Thursday, October 28, 2010

Who's the Doctor?

In my post Independent Treatment: The Whole Truth I believe I made it clear that I like the idea of independent providers for treatment of psychiatric disorders, a psychiatrist to prescribe medication, rTMS, ECT or whatever, and a non-physician psychotherapist to provide psychotherapy. I believe we can overcome the challenges posed, one of which arises when the psychotherapist advises the patient about medication.

I admit to irritation when my patient tells me her psychotherapist told her she should ask me about lamotrigine, or her chemical dependency counselor told her the acamprosate I prescribed for alcoholism really misses the mark for her particular drinking pattern. But I also must admit to considerably greater irritation when I have never worked with the psychotherapist before. If I know the psychotherapist and am familiar with his work, it just doesn't bother me as much.

Several key facts impact these situations. Psychotherapists may not be qualified to recommend or prescribe medications, but every now and then one of them has an idea that works, and I cannot claim to be perfect in my knowledge of psycho-pharmacology. Bottom line, if the patient gets better I'm glad for the help. Psychotherapists often express surprise that I, a physician, bother to contact them to coordinate treatment. This model does not require weekly or even monthly email or phone contact between psychiatrist and psychotherapist, but, especially when the two professionals do not know each other, either should initiate contact with the other on learning of the other's involvement in the case, and each should always respond promptly to attempts to contact the other. Without such open communication you cannot provide the best care to your patient.

Still, I wonder how a patient feels when his psychotherapist suggest, "Ask Moviedoc about clonazepam." I imagine my patient must wonder what's wrong with me if I didn't think of that, or what's wrong with the psychotherapist when I tell the patient what a horrible choice that would be and why. I believe we would all do better if the psychotherapist contacted me directly with the suggestion or question. I would also like to think I might not be too proud to give the psychotherapist credit for the idea if I endorse it and bring it up with the patient.

Usually such discussions between myself and the psychotherapist extend beyond a simple suggestion of a drug and thus likely lead to better treatment overall. Sometimes what's behind the suggestion of a drug is a symptom of which I was not aware, either because the patient didn't tell me, or because I didn't ask.

The independent practitioner model works, but we must do it right by working as a team. If you're a psychiatrist, always respond promptly when the psychotherapist tries to reach you about a patient. If you're a non-physician psychotherapist, consider contacting the physician directly about your idea of that medication you think might help the patient before you mention it to the patient. And if you don't get a response, consider suggesting the patient find another psychiatrist.

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