Shirah Vollmer MD

The Musings of Dr. Vollmer

Is A 20 Minute Appointment Worth Anything?

Posted by Dr. Vollmer on April 4, 2016

ABS 20-minute Appointment Book

 

Suppose you could see a patient for 20 minutes, once every month or so, with the expectation that medications can be altered, stopped or started. What if the question is whether 20 minutes is better than zero minutes, returning to the overarching question of whether bad care is better than no care. The answer, as you can imagine, is “it depends”. For some patients, this periodic check-in serves as a touchstone towards wellness. The brief visit is seen as a means to transitioning from sickness to health. For others though, there is a tremendous sense of futility, in that, patients often express the sentiment, “how could you know what is going on with me, when you hardly ever see me.” The difference between these patients is their transference. Those who are helped by a touchstone generally have a positive view of authority figures and as such, they are leveraging that history to improve their lives. Others, with more traumatic backgrounds, are tremendously skeptical of those who “ought to know” and as such, bring so much suspicion to the appointment that the therapeutic benefit is lacking. This negative transference is a way that the patient communicates that they need more time to break down their preconceived notion of authority figures such that trust can be built slowly over time. Understanding the various kinds of transference allows for an individuality to treatment which is short-changed with the twenty-minute model. In other words, well-trained physicians should be able to decide who can benefit from short versus longer appointments. This decision should not be based on the number of medications a patient is taking, but rather on the ability to form trust with the patient. To be clear, going to see your psychiatrist  as the photo might imply, is not the same as getting a haircut.

4 Responses to “Is A 20 Minute Appointment Worth Anything?”

  1. Shelly said

    Not knowing how insurance pays for psychiatry in the US, does the 20-minute appointment ever change to longer and more frequent appointments based on clear need justified by symptoms as described by the psychiatrist (i.e. not sleeping, more mood swings, risk for suicide, etc.)? Or is the model fixed and never changes and only by hospitalizing the patient can it ever change? On the other hand, in LA everyone has their therapist and it is quite a “thing” so I’m sure there are patients who can see you more frequently than just the 20 minutes once a month for medication monitoring, right?

    • We are moving towards the Kaiser model of mental health care where appointments with psychiatry are hard to get, and once obtained, follow-up is also a challenge, leading to infrequent and short appointments with the psychiatrist. The model incentives fewer appointments and so this shapes the care the patients get. I am not sure if it is still true that having a therapist in LA is a fashion statement, but that used to be true. It is true, however, that outside of insurance, I am free to practice as I see fit. That said, my concern is that newer trainees are only learning in a system which promotes short, infrequent visits, such that providers will not be able to provide more intensive care, even if they see the wisdom in that. Thanks.

  2. Mimi said

    Really well said Dr. Vollmer! And I have seen patients who appreciate the brief consult and check in. And i also agree that it takes skill and assessment to see who fits that model. One size doesn’t fit all – just tell that to the insurances though! The majority of Americans don’t have this kind of choice unfortunately….

    • Absolutely true, but how did we let ourselves become slaves to insurance companies? Who turned that system upside down? Shouldn’t we, the providers, determine who can benefit from brief check-ins, and who need more intensive work? Thanks.

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