Do people still do mostly 15 minute appointments?

[Dopamemes]

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Wondering if anyone still does mostly 15 minute appointments? I trained in a setting where 30 minute appointments were the norm but that included time to staff with the attending so basically, 15 minutes of actual patient time. Now that I'm in outpatient, I struggle to make use of 30 minutes. I'm tempted to start scheduling 15 minute appointments as 90% of the time, that's all I need. However, it seems like 15 minute slots are frowned upon by most psychiatrists?

 

[TexasPhysician]

There are plenty of insurance clinics doing this.

 

[erg923]

Send back to PCP with recs. 15 minutes means they don't need you anymore.

 

[nexus73]

15 minutes really means 10 minutes with patient though. And I find it just becomes too much of a checklist and you don’t really know what’s going on with the patient.

 

[Ironspy]

If I can see someone in 10-12 min they don’t need me. 30 min allows me to build rapport, ask about people’s families and lives which often leads to important clinical information I would not get if I were just running through a checklist. It also allows me to stretch my legs, get coffee and use the bathroom between patients which improves my quality of life

 

[nexus73]

I think one factor is some employed jobs are happy for you to see as many patients a day as you will tolerate. And won’t pay you more. So why kill yourself.

 

[Stagg737]

If you're only doing med management and completely skipping the psychosocial aspect of psychiatry, then sure, 15 minutes if fine for a lot of patients. If you're doing that you're also missing the large bulk of where we can be helping most of our patients though.

 

[smalltownpsych]

I have a couple of patients that I only see for about 15 minutes just because they benefit from the regular check-in with someone who has an understanding of their severe mental illness and can monitor for exacerbation and implement measures to prevent severe relapse.

 

[docksan]

Gosh I can't see myself only taking 15 minutes with a patient who's anything but stable and not in need of my services. 30 minutes gives you a good chunk of time for therapeutic interventions.

 

[samac]

I interviewed at a place that that was the ultimate goal and expectation. 15 minutes/patient. Cram patients in crisis in there when needed.
No thank you.

 

[romanticscience]

I hear all the time about these 15-minute med management patients. Who are they? I have less than I can count on one hand. Most of my patients have high levels of hysteria/dissociation and personality features that most of the effect comes from the non-specific ritual of checking in, measuring symptoms, and updates on life outside of treatment (relationships and work).

If I didn't talk about this stuff, we'd burn through a treatment algorithm by the 8th week. Uh-oh, treatment resistance again!

I have a lot of people who came to me for "just meds for ADHD," I keep talking to them month after month. Turns out they have no self-esteem and are entrapped in a bad relationship. We could have been on qelbree but instead, they broke up with their partner! Also, the amount of avoidance of real-life problems through meds is astounding.

 

[clausewitz2]

I hear all the time about these 15-minute med management patients. Who are they? I have less than I can count on one hand. Most of my patients have high levels of hysteria/dissociation and personality features that most of the effect comes from the non-specific ritual of checking in, measuring symptoms, and updates on life outside of treatment (relationships and work).

If I didn't talk about this stuff, we'd burn through a treatment algorithm by the 8th week. Uh-oh, treatment resistance again!

I have a lot of people who came to me for "just meds for ADHD," I keep talking to them month after month. Turns out they have no self-esteem and are entrapped in a bad relationship. We could have been on qelbree but instead, they broke up with their partner! Also, the amount of avoidance of real-life problems through meds is astounding.

The only people I see for whom 15 minute appointments are most of the time reasonable are some people that have to be seen every month for model adherence who have fairly severe SMI and are invested in being Just Fine, Thank You, Everything is Good and Nothing is Wrong. Predictably from time to time this proves to be totally incorrect and they need way more than 15 minutes, but trying to pull more than that out of them every four weeks forever would be indistinguishable from dentistry.

 

[whopper]

Yes and not surprisingly they usually do bad treatment. It's only okay to do 15 minute visits if the patient is already doing very well and only needs refills. Simply getting the note ready, refilling the meds, and asking the patient the minimum perfunctory questions is going to take almost ten minutes.

To get most patients to this level of GAF functioning usually required at least 3-5 visits of hard work that were at least 30 minutes.
Even patients that usually doing relatively such as successful Buprenorphine patients or ADHD patients will have occasional meetings where something more needs to be discussed and if you always give this person 15 minutes for every visit that one visit which will be about one out of 4 even with good reliable patients will require more time.

 

[Stagg737]

I hear all the time about these 15-minute med management patients. Who are they? I have less than I can count on one hand. Most of my patients have high levels of hysteria/dissociation and personality features that most of the effect comes from the non-specific ritual of checking in, measuring symptoms, and updates on life outside of treatment (relationships and work).

If I didn't talk about this stuff, we'd burn through a treatment algorithm by the 8th week. Uh-oh, treatment resistance again!

I have a lot of people who came to me for "just meds for ADHD," I keep talking to them month after month. Turns out they have no self-esteem and are entrapped in a bad relationship. We could have been on qelbree but instead, they broke up with their partner! Also, the amount of avoidance of real-life problems through meds is astounding.

Plenty of patients with diagnoses that could be or turn into SMI (bipolar, schizophrenia, OCD) who have been stable for an extended period but want to continue to see a psychiatrist. I've seen plenty of patients where PCP wasn't comfortable managing depakote or lithium and wanted the patient to continue seeing psych. Also some PCPs just straight up refuse to prescribe stimulants to patients with obvious ADHD who have been on stims for years but patient loves the PCP and won't change. None of those patients regularly require more than 15 minutes when stable, but can easily justify continuing to see them as a psychiatrist.

There's also plenty of patients who have treatable conditions (depression/anxiety) that benefit from meds, feel meds are helpful, and don't want to do therapy or see a psychiatrist who digs into that stuff. Would they benefit from therapy? Of course, but if meds help and they're doing okay I'm not going to fire them for wanting to keep things "good enough" and stay on their meds. One could (imo correctly) argue they can go back to their PCP, but some patients want to see a psychiatrist every 3-6 months.

Finally, I've run into a few patients where insurances require certain meds be prescribed by the psychiatrist. One insurance where I did residency stopped covering stimulants for ADHD unless prescribed by a psychiatrist. We got a flood of referrals from the primary care clinic for a while for those patients, and other than the insurance requirement for the patient to be able to afford their meds there was no need for us to see them whatsoever. 15 minutes was more than enough for those patients and I had one or two in residency where they were literally 5 minute appointments because I was just continuing the Adderall XR 30 mg QAM they'd been on for 10+ years...

I agree that most patients who actually need a psychiatrist need more than 15 minutes. Also that pretty much everyone can benefit from therapy if you really want to dig, but if patients are functioning alright and they don't want to do therapy, who are we to force that? Where I have a problem with 15 minute appointments is when docs are trying to medicate psychosocial problems that require therapy, behavioral change, or social interventions.

 

[romanticscience]

Plenty of patients with diagnoses that could be or turn into SMI

SMI and are invested in being Just Fine, Thank You, Everything is Good and Nothing is Wrong

I forgot about those! I'm 100% outpatient private practice and realize my bias.

 

[Candidate2017]

Generally, people who are on two or more controlled substances don't want appointments that go beyond 15 minutes. And ideally 1 minute or less. They don't have much to say. Businesspeople figured this out a long time ago. I'm sure there's a complex mathematical equation that can show an exponential correlation between hitting enough GABA and D2 receptors, the number of NPs employed, number of patients an hour, number of CPT codes hit, and dollars.

On the other spectrum, people on massive doses of FGAs don't have much to say either. But the equation is a little simpler.

 

[TheRightMedication]

The only encounters where I feel a 25 min appointment is overkill is stable ADHD patients for whom we are not doing the kind of psychological work that romanticscience describes above.

For med checks on stable patients, since the interval is longer, I find the longer appointment is good to catch up on their lives, and their progress in lifestyle modification and psychotherapy.

 

[TheRightMedication]

Generally, people who are on two or more controlled substances don't want appointments that go beyond 15 minutes. And ideally 1 minute or less. They don't have much to say. Businesspeople figured this out a long time ago. I'm sure there's a complex mathematical equation that can show an exponential correlation between hitting enough GABA and D2 receptors, the number of NPs employed, number of patients an hour, number of CPT codes hit, and dollars.

On the other spectrum, people on massive doses of FGAs don't have much to say either. But the equation is a little simpler.

I get that you're making a logical point about the nature of neuroleptics and the nature of what they treat. But for the trainees out there, remember, people on FGA's can have a lot to say of you sit with them for a time, and it can be pretty important too.

 

[rjs2131]

If 15 min is the standard, you’re 100% missing things or you are seeing exceptionally stable patients who don’t really need you. Embrace the 90833 and 30-min follow-ups! You’ll be less burnt out, your patients will value you more, and you’ll likely have better outcomes.

 

[FlowRate]

Usually if the f2f time of an appointment appt lasts less than 15 minutes it's because the patient is coming in to verify that the change made last time (or regimen they've been on for the last year) are working well and there's really nothing new in their life and their MH is in a great place. Or, even if it's not in a great place, it's because they're super guarded/reluctant and also wanting to stay on whatever they're currently taking and I don't personally find it enjoyable to pull teeth with those patients--usually they're seeing a therapist and so have someone to check in on those concerns more intensely.

The remaining majority of my patients take 15-25 minutes of a 30 minute appointment slot. Some take more.

I've also found it's often not possible to predict which previously stable patients are going to fall in the 5-15 minute bucket of "annual/semi-annual follow-up, totally stable, no new concerns, meds are working, life going great" and "annual follow-up, went off meds, life in the dumpster" 30 minute appointment.

The reason I have patients with 6mo/1yr follow-ups is that primary care won't take back most "specialty" regimen (AEG's, antipsychotics, won't take back pts on benzos even if not started by psych, high doses, multiple relatively less frequently used meds.)