Sunday, February 21, 2016

Hotel California

Our group of psychiatrists have a listserv -- it's a wonderful tool for sharing resources and keeping everyone up to date about the latest in professional issues.  From time to time, a discussion will ensue, and one psychiatrist posted his thoughts about patients who want to change psychiatrists.  I thought our blog readers might want to weigh in, and with permission, I'm reprinting that doctor's thoughts.  

Regarding taking patients who want to switch doctors, I have my own particular thoughts about that. Psychiatrists are a very scarce resource these days. Therefore, people who are able to have a psychiatrist are the fortunate  ones. Also, like so many of us, I'm pretty booked so I do not have that many openings to take new patients. So I prefer to use those scarce openings for people who don't already have a psychiatrist. Also, people who want to switch psychiatrists very often are having difficulty communicating with their docs about what's not working for them in their treatment. Or, there are transference issues that have not yet been worked through. Or, any one of another impasses in the treatment alliance. Or, they are on an ineffective medication regimen and the treating psychiatrist hasn't been able to ascertain alternative approaches-- pharmacological or otherwise.  So, I am always available to do a one-time second opinion consultation for such dissatisfied patients. Those consultations  provide a diagnostic reevaluation,  perhaps new ideas about treatment alternatives, recommendations to enhance communication, and observation of psychodynamic issues that might be relevant to the stalled recovery and/or treatment relationship.  I identify aspects of their doctor's practice that could be modified to make for a happier patient (e.g.  returning  the patient's phone calls in a timely manner). I make my written consultation available to both the patient and the treating psychiatrist. I am also available to discuss the case with the current psychiatrist. But, I will not take the dissatisfied patient in transfer.  This is really no less than I would hope if one of my patients has been dissatisfied with our treatment and calls another psychiatrist  to jump ship and short-circuit the process of working it out with me.  I would hope  the colleague would respond in kind to what I have described.  Sometimes, that is been the case, but sadly other times it has not. Just like, sadly, sometimes my patients go to the ER and are hospitalized and  the treating docs there never call me.

I know another psychiatrist who once mentioned that he wouldn't take on patients who are already in treatment with another psychiatrist.  I didn't ask why, I just assumed he didn't like the idea of taking someone else's patient, that perhaps he thought it made for poor professional relationships.  

As you can tell from the title of this blog post, I don't agree.  I think if there are times when treatment comes to an impasse, and it just gets stuck.  I think there may be transferential issues to work through, but that should be the patient's choice.  Sometimes people are less concerned with issues in the therapeutic relationship and are more focused on concerns that they aren't getting better.  Some psychiatrists are better than others in general, and some psychiatrists are better than others with specific patients.  And psychiatrists offer different services: I've heard from many people who've tried med-check only treatment who come looking for psychotherapy as well how, "That fifteen minute thing doesn't work for me."  I'm also not so sure that because a consultant recommends that the treating physician should return phone calls in a more timely manner that it necessarily happens. 

Finally, the psychiatrist assumes that when the going gets tough, the psychiatrist wants to continue.  If a patient isn't getting better, or if therapy has become a war zone, then sometimes everyone agrees that it would be best for a fresh start.  Also, do remember that this is one psychiatrist's personal policy for his own private practice, and certainly, I believe doctors should practice in ways they find ethical and comfortable.  No one has actually suggested a true Hotel California policy where "You can check out any time you like, but you can never leave" and patients can never change psychiatrists.

At the other extreme, Roy once told me that if ever returned to private practice he would see patients for only one year: by that point they should be better or they should try treatment with someone else.  

I think patients should be able to change doctors -- of any flavor-- if they aren't happy with the care they are receiving. I didn't post this to poke holes: the psychiatrist above makes some very good points, and he does a nice job of putting into words what others may not verbalize as well.  His comments gave me the opportunity to think about this, so I wanted to give our readers the chance to ponder and discuss as well.  Note that comment moderation is off, so please do be kind to one another. 


Mountain Woman said...

I'd be curious to hear more on Roy's point of view. How would he handle things at the end of a year. Assume things are going well, and the patient is on meds. Does he refer the patient back to their primary care doc, or see them just often enough to renew the script?

PseudoKristen said...

I think what the psychiatrist who won't see patients who have a bad relationship with a psychiatrist should realize is that not all of these relationships should be saved. Sometimes the mental health professional has psychological problems, boundary issues, or it just isn't working. I have mentioned my first therapist before. He had major boundary issues. He left me presents on my door step, he sent me a Valentine's Day card, he massaged my shoulders and showed me in a book how massage was good for depression, and I got worse and worse under his care. I should have left sooner than I did. I also had a bad experience with a couple of psychiatrists. One psychiatrist I saw (only one time) was very condescending and talked to me like I was little girl which was creepy. Another psychiatrist I saw put me on too many medications, I got worse under his care, and I later found out that he had a few appearances in front of the state medical board for bad behavior. My internist even apologized to me for have referred me to him as he was apparently hearing some things about him on his end, too. Not all mental health professionals are created equally.

I am incredibly grateful that I was able to find a therapist and psychiatrist who would work with me despite some of my bad experiences. They have both helped me tremendously. I have been with my psychiatrist for I guess over 4 years now. He found the right medications for me, where the other ones did not. I needed, and finally found, a therapist and psychiatrist who were mentally healthy, who were good at what they do, and who treated me like an adult. Mental health care is not cheap, and it's important to see someone who is helpful and treats you right. If it's not working, it makes perfect sense to go somewhere else.

PseudoKristen said...

I would also say that there is no perfect mental health professional, so if a patient wants to break it off just because there's a conflict then it might be in their best interest to stay and work it out. I like the psychiatrist I have now, but we have definitely butted heads at times. We are both very stubborn. It would not be in my best interests to leave just because we disagree on occasion. What is different about this relationship, though, is that despite a few disagreements we have always respected each other. The same goes for therapist number 2.

Dinah said...

P-K: I don't believe that the psychiatrist who doesn't accept the patients of other psychiatrists would ever think that anyone should stay with an unethical psychiatrist who has violated boundaries or a psychiatrist whose license has been questioned. Nor do I imagine that anyone feels that a single visit in which it's immediately obvious that the therapeutic chemistry is wrong would constitute being "in treatment" with someone, since we usually think of the first visit as an evaluation or consultation. I'm glad it worked out well for you!
I can't seem to prove that I'm not a robot...

PseudoKristen said...

Oh, I didn't think he would want a patient to stay with an unethical psychiatrist. I just brought it up to illustrate that there are sometimes really good reasons to not continue the relationship, and a blanket policy to not see patients who already have a psychiatrist might mean that patients who really do need support to get out of a bad situation don't get the help that they need. I'm grateful that there were people still willing to help me despite my previous experiences.

But, also I think it makes sense to maybe look elsewhere if the personalities clash. I do best with the type of psychiatrist who is really laid back and calm. I wouldn't do well with a psychiatrist who is more high strung and hyper. Nothing wrong with a psychiatrist who is more hyper, it just wouldn't be the best fit for me. The problem is you don't always know if it's a good fit until you see them for a little while.

R. said...

What about people who want to change for some sort of logistical reason. Something like a new job that makes scheduling challenging with the old doc and the new doc has hours that would work better. Or maybe you've moved across town and there isn't a reliable bus route to the old doc and you don't have a car. Or a change in insurance. I'm mostly thinking of situations where the psychiatrist is only doing meds, not therapy, but there are times when life changes make seeing a particular person impractical or more trouble than its worth, even if it is theoretically still possible.

Mountain Woman said...

Dinah, your own blog makes you prove you aren't a robot? That's not fair!

R. said...

Regarding the idea that shrinks are in short supply and people who already have one are lucky, wouldn't switching from Shrink A to Shrink B mean that A now has a new openning? So ita not like there suddenly are fewer slota for patients overall because someone switches. It just switches around which Shrinks have which opennings.

Sarebear said...

oh, boy. I've tried to write, on this. But . . .

Man, that guy is making some assumptions.

I've been meaning to post on my much neglected blog, about why I am firing my psychiatrist (though I haven't told her so, yet, as I need the topamax as it's the only med I've been able to deal with, for awhile now. And even then, the side effects, most of which, besides the tiredness, I thought were me, because nobody ever told me the thing is often called Dopamax and does all this other stuff . . . .well, The trust between us is so broken, when I asked her about these, newly realized all the brain fog, mental holes, tongue fumbles, are probably the med, I asked her if such side effects would be permanent or go away upon stopping the med. She said the latter. Of course, given the permanent effects I'm living with from two other meds, long stopped, that also makes me wonder.

But. The staying with her for years, trying to work it through, finally getting brave enough about 18 months ago to say hey, I'm intimidated by you, and find what you say to be strange sometimes (actually not what I said, i think this last would get me yelled at, she'd yelled at me before; anyway, I was trying to convey the concept, in a way that wouldn't get me yelled at, like two years previous when I'd told her I was afraid of her because of similarities to my mother. I figured a shrink, of all people, would understand this, but she yelled and shouted at me, upset. Ugh.

Okay, I'm doing poorly at this. The second time, she handled it better, we went along okay awhile.

However, a number of things, topped off with the uninformed consent of ordering unnecessary and expensive (I'm still waiting to find out how expensive, and if my insurance will cover, but when confronted with this, the two of the four genetic tests that were unnecessary, untild uninformed about, though technically I signed off on them one was described in fine print, though not in an obvious way) . . Her answer was infuriating, dismissive, and just . . . .


Basically, So? You can apply for their financial assistance program.

What? Are you kidding? My functionality is poor and she cares nothing she may have put me in horrendous debt, who knows how much!


I kept calm, and reacted as if it was ok, because I was afraid of her yelling at me.

I even before this, I didn't want her anywhere near my psychiatric care, if I needed to go in hospital, and have avoided that option because of that. So it's become dangerous to keep her, as well.

The genetic test for medications was pretty useless, anyway, and one of the unnecessary ones, has info on it contrary to how I've responded, that might make my life difficult in future, medically. Who knows about these things.

Sorry so long, rambly, inefficient, all that.

I've tried, and triied, with her. I've found her to be unprofessional in a couple other respects, switching up facts to suit theory of the moment, ignoring other blatant ones that don't fit, as if they don't exist, as though she's tired of the symptom, and treats my continued reporting of those symptoms, as a symptom of ocd, getting worse. It's what is it, gas lighting? She can spin it however she wants, to make it however she wants it to look . . .

And not telling me alot of what it is she thinks we are treating, together, treating me like a child. Our last pair of sessions together were very . . .illuminating.

Anyway, I just, ugh !

I never want to see her again.

Sarebear said...

Oh, and get this. I KNOW she doesn't listen to those symptoms, but I report them anyway, because I need to, and she lets me go on, even rambling and whatnot, never stopping me, even knowing she's not taking them at face value.

THEN . . .get this. After, by the front desk, she says something like, and we were in there, 35 minutes today, and she says it with a BIG smile on her face. I know from reading here on your blog, that that time means she gets to bill for rather more than our usual 15-20minute appointment. And she could have saved a good bit of time and redirected me, if she'd wanted to.

I was so flaming mad. I knew she let me ramble, to make money.

Argh. So. Fired.

Okay, you probably didn't want my specific story, but, yeah.

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Roy said...

#MountainWoman: You asked "I'd be curious to hear more on Roy's point of view. How would he handle things at the end of a year. Assume things are going well, and the patient is on meds. Does he refer the patient back to their primary care doc, or see them just often enough to renew the script?" (...and thanks Dinah for shouting out to me re MW's question)

I've heard of psychiatrists taking on people for a set period of time, say a year, where goals are established, transitional plan determined, and then both patient and doc proceed for that time period. Regarding meds, if someone is on them at end of year, transition is often to have PCP manage them (if no longer being treated by a psychiatrist), with recommendations as to what to do if this or that, and frequency of monitoring for changes, using something like the M3 ( once a month or so.

This way of doing things could be viewed as a bit selfish for the psychiatrist who does not want to get bogged down by more intractable problems. However, it not only keeps things fresh for the psychiatrist, but may also have some benefits for the patient. For me, I would have no trouble doing it except for those patients who wanted to continue (and I wanted to continue), then I would find it hard to stick to my own "rule".

PsychPractice said...

It's an interesting question. I don't think there's a one-size-fits-all answer. Sometimes patients switch for logistical reasons, like they want someone in-network, or in a more convenient location, or who charges less. Sometimes they want someone with a different philosophical or theoretical perspective. And then sometimes patients doctor-shop to get the meds they want, or simply repeat a lifelong pattern of not committing, and they really need to stay with one doctor and work through the transference. And a-priori, how do you know which it is?

A related problem I have difficulty with goes like this: A non-MD colleague refers a patient to me for med management only. After I've worked with the patient for a while, he or she requests to see me for therapy, as well. As a rule, I ask the patient to discuss the matter with their therapist, and then if they still feel strongly about not working with their therapist anymore, we can discuss working with me, or I can refer them to someone else. It's not a great rule. Sometimes the therapist and I decide jointly that my seeing the patient is for the best-that's happened for a number of complicated reasons-and then there's no ethical conflict. But sometimes I'm arrogant enough to feel like I could do a better job than the current therapist, and then to whom is my ethical obligation, my patient or my colleague? And what about my need to maintain a reputation as someone who doesn't "steal" patients? And what about the patient's right to get what they deem to be the best care?

Joel Hassman, MD said...

As someone who is leaving private practice completely after a year of just painful turnovers, ridiculous expectations, and at times just flagrant meds seeking only issues, did you address the fact that I would guess 10-20% of psychiatrists are just dumping insurance, often at a moment's notice and telling patients almost word for word "get lost" if insisting on staying with insurance?

Also, care to address why colleagues won't reasonably and respectfully share records, if handled by the standards of care per Release of Information documentation?

As I posted recently, you can't do private practice today and take insurance, but, you also can't expect to run a lucrative practice with a cash only patient population.

Obamacare will truly divide those who care, and those who just want to profit. Me, I am fully accepting I am a temp doc the rest of my psychiatric career.

Donna & Chris said...

Interesting conversation! Joel: I take insurance and have a thriving private practice. I like Obamacare since more people can get insurance. I do not take all insurance carriers but can see 60-70% of folks who live in my state. I do meds and therapy -- not meds only (though I have a few folks where I do meds for therapist colleagues or the patient has "graduated" from therapy but still takes meds). I make a fine living.

I started PP two years ago and filled up fast -- I think I am a "good" psychiatrist and I feel as if I am compassionate. I have accepted patients where the previous psychiatrist no longer takes insurance -- records were easy to get -- OR the psychiatrist left PP. I cannot think of anyone who did not like their psychiatrist.

I would not follow Roy's PP style -- fine for him but not me. I have seen some folks for over 16 years (they followed me from my previous HMO). We know each other and they trust me. Yes they can go to their PCP but they seldom get the time, attention and focus that they get from me.

Anyway, I do not want any of my patients to stay if they do not like my practice style but I would hope they would discuss with me prior to leaving. I also understand this can be really hard for someone who may feel intimidated by their doc -- and I hope I do not intimidate my patients!

Joel Hassman, MD said...

In reply to who I assume is Chris in the above most recent comment, I can only say this to providers who claim support of Obamacare, especially for mental health care:

The growing micromanagement by insurers through more authorizations, more challenges for adjunct procedures like psychological testing and intensive services like IOP, and the overt increases in deductibles that now make patients hesitate if not abandon services and interventions, well, I think the nicest and most respectful way to say this, is a disconnect by such providers who embrace Obamacare.

So, congratulations for your thriving practice, I hope that is truly a sincere and genuine appraisal of how your patients see it more so than you.

As for seeing patients for therapy, well, I am intrigued how you pull that off. Let's make sure we are comparing apples to apples, I treated middle class populations, so these were not folks who had disposable cash and more free time to pursue care interventions we were trained to offer. And, therapy for acute care needs is at least q 2week if not more frequent, and for a 45 minute visit. I assume that is what you provide.

As for not thinking of anyone who did not like their psychiatrist, sorry, I am calling you on that one, that is out of touch if not a tad bit disingenuous to make such a sweeping generalization. As I know not every pt has thought full regards of me.

But, appreciate your rebuttal, good luck in your practice pursuits, I know often when I am wrong, I am happy to be so!

Donna & Chris said...


Thanks for taking the time to respond. A few clarifications:

(1) I have never been asked to fill out any forms to provide the care I provide. It may be that I am on the West Coast. East Coast docs seem to have it tougher. I do 60 minute weekly or every-other-week therapy to relatively higher functioning folks (though not all are high functioning and I do some pro bono). All use insurance except the pro bono folks. I do not see many wealthy people and the ones who are wealthy use their insurance. I am truly shocked that I get away with it. It does not matter whether it is a commercial plan or Obama Care -- no one is asking me to prove medical necessity (I think I am doing a good job but I thought the days of psychiatrists getting away with doing therapy were over. Not here -- but I am trying to stay anonymous on this blog just in case.)

(2) I left a16 year career at an HMO -- it paid well. But it sucked the life force out of me. While there, patients did switch from doc to doc but we allowed it as our belief was that the patient was the customer. (I agreed with this, FYI, as I saw no need to have an adversarial relationship. I saw 1000's of patients over those years and was fired 2-3 times a year.) While there, many of the patients expressed displeasure with their shrinks. What I meant to say above: none of the patients coming to my private practice are complaining about their former shrinks. That's all. I KNOW not everyone has loved me ...

Take care,


Unknown said...

Sometimes the transference issues belong to the patient, sometimes they belong to the psychiatrist. My long term psychotherapist referred me to a psychiatrist he felt would be a good match, when my SSRI "pooped out" on me when menopause began in earnest. It went badly from the start. I worked on the conflicts with my therapist (so his issues got in the mix, too!) I was able to articulate with him what my issues were and had good insight into where they came from. I told her that I could not continue to work with her (she got me onto a medication that was starting to help, and I knew my PCP would keep up the med while I was waiting to start a new psych MD), and signed a form so she could release my records. My therapist referred me to someone else, we had a short phone call, more papers signed by me, new MD talked to previous MD and then agreed to take me on. This was always meds only, no talk therapy.
I had the ability to self pay, flexible schedule, and a high GAF (as long as the meds were working). I know these are like holding high cards in the poker game of life.
New MD and I had our struggles too, but worked them out appropriately and I stayed with her til I left the area.
Like much of the healthcare system in our country, sometimes all the parts come together and it works well and the patient improves and the doc has professional compensation and satisfaction...and much of the time that success is in spite of the system's rules and not because of it. From Clairesmum

PseudoKristen said...

I would imagine that there is probably less turnover with patients who see cash pay psychiatrists because those psychiatrists tend to have earned a good reputation or they wouldn't be successful. When I didn't have health insurance and didn't have much of a choice in the psychiatrist I saw, the quality wasn't exactly real high and I didn't stick with the same psychiatrist. There was one who didn't speak English which should be mandatory for a psychiatrist since communication is key to the relationship. There was another one who didn't have any facial expressions which was really weird. She never smiled, never frowned, her face was completely blank which was bizarre and unnerving. Also, a lot of the psychiatrists who work with the poor don't have much experience yet and may not be very good yet. So, I think sometimes you get what you pay for. I've definitely had better luck once I could pay cash for treatment.

PseudoKristen said...

Actually, I meant to say one psychiatrist didn't speak English very well. She did speak some English it was just very difficult for us to understand each other.