Delaying Sessions

[vistaril]

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In order for me to spend more time with patients I would have to drop some of them. If I spent a half hour with each patient, I would not get home that evening.

I do see your point. However, the patients that are very very chatty have productive sessions with their therapists. I speak with their therapists. Some of these patients are doing so well that they see me every two to three months; they don't need to come every month unless something comes up. When I say chatty I mean they are wanting to discuss their favorite sports team or their favorite type of animal. In one case, I had a woman that was fascinated over the fact that her PCP is no longer in partnership with another physician because they did not work well together. She spent a great deal of time talking about it. The session ended up being 30 minutes long. Admittedly it was interesting because I knew one of the doctors. But, I think you know what I mean.

1) Yes, you would have to drop some of them. Considering that many are 'doing well' and are probably on relatively straightforward psychopharm, you probably should drop them. Just send a note to their pcp telling what meds to continue.

2) For these patients that are doing well and you insist on continuing to see, why does it matter if they want to ramble on about their favorite sports team? That is probably a therapeutic improvement, to be honest, over you trying to ram sigecaps or whatever down their throat in a pt you already know is doing well.

Look, you like your model now(very brief med checks on mostly stable patients) because it's easy, straightforward, doesn't require a lot of prep, and pays decently. There is *nothing* wrong with admitting that. But don't hide your true motivation behind some "this helps pts because I can see so more" bull****.

When I did this sort of work moonlighting in a cmhc type place, I went in accepting that the patients most definitely DID NOT share my gIf you continue to do this sort of work, you're going to have to come to the same acceptance.

 

[Jester25]

Some of the comments did seem unnecessarily aggressive towards EEG. Like others have mentioned, 15 min med checks is a very common practice now and I think while we all agree 30 min would be better for both the patient and psychiatrist, there is a demand that is not met if every psychiatrist spends 30 min with a patient. So in some respects, he is doing a service to the community by seeing patients that might otherwise have to wait months to see a psychiatrist.

That being said, I don't do 15 min appointments so take my advice with a grain of salt. My appointments are set up for 30 min followups, but even in those appointments patients can get very tangential and/or circumstantial. Like Fonzie said, most of the patients I have who do this are still unstable usually for Bipolar or ADHD. In those cases, I basically get what I need without a "checklist of symptoms" therefore I don't need to necessarily ask them about pressured speech or racing thoughts or difficulty with concentration etc, I know they aren't stabilized so I can continue with up titration of the medication if have had some response.

In patients that small talk and are stable, I would do non-verbal cues to end the session. For example, if someone is going on and on about a football game, you can interject and say whatever you want to say about the football game and slowly get up from your seat which gives the patient the cue that the session is over. I have a receptionist for my moonlighting gig who calls me every 30 min when the next patient arrives. I use that to end sessions as well since this again gives the patient the cue that the session is over. I'm not sure if you have a receptionist or not.

You can also provided a "roadmap" for the type of care you are going to give at the end of the initial intake. Basically saying you will manage the medications and be in touch with their therapist now and again to coordinate care stressing that in the follow up appointments you are specifically looking to see how they are responding to the medications both with positive/ negative results and side effects.

I have had patients, specifically at the VA, ask me for checklist of symptoms to assess for PTSD. I told them, I am a psychiatrist, I don't do checklist, I try to engage with the patient to know what is troubling them and go from there. In a 15 min appointment, I feel you need to practice checklist psychiatry, and since it's your side job and you are comfortable doing it, I don't see what's wrong with practicing this way, especially if you and the patient are on the same page in terms of the expectations during the appointment.

I should also highlight that I have had numerous patients tell me that I was the first psychiatrist who talked to them and spent time with psychoeducation both about their illness and the medications they are on. I believe I have a strong therapeutic alliance with my patients due to "small talk" that really isn't small talk to them. These patients said their prior psychiatrists would give them meds only and not engage with them.

 

[Jester25]

As far as typing vs. writing vs. listening, here are my thoughts:

I have done both and I don't see a difference in typing vs. writing. Both can be distracting and disruptive so I don't think one is superior to the other.

What I find myself doing is typing while talking for some parts since I can keep eye contact better with typing than writing. However, if it is a complex case/ emotion filled appointment, I would often just write a list of 1-4 words to jog my memory and then type the note up after the patient leaves.

Ex:

CC: "things are worse"

HPI:

mom hospital
dog died
girlfriend
failed test
hopeless

I can then use those key words to write 4-5 sentences.


Even when I type, I always type up the A/P portion after the patient leaves the room. I have had rare cases when I needed to do 15 min med checks and in those appointments, I didn't need to type. I would spend 10 min with the patient and write a note in 5 minutes after they left. I think it would be more efficient to do it that way rather than spending 15 min typing and talking.

 

[splik]

As far as typing vs. writing vs. listening, here are my thoughts:

I have done both and I don't see a difference in typing vs. writing. Both can be distracting and disruptive so I don't think one is superior to the other.

there's a world of difference. i do neither but in the US patients like their doctors to make notes because they think it means you're listening to them. they don't like it when youre typing away (especially if you can't look at them at the same time that most people can't do) because they think it means you're not listening. and it probably does. most psychiatrists are too old to be able to do both, and almost no one can multitask, and no one can multitask as well as they think they can. i feel writing notes gets in the way but i've actually had patients ask why i wasn't!

 

[Jester25]

there's a world of difference. i do neither but in the US patients like their doctors to make notes because they think it means you're listening to them. they don't like it when youre typing away (especially if you can't look at them at the same time that most people can't do) because they think it means you're not listening. and it probably does. most psychiatrists are too old to be able to do both, and almost no one can multitask, and no one can multitask as well as they think they can. i feel writing notes gets in the way but i've actually had patients ask why i wasn't!

I've found for the same reason they think it means something when you write, it means something when you type. My notes convey 3 things. 1) What I need to know. 2) What an outside clinician needs to know if they read my note. 3) What billing needs to know. So when I type something, it is usually important.


Also, since I am obviously young to this field, it seems most of my patients are used to their clinicians typing whether psychiatry or not. Not why prefer typing, but just noting it has been commonplace in patients' minds. When I type, I'm looking straight ahead to the patient with the laptop in front of me so it's easy to make eye contact. I also find that after something meaningful has been said and I pause to type, it provides a space for the patient to add something to that. Whereas, if I was neither writing or typing, I might not be as good at providing that time which I think is important (and am continuing to work on…)

 

[PA-CtoMD]

I think it is a good idea to drop one of the jobs, although it is ultimately your decision. Having a large med management part-time practice while doing inpatient full-time is a receipe for burnout. In my case, I got burnt out trying to do all of that and more. I am doing everything from full-time inpatient with ECT on weekdays, and inpatient also on some weekends without ECT, inpatient job also requires on call from home for admissions, outpatient 15-20 minute med management (many suboxone patients) on week day afternoons til night, and I am also available online once in awhile.

I am going to hire other doctors to work in my practice. If this doesn't work out, I am going to hire a Physician Assistant or Nurse Practitioner.

It may be a good idea to drop one of them. You don't want to get burnt out like I did.

 

[digitlnoize]

1. I tell patients ahead of time that I'm going to take notes/type and why...because I don't want to forget or misremember something. Human memory is notoriously fallible, no matter how good we doctors think we are, and we are more likely to misremember something a patient said than not.

2. Regarding Vistaril's comment that you don't have to ask questions like an OSCE and you won't lose points for not asking: Not true. Insurance companies like to see their bullet points just as much as the OSCE examiners. If you're not documenting a thorough MSE or HPI good luck getting your appropriate level of billing.

3. I do think 15 is too fast in most cases. It could be done with a large office, a really good EMR, and the right policies/procedures, but most places do it poorly. From what I've seen though, more people seem to be moving to 30 min visits due to new billing changes.

 

[EEGNeurofeedback]

1. I tell patients ahead of time that I'm going to take notes/type and why...because I don't want to forget or misremember something. Human memory is notoriously fallible, no matter how good we doctors think we are, and we are more likely to misremember something a patient said than not.

2. Regarding Vistaril's comment that you don't have to ask questions like an OSCE and you won't lose points for not asking: Not true. Insurance companies like to see their bullet points just as much as the OSCE examiners. If you're not documenting a thorough MSE or HPI good luck getting your appropriate level of billing.

3. I do think 15 is too fast in most cases. It could be done with a large office, a really good EMR, and the right policies/procedures, but most places do it poorly. From what I've seen though, more people seem to be moving to 30 min visits due to new billing changes.

2. Yes, this is why I ask those questions.
3. In my area, 15 minutes is almost the norm.

 

[EEGNeurofeedback]

1) Yes, you would have to drop some of them. Considering that many are 'doing well' and are probably on relatively straightforward psychopharm, you probably should drop them. Just send a note to their pcp telling what meds to continue.

2) For these patients that are doing well and you insist on continuing to see, why does it matter if they want to ramble on about their favorite sports team? That is probably a therapeutic improvement, to be honest, over you trying to ram sigecaps or whatever down their throat in a pt you already know is doing well.

Look, you like your model now(very brief med checks on mostly stable patients) because it's easy, straightforward, doesn't require a lot of prep, and pays decently. There is *nothing* wrong with admitting that. But don't hide your true motivation behind some "this helps pts because I can see so more" bull****.

When I did this sort of work moonlighting in a cmhc type place, I went in accepting that the patients most definitely DID NOT share my gIf you continue to do this sort of work, you're going to have to come to the same acceptance.

Not all PCPs are willing to prescribe psych meds, even if a patient is stabilized.

 

[erg923]

I would gently remind folks that there are many practices in medicine that have become rather common place (norm) that most outside the profession view as sloppy, lazy, or both. While 15 minutes is enough to "get the job done" in some of these cases, I'm sure all of you realize that it’s the gradual eroding away of time and relationship with the patient that has made psychiatry’s reputation so poor, both in the medical community and with MH patients. The most common complaint, as someone else pointed out, is indeed something on the order of: "My psychiatrist never really listens to me; "he just Rx meds;" "they never talk to me." No one can sit here and tell me the evolution of the 15 minute med check hasn't had a role in the forming of those perceptions. Can you?

Its crystal clear that the practice of "15 minute med checks" is about volume and reimbursement. So, I suppose it’s by product IS an improvement of the MH access issue, but as V said, let’s cut the bull**** folks. You aren't doing 15 med checks for altruistic reasons, and most likely, aren’t doing them to maximize patient benefit either.

 

[Jester25]

1. I tell patients ahead of time that I'm going to take notes/type and why...because I don't want to forget or misremember something. Human memory is notoriously fallible, no matter how good we doctors think we are, and we are more likely to misremember something a patient said than not.

2. Regarding Vistaril's comment that you don't have to ask questions like an OSCE and you won't lose points for not asking: Not true. Insurance companies like to see their bullet points just as much as the OSCE examiners. If you're not documenting a thorough MSE or HPI good luck getting your appropriate level of billing.

3. I do think 15 is too fast in most cases. It could be done with a large office, a really good EMR, and the right policies/procedures, but most places do it poorly. From what I've seen though, more people seem to be moving to 30 min visits due to new billing changes.

I am going to have to agree with this. I tried to do the no note taking thing initially and found while I was better "in-tune" with the patient/ the appointments had a better flow to them, my notes were drastically worse. I'm sure it's a personal choice for everyone, but I have been able to reach a middle ground where I can take type, have good rapport with the patient, and still write great notes and bill 90% of them as 99214s.

EEG you can look at it this way. If you spend 20min coding at 99214s at $85, you will be making more money than spending 15min coding at 99213s at $55. That's an extra $35 per hour plus you get the extra 5 minutes with the patient/ better therapeutic relationship. You won't even have to do therapy. If you want to switch to a 30min model and do therapy, you can bill 99214 + 90832 and make more money seeing 2 patients per hour than 4 patients per hour. Those that don't need the 30 min/ don't make you feel rushed, you can keep them at 15 min med check appointments.

As far as erg's comment. That is not what made psychiatry's reputation poor, but it certainly has not helped it.

 

[vistaril]

I'm sure all of you realize that it’s the gradual eroding away of time and relationship with the patient that has made psychiatry’s reputation so poor, both in the medical community and with MH patients.

bingo.....the only way psychiatry is going to be respected, both by people in and outside of medicine, is if we start delivering patient centered care. quick med checks aren't going to accomplish that. I would also argue that neither are these boutique cash practices that everyone in here is in love with.....simply because they provide access to such a small % of the population.

 

[vistaril]

If you spend 20min coding at 99214s at $85, you will be making more money than spending 15min coding at 99213s at $55.

this shows a partial lack of understanding of coding. You can't simply say "I'm going to spend x amount of time with patients and because I spend x time with them code them at y instead of z".

 

[vistaril]

2. Regarding Vistaril's comment that you don't have to ask questions like an OSCE and you won't lose points for not asking: Not true. Insurance companies like to see their bullet points just as much as the OSCE examiners.

you can document enough symptoms in the context of an actual real conversation to meet this standard. If you can't, you need to improve your clinical skills.

 

[Jester25]

this shows a partial lack of understanding of coding. You can't simply say "I'm going to spend x amount of time with patients and because I spend x time with them code them at y instead of z".

As I have stated in other posts, most patients fit criteria for 99214. If you don't see that, you show a partial lack of understanding of coding. The extra time affords you the ability to document properly for the visit. Too many clinicians are undercoding especially if they feel rushed.

 

[Jester25]

bingo.....the only way psychiatry is going to be respected, both by people in and outside of medicine, is if we start delivering patient centered care. quick med checks aren't going to accomplish that. I would also argue that neither are these boutique cash practices that everyone in here is in love with.....simply because they provide access to such a small % of the population.

Again disagree. If the small population you do treat is getting excellent care, then it is good for the field of psychiatry.

 

[erg923]

Do patients percieve 15 minute meds checks as "excellect care" though? In many cases, based on the most common complaints about modern psychiatric practice, apparently they don't.

 

[Jester25]

Do patients percieve 15 minute meds checks as "excellect care" though? In many cases, based on the most common complaints about modern psychiatric practice, apparently they don't.

No, that was in response to Vistaril's statement that boutique cash practices are also bad for psychiatry because they provide access to only a small % of the population. Cash practices don't do 15 min appointments.

 

[erg923]

oh ok

 

[EEGNeurofeedback]

For me, I find that my notes are better when I write or type during the visit. I do make eye contact and respond briefly to what the patient says. As far as time goes, my receptionist schedules patients for a 15 minute block although, many of the sessions run till 20 minutes. With a couple of complex patients, it runs a little over 20 minutes. I don't find 20 minutes to be much different than 15. It is still a short and rushed visit.

 

[erg923]

If any part of my appt with a patient is compromised, I would always prefer that it be my note rather than my interaction with the patient. The note can be fixed easier than rapport, in most cases. I dont know whether this is a personal thing or just a drastically different training model?

 

[nitemagi]

Contrary to standard discussions, I agree with Erg on most points here.

At this point in your career, wherever you are, ask yourself -- why did I choose this field? Is this practice you're creating in line with that? Is it sustainable for your satisfaction into the future?

15 minute med visits have become the standard because we choose to make that the standard. Every provider who bucks the trend and does something different starts to bend the average in a different direction, towards a higher level of care IMO.

Furthermore, in line with articles that came out a while ago on "psychodynamic psychopharmacology," there are always therapeutic dynamics taking place, even in 15 minute appointments, and this may actually impact whether your patient gets better, sticks with you, and even their compliance on medications.

See above quote.

 

[whopper]

When I did private practice (and I still do outpatient in the university that is similar), I simply told patients that the way the insurance company has set this up, I have limited time to deal with patients. This was not out of choice and I fully acknowledged that spending more time would be preferable. I also did things such as if the next patient didn't show up, I'd give the patient before some extra time if needed. I also mentioned to the patient if they needed psychotherapy, we could set them up with a psychotherapist.

But I do agree with Nitemagi. I only lowered the time to medchecks when the patient was signicantly better to the degree where I didn't think there was much more to do other than medchecks. I usually spent a lot more time with newer patients. Eventually when they were stabilzied, that's when we lowered their time to 15 minutes.

Erg's been on this forum for years and as far as I remember his posts have been appropriate. As for psychologists, there's plenty of things they get trained in that we psychiatrists don't and if we exploit our differences, we can complement each other well.

 

[hamstergang]

Is that really your standard for determining whether your practice habits are offensive or not? Are you suggesting that, given the power differential that exists in that relationship, the onus is on the patient to "speak up" and let you know that he has a problem with what your doing?

No, there are multiple factors to take into account. I asked my patient so that I could have more data to consider. I have no idea why you'd respond to that in a negative tone.

 

[notdeadyet]

When I did private practice (and I still do outpatient in the university that is similar), I simply told patients that the way the insurance company has set this up, I have limited time to deal with patients. This was not out of choice and I fully acknowledged that spending more time would be preferable.

Except this isn't true. Insurance companies do not control how long our appointments are. Their reimbursements may change our practice management, but it IS volitional. Telling patients that you can not have more time with them because the insurance companies have direct control isn't correct.

The truth would be to say that due to changes made a while back in reimbursement, it is more profitable for me to see more patients via shorter visits. It definitely doesn't convey the "we're all in this together because of the big bad insurance companies," but at the end of the day it's more honest.

 

[Jester25]

If any part of my appt with a patient is compromised, I would always prefer that it be my note rather than my interaction with the patient. The note can be fixed easier than rapport, in most cases. I dont know whether this is a personal thing or just a drastically different training model?

Again, it needs to be a balance of what is optimal care and what is efficient. If optimal care is giving each patient 1 hour appointments and recording the session and then going back and using that to type my note, I am not going to do that. It would be highly inefficient.

Maybe it is a training model I don't know, but efficiency has been ingrained in me since 3rd year of medical school. How can I deliver the best efficient care possible. To me, that is 30 min appointments with typing, to others it might be something different.

It is also important to note that an overwhelmed psychiatrist also compromises optimal patient care. I rather work 8-5 and type my notes and deliver the kind of care I am and still have time to go to the gym, hang with friends, and sleep well than work 8-5, write notes 5-8, and have less time for myself. Everyone has to find their own balance.

 

[notdeadyet]

But I do agree with Nitemagi. I only lowered the time to medchecks when the patient was signicantly better to the degree where I didn't think there was much more to do other than medchecks. I usually spent a lot more time with newer patients. Eventually when they were stabilzied, that's when we lowered their time to 15 minutes.

I'm curious if folks every find themselves torn when this happens. In my limited experience, I've found that when folks reach the stage that I can manage them with 15 minute med checks, it's about the time that many of them can be managed by their PMD.

 

[erg923]

Again, it needs to be a balance of what is optimal care and what is efficient. If optimal care is giving each patient 1 hour appointments and recording the session and then going back and using that to type my note, I am not going to do that. It would be highly inefficient.

Maybe it is a training model I don't know, but efficiency has been ingrained in me since 3rd year of medical school. How can I deliver the best efficient care possible. To me, that is 30 min appointments with typing, to others it might be something different.

It is also important to note that an overwhelmed psychiatrist also compromises optimal patient care. I rather work 8-5 and type my notes and deliver the kind of care I am and still have time to go to the gym, hang with friends, and sleep well than work 8-5, write notes 5-8, and have less time for myself. Everyone has to find their own balance.

While the focus on efficiency is nice....should that be your primary concern/job? If we think of it in terms of priorities, I would imagine patient care/attentiveness/engagement while they are in the room with you takes precedent. I will never be able to swallow the notion that documenting what you're doing is MORE important than what you are actually doing. A contact note easily takes an addendum if you make a mistake. Humans, not so much.

The overarching point was that anything that creates a barrier between you and your patients (of which looking at and typing on a computer screen during session is just one) reduces the humanness of psychiatry and of the interaction in general. I think psychiatry is where the humanness of medicine (interaction between healer and patient) is probably MOST important. The end result of the trend towards inserting barriers between yourself and the patient is 15 minute "med checks" (all reference to actual human problems are removed from that title and we are simply checking "the meds" now), trained psychiatrists who seem dumbfounded about how to handle a patient who wants to "talk" vs go over a symptom list, and a public who thinks your profession is a bunch cold med pushers.

If you owned a restaurant and the word of mouth around town was that your steaks were dry, dont you think you should try your damnest to change the way you cooked your steaks?!

 

[Armadillos]

As an aside, atleast from a medstudents perspective it seems like there are definitely psychiatrists out there who waste too much time making too detailed of notes. Even to the point where the over documentation likely could open themselves up to more liability because hypothetically someone in retrospect could over analyze whats there to make it look like they should have acted differently. But if they stuck to a more basic/concise note there would be no extraneous data available for anyone to doubt their assessment.

 

[michaelrack]

If you owned a restaurant and the word of mouth around town was that your steaks were dry, dont you think you should try your damnest to change the way you cooked your steaks?!

You could always lower the price of your steak and try to get customers in and out quickly and make more $ that way. That's what I would do

 

[heyjack70]

Except this isn't true. Insurance companies do not control how long our appointments are. Their reimbursements may change our practice management, but it IS volitional. Telling patients that you can not have more time with them because the insurance companies have direct control isn't correct.

The truth would be to say that due to changes made a while back in reimbursement, it is more profitable for me to see more patients via shorter visits. It definitely doesn't convey the "we're all in this together because of the big bad insurance companies," but at the end of the day it's more honest.

I disagree. Insurance is dictating rates, and has an oligopoly on payments. You can't negotiate with insurance; accept their rates or you're kicked off the panel. If after 12+ years of training a physician chooses to not except a payment that he/she believes is not worth the effort/time, that's the physician's choice, but the unacceptable rate is dictated by insurance, not the psychiatrist. We are in this with the patient.

 

[heyjack70]

I'm curious if folks every find themselves torn when this happens. In my limited experience, I've found that when folks reach the stage that I can manage them with 15 minute med checks, it's about the time that many of them can be managed by their PMD.

You could refer them back to the PCP who will see them maybe every six months, for less the 10 minutes total each visit, so probably 1-2 minutes max for the psych issue. Or you can keep them in your practice and see them for 15 minutes every 3-6 months and focus all your attention on their psych issue. What's better patient care in this situation?

 

[Jester25]

While the focus on efficiency is nice....should that be your primary concern/job? If we think of it in terms of priorities, I would imagine patient care/attentiveness/engagement while they are in the room with you takes precedent. I will never be able to swallow the notion that documenting what you're doing is MORE important than what you are actually doing. A contact note easily takes an addendum if you make a mistake. Humans, not so much.

The overarching point was that anything that creates a barrier between you and your patients (of which looking at and typing on a computer screen during session is just one) reduces the humanness of psychiatry and of the interaction in general. I think psychiatry is where the humanness of medicine (interaction between healer and patient) is probably MOST important. The end result of the trend towards inserting barriers between yourself and the patient is 15 minute "med checks" (all reference to actual human problems are removed from that title and we are simply checking "the meds" now), trained psychiatrists who seem dumbfounded about how to handle a patient who wants to "talk" vs go over a symptom list, and a public who thinks your profession is a bunch cold med pushers.

If you owned a restaurant and the word of mouth around town was that your steaks were dry, dont you think you should try your damnest to change the way you cooked your steaks?!

I will refer you to the first sentence of my last post.

Again, it needs to be a balance of what is optimal care and what is efficient.

No one said efficiency is the focus.


Also Erg, while what you are saying is nice, but I don't think it's practical for everyone. If your VA is anything like my VA, then it is very easy for you practice the way you want. Not as easy in a chaotic CMC. A day at the VA feels like vacation compared to the rest of my clinic sites. I love CPRS.

 

[Jester25]

During my intern year, I would often tell my fellow interns that their notes were too long. I don't need to read a 5 paragraph HPI. A lot of them had difficulties with night float for this reason. I was able to write concise notes and even when I had 8 admits overnight, I was still able to get some sleep. We had an excellent resident who was so through, it was borderline OCPD. She ended up burning out and dropping out of residency. She probably provided optimal care, but it didn't help her in the long run. I like to believe I provided a good balance and have enjoyed every second of residency.

 

[hamstergang]

While the focus on efficiency is nice....should that be your primary concern/job?

As the poster above me said, balance is really the key. We simply can't spend an hour with each patient and then write notes at the end of the day because there are too many patients to make this work, and if all we did was work we'd start doing our job poorly.

I feel I've found a good balance at the VA. I type my notes as I go, but only rarely look at the computer screen (mostly try to do so when they look away so it's not as obvious to them). That allows me to see the larger load of patients, write notes that clearly state and justify my plan, and still get out of there before they lock me in the building. I could certainly be more efficient than this, but then I'd feel like I was delivering poor care.

 

[erg923]

Also Erg, while what you are saying is nice, but I don't think it's practical for everyone. If your VA is anything like my VA, then it is very easy for you practice the way you want. Not as easy in a chaotic CMC. A day at the VA feels like vacation compared to the rest of my clinic sites. I love CPRS.

Well, I was really speaking mostly about PP, since thats the setting from which this whole discussion emerged. Nevertheless, you are an ind. licensed professional and I do think we all have the right to practice the way we want within certain parameters. And there are somethings I am just NOT willing to compromise. The notion that the session 100% belongs to the patient and that you do not allow barriers/distractions during said sessions (taking phone calls, desk between you and patient, clipboard or computer in front of your face) is/was basic bedside manner... at least in the 1980s. 🙂

 

[hamstergang]

Btw, in my situation, the computer and keyboard are off to the side and there is nothing but air between me and my patient.

 

[Jester25]

Well, I was really speaking mostly about PP, since thats the setting from which this whole discussion emerged. Nevertheless, you are an ind. licensed professional and I do think we all have the right to practice the way we want within certain parameters. And there are somethings I am just NOT willing to compromise. The notion that the session 100% belongs to the patient and that you do not allow barriers/distractions during said sessions (taking phone calls, desk between you and patient, clipboard or computer in front of your face) is/was basic bedside manner... at least in the 1980s. 🙂

Yeah bedside manner has changed…but I do agree with you that your way is superior for patient care. If a psychiatrist is able to do it like you and Splik, they should. At this stage in my career, I can't, but maybe that will change years down the road.

As an aside, my wife is a family medicine physician and she said her patients who see psychiatrists always complain to her that the psychiatrists don't really listen and only care about handling medications. So even if important life events are going on impacting their mental state, they won't always bring it up with their psychiatrists, instead they talk to their therapists and obv FM doc. Now that is terrible for our field. There is no therapeutic relationship there.

 

[EEGNeurofeedback]

delete

 

[erg923]

Yeah bedside manner has changed…

Did it need to?

 

[erg923]

and she said her patients who see psychiatrists always complain to her that the psychiatrists don't really listen and only care about handling medications. So even if important life events are going on impacting their mental state, they won't always bring it up with their psychiatrists, instead they talk to their therapists and obv FM doc. Now that is terrible for our field. There is no therapeutic relationship there.

Right. Patrons are unamimous that the steaks are dry, but no one seems interested in changing the cooking process. I just dont get it.

 

[BritTrooper]

Therapy needs to be outsourced to the least expensive provider. Pilots don't serve peanuts on flights, they fly the plane.

 

[erg923]

Your biases toward who should be conducting psychotherapy (which comes off as denigrating towards therapy, btw), is completley irrelavant to this discussion because ALL interactions with a psychiatrist in the clinical setting should be considered "therapy" and therapeutic, even you are not doing a formal psychotherapy session. I don't know who would have taught you any different?

 

[vistaril]

Therapy needs to be outsourced to the least expensive provider. Pilots don't serve peanuts on flights, they fly the plane.

terrible analogy because the therapy *is* the hard part. In most cases, psychopharm(even when done fairly well) just isn't very difficult.

 

[Doctor Bagel]

Therapy needs to be outsourced to the least expensive provider. Pilots don't serve peanuts on flights, they fly the plane.

Seriously? So one thing I'm curious about -- all these psychiatrists who both have no interest in doing psychotherapy and mention having no feelings of competency doing it, where did you train? Not literally, but I think this is something applicants should figure out.

 

[michaelrack]

Right. Patrons are unamimous that the steaks are dry, but no one seems interested in changing the cooking process. I just dont get it.

It depends on what kind of steak house you are running. People are willing to pay for dry steaks at Waffle Hut (I like their steak and eggs); and aren't willing to spend more for better steaks there. On the other hand, if you are running a Ruth's Chris Steakhouse, you better make sure the steaks aren't dry. In other words, good $ can be made serving both dry steaks and moist steaks- it is not unethical to serve a low quality (but not unhealthy steak) to someone willing to pay $5 and a high quality steak to someone willing to pay $50. It can be unethical to provide medical/psychiatric care in the same manner.
All of this boils down to: steaks are not a good analogy for psychiatric care.

 

[cookymonster]

I can't stand doing therapy either. What it boils down to is that I realize I don't have the cognitive flexibility to concentrate as hard as possible on what the patient is saying while AT THE VERY SAME TIME also mentally trying to sort through 20 different defense mechanisms, deciding how strongly I want to reflect, support, or confront it, reflecting on the transference and countertransference that's taking place, and delivering a response in an empathic fashion without signing awkward... all in a matter of seconds. And then repeat that dozens of time in an hour for several hours all day long. It is utterly exhausting, and after a couple of these sessions I am totally burned out. When I asked my supervisors how people could actually perform all of these mental gymnastics, they didn't have what I thought were satisfactory answers. I feel like I can never keep up with what's happening within the session, and I don't want to spend every night pondering all of my cases via process notes either. I need something lower stress.

I know I'm talking about psychodynamic therapy, but I encountered similar frustrations with CBT and other modalities as well.

 

[F0nzie]

I can't stand doing therapy either. What it boils down to is that I realize I don't have the cognitive flexibility to concentrate as hard as possible on what the patient is saying while AT THE VERY SAME TIME also mentally trying to sort through 20 different defense mechanisms, deciding how strongly I want to reflect, support, or confront it, reflecting on the transference and countertransference that's taking place, and delivering a response in an empathic fashion without signing awkward... all in a matter of seconds. And then repeat that dozens of time in an hour for several hours all day long. It is utterly exhausting, and after a couple of these sessions I am totally burned out. When I asked my supervisors how people could actually perform all of these mental gymnastics, they didn't have what I thought were satisfactory answers. I feel like I can never keep up with what's happening within the session, and I don't want to spend every night pondering all of my cases via process notes either. I need something lower stress.

I know I'm talking about psychodynamic therapy, but I encountered similar frustrations with CBT and other modalities as well.

Ahh the art of psychotherapy. Nobody wants to do the hardest part of Psychiatry and get paid $60 an hour.

 

[erg923]

Michealrack, I am not going to debate philosophy on here but I guess I was speaking from a moral stance. Low quality healthcare service delivery is not something that I would consider an option to practice.

And why do some recent posters seem to equating what I have said to doing psychotherapy, specifically dynamic oriented therapy? I haven't said a dynamic phrase in this whole discussion. And Cooky monster is thinking WAY to much about process here, btw. Properly Attending to a patients emotional experience takes a lot LESS than all that.

 

[OldPsychDoc]

It depends on what kind of steak house you are running. People are willing to pay for dry steaks at Waffle Hut (I like their steak and eggs); and aren't willing to spend more for better steaks there. On the other hand, if you are running a Ruth's Chris Steakhouse, you better make sure the steaks aren't dry. In other words, good $ can be made serving both dry steaks and moist steaks- it is not unethical to serve a low quality (but not unhealthy steak) to someone willing to pay $5 and a high quality steak to someone willing to pay $50. It can be unethical to provide medical/psychiatric care in the same manner.
All of this boils down to: steaks are not a good analogy for psychiatric care.

Mmmm....steak.....

(Had an amazing seared hanger steak last night...crispy outside, tender, juicy and red inside...only $18, too. I'm going back.)