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Comments and Controversies

Med check distress

Vol. 9, No. 10 / October 2010

We read with distress “Successfully navigating the 15-minute ‘med check,’” (Malpractice Rx, Current Psychiatry, June 2010, p. 40-43). Even if 15-minute med checks have become “standard care,” they should not be. Unless a patient is stably medicated, 15 minutes is insufficient to evaluate the situation and make treatment decisions. Psychiatric diagnoses cannot be made by drawing blood or doing physical exams, so information beyond superficial questions must be elicited.

Does it make sense, as Table 2 suggests, that a psychiatrist should “have a psychotherapist or case manager present to facilitate communication?” Clearly not. Although theoretically possible, these therapists—apart from the question of their level of competency and training—are overworked and lack time to join psychiatric sessions.

Again, in Table 2, is apologizing sufficient “when a patient truly needs more time”? Clearly not. Although the author notes that intakes should warrant extra time, there is little awareness of the “real-life” difficulty involved in seeing patients who are not new to the clinic but new to a particular psychiatrist. Patients often arrive with as many as a dozen medications and multiple conflicting diagnoses. Charts are voluminous. To become thoroughly familiar with what has transpired takes a competent psychiatrist a minimum of 30 minutes to review. Rapid staff turnover and disconnected care exacerbate this problem.

Having worked in academic settings and in the field, we can state with certainty that dangerous shortcuts are now the norm. Who, if not the psychiatrist, will be addressing the fact that many of these patients have no teeth, out-of-control diabetes, no primary care physician, etc.? This raises more than malpractice issues, this raises quality-of-care issues.

Some days there are “no-shows” and some days every patient comes. In practice, the need for more than 15 minutes per patient exceeds the time gained when a patient does not keep an appointment.

Psychiatrists should serve as purveyors of quality care, not merely signers of prescriptions.

Elizabeth H. Levin, MD
Former director of residency training
Trenton Psychiatric Hospital
Former clinical associate professor
Robert Wood Johnson Medical School
Camden, NJ

Arthur H. Schwartz, MD
Retired professor of psychiatry
Robert Wood Johnson Medical School
Piscataway, NJ

Dr. Mossman responds

Unlike Drs. Levin and Schwartz, I am unwilling to declare that colleagues who conduct 15-minute med checks are, by that fact itself, doing something psychiatrists should not do. That does not mean 15-minute med checks are ideal. But several psychiatrists feel that despite severe time constraints, they can do many patients much good in 15 minutes—certainly more good than if those patients had no time with a psychiatrist at all. No scientific evidence that I know of contradicts this position.

Drs. Levin and Schwartz and I agree that certain types of patient visits require more than 15 minutes, which is why my column contained suggestions about negotiating for “seeing no more than 3 patients an hour, scheduling longer appointments for new patients, and having some built-in time to return phone calls, do paperwork, review charts, and complete progress notes.” The “strategies” listed in Table 2 are ideas about improving care and efficiency that come from psychiatrists with a lot of med check experience. Like most clinical suggestions, the strategies may make sense in some settings, but certainly not all.

Douglas Mossman, MD
Glenn M. Weaver Institute of Law and Psychiatry
University of Cincinnati College of Medicine
Adjunct professor of clinical psychiatry
University of Cincinnati College of Medicine
Cincinnati, OH

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