Tuesday, November 27, 2007

My Other Life


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I work in two different clinics where I see patients just for medication management. Though I've ranted about the wonders of seeing a single psychiatrist for psychotherapy who also can evaluate for, monitor, and adjust medications, the financial reality of the world is that this is not the cheapest way to offer care, and in a setting where 30% of the patients don't keep appointments, it's not practical to schedule a psychiatrist with hour-long therapy sessions. Many patients in clinic populations need case management, help negotiating benefits, and liaison with rehabilitative and vocational services-- things psychiatrists aren't trained to do.

I've said I don't do med checks. I lied. Or rather, when I'm blogging, I tend to think about my private practice, not the clinics. I do med checks. Do I think I'm giving a lower standard of care to people who can't afford to pay me? Yup, sometimes I do. Mostly though, I've come to terms with it because of these issues:
-- The financial reality: given the No show issue and poor reimbursement rates for medicaid and uninsured patients, I am often paid than the clinics are reimbursed.
--Chronically mentally ill patients need a lot of care coordination with other specialists, care providers, supported employment, psychosocial rehab programs-- and they all have forms that need to be filled out. Charts are kept separately and have to be hunted for. Billing issues must be done as well. These things are done best by other mental health folks or secretarial people.
-- Coordination of care and continuity of treatment work best if patients are seen at an outpatient clinic that is affiliated with an inpatient unit and partial hospitalization program.
--Split therapy works best if the psychotherapist is readily available for consultation, and in one clinic where I work, the patients see the therapists and the docs together. Private patient split therapy can be a hassle with regard to communication and with regard to who does which pieces of the patient's care.
-- Many patients I see in the clinic have no interest in psychotherapy and little inclination to offer much information about their lives. I ask about any new things going on in their lives, their sleep, their appetite, their symptoms, do they hear voices, are they suicidal? Any side effects? Are the meds working? Any new medical problems or medications? The patients don't necessarily come with an agenda for introspection.