Tuesday, February 17, 2009

When Will I See You Again?

In the out patient mental health clinics in Maryland, regulations make it clear: any patient on medication must be seen by a psychiatrist every 90 days, patients who are not on medications are seen by the psychiatrist every six months. This assumes the patient is stable and all is going well, and certainly some docs in some clinics see the patients more often, but a minimum is regulated.

In the world of private practice, it's less clear. If patients are in psychotherapy, it's easy enough to deal with medications during a regularly scheduled appointment. But what about the patients who are done with therapy, who feel good, who want to continue on their medication? Some patients are fine with coming in monthly, others clearly don't want to, and if things are really stable, I'm happy to see folks every three months, the standard of the clinic. There are people though, who really don't want to come in that often, where it's a hassle for them to get off work. Sometimes their pharmacies start calling for refills (--with the mail order pharmacies, this can include twice daily phone calls and repeated faxes) and there is no contact from the patient. I've taken to ignoring these calls (especially the ones from the mail order pharmacies who want okay's for a 30 month supply) if I haven't seen the patient in a long time because returning them often involves a long time in voicemail hell to convey the message, "The patient needs to call me." Patients know to call me if they are having problems, I'll get them in soon. But for someone who doesn't want to come in, who says they are fine, I'm still not sure how often to insist on face-to-face contact. Here and there someone pops up who I've long ago assumed was gone--- If someone is to call me in 3-4 months, and they don't, I don't always remember to chase them down. And when I do, sometimes they've stopped their meds, or asked their internist for a prescription.

So is there an absolute answer? Is there an absolute minimum that a patient needs to be seen for a refill? Internists prescribe for a year a a time, and so do some psychiatrists (I think). What's your thoughts?