If we had 1 extra minute with our patients, what question would we ask?
FROM THE EDITOR
During the last year of my residency in psychiatry, I watched a TV series called Northern Exposure, a comedy-drama series that played for 6 years. Main character Joel Fleischman was a neurotic physician from New York City who had just completed his residency in family medicine. Joel had agreed to work for 4 years in Alaska in exchange for the state financing his medical education. He was assigned to work in the remote fictional village of Cicely, which had a lively and eccentric population.
John J. Miller, MD
One of my favorite scenes, which I can still vividly recall, was a conversation between Joel and Leonard, the local Inuit shaman. Leonard shares with Joel his wonder at the ways of modern medicine. He cannot understand how Joel can spend only 15 to 20 minutes with a patient and be able to construct a diagnosis and treatment plan from that brief encounter. Leonard explains to Joel that for him to diagnose and treat a patient he needs to live with that individual for several days to see what their stressors are, watch them while they sleep, understand their lifestyle and interpersonal interactions, and observe their diet patterns and exercise activity.
At that time, in 1990, insurance companies allowed us to meet with our patients for 1-hour visits each week. The first 10 minutes was usually focused on medication management, and the remaining 40 minutes were spent engaging in various types of psychotherapy. After my residency I practiced this style for a few years at a local community mental health center. Despite the weekly 50-minute appointments it often took me 6 to 12 months to begin to understand the complexities and biographical significances of each patient. I treated a man who presented with a classic major depressive disorder. He was a successful local businessman who rarely missed his weekly 50-minute appointment. It was only after meeting for 12 months that he started to discuss his chronic and disabling obsessive compulsive symptoms. He felt shame and embarrassment when he first began to share his dark secrets, but ultimately had a great response to treatment.
It was in the early 1990s that the ensuing tragedy began. As managed care intruded into the medical profession, patients had to get authorization for their initial psychiatric evaluation and for 1 or 2 follow-up visits. I would then have to fill out a treatment plan form and request authorization for 3 or 4 more visits. After several years of this nuisance, the insurance plans determined they were spending more money to manage treatment authorizations than they were saving by managing us, so this protocol was discontinued.
The next step was a classic move-countermove battle of wits. Insurance companies decreased payments to psychiatrists for a 50-minute visit, because the insurance companies were of the opinion that lengthy visits could be provided by other professions who could be paid significantly less. As a result, psychiatric visits shrank to 30 minutes; payment for two 30-minute visits was significantly more than one 50-minute visit. The insurance companies executed their next countermove by lowering the payment amount for a 30-minute visit. A counter-countermove by some psychiatrists was to then see 3 patients per hour, allowing the billing for 3 units of treatment instead of 2. Alas, the response was a predictable counter-counter-countermove that ultimately led to the current general structure for psychiatrists to see patients for a so-called “15-minute medication check.”
Leonard the shaman would be extremely impressed or, more likely, appropriately deeply saddened by how little time psychiatric providers in most clinics now spend with patients. I would like to propose a new model: the 16-minute medication check.
Think of all the additional information we could learn about or convey to our patients if we used that extra minute to simply ask 1 or more of these questions:
1. Tell me about the most important individuals in your life.
2. What is it like for you in your work environment?
3. Do you have any questions about any of the medications that I am prescribing for you?
4. Have you considered a trial to lower one of your medication’s dosage?
5. Could you remind me of your active medical problems?
6. What are your long-term goals in life?
7. Who lives with you, and how do you get along?
8. What are you most afraid of?
9. What is a typical breakfast, lunch, and dinner for you?
10. Do you feel rested when you wake up in the morning?
11. Who do you feel had the greatest influence on you growing up?
12. How do you express anger?
13. What do you do for relaxation?
14. Do you exercise regularly? If so, what type and how often?
15. Would you like me to review the common and rare side effects of your medications?
16. What is the one bad habit you would like to change?
17. When do you feel most at peace with yourself?
18. Do you feel safe in your home and your neighborhood?
19. How do you feel your treatment here is going?
20. Do you have any questions about your diagnosis(es)?
A final reflection: if you were meeting with a psychiatrist for a 15-minute medication check, how would you feel if you were asked any of these questions? Just asking! ❒
Dr Miller is medical director, Brain Health, Exeter, NH; editor in chief, Psychiatric TimesTM; staff psychiatrist, Seacoast Mental Health Center, Exeter, NH; consulting psychiatrist, Exeter Hospital, Exeter, NH; consulting psychiatrist, Insight Meditation Society, Barre, MA.