Thursday, April 21, 2011

The Good Med Check IV: Getting Physical

(Continued from The Good Med Check III: Time Is Money)

Critics of the med check often equate the abandonment of psychotherapy by psychiatrists with tragic abandonment of the biopsychosocial model, viewing psychotherapy as a necessary ingredient of every patient encounter (if only for psychiatric patients). You might think they were invoking the bio-psychotherapy-social model. But in fact when psychotherapy in the form of psychoanalysis stuck it's foot in the psychiatric door a hundred years ago was it not the "bio" that was abandoned? Back then  few drugs competed with non-"biological" treatment modalities, but as the model of psychiatrist as psychotherapist (or just "therapist") evolved psychoanalysts pronounced the physical examination, so long an integral part of patient-physician encounters, incompatible with analysis, and eventually any psychotherapy, citing potential boundary violation: talk, but don't touch. (Thankfully, we do not hear protests that psychotherapy should accompany electro convulsive therapy.)

To be sure physicians of many specialties have abandoned the physical exam in favor of laboratory tests and imaging studies. If your non-psychiatrist physician lays hands on you at all, she will likely limit or direct the examination to only that which relates directly to your complaint or diagnosis. Admittedly, at least at first look, few aspects of the physical (other than the mental status exam) seem directly related to psychiatric complaints or disorders, unless the psychiatrist assumes the role, as some do, of primary care provider. But a psychiatrists probably could do a better job by attending to a few physical findings, whether part of a med check or a psychotherapy session. A few examples follow:
  • Monitoring blood pressure in patients taking venlafaxine, and some other drugs
  • Weighing eating disorder patients or patients taking drugs that affect weight
  • Pupil diameter when you suspect unadmitted drug use
  • Examination for cogwheel rigidity in patients taking dopamine antagonists
  • Neurological examination to rule out neurological causes for psychosis or conversion
One could argue that the psychiatrist needs to "see" the patient more than the patient needs to see the psychiatrist. In some ways physical examination of a psychiatric patient stands at the opposite end of the spectrum of clinical tasks from psychotherapy, but it is at least as legitimate.


  1. I absolutely agree that not every patient who needs meds needs psychotherapy, and certainly not every patient who needs psychotherapy needs meds, but that some patients need both.

    In the latter case, although "split treatment" may not be ideal, it is certainly workable. It's only when one or the other consideration is completely ignored, which has often become the case with both psychiatrists and psychologists, that the patient is being short changed.

    We should all have the opportunity to practice what we like to practice and what we are competent in, without insurance companies telling us that psychiatrist can't do psychotherapy if they so choose.

    If a psychiatrist keeps up on physical exam skills, they should do that too, although I personally would not let a psychiatrist do a physical exam on me since most of them are not as good at it as primary care docs and other specialists unless they just finished training.

  2. We mostly agree, David. But I would have no problem with letting an older psychiatrist perform a physical exam on me. I just wouldn't trust their assessment. And it might be entertaining.

  3. I feel if your a psychiatrist you have a duty to all paitents to conduct a complete physical exam and treat medical issuse as they arise. You have to be a doctor first and psychiatrist second thats why when I get to medical school and then even in residency I will always do physical exams no matter what not only because its necessary but I need to establish my role as a doctor and stay up on treating things seen in primary care medicine and the like because at the end of the say I will be prescribing powerful meds to a paitent who may have an underlying medical condition and If I depend on a paitents honesty more sop then my very own medical judgement I could make things much worse by ignoring a physical exam