Strategies for outpatient

[RedPeony]

I'm a resident starting to do outpatient work, and I have a few questions:

1) Do you have any tips for time management without trying to be rude/look too rushed?
I often find that patients want to have a giant vent session about whatever stressors are going on in their lives, and it can be hard to interrupt them to ask basic questions about history, symptoms, med compliance, side effects, etc. Normally I'll try to let them vent for a few minutes before I get more aggressive with interrupting and sometimes I just realize that I won't be able to get all of the info I'm looking for. And these are 30 mins visits, I can't imagine doing 15 min visits for some of my more talkative patients.

2) What is a psychiatrist's role in trying to help patients through interpersonal, romantic, financial, job, etc stress that isn't necessarily symptoms of a psychiatric illness? I work in a mostly low functioning population so it's a lot of crisis management. Beyond suggesting really basic solutions (perspective taking, goal setting, assertiveness, relaxation techniques, exercising more, etc) I will try to refer patients to therapy. Often they don't want to go or say "it doesn't work for me."

Thanks so much!

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[erg923]

I'm a resident starting to do outpatient work, and I have a few questions:

1) Do you have any tips for time management without trying to be rude/look too rushed?
I often find that patients want to have a giant vent session about whatever stressors are going on in their lives, and it can be hard to interrupt them to ask basic questions about history, symptoms, med compliance, side effects, etc. Normally I'll try to let them vent for a few minutes before I get more aggressive with interrupting and sometimes I just realize that I won't be able to get all of the info I'm looking for. And these are 30 mins visits, I can't imagine doing 15 min visits for some of my more talkative patients.

2) What is a psychiatrist's role in trying to help patients through interpersonal, romantic, financial, job, etc stress that isn't necessarily symptoms of a psychiatric illness? I work in a mostly low functioning population so it's a lot of crisis management. Beyond suggesting really basic solutions (perspective taking, goal setting, assertiveness, relaxation techniques, exercising more, etc) I will try to refer patients to therapy. Often they don't want to go or say "it doesn't work for me."

Thanks so much!

Set an agenda/schedule for the visit at the beginning of the session.

 

[Shikima]

"We have a limited time for this appointment and for me to get a lot of information I have a structured interview for us. Don't worry, there is still plenty of time for us to meet and talk with future appointments."

 

[birchswing]

I've heard, "Remember what this is." Chilling and direct.

Remembered another one: "Don't open any doors in this room that can't be closed."

 

[wolfvgang22]

Take control of the visit immediately when you sit down, and already have a plan of how you want the appointment to go before hand and how long you will spend on each topic. Already know what is in the chart. I immediately ask "How are you doing with your medications?" to focus the conversation on that. Then I will ask about side effects. I will ask about medication adherence. I express empathy and I'm friendly and supportive, but I keep moving. When they begin lengthy venting, I will express empathy and make ONE statement of support ( it's all they will often retain anyway), and if time is ticking I will state that my role is unfortunately limited by the clinic to medication management but we also have several wonderful therapists and offer to help them make an appointment today. I remind them we talked about that when we first met. I will tell them I think it's really good they want to work through things and improve with therapy because research shows that often works even better than medication. I walk them out to the front desk and introduce them to the receptionist to make an appointment if they show interest.

Always expect "one more thing doc" or "I have to tell you about this doc" between the chair and the door. Be alert, but if it is more venting and you assess quickly it is not urgent or clinically relevant, redirect. I apologize and inform them I have another patient waiting on me and say I really don't want to make anyone wait. This works because I rarely make anyone wait more than 10 minutes.

As you get to know each patient you will also learn how to approach each one and what particular chronic issues they will bring up. I rarely have to be rude or cold but sometimes you have to be very strict with certain people.

Use body language. If you need to be done in 15 minutes, don't recline in your chair, sit up on the edge. Don't have a cushy chair for the patient if you are doing 15 minute med checks. When you are wrapping up, move your chair back, turn toward the door, lean forward, motion to stand.

If a patient is not ready for therapy, that is fine. Make your recommendations, and just say "ok." If there are barriers like transportation they want to solve, refer to the social worker. If just not ready, move on. Be kind but be honest with the patient who expects a pill to solve all problems. I sometimes express something like "I can see you aren't ready for therapy right now, and that's ok. But I think what will really help you long term is therapy, because medication alone is probably not going to be enough."

 

[SpongeBob DoctorPants]

Avoid starting the visit with "How are things going?"

 

[wolfvgang22]

Avoid starting the visit with "How are things going?"

I actually do start the visit that way a lot, but I make certain I have a plan to redirect within 2 minutes and I don't attempt this with known difficult patients. This requires more advanced interviewing skills.

Sometimes, my opener is "How are the medications working for you?" You'll still need to plan to refocus on the medications again, though, which is why my follow up question is often "Have you experienced any side effects?' I actually often start with a medication reconciliation process with the patient and assess adherence, going down the hopefully short list of psych meds one by one. This often helps orient the patient to the purpose of the medication management appointment.

Another way to open is to ask the patient to complete a subjective clinical scale, like a depression inventory. Sometimes I even more quickly open by asking a patient to rate their mood on a scale of 1 to 10 and then focus on symptoms and move the subject to each medication for the symptoms. Done the right way, with empathic tone of voice and body language, the patient feels I truly care what the answer is ( and I do, but I am purposefully controlling the tone and direction and timing of the interview.)

I often ask the patient to identify "What do you feel is the biggest problem/symptom/issue today?" and then focus on treating that. If they say "I dunno" I reassure the patient and I ask more questions. I do not allow them to ramble more than 2 minutes.

For the novice interviewer, you must be very structured and stick to the fundamentals of the psychiatric mental status exam. Try one or two new techniques at a time. Different schools of psychotherapy offer a rich variety of approaches and useful techniques. After a while you will develop the ability to adapt to each situation and can make the interview seem like a conversation with a natural ebb and flow that enhances all important therapeutic rapport. But like any professional, fundamental skills come first.