Thursday, August 16, 2012

Psychiatrists, Light Bulbs, and Bad Medicine

Had it not inspired me to compose a new light-bulb/psychiatrist joke this apparent accusation from David M. Reiss, M.D. on a recent listserv posting that implies I practice "bad medicine" might have offended me: 

"Another (less obvious reason) why the "15 minute med check" that is now the U.S. "standard of practice" is bad medicine. No therapeutic relationship by which to know your patient and communicate effectively on an emotional basis as well as simply providing a few "facts" = increased risks."

Here's the joke:
How many psychiatrists does it take to change a light-bulb? (punchline below)

So a medication management visit that lasts 15 minutes or less is bad medicine? Does that only apply to psychiatrists? What about internists and orthopedic surgeons? There must be a lot of bad medicine out there.

Maybe Dr. Reiss really just wants psychiatrists to provide psychotherapy to every patient on every visit. But what about those non-psychiatrists again? Must the gynecologist do psychotherapy? What about the dermatologist? More bad medicine?

Maybe Dr. Reiss just thinks patients with psychiatric disorders need this extra time. But psychiatric patients need gastroenterologists and ophthalmologists too. Still more bad medicine.

What about knowing your patient? Would Dr. Reiss have us believe that every encounter in which a physician does not "know" the patient constitutes bad medicine? That would probably cover almost every emergency room and urgent care encounter. What's more, I suspect most psychoanalysts would tell us that it takes years to know a patient. Until then, bad medicine? Besides, I would argue that even in intensive long-term psychotherapy the psychotherapist only knows the patient in the context of that artificial setting in the office with no one else around.

Apparently reading my mind, Dr. Reiss jumped the gun, sending me a comment even before I could post this, taking some of the wind out of my sails. He says:

"My argument is not that 15 minute med checks are always "bad medicine", not at all, I believe that it should be a clinical decision how long and how often a pt should come in, not an administrative decision. I would go heavy on 15 minutes being inadequate in the situation that I see advertised all the time - come in as a new doc/locum, take over a case load, but for existing cases, you don't get time to do your own eval or really meet the pt, it's all pre-scheduled at 15 minutes."

Perhaps we agree after all. Even a 30 minute med check may not suffice for a complicated patient, but for a stable patient taking only one medication for a long period of time five minutes may be more than adequate. This is no more true for psychiatric patients than for non-psychiatric patients. Good -- and efficient -- medical practice requires that the physician know which questions to ask in a minimal amount of time. We cannot afford the luxury of truly knowing our patients. Forcing every patient to undergo a 50 minute psychotherapy session whether they need it or want it or not would also constitute bad medicine in my book.

In his "comment" Dr. Reiss addresses two other important problems. He mentions the practice of a new physician jumping in with short follow up visits having not performed a full evaluation. I share his concern. However, one might not be able to accommodate such a thorough evaluation in situations like locums or when covering for another physician at home. As for the prescheduled 15 minutes slot, one can only hope that a no-show or other shorter than scheduled encounter might compensate for a patient who requires extra time. I might add that the old practice of scheduling one patient per hour usually results in less such flexibility of scheduling.

Only one, but the psychiatrist has to know the lightbulb.


  1. And the lightbulb has to WANT to change...

    Perhaps I should add a corollary to my opinion that that 15 minute med checks often make for bad medicine - "140 character statements [on Twitter] make for bad conversations." IMO, there is disagreement here, but not all that much. As explained above, my abbreviated "tweet" certainly was not a comprehensive statement. I have patients for whom I feel very comfortable with 15 minute med checks. I know them, I know their history, they are stable - and if they are having problems or "issues", they know to contact me in advance for a longer sessions. My problem is with 15 minute med checks becoming the "standard of care" wherein anything but a 15-minute med check has to be "justified." I do believe this applies to most specialties. The art of medicine is being lost as we become technicians. When a technical intervention is all that is needed, that is fine and good. But patients are people, and we do not only treat illness and disorder, we treat dis-ease. IMO, many more times than not, the extra time it takes to talk to a patient rather than offering an impersonal "oil change and lube" is well worth it in terms of efficacy of treatment, comfort of the patient and long-term cost efficiency.

    And yes, this is especially true in psychiatry. If an ortho is seeing you for a broken arm, he/she really doesn't need to care if you had a argument with your significant other last night. But as a psychiatrist prescribing medication for anxiety and depression, that information may be crucial in making an informed decision.

    I do believe that most - not all, but most - psychiatric patients should be receiving some type of counseling or psychotherapy. That is NOT to say that everyone requires psychoanalysis or weekly 50-minute psychotherapy sessions. At times, a 10-minute psychodynamically-informed interaction can be extremely useful.

    But IMO, a physician prescribing medications for psychiatric disorders purely on a biochemical basis is a technician - in current parlance, a "prescriber" - but he/she is NOT what a psychiatrist should be and he/she is not providing optimal care.

    To be continued: the imposition of the limit of 15 minute med checks by insurance companies, Utilization Review, facility "policy" etc. - IMO, gross negligence in applying an arbitrary limit that is NOT "evidence based" in the name of the almighty dollar.

  2. Your gripe is really about reimbursement. Nobody will likely remove that patient from your office after 15 minutes. You either resign yourself to getting paid less or charge what you want and tell the payers where to go. Then you justify it only to the patient who has to pay for it. That gets harder when you're dipping into "other people's money."

  3. No. That is NOT a gripe about "reimbursement." In fact, my comment never mentions reimbursement. If you work for a facility that only allows 15 minute med checks, you will have patients "booked" every 15 minutes. You do not have freedom to see people as long as you feel it is medically necessary.

    Look at recruiting advertisements for psychiatrists - the all list how many patients per day are expected going to be seen - usually, 12-15, including new evaluations, and that "day" includes time needed for record keeping, paperwork, meetings, communicating with insurance companies, etc. Your

    comment does not represent the world of medicine as it actually exists.

    Further, what you are suggesting is that insurance companies should be allowed to set arbitrary limits and restrictions, even if they are counter to appropriate treatment standards, and if a doctor wants to provide appropriate treatment, he/she must do it pro bono or charge the patient outside of their insurance, even though they have purchased a policy that is supposed to be providing for appropriate treatment. For MediCaid, MediCare and many patients in PPO's, etc. the doctor is not allowed to charge additionally.

    It is not the doctor's responsibility to provide to provide free care on the order of an insurance company; it is not the responsibility of a person with a health insurance policy to pay over and above what is "covered" simply to obtain appropriate treatment.

    I do provide pro bono care, plenty of it - when and where I believe it is needed and appropriate. It is not up to the insurance companies to dictate to me when to do that, in the name of their profits.

    I am not suggesting "dipping into other people's money", that is a total distortion.

    I am stating that when a patient comes for treatment, they should get appropriate and not "half-baked" treatment.

    What you are supporting is insurance companies, etc. "diping into other people's money", i.e., the doctors' pockets and the policy-holder's pockets.

    May I ask - do you believe it is fine and dandy that you get paid for only a portion of your work? Or where you sell your customer a product, but then tell them afterwards that if they want it to really work, they will have to pay extra? Certainly, my plumber, barber, accountant, attorney, grocery store, etc. do not live it that world - why should I, as a physician or as patient, tolerate such abuse?

  4. If it's not other people's money you want, where does it come from? Why should inscos or the gumment pay me when you will work for free. And how many people reading this conversation will want to become psychiatrists? How will they pay off huge student loans. In this real world if you work for those clinics, contract with insurance companies and treat patients who have Medicaid or Medicare you enable the economics you're ranting about.

    Where will you get the money to pay for better reimbursement? Raise the premiums? That's my money.

    Insurance is a contract. "Should" does not apply. You get what you pay for and agree to. Maybe it will improve under Obamacare. I'm not holding my breath.

    I fired all my Medicare patients ( early this year and will accept no more. I have no contracts with inscos.

    Don't tolerate the abuse. Work only for your patients, and let them fight for reimbursement. It's their insurance.

  5. There is nothing magical about 15 or 30 minutes if you actually know the person and have had enough time to do the original evaluation. The 12-15 patient per day productivity expectation is built on inadequate reimbursement and in many cases inadequate contract negotiations between your employer and a health plan. After all, how will an administrator look good - by getting a lot of contracts that poorly reimburse physicians or a few contracts that allow physicians to see fewer patients due to more adequate reimbursement?

    Dr. Reiss makes a good point about the information exchange during a psychiatrist visit as opposed to a medical or surgical visit. After all a nonpsychiatrist can hand their patient a review of systems checklist in the waiting room and end up charging an E & M code based on that ROS that can be quite hefty for a brief encounter or procedure. A psychiatrist could spend 15 or 30 minutes for a 90862 and end up getting paid the same amount for both exchanges. I think we have all seen physicians and were billed the max (H & P) for a 15 minute encounter.

    So I would not put too much stock in a billing and coding system that was designed to control the physician expenditure side of the Medicare budget and like all things medical - disproportionately penalizes psychiatry. It is not designed for quality. It is after all a product of the government.

  6. To moviedoc: We have no disagreement. I will not be part of a sick system and then piss and moan. I am speaking in support of patients who need good treatment, but no longer have realistic access to good treatment.

    Myself - I no longer accept MediCare, Medi-Cal or CA workers comp because I refuse to have the choice of being abused, being co-dependent to an abusive system, or providing substandard care. In fact, I no longer accept any private insurance.

    But this is not how the system should be, where decent doctors who want to provide good care - and are not just looking for "the highest buck" are driven out of the system. I would accept - and I do accept, on a private basis - significantly reduced fees, to be able to provide good care in a direct contract with the patient.

    I also agree that an insurance contract is a contract, not something to be debated on an ethical basis - but I have seen contracts that cover "appropriate treatment" but then UR denies appropriate treatment. Before I left the system, I had prescriptions denied authorization based on a "cherry picking" of literature that was completely illogical, irrational, and focused only on the primary diagnosis, ignoring secondary diagnoses or any consideration of complicating Axis II pathology.

    The only "should" is that the company "should not" be in breach of contract.

    I also agree that perhaps this will improve with Obamacare, but with you, IMO, all bets are off and no breath is being held.

    Dr. Dawson: Well said.

  7. Yes, I forgot workers's comp, which like other payers, can, by law, decide years later that they paid you by mistake, so please return our money or we'll deduct it from your other patients.

    The problem with bad UR and breach of contract may still be ERISA which protected payers from litigation, at least to a degree.

    We need a new system, possibly even single payer. Look into,,, or if you are not a joiner use

  8. Yes. Anthem wrote me that they "miscalculated" the deductible - on a patient who had moved out of state six months previously. They deducted $500 from their next payment to me, for other patients. I had no way to contact or collect from the patient (even if the patient could have afforded it). Anthem's mistake; my financial responsibility. I immediately withdrew from being an Anthem provider (which was the last insurance list I was on).

  9. This article in today's NYT reinforces my belief that this is not just a problem for psychiatrists or psychiatric patients:

  10. Sometimes, as a psych patient, the whole 15 minute med check thing makes me feel like I'm in the Hunger Games. Everyone in the Hunger Games are put into this insane situation where they have to fight to the death in the Games. Why do they have to do this? Because it was manufactured this way by the Capital. There is no earthly reason why it has to be like that. It is all manufactured by greedy people who don't give a crap.

    And that's what psychiatry feels like to me sometimes. I feel like they stole my childhood by putting me and all these other kids in the psych patient version of the Hunger Games. They threw EVERY single med at us under the sun. Only instead of us battling to kill each other, we were battling the drugs and fighting to stay alive through discontinuation syndromes and severe psychological changes. Antipsychotics, stimulants, mood stabilizer, antidepressants, never interviewed us (just our parents/caregivers), and then sent us back out to deal with our demons. And if I ever complained about how the drugs made me feel suicidal or bad it was considered a behavior problem and I was expected to fight against the effects of the drugs. I was threatened and bullied by docs and sometimes I want to kill myself when I think of it.

    I took a hiatus for several years when I became an adult, before I put myself back into the Games. They were good years off the drugs, even though I spent them on disability. But then I wanted to work, and the vocational rehabilitation people looked very suspicious of the fact that I wasn't on meds. And oh dear....this past 6 months...the mood changes, severe health problems...I can't believe i went back to psychiatry...the Games continue for me.

    I really don't think it needs to be that bad. I've been mentally disabled since 11 years old and have had every diagnosis under the sun. Panic Disorder, ADHD, BD, MDD. And I wonder if they had ever interviewed me it might have been different? If they hadn't spoken to my Dad, prescribed the meds, and expected me to fight in their Games? Or maybe not. My last pdoc who put me through hell on stimulants and strattera thought i have ADHD. This new one is thinking the bipolar route. Two different diagnoses and they both interviewed me. No clue what that means.

    My 20s so far have been so much better than my teen years...unless you count this hiccup of me going back to psychiatry for another round of psychiatric hunger games i volunteered for. And that is really what the 15 minute med checks are for poor psych patients on disbility. They are just prep time to put you through another Game they follow you through.

    The care for the sickest of psych patients is terrible.

  11. Just to play reason's advocate, with the first analogy Dr Weiss presented:

    "And yes, this is especially true in psychiatry. If an ortho is seeing you for a broken arm, he/she really doesn't need to care if you had a argument with your significant other last night."

    What if that's how your arm got broken? . . .

    1. Keep going Jake. I doubt the orthopod will handle the fracture any differently. I suspect most would ask, but how do you think things might proceed whether the arm was broken in a fight, jumping off the roof, skydiving, or playing baseball? My guess is the patient will be told to be more careful.