Friday, January 06, 2012

What Makes a Good Psychiatrist?

A while back, I wrote a blog post called What Makes a Good Therapist.  Readers were kind enough to write in and help clarify what characteristics they like in a therapist.  Recently, a number of friends have asked me for referrals for psychiatrists, and it's occurred to me that the question of what makes a good therapist is only partially related to that of what makes a good psychiatrist, and this is a really difficult topic to address. 


Why is it so hard to figure out what makes a good psychiatrist?   I believe it's because we've had this traditional biological/psychological split in psychiatry.  In the old days, some training institutions were known for teaching residents to be good psychotherapists---and by psychotherapy, I mean psychodynamically-oriented psychotherapy, and a segment of these trainees would then go on to become psychoanalysts.  Other institutions were known for teaching their residents-in-training how to use medications effectively. 

As time has gone by, the emphasis in resident training has shifted towards the evaluation and diagnosis of psychiatric disorders and treatment with medications, and now the younger psychiatrists are good at this, but there has been a shift away from training psychiatrists to do psychotherapy, and people vary with how important they believe it is for both therapy and medications to be done by the same person.  Now throw in another variable: financial pressures favor short appointments, so some psychiatrists will see one patient in an hour, while others may see four or more patients in an hour.  There is nothing inherent in a medication-model that says appointments should be brief, and many psychiatrists who do not do formal weekly (or more often) psychotherapy sessions, still see patients frequently and for full sessions, especially when they are having a rough time.  


So here's my problem when a friend asks for a referral to a private practice psychiatrist, and it's often for a relative, or a friend-of-a-friend: I don't know what the patient needs.   While quick med-check 15 minute appointments probably do a lot of people a lot of good, I don't refer people to anyone who works this way; I just don't think it makes for good psychiatry and I don't believe that medications should be prescribed from a checklist of symptoms taken out of the context of what is transpiring in the patient's life and what is meaningful to them.    But after crossing off the 4 patients/hour shrinks, I'm still left with that idea that I'm going to refer someone who needs mostly therapy to one psychiatrist, and someone who might need some tinkering with medications to another psychiatrist.  Sometimes patients know they want to at least consider medications.  Some patients have an idea about what they need, but a large part of having a professional evaluation is to figure that out. If they've been to someone and are unhappy with their care, figuring out what they haven't liked can be a good place to start.

Over on KevinMD, Dr. Raina wrote a post a while ago about what makes a good, competent psychiatrist.    I'm going to do my own list here.  

A good psychiatrist....
  • Spends an adequate amount of time with a patient and asks targeted questions that enable him/her to at least try to figure out a diagnosis and treatment plan.
  • Listens, really listens, and conveys concern to the patient.  
  • Is respectful of the patient's concerns and feelings.
  • Has a good understanding of medications and their safety issues and interactions. 
  • Stops medications if they haven't worked after a reasonable trial.
  • Respects a patient's wishes to lower doses or change medications if there are side effects, provided this is a reasonable thing to do (it usually is, but not always). 
  • Is cognizant of the possibility that the risks of medicines may outweigh the benefits.
  • Uses addictive medications with appropriate caution, as if anyone is exactly sure what that means.
  • Is hopeful and optimistic.  No one needs a shrink to tell them they are going to have an awful life.
  • Is flexible enough to try another treatment or approach (and another and another) if the first ones don't work.
  • Seeks consultation when the going gets rough.
  • Sees patients in distress frequently.  Sessions every three months may be fine for someone who is doing well, but "come back in three months" is not reasonable if the patient is not doing well and a medication change is needed.  Phone contact may be a reasonable alternative.
  • Includes family when it is indicated and the patient wishes this.
  • Communicates with other physicians and therapists if necessary.
  • Gets patients in quickly if there is an emergency.  "My next appointment is six weeks, if you can't wait go to the ER," doesn't cut it for me.  
  • Is conscientious and respectful of the patient's time.  Returns phone calls and generally runs at least sort of on time (15 minutes late is one thing, consistently 2 hours late is another thing).
  • Is warm and empathic and has a manner that makes it easy for patients to feel comfortable confiding in him/her.  Unfortunately, this is a very personal thing and one person's wonderful shrink may be another patient's evil monster.  It's also probably the characteristic that is most subjective and most important to patients. 
Please note that my Good (ideal?) Psychiatrist criteria apply only to the outpatient setting in a world devoid of monetary pressures.   The pressures on psychiatrists in institutions are such that logistics may make these ideals impossible to uphold.  Also, this is life in my ideal 'bubble' world, in areas where there are shortages of psychiatrists, upholding these standards may be impossible, and it's not good psychiatry to practice in such a way that 95% of the population go with no care because the psychiatrist is spending so much time with 5% of the population.  


You know how this works: please add you thoughts on the good psychiatrist to our comments below! 

43 comments:

jesse said...

This is an incredibly complex problem and you have delineated it perfectly. I refer just as you do, trying to ascertain the best practitioner for the individual problem. I was trained at one of the psychoanalytically-oriented institutions in town and chose it precisely because it fit my interests. I want to help people and try to understand what the issue really is, which is often quite different from what the patient initially identifies it to be.

That said, the basic problem is trying to help the greatest number of people vs. listening empathically and helping people as I am best equipped to do.

I certainly can see a lot of people in a short amount of time but that is not what I choose to do. My interests are in the complexities of what makes us human, not in the quickest fix because there are people lined up to see me. If I were in a situation where working in that mode were necessary, I could do it, but it is not where my interest nor abilities lie. Chemistry as it is is not my interest.

So I generally spend an hour, or more with each patient. I find it fulfilling and am glad I can help the patients I do. Yes, there are a sea of other patients who need help, but until I am personally acquainted with them they do not weigh on me: those that I have seen, whose lives I understand, do. I have come to terms with this: I cannot treat the universe and need to find a compromise in which I do the best work I can and help those I can. Others find different solutions to fit their own needs, which I completely respect.

Anonymous said...

Being present is also a good thing. Showing any sign of boredom is bad.

Being aloof is bad. Being actively engaged is good.

Never speaking an encouraging word is bad. Occasionally saying things like, "you can do it" or "you're good at xyz" is helpful.

Not moving patients in an out on an assembly line is good. As you mention in the post, seeing 4-5 patients an hour is not only bad, it's borderline negligent, in my opinion.

Being willing to consider the fact that drugs aren't for everyone is good. Writing a prescription for every single patient who walks through your door is not only bad, it's demeaning to you and your training as a physician (but awesome for your wallet).

Getting annoyed when a patient doesn't want to take a drug you recommend is bad. Respecting patients' treatment goals, wishes and values is good.

Viewing everything you don't like about a patient through a "transference" or "borderline personality" lens is horrendously bad and you should be ashamed. Viewing each patient as an individual with individual characteristics that you may or may not like is better.

Calling people by their disease names (e.g., "the borderline I saw earlier today" as opposed to the person with borderline personality disorder whom I saw earlier today) is awful. Respecting people as human beings who may or may not have what amounts to a socially constructed disorder is better.

frenetic said...

So your definitions of the ideal psychiatrist? Almost all of those criteria fit with my current psychiatrist. I feel lucky.

Trust is a big one for me. If you don't trust someone, the relationship doesn't go anywhere.

Validation - don't tell your patient how someone else they treat has been able to handle your situation or worse, much better than you.

Rapport - you have to feel comfortable to tell them anything, no matter how embarassing.

I see a psychiatrist anywhere from once a month to a couple of months, depending on where I am at... usually for 45-60 minutes. Mostly medication, some talk therapy. They have always called within the day when I was going through any crisis and I had called them.

Weekly I see a psychotherapist.. for well, therapy!

In the end, the ideal psychiatrist is the one that whenever you interact with them, gives you the kind of attention that makes you feel like you are their only patient. I've been there and it makes me totally respect ( and in awe) of my psychiatrist. I know this is not an easy feat for them, as they are human and have their own life... but I appreciate it!

Sarebear said...

all three of my psychiatrists "violated" some of the criteria on your list; one jumped to conclusions alot and would not listen once he had jumped, one left me on a med for 7 months that was clearly bad for me and eventually, zombi-fied tho i was on it, I figured it out and tapered myself off it and quit that shrink, then the third one was disrespectful of me and my feelings, yelling at me when I told her I was afraid of her.

Then again, in a market with maybe not enough psychiatrists, or at least not enough that take insurance, flawed practitioners is what you get. Everyone has flaws, of course, but I couldn't live with any of these, ultimately, in the course of treatment with them; I tried for almost a year after the last one yelled at me.

To her credit, tho, she sort of recently prescribed me a refill for three months on my mood stabilizer, even though I have no way to get in to town to see her (well, I didn't until my husband got laid off, yesterday).

It's just to bad it is seeming like this mood stabilizer is causing unacceptable side effects similar to others in the past, darn it.

rob lindeman said...

{Bullet} a good psychiatrist doesn't coerce his/her client

{Bullet} a good psychiatrist doesn't excuse his/her clent's bad behavior

Anonymous said...

Great blog entry.

I would also add supports patient's desire to stop all medication and doesn't try to subtly undermine the process.

My former psychiatrist did cooperate with my desires to stop all medication even though it was clear to me he was opposed. Unfortunately, his opposition was reflected in subtle attempts such as the type of questions he asked. It was clear he expected me to relapse any moment which was quite demoralizing.

What would have been nice if he had provided encouragement such as you're doing a great job of tapering in spite of dealing with factor X.

AA

Daniela said...

Great post! You've succeeded in explicating, without defensiveness, the bedeviling cloud of reasons that make the delivery of competent, much less excellent, psychiatric care so difficult today. What a public service. Write on! Please.

Manchester Psychiatry Society said...

Do you think part of the problem is that Psychiatry doesn't really seem to have a good working model of mind? There's so much emphasis on the biological aspects of mental disorders, presumably because of big pharma's influence and time constraints of psychotherapy?

It seems as if Psychiatry is desperately trying to cling to a biomedical model because it feels more scientific. Yet there is good evidence supporting the efficacy of psychotherapies such as CBT. For British readers the NICE guidelines recommend offering CBT even for disorders such as Schizophrenia, yet this is rarely practised. I think being open and aware of the evidence base for psychotherapies as well as medication and therefore offering both, rather than a 'quick fix' is very important.

Liz said...

ooohh-- this is a fun one.

i want a psychiatrist who is extremely knowledgeable-- someone who is well educated and somewhat experienced but open to new research and ideas. i want a psychiatrist who is also a good listener and a clear communicator.

i want a psychiatrist who is invested in my care but maintains good boundaries. for example, i had one psychiatrist (dr. z) who tried to fire me because he was "too old to worry so much." this, to me, indicated a bit of a boundary issue, but we ended up working it out and i was with him for two years until he retired.

i want a psychiatrist who is humble enough to say, "wow. this isn't working. let's try something else." or, like one psychiatrist did a year or so ago (dr. m), "what can i do differently from here on out?" and who is confident enough to say things like (dr. m's intern): "we know what you have. we know how to help you. but you have to try harder." and i want to have a good enough relationship with this person that i am able to hear those words and believe them.

and that hopefulness you mentioned-- that may even be most important-- i want a psychiatrist who can envision me living the healthiest life possible, and has the skills to assist me in getting there. (for example, i remember when i got out of the psych hospital when i was sixteen, and i read that the psychiatrist (dr. a-h) had written-- PROGNOSIS: POOR. it hurt me deeply.) dr. m., on the other, asked me questions that led to me believe he could see a better future for me, such as, "have you considered what you want to study in graduate school?"

i think psychiatrists have far more power than they believe. the ones who have helped me have helped me tremendously, such as the one who referred me for dialectical behavioral therapy. the ones that have hurt me have hurt me worse than anyone else i have ever encountered, confirming everything negative i believed about myself. the biggest difference between the good and the bad? the good are most interested in how they can help a patient enhance their quality of life. the bad are more concerned about other things-- avoiding a law suit, acting out their own dramas, etc.

Anonymous said...

-seeks out consultation/supervision when the going gets rough -- can't emphasize enough, and I suspect that often psychiatrists in solo private practice fall prey to not doing that most often. It is a tremendous disservice to the patient, perhaps even a form of abuse (not technically, perhaps, but quite practically). When meds are being played with, my shrink often says, I think x or y will work, but if this lasts for another 3 days then I'm going to consult with x, the head of the neuropsych dept at the local world renowned psych unit. I never think less of her; the opposite, I greatly respect that she is not so arrogant as to not ask for help when might be needed. Every other profession in the world bounces ideas off of each other. What might possibly possess shrinks to think they are above that?!

I'd also add a good psychiatrists needs to actively stay up to date with current psychopharm research and practice. Perhaps psychotherapeutic research if they practice that as well; however, I am not convinved any of the psychotherapeutic research out there is scientific in any way, and therefore valid as anything more then case study reading. Though that is another topic.

-Sees patients in distress frequently, or finds a way to be in contact if schedules don't work, etc.

-Flexible enough to try another approach -- can't agree more. Or, if the shrink can't do that, to recognize it, acknowledge to the patient that s/he isn't able to treat x,y,z in the best way possible, and refer the patient onward.

Which brings up - self-awareness? If the patient isn't getting better, or the therapy is not effective, or the match isn't a good one....refer on to someone who can be effective for that patient. You are wasting valuable time in the patient's life. It is selfish to decide that all issues in the treatment are interpersonal and can be worked through. This is a patient's life - refer them to someone who can treat them appropriately.

Pretty good list, Dinah. But in answer to your initial question, I would say that when you do make those referrals, make sure that it's a clinician you respect, and that s/he has a network of his own that he can refer to if it doesn't work out. You aren't responsible for everyone.

Teufelhunden said...

Essentially, you're saying that a good psychiatrist is someone who makes far less money than a "bad" psychiatrist. If you see a patient Q hour versus Q 15 min, you're going to bill for essentially one-quarter of the amount. Is that correct?

I guess the other alternative would be to accept cash patients only, where you can charge a reasonable fee for your hour-long appointments.

One of the (few) things I've enjoyed about practicing in the military is that I can spend as much time with patients as I deem necessary, and my salary goes unaffected. This will be a tough transition when I get out in a few years. I'm just going to be honest: I don't want to be poor. I want to make a good living, so I'll probably have to compromise some things. There's no way (outside of a cash business) you can make a living in psychiatry seeing one patient per hour.

pre-med psych patient said...

As a psychiatric patient who hopes to become a doctor (and perhaps even a psychiatrist), I have made a mental list of the ideal psychiatrist:

-is on time, at least and especially for the first appt. Meeting with a psychiatrist for the 1st time is a very anxiety-provoking experience, and the longer the patient waits, the more hell s/he goes through.

-asks a patient what s/he means when s/he says that he is not "seriously suicidal". This topic is very difficult for patients to talk about, and we frequently downplay the severity of these thoughts and feelings. It's very dangerous not to ask for clarification. And then ask again.

-doesn't go on vacation for a month with no way to be reached. I fired the psychiatrist who inspired this point.

-loves her/his job. Like the shrink rappers, s/he is very passionate about psychiatry.

That is it for now.

shrunkenhead said...

@pre-med psych patient:

With my shrink (psych, MD) it goes like this: if you are my patient, you are stable enough to make it through a month or three of my vacation without any back up, and in the event you run into trouble, call 911. Best of luck to you all in finding someone that lives up to list in this post. That is a dream from another era. And if that means that Dinah and Jesse are from another era, yep, they are.

Carrie said...

I'll just say that I am very lucky. :) Nice post!

Anonymous said...

A good psychiatrist:

is honest about what they don't know (i.e. doesn't say things like "you have a chemical imbalance" when they don't know that);

doesn't talk down to the patient;

doesn't hide things from the patient - if they write it in the medical record they need to have the guts to tell the patient their opinion as that's what the patient is paying for;

doesn't coerce, threaten, or force;

discusses side effects with patients;

recognizes if the patient gets worse with treatment then maybe the treatment is the problem;

actually has patients that get well and don't need them anymore;

doesn't look at their patients sadly and say "you will probably have to take medication the rest of your life;"

respects an adult patient's right to make their own decisions, even bad decisions;

puts themselves in their patients' shoes - i.e. how would the psychiatrist feel if they were depressed, had a h/o being sexually assaulted and were re-victimized by being forced to strip, put in a room with a metal door, etc. during hospitalization;

Pearl Imber said...

Pearlie said....
Yes Virginia, there really is a Jesse, who happens to live and practice Psychiatry in this era! My thanks and gratitude go out to him.

Anonymous said...

@shrunkenhead: cannot even imagine. My psych has other back ups within the office that I would trust.

One thing I think is important, is where you live. Do you have a lot of psychiatrists available or no? There is a shortage of child psychiatrists in my area, very few based on the population, so they are in demand,and most not taking new patients. Adult psychiatry is different. But in the end, how good a psych is, partially has to do with the psych's personality, how much they actually like their job and how overworked they are -whether by choice or not.

I often wonder what kind of a toll this specialty takes on these psych's families. Perhaps it is no different than any other specialty??

Anonymous said...

A good psychiatrist practices like it is what he would be doing even if it were a low paying job or had little chance of ever paying very much--like someone who dreams of becoming a dancer or an actor and does everything to keep that dream alive even though he may never be a Hollywood star or a famous dancer.

Jen said...

@military psych guy -
move to new york city, where even lousy psychiatrists in their first year of practice can and do charge $300/hour and keep a full practice with a long waiting list. I think it's insane for the good ones, but at least with them you're getting what you're supposed to be paying for.

amazing.

Dinah said...

The good psychiatrist is not easy to find. I don't meet my own criteria consistently.

Some of the comments center around uncontrollable factors in the shrink's own psyche. Loving what they do, not being bored? What's a shrink to do if he finds a patient to be boring? What if he's preoccupied with a personal problem, or fighting off the flu? We are people, with good days and bad, and while it would be nice if we could have our hearts fully invested every moment, no one can really do that for every patient at every moment, and still it seems to me that patients who are boring or who come on a day when the shrink is not at their best, still get better from their illnesses.

AA-- here's the dilemma, if the psychiatrist truly feels that stopping the medication is risky, should they lie in the name of "support?" It seems to me that if the shrink feels there is risk, that a good shrink says "here is the risk, here is the benefit, the statistics are that 90% relapse and I think it's wiser to stay on the medications" That seems like it might feel like it's undermining, but it's honest.

I guess I'm commenting on comments that ask if a good shrink is honest. And for the most part, I feel like honesty is essential with the exception of what might be unprofessional or hurt the patient's feelings or violate the shrink's right to privacy. ("You're really boring" or "I'm waiting for biopsy results on my prostate and I'm a bit preoccupied"or "I find your political views despicable" etc).

A good psychiatrist has another psychiatrist covering if they are not available by phone, for more than a day/weekend. I thought that was a given. Apparently it belonged in the original post.

Teufelheuden-- it depends. Many good psychiatrists charge high fees and don't participate in insurance networks and make decent money. You are probably right that someone seeing 30 patients a day, every day, makes much more money. It's work I couldn't do.

Anonymous said...

I think the problem with writing things that are not addressed is that the patient may at some point read their records and will realize the dishonesty. I would much rather have read the catty comment from my psychiatrist in the beginning before I invested all that money. I would have gone somewhere else and we would have both been a lot happier. In the end all that did was waste a lot of my time and money.

Anonymous said...

@Dinah: I will have to disagree with your comment about sick and/or bored shrinks. I would really hope a shrink fighting off the flu would not be at work. I could understand a small cold, but I don't want a shrink working while impaired. And actually, I did once see a shrink have an allergic reaction to something someone had given him as a gift while we were talking. I graciously excused him.

For me it is more of a work ethic issue. McDonalds doesn't care if you feel bored or unwell. You still have to be quick on your feet, clean those tables, and be friendly with customers. I saw a human sign get in trouble once for taking a sip of water while on the job in scorching hot weather. He bent down, took a sip from his sports bottle, and went back to work. The employer just happened to drive by at that moment. He was informed that he had only been scheduled to hold the sign for two hours. That meant no water or bathroom breaks. And that was in heat stroke weather.

My point is, psychiatrists get paid so much more than people who clean tables at McDonalds and people who hold signs for a living. They should not be noticeably bored or unenthusiastic about what they do. I've met pizza delivery boys with better work ethic. What if your hair stylist wasn't feeling well and didn't do a very good job with your hair? Or seemed completely bored by you? Don't you like going to hair stylists who seem to love playing with hair and make small talk with the customers?

Anonymous said...

I agree with the previous post. Patients are paying a lot of money to have the psychiatrist's undivided attention. If the psychiatrist for whatever reason cannot provide that, then they need to take time off until they can.

yayayatlada said...

Oh, I have spent a lot of time, sometimes a lot of money, to be in the presence of a shrink who was not really there. Going forward, I will go see a shrink to help me manage meds. I have found that expecting anything else is akin to searching for the Wizard of Oz, and I am quite weary, not to mention wary, of that. Although I have not met a shrink who admitted to taking meds to manage a mental health condition, I have not met any who qualify as mentally healthier than I am.

Sarebear said...

Well, I had summarized my problems with my shrinks which admittedly does not describe the WHOLE situation. Let's just say I would not dump a psychiatrist just cause she yelled at me once; there's other things involved, although her attitude over time tends to lead me to believe that her personality might be prone to yelling again at some future point . . .

The first one, who jumped to conclusions and wouldn't listen after doing so, well I invested myself in working on the relationship between us and on trying to tell him what he did and didn't do (like listening, he didn't do some appointments), and there were some times when we worked together brilliantly. By the end of our relationship, though, if he hadn't been leaving private practice I was at the point where it was time to fish or cut bait; I'd put the time in and he was consistently inconsistent with me.

Then again, he was going through some stuff, which is likely a factor in at least some of his inconsistency, among other things, but when that goes on for several years and my trying to improve the relationship doesn't help, it's time to move on.

Anyway, my relationships with my psychiatrists were more complex than my little summary of succint problems made them sound, but that's what happens when you summarize.

I don't feel like anyone was attacking me or what I said, I just felt the need to expand on why they were a problem for me.

Cris said...

Articles like this make life so much simpler

Dr. Psychobabble said...

I find it fascinating that the last item, "warmth and empathy" is the most subjective yet also the most important to the patient, as you mentioned. I think when many folks ask for a "good psychiatrist," they mean one with whom they can establish a good rapport (warmth and empathy critical here), yet that tends to be one of the more difficult to evaluate and predict....

Anonymous said...

Competent and ethical

Dinah said...

Ah Dr. Psychobabble...but certainly there are some people who get more "warm & empathic" votes than others, it's just not a clearly measurable thing.

And the funny thing is that while patients do feel this is crucial, maybe it's not what makes a good psychiatrist? Would you rather have a warm, empathic, likeable psychiatrist you can talk to, but who doesn't get you better from your depression, or someone with the social skills of an iguana (to quote Shrink Rap the book) who finds the right medication to get your treatment-resistant depression to remit?

notoreptileshrinks said...

The iguana won't be of much use to me after the medication stops working and I am at the end of my rope. Then again, neither would a warm empath who only works every other day all year and takes a three month summer hiatus.
Seriously, I have an iguana for a physician. That may explain why I avoid going to the doctor. if my shrink were an iguana, I would probably not go long enough to be prescribed the right med.

pre-med psych patient said...

Interestingly, how the patient perceives the psychiatrist can have a very profound effect on how the patient responds to any meds prescribed. I suggest that everyone read this: http://www.psychiatrictimes.com/dependent-personality-disorder/content/article/10168/1946385

Fascinating.

Dinah, I didn't mean to say that a good psychiatrist has to love his/her job at all times. I meant that generally, s/he has a love relationship with psychiatry. From what I gather from your blog, you more than fulfill this requirement. :) In fact, that point exists because I wish that every psychiatrist was as passionate about his/her profession that s/he would want to spend hours each week blogging about it!

Anonymous said...

Ethics and competence rank higher than empathy, for me. I had psychiatrist who was unethical and kept landing in front of the medical board, but he was a master at establishing rapport with patients. That ends nowhere good.

My favorite physician was a bit of a curmudgeon. Anything he wrote he would have the guts to address. I may not have always liked or agreed with what he said, but I respected him and his opinions. That's the kind of doc I prefer. Open and honest, no hidden stuff to try and protect my feelings.

Sean said...

These are great guidelines. The major consideration is time and reimbursement. Insurance companies really resist paying for appropriate payment for psychotherapy, especially when patients are not taking medications. I think one alternative is a close collaboration with a group of psychologists who perform psychotherapy.

Anonymous said...

I think I kind of made it sound like empathy is a bad thing. I definitely don't mean that. I just think ethics and competence rank higher in importance, at least to me.

That said I've met some ethical psychiatrists who were complete duds at communication, so, hmm...

Maybe, I should rethink this.

Anonymous said...

"here's the dilemma, if the psychiatrist truly feels that stopping the medication is risky, should they lie in the name of "support?" It seems to me that if the shrink feels there is risk, that a good shrink says "here is the risk, here is the benefit, the statistics are that 90% relapse and I think it's wiser to stay on the medications" That seems like it might feel like it's undermining, but it's honest. "

Dinah,

As an FYI, my tapering occurred close to 4 years. So my psychiatrist had plenty of time to see I wasn't relapsing. I still feel like I was undermined in a subtle way.

By the way, I would love to see a link to a study for those statistics. As we have previously discussed, I feel the the psychiatric literature greatly minimizes withdrawal issues and confuses them with a relapse due to a way too fast tapering. I know you disagree vehemently but I wanted to mention that.

To answer your question, no doctor should ever lie but in the end, it is the patient's decision. And you know, you actually could be wrong.

By the way, I am not just talking about psychiatry as many patients do well going off of blood pressure meds even though their doctors acted like they were going to have an immediate stroke if they did that.

Finally, what scares me about sentencing patients to life on meds is they could perhaps have a medical condition that is causing psychiatric symptoms that has been overlooked. Or perhaps the psych meds might worsen the medical condition so badly that the disadvantages of staying on the meds outweigh the positives.

Just so you know I am not picking on psychiatry, I think this happens in the regular medical world constantly. In fact, I have heard of psychiatrists who actually realized the person was misdiagnosed.

AA

Anonymous said...

I appreciate a psychiatrist considers side effects as important a factor as effectiveness in starting or stopping a medication.

For example, if I say I don't want to take an SSRI because of sexual side effects, I'd rather hear "well, sexuality is important, so let's see what other options there are" than "these medications work well if you can tolerate the side effects" or "some people consider that side effect a benefit".

Anonymous said...

A good psychiatrist would treat each patient like they are their own family member. Simple as that.

Jimmy said...

Dear Dinah:
Not Treating patients like a human being.

Some examples:
(1) Referring to patients by disorders (2) Insisting that patients tell them only the symptoms (my personal experience) (3) Angry at patients who didn't want to take psychiatrist's recommendation yet not interested in finding out why (4) Bossy (Like "Don't ask, just take it)

To make it worse, some patients, who got the first impression like this, never wanted to see another psychiatrist dued to previous bad experience and feeling like psychiatrists are all the same.

EastCoaster said...

I know that at Brigham and Women's in Boston, psychopharmacology appointments last 30 minutes. They can do this, because Partners hospitals have negotiated higher reimbursement rates than others.

There's a cash-only psychiatrist I've heard of who charges about $400 for a 10 minute appointment. I don't care how brilliant he is, I doubt that that's enough time to use his skills to good effect.

Once a month or once every 2 months for 30 minutes seems okay.

Anonymous said...

My psychiatrist meets pretty much all of these and I think we have a very good rapport, and he's been very helpful.

The exception - I don't phone him or expect him to phone me, and if it is urgent the deal is to go to the ER. I actually think this is reasonable, I like reliable boundaries and I know he has a lot on his plate.

COAlikesnam said...

lol... it seems this Dinah fellow believes that life is a bitch and people should suck it up (despite him being a doctor, whose job is to cure/manage illness). For what it's worth, I accept that life has challenges, but I genuinely feel that people who hold a downbeaten attitude shouldn't push their misery onto others.

I would generally agree with the list, but I would also add that a psychiatrist should pursue any feasible length to cure/manage the condition. Even if this is unconventional means such as taking up sport (if it makes one happier/more content), or even going to church often (if one is religious of course), then these should be avenues to pursue.

The basic point of a doctor in any branch is to remove or limit illness, so IMO any means to do so should be considered. A bad psychiatrist IMO is one who shows no overarching desire to treat the condition, or is limited to specific approaches/treatments.

I would also say that social understanding is key. A good psychiatrist understands the norms, values, and culture of the society s/he practices in, and thus is able to relate to the customs and experiences patients face in that context. A good psychiatrist, in this context, will not berate a client for not going to church, if religious attendance is not common in his or her society or at the least is not condemned or made taboo.

Lastly, a good psychiatrist should be able to relate to a patient's personality and acknowledge that everybody is different. they should not scold a patient for being loud, quiet, shy, boisterous, or any other trait s/he may display. This also pertains to beliefs and values. Even if a client admits s/he is a neo-Nazi for instance, this should not influence the psychiatrist's judgments or practice. If the doctor in question is non-white or Jewish in this case, s/he should professionally state "I respect your right to your beliefs, however given my being, I do not believe I will be a good fit for you. I sincerely wish you the best in your recovery."

Another thing is that many cite this as "pie in the sky". lol.. really? If one goes to a restaurant, doesn't one expect it to be clean? If one buys a loaf of bread, does one expect it to be mouldy? It's not even a matter of economics, but as aforementioned I don't concur with the OP's reasoning.

jcat said...

All of the things that Dinah lists contribute, but above all, trust, empathy and hope. From both sides. Maybe part of what makes a good psychiatrist is a willingness to be a good patient?

I know I'm mentally "interesting" - that's why I ended up seeing a psychiatrist to start with. Actual diagnosis is BP2 with a heavy emphasis on the depressed bits. From there on in it's a partnership - I trust my psychiatrist to look for the best solution for me, and in turn, I will be treatment-compliant. And he trusts me enough to know that if I say it's unworkable, it really is. Be it meds or meditation or any other suggested treatment. I know he cares enough about me to give me 24/7 contact info for when I really need it (and oh boy, there have been times when I have needed that), and in turn, I care enough not to abuse it. The biggest one though is the hope - not that I am going to miraculously be cured and live meds-free forever, but that there are ways to have a pretty good life in spite of the diagnosis, and that he is fully invested in finding the ones that work for me, and in being around to tweak them when they don't.

I guess that I am really lucky, in that over the twenty-plus years since I first tried to kill myself, I have had four really good psychiatrists, who have all offered me those three things. I know that there are doctors out there who aren't that good.

jcat said...

All of the things that Dinah lists contribute, but above all, trust, empathy and hope. From both sides. Maybe part of what makes a good psychiatrist is a willingness to be a good patient?

I know I'm mentally "interesting" - that's why I ended up seeing a psychiatrist to start with. Actual diagnosis is BP2 with a heavy emphasis on the depressed bits. From there on in it's a partnership - I trust my psychiatrist to look for the best solution for me, and in turn, I will be treatment-compliant. And he trusts me enough to know that if I say it's unworkable, it really is. Be it meds or meditation or any other suggested treatment. I know he cares enough about me to give me 24/7 contact info for when I really need it (and oh boy, there have been times when I have needed that), and in turn, I care enough not to abuse it. The biggest one though is the hope - not that I am going to miraculously be cured and live meds-free forever, but that there are ways to have a pretty good life in spite of the diagnosis, and that he is fully invested in finding the ones that work for me, and in being around to tweak them when they don't.

I guess that I am really lucky, in that over the twenty-plus years since I first tried to kill myself, I have had four really good psychiatrists, who have all offered me those three things. I know that there are doctors out there who aren't that good.