, but this impugns the prescriber without knowledge of the patient.


jesse said...

"Still, integrated care is a big adjustment for psychiatrists, whose training typically focuses on one-on-one relationships."

Ah, there's the rub. What psychiatry is has been changing. Yesterday I was on a plane, seated near a young woman who was reading Yalom's The Theory and Practice of Group Psychotherapy (fifth edition). Ph.D psychology student. I had read the first edition long ago. Said I was a psychiatrist and she said she was surprised that Yalom was a psychiatrist because psychiatrists don't work with groups and don't do psychotherapy, just medication.

The biggest problem in my mind is that if you don't actually do psychotherapy you don't know what it can do, what it can't, and when a blend of it with medication is best. You just don't know, and the result is check box practices in which each person has no real idea of what is possible. Perhaps there is no alternative to this today, but it is unfortunate. Having a wide range of knowledge helps us treat our patients.

I told the student that perhaps one day she would be on a plane next to someone reading the tenth edition,, who would be surprised that the book had been read by a psychologist. "I didn't know psychologists talk with patients, I thought all they did was testing."

We should never think we are the final results of evolution. There is always change.

ClinkShrink said...

I'm waiting for the day when I sit next to someone on a plane who says, "Schizophrenia? Oh yeah, we used to give meds for that. Good thing we've got prenatal testing for the genome now."

jitterbug said...

I think a time will come when psychiatrists don't see patients, and they just consult with a primary care physician who also does not see patients. The PA or NP will see the patients, who will use the GP as a consultant, and the GP will use the pdoc as a consultant.

For psychotherapy, the psychologist wil not see patients but be used as a consultant for psych testing and therapy. Someone trained only to do the test will administer it and then send the findings to the psychologist.

If it is a psychotherapy question, the psychologist will be used as a consultant for an MFT or LCSW. The MFT and LCSW also will not see patients. They will supervise "peer counselors" who have had brief training in crisis counseling. The peer counselor, who will typically have a BA or even an AA, consults with the higher trained LCSW and MFT, and they consult with the psychologist.

If someone in the higher ups needs to be notified of mental or mood changes, the peer counselor tells the LCSW, who tells the psychologist, who notifies the PA, who notifies the GP, who notifies the psychiatrist, who sends a recommendation to the GP, who funnels that down to the PA, and everyone hopes to God all of the information was passed on correctly.

jesse said...

@jitterbug, you understand my concerns precisely. But in addition, what all of these notes that get referred to others don't show are associations, questions, observations that were never made.

So when anxiety increases who can notice that the therapist might pursue a different tack? The therapist does not know what he does not know, and the inevitable assumption might be that medication needs to be changed or increased.

The psychology student I met said that she was talking with a psychiatric resident who told her he was going to work with a particular problem with psychotherapy. "i have been doing therapy for three years and I would not try that, and he thought he could do it after one month of having done therapy..."

Anonymous said...

one day shrinks will be forced to help their patients get better by offering useful advice and constructive criticsm
long experience has taught me that essentially shrinks don't want their patients to get better

jesse said...
This comment has been removed by the author.
jesse said...

There was a NYTimes article on funding for psychotherapy, and it generated many good comments. Here is one, by RA, which struck me as particularly wise and true. I quote it here just to share it:

"I am a psychologist in private practice, and read this op-ed as I sit in my office preparing for a full day of sessions. I appreciate the author's point that psychotherapy suffers from an image problem, but I disagree with him as to the nature of the problem. Psychotherapy does not suffer from a lack of focus on "empirically supported treatments." Rather, it suffers precisely from this focus, which is pushed by insurance companies who want to see psychotherapy as something like a drug that can be doled out in discrete, titrated doses with discrete, predictable effects, chief among which is symptom reduction.

"In reality, psychotherapy is nothing like a drug. Rather, it is a complex but profoundly rewarding process of examining one's life, history, desires, relationships, hopes, and fears in order to open up new possibilities and make new meaning out of one's experience. It is inherently discursive, inherently existential, and inherently relational. At the outset, we never know quite where it will take us, what we will discover in the process, or indeed whether we will achieve our initial goals. However, psychotherapy of some duration undertaken with a competent therapist seldom fails to be deeply meaningful. Yes, there are bad therapists out there as well. In my experience, they are often the ones who derive a false sense of mastery from the very techniques the author is touting, instead of remaining humble and self-critical, and trusting the client and the process."

jamzo said...

check out Psychiatric News

Professional News
September 21, 2013
DOI: 10.1176/appi.pn.2013.IC_1
Integrated Care: What Does It Mean for You?

"Integrated care" is everywhere—in theory, at least, and increasingly in practice. The concept is a feature of the delivery-system improvements in the new health care reform law, and policymakers and many clinicians have converged on the idea that general medical and behavioral health services should be brought together in a patient-centered manner. Today, a small but dedicated and growing cadre of psychiatrists is advancing the cause of integrated care and the participation of psychiatrists in collaborative-care models.

APA has established a number of initiatives in this area, headed up by..."

L said...

My flavor of depression is complex and my shrink has consulted with psychiatrists many times. None of them have met me. I don't have a problem with that.

Anonymous said...

Somewhat unbelievable to me that no one on this site has acknowledged that clinically trained LCSWs do more than 60% of all face to face therapy and we don't need a doc(MD or PhD) to tell us how to do our business. We have our own supervisors for that. We do consult regularly for issues of testing and meds with the other terminal degree and licensed professionals. Psychiatrists abandoned therapy for med consults a long time ago; the field was set up by you based on a firm belief that meds rule the mind. The fact that this is not the case is not a shock to me but I can't imagine doing evaluation and prescribing without face to face examination.

Joel Hassman, MD said...

Over 2 weeks without a new post.

Hope all of you are well. I won't be reading to know better. Look forward to read interesting and valuable points of view in the coming week or so. Maybe the country will still be in place.

If DC is gone, well, no loss to me!

Be safe, be well! Hope some of these politicians are gone next year! It's Fall, get outside and see the world!

Anonymous said...

Like Joel, I find myself missing shrink rap and wanting a new post. It's strange how attached we get to these blogs. You go on one of your favorite blogs, and then go...awww....they are on hiatus.

It's was almost tragic for me when the doctor from Thought Broadcast stopped blogging.

Anonymous said...

I would stop getting mental health care if it looked like this model. Under this model of "care," and I use that term quite loosely, I spend about 5 minutes with my PCP who will somehow know to collect all the pertinent details the consulting psychiatrist will need to make treatment recommendations about someone the psychiatrist couldn't be bothered to meet. Sounds fabulous.

If psychiatrists do not need to see patients to diagnose and treat, then I can't see why we would need them anymore. Sounds like a vending machine would work just as well. No exam needed. Depressed? Press 1 for drug X. Still depressed, press 2 for more drugs.

My psychiatrist has not known me as long as my PCP, but he already knows so much more about who I am as a person than my PCP does. I would never listen to some shrink's opinion about what I needed, if they could not be bothered to spend even 5 minutes talking with me.


a psychiatrist who learned from veterans said...

In the context of the discussion of antipsychotic drugs and reflecting on the usefulness of drugs for schizophrenia also being useful for (bipolar) depression, my thoughts on that and narcissism: http://irvingpsychiatrist.blogspot.com/2013/09/anti-psychotic-drugs-and-bipolar.html

spaustuve said...

Psyhiatritcs MUST see patients. Because it is very sensitive kind of medicine... We are not robots, we are humans...