Futility of training

[dozitgetchahi]

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I call therapy appointments a psychotherapy appointment.

I have no idea what you mean by this roundabout way of saying "med check" means like a less intense visit or something.

My experience is much more around @clausewitz2 where it seems to be used to devalue our appointments to a med vending machine appointment, kind of like "prescriber". Nobody goes around calling a endocrinologist or allergist or (pick any other speciality) a "prescriber".

I don’t understand what you guys are getting so worked up about.

Try to call any script into a CVS: “Prescribers press 1”. No delineation there.

Many other specialties of medicine predominantly revolve around prescribing medications. I am a rheumatologist. Many times, some scheduler will have labeled my appts a “med check” in Epic. It doesn’t offend me in the slightest. It means that it’s an appointment where we you get your monitoring labs and we talk about how well the medication is controlling your symptoms. I get that I’m checking up on methotrexate and Humira and you guys are checking up on citalopram and Abilify, or whatever, but I’m not sure why “med check” is a derogatory term? You’re doing what the rest of us are doing.

As a rheum, I’m actually thrilled for the visits when I get to use our DMARDs against real rheumatologic disease…so give me more “med checks” please, it means I’m doing real rheumatology. The worst visits are when the pt expects me to do some sort of woo-woo magic dance before them, and instantly make their fibromyalgia symptoms vanish. But I digress.

 

[Ludwig2000]

Highest I saw was $1,500/hr advertising themselves as an expert sex therapist.

Were they hot?

 

[ObsequiousAplomb]

Please provide a link to the NP billing $750 an hour. They must have some sort of web presence to bill that and I'd really love to see it.

To avoid shaming the ones who severely outprice me, I'll only share links to ones that are more expensive than I am or that offer services that are a little much.

These two NPs charge $165 for a 10-minute follow-up Expert Medication Management & Mental Health Services | Washington, DC | Tenley Town


This one does IV Ketamine assisted therapy for $700, lozenges for $600.

$220 for a 15-minute med management visit.

They also do Botox, filler, platelet-rich plasma, Kybella, etc

Ketamine Assisted Therapy | Tranquil Health

Innovative therapy for depression, anxiety & pain. Fast-acting relief. Consult for personalized care plans. Learn more!

www.tranquilhealthcare.com

This one does $700 initial evals, though that's 75 minutes. $250 for 25 minutes. He used to charge a bit more for shorter appointments, but I see he no longer does.

Fees for Psychiatric Services | Washington DC | Proactive Psychiatry

Trusted integrative psychiatry. Compare to your current psychiatrist. Pricing for psychiatric services in DC including medication management & therapy.

www.proactivepsychiatry.com

This one bills on a subscription model

Brewing Encouragement Acceptance and hope

Services Medication Treatment Strategies to Sustain Weight Loss Genetic Testing & Lab Interpretation Documentation Request

mentalhealthcafe.org

 

[splik]

But we call these things check ups all the time? And a "check up" implies something quick and fairly routine? Like not all oncology appts would be called a check up, but some might be.

Med check just acknowledges the reality that psychiatrists can offer more than one valuable service, but since the exam is almost never a physical one (I think check up implies/allows that it might be) we tack med on it for medication, and it implies the least intensive of interventions, as opposed to an intake or urgent appt etc. Talk therapy by its nature, as would be a treatment oriented visit to the oncologist, (not a "check up") would always I think to most patients imply something more intensive. So you can't have a "talk check up." Although I have heard a patient call it a "check in" - to imply it isn't a "heavy" visit.

I get what you're saying, but I don't think it's as negative as all that compared to other specialties.

We are not pharmacists. Med check is a pejorative term that was used to describe the brief (sometimes ultra brief) medication and symptom checklist focused visits that arose during the era of managed care where 15mins or less became the new norm for psychiatry. Some of the biological psychiatrists did 5 min visits (one of the well known psychiatrists from my program was known to put his hand up to patients if thet tried to talk to them before ushering them out of the office). Today, 25-30 min follow ups is the norm and 5 mins is I think highly unusual.

It is absolutely devaluing and dismissing of our work to talk about med checks if people are providing thoughtful care that involves psychological formulation and psychotherapeutic interventions. In the post above, where they were talking about pharmacotherapy in the context of hour long weekly therapy sessions, it essentially negates that work though I don’t think that was intended.

Personally I would also banish terms like “med management” and “prescriber” but that is a losing battle.

 

[calvnandhobbs68]

We are not pharmacists. Med check is a pejorative term that was used to describe the brief (sometimes ultra brief) medication and symptom checklist focused visits that arose during the era of managed care where 15mins or less became the new norm for psychiatry. Some of the biological psychiatrists did 5 min visits (one of the well known psychiatrists from my program was known to put his hand up to patients if thet tried to talk to them before ushering them out of the office). Today, 25-30 min follow ups is the norm and 5 mins is I think highly unusual.

It is absolutely devaluing and dismissing of our work to talk about med checks if people are providing thoughtful care that involves psychological formulation and psychotherapeutic interventions. In the post above, where they were talking about pharmacotherapy in the context of hour long weekly therapy sessions, it essentially negates that work though I don’t think that was intended.

Personally I would also banish terms like “med management” and “prescriber” but that is a losing battle.

Absolutely. This all comes back to the impact of language and the way we use language to shape ideas and perspectives. I personally have a high suspicion that language like this contributes to scope creep and a general attempt to make what we do overall seem simple.

"Med check" doesn't sound so hard....surely some other "prescriber" or even one of those new AIs could do a simple "med check"?

Exhibit A:

 

[Chimed]

We are not pharmacists. Med check is a pejorative term that was used to describe the brief (sometimes ultra brief) medication and symptom checklist focused visits that arose during the era of managed care where 15mins or less became the new norm for psychiatry. Some of the biological psychiatrists did 5 min visits (one of the well known psychiatrists from my program was known to put his hand up to patients if thet tried to talk to them before ushering them out of the office). Today, 25-30 min follow ups is the norm and 5 mins is I think highly unusual.

It is absolutely devaluing and dismissing of our work to talk about med checks if people are providing thoughtful care that involves psychological formulation and psychotherapeutic interventions. In the post above, where they were talking about pharmacotherapy in the context of hour long weekly therapy sessions, it essentially negates that work though I don’t think that was intended.

Personally I would also banish terms like “med management” and “prescriber” but that is a losing battle.

yes, and I would add that studies demonstrate improved patient outcomes and response to medication based on the quality of the interaction with the psychiatrist. So, even in a "med check" there is a lot more going on.

 

[comp1]

The era of managed care ended? What caused that? Anyways, that $700 intake from the NP is very interesting. He seems to be an influencer of some kind and is running for Congress. The subscription model, follow-up costs and ketamine treatment billing seem more in line with standards.

 

[Atreides]

"Med check" doesn't sound so hard....surely some other "prescriber" or even one of those new AIs could do a simple "med check"?

My hospital calls them "psychopharmacology visits". I was super confused reading resident notes that had that listed as the visit type, then found out that's the official name in Epic for psychiatry appointments.

 

[ObsequiousAplomb]

The era of managed care ended? What caused that? Anyways, that $700 intake from the NP is very interesting. He seems to be an influencer of some kind and is running for Congress. The subscription model, follow-up costs and ketamine treatment billing seem more in line with standards.

I've had a few of his patients. Interesting that he is running for Congress.

I was more surprised that NPs are running ketamine therapy clinics while also offering cosmetic procedures. Feels a little weird that I'm not supposed to touch patients even to assess for vitals and there's NPs out there providing ketamine therapy and cosmetics. If that's normal, then I guess I'm lame.

 

[Taddy Mason]

I've had a few of his patients. Interesting that he is running for Congress.

I was more surprised that NPs are running ketamine therapy clinics while also offering cosmetic procedures. Feels a little weird that I'm not supposed to touch patients even to assess for vitals and there's NPs out there providing ketamine therapy and cosmetics. If that's normal, then I guess I'm lame.

We did physical exams on all new patients admitted to the inpatient unit (I also helped run a code, placed a couple NG tubes in a psychotic pt who refused to eat or drink to the point of developing a nice AKI, and was the only time I actually ever did a DRE outside of med school…) and gave injections in the outpatient clinic where I went to residency - which was interesting considering it was a very psychodynamic heavy program.

 

[hallowmann]

Assuming we're talking about solo PP, does that include a med check or is that for psychotherapy only? If the latter, is the fee that high to incentivize patients to seek psychotherapy elsewhere (i.e., "sure you can see me, but it's going to cost you").

These psychiatrists are doing both. They usually have 2 types of visit options that the patients can choose from based on length. The clientele is such that if it isn't that expensive, it must not be worth it.

 

[splik]

My hospital calls them "psychopharmacology visits". I was super confused reading resident notes that had that listed as the visit type, then found out that's the official name in Epic for psychiatry appointments.

This is a relic of a time when psychiatry was more psychoanalytic and there was a need to distinguish those who focused on pharmacotherapy (psychopharmacologists) from the psychodynamic psychiatrists. It was not uncommon (and still happens in the cash world) for patients to have 2 psychiatrists- one for therapy and one for psychopharm. Combined treatment is more common these days. This kind of distinction seemed to be more common on the east coast, especially in NYC and Boston where psychiatry had been very psychoanalytically oriented for many years.

Assuming we're talking about solo PP, does that include a med check or is that for psychotherapy only? If the latter, is the fee that high to incentivize patients to seek psychotherapy elsewhere (i.e., "sure you can see me, but it's going to cost you").

To answer your question (which seems to have been completely missed) - My fee for therapy only is >$500/session (I won't say exactly how much). It is not to disincentivize patients to go elsewhere but so I don't take a large loss on providing therapy (I would make even more if I did primarily 30 min visits) and because there is enough of a demand for people to pay it (and no, they are not all wealthy). I do have a sliding scale, but I try to charge similar or more to psychologists on my sliding scale and 99% of pay pay the full fee. That said, nowadays it is uncommon for patients to see psychiatrists for psychotherapy alone except for the older psychoanalysts or someone providing a specific niche of therapy. I do have specific niches but I also see some patients for basically problems of living who definitely could see a non-physician but choose to see me.

I believe psychiatrists are well placed to offer psychotherapy for bipolar disorder, psychosis, somatoform disorders, patients with chronic medical illness, severe personality disorders, high risk and treatment-refractory patients, and patients who prefer and benefit from combined vs split treatment. There are so many terrible therapists out there that I only like to work with patients in split treatment if I know that their therapist is actually competent.

 

[FatherPsychiatry]

We did physical exams on all new patients admitted to the inpatient unit (I also helped run a code, placed a couple NG tubes in a psychotic pt

Your inpatient psych unit allowed NG tubes???

 

[Taddy Mason]

Your inpatient psych unit allowed NG tubes???

It was case by case and usually caught the ire of nursing, but yes. We didn’t do eating disorders on our unit either. Any time an NG was placed it was for a psychotic patient or catatonic patient.

 

[Merovinge]

We did physical exams on all new patients admitted to the inpatient unit (I also helped run a code, placed a couple NG tubes in a psychotic pt who refused to eat or drink to the point of developing a nice AKI, and was the only time I actually ever did a DRE outside of med school…) and gave injections in the outpatient clinic where I went to residency - which was interesting considering it was a very psychodynamic heavy program.

There's shades of grey on this. I have given a truck load of LAIs both in my adult psychosis and public health clinics and to adolescents during my CAP fellowship, but I would only do deltoid injections. The gluteal ones we passed off to our highly capable PharmDs or nursing. I do see an advantage to feeling the psychiatrist given the direct intervention, but I don't ever want my patient taking their pants off around me. I would not do a DRE on an IP unit and also be the psychiatry resident directly caring for the patient, but yes I would otherwise do a full physical particularly with concern related to the often underdiagnosed catatonia. I do think it's important that there be boundaries when you are the mental health attending/resident for the patient whilst also avoiding the stereotype of psychiatrists who do not know any physical medicine.

 

[Taddy Mason]

There's shades of grey on this. I have given a truck load of LAIs both in my adult psychosis and public health clinics and to adolescents during my CAP fellowship, but I would only do deltoid injections. The gluteal ones we passed off to our highly capable PharmDs or nursing. I do see an advantage to feeling the psychiatrist given the direct intervention, but I don't ever want my patient taking their pants off around me. I would not do a DRE on an IP unit and also be the psychiatry resident directly caring for the patient, but yes I would otherwise do a full physical particularly with concern related to the often underdiagnosed catatonia. I do think it's important that there be boundaries when you are the mental health attending/resident for the patient whilst also avoiding the stereotype of psychiatrists who do not know any physical medicine.

The DRE was definitely a special case. He was nursing home dump awaiting placement and we weren’t doing anything for him psychiatrically. He developed rectal bleeding and ran into issues getting a stool sample. I discussed with my attending and the patient of me doing it v. placing a medical consult just for a FOT. We were encouraged to manage basic medical issues to a point before consulting.

I do think that being able to do an appropriate physical exam as a psychiatrist is important and caught a number of things missed by the ED or medicine. When I was chief resident, one of our junior residents caught an incarcerated hernia on a patient that had been boarding our ED for ~3-4 days prior to admission 😕

 

[oliversacks4thewin]

I believe psychiatrists are well placed to offer psychotherapy for bipolar disorder, psychosis, somatoform disorders, patients with chronic medical illness, severe personality disorders, high risk and treatment-refractory patients, and patients who prefer and benefit from combined vs split treatment. There are so many terrible therapists out there that I only like to work with patients in split treatment if I know that their therapist is actually competent.

I really respect this sentiment. I am curious if you can post specific avenues/websites/books, to the places where you learned any of the following: IPSRT, CBTp, Cognitive Remediation, Assertive Community Treatment, RO-DBT, MCP, and ReACT, because I am always overwhelmed by the price and time commitments associated with learning these EBP's and would appreciate the assistance in finding a direction for honing my skills further. Any additional suggestions are always welcome too!

Much appreciated in advance!

 

[slowthai]

I believe psychiatrists are well placed to offer psychotherapy for bipolar disorder, psychosis, somatoform disorders, patients with chronic medical illness, severe personality disorders, high risk and treatment-refractory patients, and patients who prefer and benefit from combined vs split treatment. There are so many terrible therapists out there that I only like to work with patients in split treatment if I know that their therapist is actually competent.

How did you get a feel for whether they were competent or not?

 

[splik]

How did you get a feel for whether they were competent or not?

I see whether their patients (our mutual patients) seem to be getting better or not. I ask patients what they work on with the therapists. I get a feel for how the patient is progressing. I talk with the therapist and get a sense of their formulation, treatment goals, and whether we can partner together. I also look at their websites etc to get a sense of their background and qualifications.

If the patient has been in therapy for years with the same therapist and they have no coping skills, no ability to identify and verbalize their emotions, no ability to identify treatment goals the therapist is probably incompetent or out of their depth. If the therapist is very quick to suggest medications, it is usually an indication of their own lack of confidence in their therapeutic skills. I've noticed a lot of incompetent therapists think everyone has ADHD and can't distinguish this from developmental trauma.

One patient I saw in her 20s was in therapy with the same psychologist since childhood. She was very impaired and the psychologist had wrongly diagnosed this obviously borderline patient (even her own psychological testing indicated this but many psychologists can't interpret psychological testing) with schizophrenia. Shortly after the therapist died, the patient began to flourish.

The fact is most therapists are not very good when it comes to psychiatry level patients, and some are harmful. Psychotherapy is not a benign intervention. This is not even including the therapists who focus on woo including past life regression, spirit release, tarot, witchcraft, enneagrams, numerology and so on.

 

[splik]

I really respect this sentiment. I am curious if you can post specific avenues/websites/books, to the places where you learned any of the following: IPSRT, CBTp, Cognitive Remediation, Assertive Community Treatment, RO-DBT, MCP, and ReACT, because I am always overwhelmed by the price and time commitments associated with learning these EBP's and would appreciate the assistance in finding a direction for honing my skills further. Any additional suggestions are always welcome too!

Much appreciated in advance!

I'm not trained in those (and Assertive Community Treatment is model of community psychiatry not a psychotherapy modality) and not familiar with a few of those acronyms.

I learned CBTp during residency training but I think ACT and supportive psychotherapy are often better for those with psychosis. Dialoging is also helpful for some patients experiencing voices. A CFT approach is also good for patients who have a lot of critical voices.

My training was heavy on psychoanalytic psychotherapy, CBT, DBT (though I didn't do the full training), and hypnosis. In recent years I received training in mentalization based treatment (with Fonagy and Bateman), schema therapy, and acceptance and commitment therapy (ACT).

I would suggesting picking what resonates with you and most applicable to your practice, and make the investment in time and money to make it work. Though sometimes you don't know. I thought I would love MBT but I didn't like it in practice, and found schema therapy and ACT to be more aligned with my world view.

 

[Merovinge]

The fact is most therapists are not very good when it comes to psychiatry level patients, and some are harmful. Psychotherapy is not a benign intervention. This is not even including the therapists who focus on woo including past life regression, spirit release, tarot, witchcraft, enneagrams, numerology and so on.

I threw up in my mouth when I saw a therapist actually advertising this stuff. I know the bar for a master-level therapist isn't Mount Rushmore, but man that hits hard. Then I read some stuff by RFK jr and realize they are in the kiddie leagues.

 

[MedMan80]

the last place i worked at was into enneagrams, didnt last there long 🙂