tag:blogger.com,1999:blog-26666124.post1941751725337049910..comments2024-03-18T03:28:36.581-04:00Comments on Shrink Rap: The "Magic" of the Doctor-Patient RelationshipUnknownnoreply@blogger.comBlogger41125tag:blogger.com,1999:blog-26666124.post-46732698587142748802013-12-04T12:43:16.057-05:002013-12-04T12:43:16.057-05:00@dinah: "Being bad" about stopping at 5...@dinah: "Being bad" about stopping at 50 minutes isn't only a question of whether it runs you down or delays the next patient. In dynamic work it's also a frame issue. It invites the patient to fantasize that he or she is doing something to prolong the session (or not, on the days you don't). The importance of this will vary from patient to patient, and depending on the nature of the therapy.<br /><br />The CPT issue is subtle. If it's your practice already to see patients for 55 or 60 minutes, then obviously you should use a code to reflect that. I'm less sanguine about adjusting my practice to fit the codes, a slippery slope that can lead nowhere good. I touch on some of this in my 2 latest posts, e.g.:<br />http://blog.stevenreidbordmd.com/?p=797<br /><br />Freud tried all sorts of variations and exceptions. I like to imagine that most of the time he was experimenting, not merely bending to expediency or external pressures. In any case he wasn't faultless, so we can admire his groundbreaking work and continue to improve upon it.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-90944906968645356642013-12-03T20:20:56.614-05:002013-12-03T20:20:56.614-05:00@ Dinah: I think it just depends on the therapist....@ Dinah: I think it just depends on the therapist. If you can handle back-to-back psychotherapy patients without feeling overwhelmed then your doing fine and can get your patients reimbursed a little more money. I mean this more for therapists who feel rushed (and it shows in therapy) and are distracted by seeing back-to-back patients.dishnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-9011954951143615472013-12-03T19:42:42.490-05:002013-12-03T19:42:42.490-05:00I've always been bad about stopping at 50 minu...I've always been bad about stopping at 50 minutes and often run closer to 60 minutes -- it's fine by me and I don't think I get run down (I do try to schedule an hour off every 4 hours, and sometimes people run a few minutes late so I don't end up feeling exhausted and spent). <br /><br />So when the new CPT rules went into effect, the choice becomes to do 37-52 minutes of therapy (~roughly a 45 minute session) or 53+ minutes(a 60 minute session) of psychotherapy, plus the time for E/M services. I decided that for most people, I code it as a 60 minute session --- my fee is the same, but the patient gets reimbursed more (or so I believe). So, would a patient rather have a 50 minute session and not see the next patient in the waiting room come in and get paid roughly $50 less per session by the insurance company, or have a 58-60 minute session, and get paid more by the insurance company, but not see the next patient enter the consulting room? <br /><br />Obviously, not about 'magic' but there are some external forces that go on here that often aren't discussed with the patient. Don't tell Freud that the CPT codes won't allow for his style. Also, I think he made exceptions and was not terribly rigid about these rules. Dinahhttps://www.blogger.com/profile/09227988351623862689noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-62036590205673543542013-12-03T13:57:23.602-05:002013-12-03T13:57:23.602-05:00@dish: "I would discharge that patient. Sound...@dish: "I would discharge that patient. Sounds like an unhealthy relationship."<br /><br />Of course it's an unhealthy relationship. In a nutshell, that's what dynamic psychotherapy is about: making the unhealthiness of the patient's relationships conscious so it can be seen for what it is. In the case of the patient threatening (well, hinting) suicide at the end of the hour, it's only unhealthy if I don't say anything about it. But I did, and it ended up being useful therapy material. In my opinion, one needs a high threshold for discharging patients in dynamic psychotherapy. As I tell psychiatry residents: if patients all had pleasant, healthy personalities they wouldn't need to see you.<br /><br />The 50-minute hour was invented by Freud himself, to leave 10 minutes between patients to collect himself, jot down notes, use the bathroom etc. While there is nothing magical about the 50 minute session length, I agree very much that being in the proper frame of mind — settled, open, not rushed, preoccupied, irritated by something unrelated, etc — is a prerequisite for doing good dynamic work, and for a good doctor-patient relationship generally.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-30029444578964885322013-12-02T22:30:16.092-05:002013-12-02T22:30:16.092-05:00"Some patients threaten suicide at the last m..."Some patients threaten suicide at the last minute to assure they'll be on my mind all week."<br /><br />@Reidbord: I am not a doc, but if I was, I would discharge that patient. Sounds like an unhealthy relationship.<br /><br />And thank you for saying that about spacing the time between patients by about ten minutes. That's how I thought it was supposed to be for psychotherapy. Literally, every psychotherapist I find who is constantly rushing in the patients back to back has been soo distracted during the session.<br /><br />There was one guy that I saw who was always rushed. He was late if I was the first appointment, late if I was just after his lunch break, late at all other times. He once came in late from lunch and his next psychotherapy patient went the bathroom. They missed each other. When he finally noticed her he rushed her in, and then rushed me in directly after. I had never seen him more impatient and difficult to work with.<br /><br />Psychotherapists! please give yourself at least a 5 minute breather between patients. It's sucks for that patient probably as much as it sucks for you.dishnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-21186053163392994552013-12-02T22:19:01.917-05:002013-12-02T22:19:01.917-05:00I hadn't thought of all the other possibilitie...I hadn't thought of all the other possibilities. I specialize in avoidance, so I just assumed people were doing it for the same reason. The delay tactic.<br /><br />P-KAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-18064242464452825452013-12-02T21:25:05.593-05:002013-12-02T21:25:05.593-05:00@P-K: Not uncommon at all in my experience. But w...@P-K: Not uncommon at all in my experience. But what makes psychotherapy fascinating are the myriad other possibilities. Some patients threaten suicide at the last minute to assure they'll be on my mind all week. Some try to prolong the hour out of dependency or desperation, others out of hostility or sadism. Some half-wish I'll raise the topic when we next meet — and simultaneously half-wish I'll forget or brush off their comment as unimportant. And so on.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-35068622373697576652013-12-02T18:47:36.402-05:002013-12-02T18:47:36.402-05:00I have brought up issues at the end of therapy ses...I have brought up issues at the end of therapy sessions because I knew I didn't have the courage to talk about it right then, but also knew it was important to get it out there so I wouldn't be able to continue to avoid it next session. I would imagine that's not all that uncommon?<br /><br />Pseudo-KristenAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-35921923096830957872013-12-02T14:56:52.929-05:002013-12-02T14:56:52.929-05:00For dynamic psychotherapy I try quite hard to star...For dynamic psychotherapy I try quite hard to start and stop on time, and as a result I almost always do. ("Almost" because I'm human.) The clock is visible to both of us. This way, if someone raises a critical issue at the last minute I have grounds to wonder why they do this when they know as well as I do that the time is about up. There are a number of possibilities, and on occasion I'll go over a few minutes exploring it. The point is not to adhere blindly to a rule, nor to pack patients in back-to-back — I leave 10 minutes between patients, which I do NOT consider optional expansion space for the prior patient's session. The treatment frame creates a safe, predictable, even monotonous environment to highlight the personality features of the patient.<br /><br />For medication-only visits there is less need to adhere to such a frame, although courtesy and collaboration are still crucial. I see a few meds-only patients for between 15 and 30 minutes. I don't usually link the frequency of visits to the timing of refills, since these are usually not logically related.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-68186433934051907462013-11-30T19:57:35.255-05:002013-11-30T19:57:35.255-05:00The description is so distant from my own experien...The description is so distant from my own experience that it almost makes me want to cry. I had to deal with a psychiatrist who took one look at me and thereafter treated me only with distaste. She would not shake my hand, would not address me by name, and would not make eye contact. She was openly scornful and derisive. She may have been acting out some race and gender issues, but that does not make her behavior any less painful and destructive. I lasted three appointments and to this day regret that my depression kept me from bringing ethics complaints against her. It is years later and I still feel almost as if I had been molested. I still shiver at the thought of it.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-66879346452442301692013-11-30T12:33:00.069-05:002013-11-30T12:33:00.069-05:00Not trying to compare med management with psychoth...Not trying to compare med management with psychotherapy/med management combined. They are very different. <br /><br />Though I do think that there can be some very real magic in the doc/patient relationship in med management. Even more so than in psychotherapy. I have had zero chemistry with some psychotherapists, but had loads of it with a med management doc. I think the high distractibility and overbooking in some high volume practices is very detrimental to this. I think it is easier to be open with a pdoc you click with in med management.<br /><br />And I'm not talking Medicaid practices, which I have heard do have a high no show rate. I have seen plenty that accept Medicare (same kinda problem maybe?). Some of those high volume practices never felt rushed, they weren't more than a half hour behind, and the doc was very attentive. And they would spend around 20 minutes with me sometimes. I can't explain why some high volume practices that take undesirable insurance seem warm, attentive, and there is great chemistry and others feel rushed, harried, and cold.dishnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-65676102268545554102013-11-29T20:53:40.509-05:002013-11-29T20:53:40.509-05:00dish, no need to worry in this case-- with a docto...dish, no need to worry in this case-- with a doctor who double books appointments, chastises patients who come in before they need a refill, and tells people with emergencies to go to the ER, we have already ruled out any issue of "magic" or healing as a result of the doctor-patient relationships.<br /><br />Docs deserve to make a living, and if the doc is taking insurance because they are either socially conscious, or because they can't get enough referrals without doing so, and if they double book because they have a high no-show rate, and if they run their practice very efficiently because there is a shortage of docs in their area and they are trying to fill a need, then more power to them. The truth is that the doc who doesn't take insurance and charges much more than the high volume, in&out, go-to-the-er or google-it doc, will be seen as the kinder, gentler doc who takes the time to listen and care and form a healing relationship. But in-and-out doc may still be providing treatment to many more patients who have no where else to turn.<br /><br />And as I've always contended, a doc who doesn't like doing therapy shouldn't do it, no one ends up happy.<br /><br />So pros and cons of both styles. Some of it is in personality and delivery, so you will find high volume docs who are just more low-key and empathic who are well liked, but in meds only treatment, it's not usually the relationship that heals.Dinahhttps://www.blogger.com/profile/09227988351623862689noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-48842383151526815652013-11-29T20:32:56.247-05:002013-11-29T20:32:56.247-05:00I think that there's a baseline to what makes ...I think that there's a baseline to what makes therapy successful -- and it involves being attentive to the patients' needs. Each person is different and knowing what is important to that specific client is key.<br /><br />For example, let's say that you have a client who is very impatient and needy, who also has an attachment issue. You wouldn't want to run late, so maybe you'd want to (1) consider scheduling med-checks for the prior appointment or (2) make sure you have a larger break after the appointment just-in-case of overage. Maybe you have a client with a control issue. Pre-scheduling appointments or not asking what he/she wants to discuss may want to be avoided.<br /><br />I feel it's paying attention (listening) that is an important element in successful therapy. However, I also feel it's a two-way street. Therapy as a patient involves work. You need to be able to take note and identify the issues/problems. So if you're the type of person who can't say no to people (but are frustrated because damned-if-you-do, damned-if-you-don't), you need notice it and learn to speak up.<br /><br />Each therapist has his or her own way of conducting therapy. Some are more empathetic than others. Some are way more empathetic than they need to be. And some, well, have no empathy at all. There are reasons why and it's dependent upon the therapist and the patient. One thing for sure though, "Listen, Listen, and Listen!"HIGurlnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-83212302571201190022013-11-29T19:56:56.955-05:002013-11-29T19:56:56.955-05:00And rigid pdocs always, without fail, doublebook....And rigid pdocs always, without fail, doublebook. That way they see about six patients or more an hour and if someone doesn't show they still get a good income. Ugh. So annoying. And yet they always think their time is so important.dishnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-4702049398477924722013-11-29T19:51:24.494-05:002013-11-29T19:51:24.494-05:00Do people still wear watches? I just look at my ce...Do people still wear watches? I just look at my cell phone, but I think that might look weird in a therapist's office. I guess I could buy a watch specifically for those occasions so I can discretely look down and notice the time. <br /><br />It probably also depends on insurance and the nature of the practice you are going to. I get what Dinah is saying about just scheduling two appointments, one after the other, if you think it's gonna take longer. But, and I have no clue if this is insurance related, most pdocs I have seen are VERY rigid about their schedules. No one gets in to see them for more often than they dictate. They won't allow that kind of appointment scheduling. I have been in to see a med management pdocs a couple of times where it was requested that I come back in a week or two because they couldn't decide what to do (these were new guys). But, regardless of what is wrong, they typically demand that you only come in when it's time for a refill. And if you have any kind of intervening problem that you think requires a doc then you should go to ER or urgent care. I'v had pdocs get pissed when I've had a problem and got in early (I gave you three months worth of pills! What are you doing back here in 2 months?).<br /><br />Though, ocassionally, I do find a gem who will fit me in earlier if there if a problem. But I think the most annoying thing is when I show up to a rigid pdoc's overflowing waiting room, he is an hour behind, and I hear a patient ask the receptionist, "Why did you guys rush me in? All I needed was a refill. You could have just refilled and fit me in later when there was less people."Refills are immediate problems requiring rush appointments for these docs? The logic escapes me.dishnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-5501981881839079462013-11-29T16:00:38.296-05:002013-11-29T16:00:38.296-05:00Going right with the clock fits well if one has an...Going right with the clock fits well if one has an analytic/psychodynamic psychotherapy practice, otherwise it can be very disconcerting as people have noted. P-K, it is good to hear of your experience with your doctor. Intelligence, ability, and flexibility are all good traits! <br /><br />But, dish, if you are seeing a doctor who goes precisely by the clock can you not wear a watch? In my own office I have two clocks set up so that both I and the patient know the time. It is useful to know the time, as both the doctor and patient have good reasons to know how much of it is available.<br /><br />jessehttps://www.blogger.com/profile/11077223398907532291noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-87783835416996827032013-11-29T15:52:47.437-05:002013-11-29T15:52:47.437-05:00P-K left a post that got eaten by Blogger, but it ...P-K left a post that got eaten by Blogger, but it went out over email. So here is that post:<br /><br />My psychiatrist is generally on time, but sometimes late. I assume if he's late, that he was helping a patient in crisis. It doesn't bother me. Sometimes my appointment goes over 15 minutes, sometimes less. But, it always seems to work. If I'm doing well, and I've been on a particular medication for a while, then I don't need (or want) the full 15 minutes. When I was not doing well; paranoid and agitated, my thoughts all over the place, he also kept it really short. There have also been times when it's gone over 15 minutes because there were things that needed to be addressed. <br /><br />I don't ever feel slighted if the appointment is less than 15 minutes, though, because he has gone over the 15 minutes other times. He is also available by phone and has made it clear that I should call him if needed. He doesn't charge for the time spent on the phone calls, so patients are definitely not being slighted. I think I've only ever contacted him twice outside of an appointment - once for insomnia, and once because another doctor wanted my psychiatrist's opinion about starting me on a particular medication. He didn't charge me for those phone calls, so really it all works out.<br /><br />It would bother me if he always ended the appointment at exactly the 15 minute mark, because I would feel he was spending the 15 minutes counting down the seconds until the appointment was over. That would be irritating.<br /><br />Pseudo-Kristen jessehttps://www.blogger.com/profile/11077223398907532291noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-87533752463357978932013-11-29T14:41:37.643-05:002013-11-29T14:41:37.643-05:00I think the patient should only have responsibilit...I think the patient should only have responsibility for flow if there is a clock near the patient. Some therapists, for whatever reason, don't have a clock within the patient's line of sight. In that case, the therapist should say if they are halfway done or ten minutes to finished.dishnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-7293693799963834422013-11-28T13:10:52.124-05:002013-11-28T13:10:52.124-05:00Completely agree with what Dinah just said. In psy...Completely agree with what Dinah just said. In psychotherapy the patient understands how the therapist conducts the session. there is no "right" way but each variant has its own advantages and disadvantages. In insight oriented therapy anything that happens can provide an opportunity to learn.<br /><br />If a patient brings an important issue up right at the end of a session when the patient knows that time is up shortly, is there a reason for this? <br /><br />A doctor can go over the time allotted for his own reasons, not just for the patient's good. jessehttps://www.blogger.com/profile/11077223398907532291noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-86216560935774892812013-11-28T12:23:59.377-05:002013-11-28T12:23:59.377-05:00So is the issue one of saying it's harmful to ...So is the issue one of saying it's harmful to the doctor/patient relationship for the doctor to start/stop the sessions on time? Or is it one of saying that it's a problem if the doctor is dismissive of the patient's concerns,or does not allow enough time in the appointments to adequately address concerns? Maybe ask for longer sessions or for 2 "med check" spots? <br />I think the issue of "Listen" includes "be tactful." <br /><br />I admit, if a patient starts to bring up a very difficult topic at the very end of the session, I interrupt and ask them to save it for the next time, rather than risk having to cut off someone at a very sensitive time. And people often will ask if there is time for them to bring up a new topic, but is only the therapist's responsibility for controlling the flow of the session? People bring things up at the end for a reason. Dinahhttps://www.blogger.com/profile/09227988351623862689noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-50669388119441716182013-11-27T23:40:16.026-05:002013-11-27T23:40:16.026-05:00Jesse is in love with Roy?Jesse is in love with Roy?dishnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-23039659032995285012013-11-27T23:17:59.440-05:002013-11-27T23:17:59.440-05:00LOL Clink definitely doesn't wear yoga pants. ...LOL Clink definitely doesn't wear yoga pants. That leaves Roy.ClinkShrinkhttps://www.blogger.com/profile/13316134491751195651noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-27914077334695697162013-11-27T21:53:13.904-05:002013-11-27T21:53:13.904-05:00Oh okay. I see now. Joel finally revealed his true...Oh okay. I see now. Joel finally revealed his true feelings for Clink.dishnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-64172778420752648072013-11-27T21:34:40.185-05:002013-11-27T21:34:40.185-05:00Nope. Dinah doesn't wear yoga pants.Nope. Dinah doesn't wear yoga pants.ClinkShrinkhttps://www.blogger.com/profile/13316134491751195651noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-16917093192471166572013-11-27T21:24:26.907-05:002013-11-27T21:24:26.907-05:00Wow. Did somebody write Dinah a love letter? I kin...Wow. Did somebody write Dinah a love letter? I kinda didn't follow it but whoa. That was a really descriptive anon comment. dishnoreply@blogger.com