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!