Shirah Vollmer MD

The Musings of Dr. Vollmer

7 Minute Evaluation

Posted by Dr. Vollmer on December 6, 2013

 

“That doctor gave me Zyprexa after talking to me for seven minutes,” or so I have heard, so many times, from so many patients, particularly patients who have been psychiatrically hospitalized. On the one hand, I can understand that diagnosing psychosis is often a quick endeavor, and Zyprexa is an antipsychotic, so that is a linear and logical path. On the other hand, the patient cannot develop confidence in his treatment after such a brief encounter, where the psychiatrist has most likely not inquired about his social or cultural history. Yes, this history could have been obtained by a non-MD professional, but is there value in the physician asking the questions so that he/she can hear not just the answers, but how those answers are formulated? Is there value for the patient in spending time with his physician so that he can develop trust in order to increase the likelihood of  compliance? All my readers know my perspective. Spending time with patients is a critical art that psychiatrists must learn and practice to develop an understanding of patients and in order for patients to develop an understanding of themselves. Prescribing psychotropic drugs is an enormous privilege, which can only be done judiciously after thorough history taking, and relationship building. The privilege to give a medication that alters mental functioning must be treated delicately and respectfully. This requires time, patience, skill, and education. Our field is doomed without that. I live in fear.

4 Responses to “7 Minute Evaluation”

  1. Jon said

    Half a century ago the generic dismissal of the GP doctor was “Take two aspirin and call me in the morning.” Now it appears that the generic dismissal of the psychiatrist is “Take Zyprexa and come back later.” I would like to think that general health care is better now than it was fifty years ago. This might give hope to counter your fear for the future of those who currently prescribe psychotropic drugs. Then again, maybe not…

    • The general health care is certainly better than fifty years ago, as evidence by our longer lifespans. In the psychiatric world, progress is slower. Our biggest break through was Prozac in 1988, and since then, we have been stalled in our search for new modalities of treatment. Given that, we, as I was taught in medical school, must fall back on our building blocks of good medical care-a thorough history and the cultivation of a doctor/patient relationship. These building blocks, I fear, are going away, leaving us too dependent on technological interventions and pharmacology. Thanks, as always.

  2. Shelly said

    Interesting…if a patient receives a quick diagnosis and medication after being hospitalized, is it not different than if he/she turned up in your office? If a patient has a psychotic break and is being held for his/her own safety in an inpatient ward, wouldn’t even you yourself prescribe Zyprexia for this patient? I agree that if the patient came to you in your office, it would be an entirely different set-up: you would take a careful history and listen to how the patient presents, and consider all the factors of how the psychosis interferes with his life and then would discuss which medication to try, if any. But as a first response, in an emergency setting (like an inpatient ward), wouldn’t you yourself prescribe something after little talk with the patient?

    • My issue is not with the prescription, but with the lack of confidence that the patient expresses over the prescription. Granted, many folks lack the insight into their illness to understand their need for medication, but at the same time, physician time with a patient can help develop this trust that enables the prescription to be given in the context of care and concern, rather than a sense of rote behavior. Even if time is not necessary for a diagnosis, it is still necessary to reassure the patient that with understanding comes treatment. In addition, there is a way to listen to make “seven minutes” feel meaningful, but in these situations, patients do not accuse the doctor of spending so little time, since the patient feels heard. There are no metrics to say the exact amount of time a physician should spend with a patient, so each physician is left to his/her own judgment on this issue. I am fearful that with each encounter and each “click” on the computer translating to dollars, then the motivation to spend less and less time with patients will create an environment in which history taking is delegated to people with less understanding of the human mind. This, in my mind, would be tragic.

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