Psychiatry’s Med Check: Is 15 Minutes Enough?

In the old days, people made fun of those rigid 50 minute appointments psychiatrists had with patients that focused mainly on psychotherapy. In today’s world, however, an appointment that long for all but new patients has become a dinosaur of the past at many clinics. In its place is now the infamous 15-minute “med check” which focuses on symptoms, medications, and side effects. Psychotherapy may still occur, but generally when it happens it is provided by someone else like a psychologist, social worker, or mental health counselor who often is not affiliated with the psychiatrist.

This shift occurred as insurance companies began to exert more and more control over medical care. Reimbursements dropped more sharply for psychotherapy relative to other types of services. Yes many psychiatrists will be quick to say that they still are the primary therapist, but increasingly these are folks who no longer accept insurance at all or, if they do, accept only higher paying private insurance. For patients with public insurance like Medicaid, good luck.

While it is easy to blame the greedy doctors, the reality is that psychotherapy payments have become so low relative to more procedure-based practices that hospitals and clinics simply can’t afford to use M.D.s as therapists, especially when there are other qualified mental health professionals who can do this competently. Prescribing psychiatric medications, on the other hand, is something that few people other than psychiatrists have been trained in and feel comfortable doing (although many primary care physicians do it out of necessity). This brings me to the issue of patient volume. A psychiatrist who is willing to see patients briefly can see up to four times as many patients as a professional who works on the 50 minute patient hour. With psychiatric practices and clinics now experiencing painfully long waiting lists, the psychiatrist as therapist increasingly looks like a luxury nobody can afford.

Economic realities aside, however, one must still ask a very fundamental question. Can a 15-minute med check constitute good care? In my view, the answer in many if not most cases is no. Along the lines of the famous saying that “when you‘re a hammer, everything looks like a nail,” the med check almost begs for an approach that overly relies on medications. Contrary to some public opinion, it actually does take quite a bit of skill to be a good “psychopharmacologist” — the term that is now often applied to psychiatrists who focus mainly on medication treatment. In 15 minutes, however, there is barely enough time to go over side effects, dose and medication changes, and informed consent, let alone engage in discussions about what may really be going on in a patient’s life and how a multitude of other possible interventions (improving sleep, exercise, nutrition, relationships) might be useful. Even when patients are discussing these things with a different person doing the psychotherapy, there usually is no good mechanism to communicate between providers and use this information in real time, in part because that precious time spent discussing care between clinicians is paid for by no one.

The end result is a mental health care system that is overloaded, uncoordinated, and over-focused on pharmacological solutions. Complaints against the med check format and the system that surrounds it have been aired for years, coming from both patients and psychiatrists alike. While some patients welcome the efficiency of a quick in-and-out visit, it is probably fair to say that most patients find these sessions woefully inadequate to convey the information needed to make good decisions and build a positive alliance with their doctor.

Fortunately, there may be some positive change ahead. Our own university-based child psychiatry clinic has essentially “banned” med checks and insisted on patients being seen no more frequently than two per hour. We are also experimenting with technology that might make communication between providers quicker and more efficient. On a larger scale, the possible replacement of the current fee-for-service model of care (in which providers get paid only when they have face-to-face time with a patient) with systems such as accountable care organizations, which pay a set amount for a population and leave the clinicians to figure out how to provide care best, hold promise, yet certainly have their own set of challenges.

In the meantime, my advice for people seeing psychiatrists or primary care physicians for 15-minute med checks would be following:

• If you don’t have a psychotherapist to discuss things in more depth, consider getting a referral. It is rare that someone who needs to take a medication would not also be helped by seeing a good counselor.
• If you do already have a counselor, encourage the psychiatrist to collaborate with that person and perhaps even agree to have a “conference call” during your session.
• Find out what you can about science-backed nonpharmacological approaches to emotional-behavioral problems. If possible, hold off of new medications or increased doses until you get the information you need to make a truly informed decision.

Overall, be skeptical of any prescriber who seems to be interested in nothing but symptoms and medications. Of course, there are many instances when medications can have a very important role in treatment, but what should be “checked” in doctor visits is the patient, not the medication.

@copyright by David Rettew, MD

David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.

Follow him at @PediPsych and like PediPsych on Facebook.