The Good Med Check I: Checking the Med

The much maligned "psychiatric medication management" visit, sans psychotherapy, pejoratively labeled the "med check," has become standard for many if not most psychiatrists. Contrary to the mantra, everyone does not need psychotherapy, but all med management encounters are not created equal. My concept of the elements of a good, even great, and comprehensive, med check follows. Don't expect to cover every one of these on every visit. Feel free to suggest additions to the list:

• Inventory of target symptoms and behaviors
• Assessment of success or failure of treatments
• Discussion of dose adjustments and adding or removing medications
• Monitoring of substance use emergence or relapse and use of recovery tools such as 12 step groups and sponsors
• Reassessment of working diagnosis and safety
• Review of status of psychotherapy or other treatments provided by other professionals
• Inventory and management of side effects
• Prior and emerging medical problems
• Review of medications for other conditions started since last visit and potential interactions
• Overall assessment of treatment status
• Review of long term goals and plans
• Education about the illness and its treatment
• Education about new related developments and treatment alternatives
• Referral to other services or professionals
• Laboratory and other tests: drug screen, medication levels, thyroid, liver function, renal function, imaging
• Administrative matters such as reimbursement, refills, appointments, changes in practice policies and procedures
• There's no law against throwing in one or two brief and carefully selected psychotherapy interventions, especially CBT or systemic
• Getting to know the patient (next post)

How many of these items might we apply to almost any patient-physician encounter, not just psychiatric, even perhaps including the psychotherapy interventions?

(Continued in The Good Med Check II: Getting to Know You)

"Self Abuse" Redefined

Consider "child abuse": Who gets hurt? The child.

Now consider "Drug abuse." Who gets hurt? The drug? Hardly.

One who "abuses drugs" hurts oneself.

"Self abuse."

I propose we abandon the old use of the term. Who uses it that way anymore anyway? The light bulb flashed on in my head as I became embroiled in yet another dispute over the notion of "self medication," once more misapplied to an individual using drugs and alcohol in the context of another separate (presumed) psychiatric disorder.

As in most such cases the drugs and alcohol more likely hurt rather than help the patient, as I argued in my earlier post: A Working Definition for Self Medication

So when you hear or see the term self medication in the future think self abuse and see if it doesn't lead to more accurate conceptualization of the case.

Sleeping for Fun and Profit

The recent New York Times article describing the psycho pharmacotherapy practice of Pennsylvania psychiatrist Donald Levin, M.D. garnered considerable negative attention from the psychiatric blogosphere, mostly from advocates of psychotherapy and detractors of psycho pharmacotherapy. Desperate to garner support for what I call sporkiatry, the practice of combining psychiatric medical treatment with psychotherapy (sporkology when performed by psychologists with prescribing privileges), they all seem to have ignored an article published in New York Times Magazine only a few days prior in which the author describes his multiple experiences of psychoanalysts falling asleep during his sessions.

Although I cannot recall ever having fallen asleep myself during a psychotherapy session I came close on a few occasions, and I know that the problem is not peculiar to psychoanalysts. However, regardless of how you feel about Dr. Levin's short patient encounters, I would be surprised to hear that he ever fell asleep during one of them, regardless of how "boring" (Danny Carlat's suggestion) or "unfulfilling" he may find medication management. (If you know of a psychiatrist who fell asleep while administering electroconvulsive therapy or transcranial magnetic stimulation, please report below.)

Blogger Carlat places more importance on the psychiatrist's job satisfaction than on what best serves the patient: "doing therapy is fun--it's involves getting paid for having interesting and intimate conversations with people." Or interesting dreams?

Blogger Steven Balt accuses Levin of "selfishness." [correction: Dr. Balt in his comment points out that the article, not Dr Balt himself, accuses Levin of selfishness.] Is Dr. Levin selfish to sacrifice the "fun" of psychotherapy? Balt still seems to think it's all about the session: feeling good about what goes on during the 50' hour rather than relief from symptoms outside the psychiatrist's office. Or maybe it's whether the psychiatrist reaches REM sleep.

According to blogger 1 Boring Old Man, "Days like Dr. Levin describes change you into a machine, and you become kind of brain dead." Might this result from sleep deprivation?

In contrast blogger Reidbord at least understands the proper purpose of psychotherapy:  "I’m a huge advocate of psychotherapy, yet I don’t recommend, much less provide, it for everyone.  It’s a treatment..."

It is not so much that these (we?) fallible professionals fell asleep in the course of their (our) work, but as the author points out, at least one psychoanalyst writing in a professional paper appeared to blame the patient. And it took the author's mother to raise the question of whether he might not have needed psychotherapy to begin with, underscoring the fact that almost no professional providing psychotherapy will likely tell the patient after the first interview, "Get outta here. You don't need treatment."

Everyone makes compromises and mistakes, and there is no perfect psychiatrist or psychotherapist, but I'll take a Dr. Levin, awake, alert and responsive, over a somnolent psychoanalyst any day.

How $MUCH.00 for the Psychiatrist?

Pennsylvania psychiatrist Levin sounds like he's working very hard to make money for retirement (Talk Isn't as Cheap as Drugs), but is he making too much? How much should I psychiatrist make? Yearly? Weekly? Hourly? Remember even a newly minted board eligible psychiatrist has completed four years of college, four years of medical school, and a four year residency.

Keep in mind what attorneys charge per hour, automobile mechanics, accountants and neurosurgeons. Physical therapists. Chiropracters.

Psychotherapy or medication management.

Also, include overhead: vacation, sick leave, malpractice insurance, office staff, office rent, furnishing and maintenance, continuing education, telephone and information technology.

What's it worth to you?

Now think about insurance. How much would you be willing to have your monthly health insurance premium go up to pay for psychiatrists to do unlimited psychotherapy. Four days a week, five or more years. Not just you paying higher premiums. Everyone.

What am I worth as a "therapist" and as a physician? How much?

Talk Isn't as Cheap as Drugs

This article in today's NY Times has generated considerable discussion.

Here's my take:

• 39 patients in a day: too many for me
• Dr. Levin has a right to practice as he chooses
• Dr. Levin's wife's role counts. She's appears to do things many psychiatrists would incorporate into their own roles. This makes the 39 patient count more reasonable.
• Dr. Levin must be doing something right to attract so many patients.
• Dr. Levin may be a lot better at psychopharmacotherapy now that he is doing so much of it.
• Dr. Levin needs to get a... blog. Or maybe tweets would suit his practice better.
• Sometimes 15' is more than enough time.
• Sometimes 50' is not enough time.
• Dr. Levin should have told his drinking patient to stop, if only because of potential interaction with prescribed drugs, and recommended appropriate help if needed. He could even have prescribed a drug to help him stop drinking.
• Many patients just don't want psychotherapy and shouldn't be forced into it.

It's not all about the money:

• Dr. Levin's patients get to choose their psychotherapist. They are not stuck with him.
• Dr. Levin's patients can get the type of psychotherapy best suited to their diagnosis, not just the kind that he happens to practice.
• Dr. Levin's patients don't have to get psychotherapy at all unless they want it.
• Dr. Levin's patients get to start and stop psychotherapy independently of medication.
• Dr. Levin's patients get to start and stop medication independently of psychotherapy.

My related posts:

• The Real Reasons Psychiatrists Want to Provide Psychotherapy
• Who Wants to Be a Sporkiatrist?
• The Sporkiatrist Tries to Do Psychotherapy