Thursday, March 31, 2011

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)

1 comment:

  1. And be sure to get it all done in the 15 minutes you're allotted for each patient!!

    Sorry, couldn't resist.

    Seriously, that's a very good list and something we all must keep in mind, regardless of our approach and regardless of how much time we have with the patient.

    The problem, though, is that it often takes quite a while to determine which facet requires the most attention for a given patient. For instance, some require constant psychoeducation, others have numerous resistant symptoms that deserve attention, while still others have predominant medical features to their illness.

    The good clinician zeros in on what the patient needs and gives it to him/her. I envision a "funnel," in which everything on your list is covered in the first several visits, while long-term treatment focuses on the one or two aspects that are most important for the patient (of course, with periodic checks of the others, too). Unfortunately, with few exceptions, we don't have the luxury of longer appointments at the beginning, followed by brief, less frequent visits later-- which results in the cookie-cutter treatment mentality we currently have.