Psychiatrists, Light Bulbs, and Bad Medicine

Had it not inspired me to compose a new light-bulb/psychiatrist joke this apparent accusation from David M. Reiss, M.D. on a recent listserv posting that implies I practice "bad medicine" might have offended me: 

"Another (less obvious reason) why the "15 minute med check" that is now the U.S. "standard of practice" is bad medicine. No therapeutic relationship by which to know your patient and communicate effectively on an emotional basis as well as simply providing a few "facts" = increased risks."

Here's the joke:
How many psychiatrists does it take to change a light-bulb? (punchline below)

So a medication management visit that lasts 15 minutes or less is bad medicine? Does that only apply to psychiatrists? What about internists and orthopedic surgeons? There must be a lot of bad medicine out there.

Maybe Dr. Reiss really just wants psychiatrists to provide psychotherapy to every patient on every visit. But what about those non-psychiatrists again? Must the gynecologist do psychotherapy? What about the dermatologist? More bad medicine?

Maybe Dr. Reiss just thinks patients with psychiatric disorders need this extra time. But psychiatric patients need gastroenterologists and ophthalmologists too. Still more bad medicine.

What about knowing your patient? Would Dr. Reiss have us believe that every encounter in which a physician does not "know" the patient constitutes bad medicine? That would probably cover almost every emergency room and urgent care encounter. What's more, I suspect most psychoanalysts would tell us that it takes years to know a patient. Until then, bad medicine? Besides, I would argue that even in intensive long-term psychotherapy the psychotherapist only knows the patient in the context of that artificial setting in the office with no one else around.

Apparently reading my mind, Dr. Reiss jumped the gun, sending me a comment even before I could post this, taking some of the wind out of my sails. He says:

"My argument is not that 15 minute med checks are always "bad medicine", not at all, I believe that it should be a clinical decision how long and how often a pt should come in, not an administrative decision. I would go heavy on 15 minutes being inadequate in the situation that I see advertised all the time - come in as a new doc/locum, take over a case load, but for existing cases, you don't get time to do your own eval or really meet the pt, it's all pre-scheduled at 15 minutes."

Perhaps we agree after all. Even a 30 minute med check may not suffice for a complicated patient, but for a stable patient taking only one medication for a long period of time five minutes may be more than adequate. This is no more true for psychiatric patients than for non-psychiatric patients. Good -- and efficient -- medical practice requires that the physician know which questions to ask in a minimal amount of time. We cannot afford the luxury of truly knowing our patients. Forcing every patient to undergo a 50 minute psychotherapy session whether they need it or want it or not would also constitute bad medicine in my book.

In his "comment" Dr. Reiss addresses two other important problems. He mentions the practice of a new physician jumping in with short follow up visits having not performed a full evaluation. I share his concern. However, one might not be able to accommodate such a thorough evaluation in situations like locums or when covering for another physician at home. As for the prescheduled 15 minutes slot, one can only hope that a no-show or other shorter than scheduled encounter might compensate for a patient who requires extra time. I might add that the old practice of scheduling one patient per hour usually results in less such flexibility of scheduling.

Only one, but the psychiatrist has to know the lightbulb.

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