By Dina Sokal, MD
[Winter 2007; Vol. 33, No. 2; Pg 7]
I
was recently told that I wasn’t “productive” enough and needed to do more
20 minute med checks.
However, there were no issues with the quality clinical care I gave to
patients.
I felt that this was a terrible catch 22 situation—on the one hand,
I often needed to spend more than 20 minutes with patients especially if
they were suicidal, needed to be hospitalized, or were experiencing side effects
and needed to change medications. These issues took time but had to be
addressed, especially if the agency didn’t want its reputation blemished by a
“suicide”.
On the other hand, productivity meant seeing as many patients as possible
and as quickly as possible to make more money for the agency, perhaps even a
profit!
It’s not clear to me how one juggles productivity and providing quality
care to make sure that both are achieved.
Isn’t
providing quality care “productive”?
It can prevent suicide, decrease hospitalizations, and lead to a positive
rapport with patients so that they remain on their medications, keep
appointments, and are more stable due to continuity of care.
Over the long run, the agency would make more money as referral sources
heard about the quality of care and patients kept coming for treatment.
Instead, the 20 minute med check was promoted as the sole means to the
end—PRODUCTIVITY.
I
also maintained my private practice while working for the agency and could
readily see how different 30 minutes is from 50 minutes and 20 from 30.
In 50 minutes, the patient takes time to let their thoughts/feelings
flow, and more information about
diagnoses, conflicts, factors interfering with compliance, and ways to
build a rapport emerge in a relaxed atmosphere.
This seems absolutely necessary for the psychiatric evaluation.
When someone else is doing the therapy, a 30 minute med check is doable.
It gives enough time to assess a person’s response to the medications
and ask questions about compliance, side effects, issues in the person’s life,
and you don’t have to rush them in and out of the office to write your note.
However, back-to-back 20 minute med checks give little time to each
person, especially if someone isn’t doing well or doesn’t feel listened to
enough.
You might even have to cancel two to three patients to get one person
into the hospital thereby losing income for the agency anyway.
In addition, keeping contact with the therapists, answering messages,
calling pharmacies, and doing paperwork is more difficult to complete.
I
am concerned that the quality of our relationships with patients is suffering in
this age of managed care and productivity.
People referred to my private practice sometimes complain that
psychiatrists see them for ten minutes, give them their medications, and don’t
really listen to them.
I see how there is pressure to see more patients and provide less, and in
fact, I was being asked to do that but wasn’t able to compromise as I felt
patient care would be jeopardized.
I’m curious how others are dealing with these pressures.
It was hard to realize that rapport building and relationships with
patients are not viewed to be as significant as productivity.
Hopefully,
some of you will write about your experiences with this issue for our next Maryland
Psychiatrist.