Why I don’t do “med checks”

Sandra Steingard, M.D.

April 25, 2012

I first heard the term “Med Checks” when I started working at my current job in a community mental health center 17 years ago. There was even an office with a sign on its door, “Med Checks”.  This term has never had meaning for me and the title of this blog is one I used for an essay I wrote many years ago for an in-house newsletter explaining how I conceptualized psychiatry and the role that psychiatrists play in a community mental health center. This essay comes to mind as I read on this website the various opinions about what psychiatrists should be doing.  I have been fortunate to have worked at an agency that has allowed me – perhaps out of desperation over loosing yet one more psychiatrist – to shape the role that psychiatrists have within our agency and I will describe that role in this blog.

We are a large – at least by Vermont standards – community mental health agency – and we employ hundreds of people of whom only a handful are psychiatrists.  That says something – psychiatrists play a small part in the services we offer to our clients.

Psychiatry remains a subspecialty of medicine.  Within that tradition, the psychiatrist’s main role initially is one of evaluation. Whatever one thinks of psychiatric diagnosis, the role of evaluation is nevertheless important.  When someone comes in complaining of hearing voices, the list of possible diagnoses is enormous, ranging from brain tumor to endocrine dysfunction to what Corinna West and others call emotional distress to what Michael Cornwall calls madness. I have written elsewhere about how I conceptualize psychiatric diagnosis.  Whether one likes these labels or not, the process that precedes it – listening to someone’s story, hearing how his life has been, learning of important relationships, asking about head injury, substance abuse, and medical problems, learning of his family, how he was raised, what problems or challenges other members of the family had, hearing what has meaning and value for him as well as where he feels he has been successful – is valuable.  The label that we give to the symptoms is not the most important outcome of this process but rather it is understanding what brought the person to my office in the context of this person’s life that is most valuable.  It is only after this process is completed that one might make a recommendation about treatment.

The outcome of this evaluation may lead to recommendations that have nothing to do with medications.  We help people to get housing and work. We offer different types of non-drug treatments – groups and individual counseling of various types. We might offer help achieving sobriety.  If the recommendation includes pharmacotherapy, the psychiatrist is the one who prescribes since she is the only one who can do that.  But when someone for whom I am prescribing medications returns to my office, this visit is not a “med check”; I am not checking on the medications, I am checking on the person.  I do review ongoing symptoms but more importantly, I talk to a person about her life, how she is spending her time, what is important to her.

It is true, that on a practical level, our psychiatrists are often in our offices talking to patients about medications. We are expensive and by limiting our roles to the things that only we can do, we are trying to free up resources within the agency to offer our clients the many other important services they need and request.  I guess I do not mind this role although I try to prescribe in a deliberative, careful manner. However, it is not all we do.  Our psychiatrists also spend a good amount of time in collaboration with others; we consider that critical to good quality care. We do not ask doctors to see people every 15 minutes and do nothing else. We schedule in time to talk to patients, family members, and collaborating colleagues outside of office visits.  We have insisted on this because we believe that this is what is required for us to provide good care.

It is funny that this term “med check” may have arisen within my profession.  I believe it was coined to distinguish what I do in contrast to what a colleague offering psychotherapy does.  There was a notion that I just handed out medications while my colleagues actually talked to patients.  However, I have never known how to work with someone who is, let’s say, hearing voices -without talking to the person about his experience and trying to understand what this feels like, what it means to him, and how it might be disrupting his life.  If I am not talking to my patients, what else am I doing?

So if I talk to my patients, what do I actually say? I have tried to listen carefully to what is written here and elsewhere and to incorporate that into what I have learned on my own and from my own patients.  I believe that the conversation should include a full assessment of the short and long term risks and benefits of drug treatment. This has manifested itself in my having serious discussions repeatedly about the long term use of medications and making changes to insure that a person is on no more medications than necessary.  I believe it is critical to be extremely cautious at the outset and to try and avoid the introduction of medications. Given our current cultural climate, this sometimes requires much explanation.  I am in the process of tracking my experience with systematic tapers of neuroleptic drugs and I hope to be able to report on this soon. This is often a values ladden discussion and some people choose to remain on medications despite the risks while others are extremely eager to stop.

Corinna West, Dan Fisher and others have articulated how language matters and there is nothing in what I have described here that is inconsistent with talking to people in a respectful way that promotes hope and recovery.  I try to be careful in asking people what certain words mean to them; for instance, it was not apparent to me that talking about the brain would translate into someone thinking she has a fixed problem not amenable to recovery because that is not what it means to me.  I am spending much of my spare time lately reading about stories of recovery so that when I talk to people about this, I am talking with genuine conviction rather than parroting words so that I am politically correct. It is the nature of clinical work that we tend to see people who are doing less well since the ones who are recovered have no reason to come to our offices; I have come to believe that we have an obligation to actively fight against the distorted perceptions that can develop over time.

Although we try to be cost effective, we do not limit our psychiatrists to office visits. These are some other things that psychiatrists have initiated at our agency in the past few years:

-Cognitive Behavior Treatment for insomnia – One of our psychiatrists was dismayed at the long term use of hypnotic agents (sleeping pills) to treat insomnia.  He has given lectures to our staff about sleep and he has explained why drugs are often the last choice for treatment of poor sleep. He emphasizes the role of differential diagnosis of this condition – i.e., does the person have sleep apnea or some other condition that would be best treated with non-drug interventions.  For several years now, he has offered a group for CBT for insomnia, an effective, evidenced based approach to this disorder.

-Food Education group – I have written about this elsewhere.

-Education- Every year, my colleagues and I lecture to our staff about drugs.  In these lectures, we talk not only about the drugs we prescribe but also about their limitations. I have talked in the past about the impact on advertising on prescribing practices and this year I discussed Anatomy of an Epidemic.

-Book and movie group-I just started a reading group open to any one who works or uses services at our agency.  In the spirit of Open Dialogue, this is meant to be an inclusive discussion.  We read I Never Promised You a Rose Garden by Joanne Greenberg and next month we will begin watching Daniel Mackler’s documentary, Take These Broken Wings. If you are interested, stay tuned! Our first group was a huge success and I may blog about this in the future.

Sandra Steingard, M.D.

Anatomy of a Psychiatrist: Dr. Steingard chronicles how she is integrating information from Anatomy of an Epidemic into her community mental health practice. She also discusses changes in Vermont’s mental health system and the influence of pharmaceutical advertising on clinical practice.


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26 thoughts on “Why I don’t do “med checks”

    • Dr. Steinberg,

      I agree that you are trying to be the best doctor possible while sincerely trying to do the best for your patients. Though we still have some disagreements, I am very impressed with your hard efforts on behalf of your patients and your ongoing interactions here to engage with others to adopt the latest, real evidence based health strategies.

      I guess I will have to plead “temporary insanity” for some of the awful comments I made on your first blogs. My only “excuse,” which really isn’t one, is it reflects the horrible, abusive, dishonest psychiatrists I had the misfortune to meet quite a few years ago from whom I was trying to rescue loved ones who had suffered much abuse and trauma.

      I am sorry for that and I must say you have more than earned your place here! You have been a very good sport and more than earned my respect and admiration.

      • ADDENDUM: My comment here has nothing to do with Bob Whitaker’s call for civility, etc. It has been something I have been thinking about for some time and comes from the heart! Though I agree with Bob Whitaker for the most part, I do believe in honesty because otherwise “your are just parroting to come off as politically correct” as Dr. Steingard would say. However, mutual respect is important too for any relationship to survive in order to thrive. I think Duane is speaking from the heart too.

  1. Since the call by Robert Whitaker to exercise more restraint, and to open dialogue, I have also begun to open my mind more, and listen to what some of the more conventional docs have to say… to just relax, and listen – really “listen”.

    And I like much of what you have to say, in that I hear a lot of sincerity, from someone who seems to truly want to do right by her patients. And so, even though I do not agree with the concept of assigning a “diagnosis”, I find the warmth and concern you seem to have for the people you meet to be geniune. And this helps me open my mind to (slightly) less black-and-white thinking, and has given me a sense of healing from the many stories (of much different “treatment”) that I have read for the past seven years online.

    In short, you seem like a good and decent human being. And I do appreciate your willingness to question the conventional model, and to consider other options. I made a committment to myself to be open to reconciliation. And I’m doing my best, doctor.

    Repectfully,

    Duane Sherry, M.S.

    • Thanks, Duane. I have appreciated the information you have shared here. I have also tried to be more open to ideas and concepts that I might have more readily refected at some point in the past. There is room for humility to go around although I understand that people sometimes expect a higher standard from physicians.

  2. You are setting up a terrific clinical system, but, alas many places in the country to not have the financial resources to do so and therefore “med checks” are the best they can do. I, too, hate the term; in the very least it should be something like medication re-evaluation.

    To make a short session the most valuable, I have taken to asking people what gives their life the most meaning (this is how I translate recovery) and then see if we both think medication (or something else) can help them achieve what they want. We all want meaningful lives, do we not?

    • With all due respect, I think we have an obligation to take a stand on what we think quality care means. I could have gone along mindlessly with the notion of the 15 minute “med check” when I came here but I made it clear what my practice standards were. By setting this standard I have been successful in recruiting high quality like minded physicians despite the fact that our salaries are low. And you know what, sometimes my appointments last 15 minutes but that is because that is all the time we need rather than all the time allowed.
      I have found that administrators are nervous about supervising physicians and they look to us to set the standard for good care.

      • Also, when you go to your physician to evaluate your cough,for example, is it a medication re-evaluation or just a plain old physician visit? I actually insisted that we pay extra so that our new EHR dropped the term “med check” and replace it with “psychiatric follow up visit”. Words count and being careful about terminolgy can have an impact on what we do and what others precevie us as doing.

    • It is entirely possible to supervise a taper off medication and still bill the visits as a “med check.” It is a med check.

      There is no financial excuse whatsoever for not providing the service of safely tapering people off whatever hellish cocktail of psychiatric drugs they’re on.

  3. “It is the nature of clinical work that we tend to see people who are doing less well since the ones who are recovered have no reason to come to our offices”

    I think it is true that a lot of people actively avoid ‘clinics’ because they lose faith in psychiatry and or are afraid of being coerced again.

    With all due respect, disclaimers, etc, this isn’t a personal attack, but I wouldn’t walk through the doors of any clinic housing psychiatrists. Period. I also know that someone who sees my problems as ‘symptoms’, and you did use the word ‘symptoms’ in your above piece, is just someone who is going to medicalize my problems. If you think problems in life are medical problems, you either see or become a psychiatrist.

    • That is certainly your peragative and I respect that. The best I can do is to be straight forward about how I think about things. At the same time, I am the first to admit to my limitations.
      The funny thing is my biggest problem is not finding people to come to my clinic; it is triaging care with limited resources.

  4. I also admire you taking a stand for quality, and expect us all to do so. I wish we could, but there are still inadequate resources available and to join together we’ve been accused of restraint of trade. Vermont has always been one of the better states as far as mental healthcare. Moreover, when I’ve seen some psychiatrists refuse to go below a certain standard, they are readily replaced with someone who will.

    One of the other problems we have to overcome is a lack of any comparative research comparing the results of 15 minute versus 30 minute versus 45 minute visits. Nor have psychiatrists established any standards. I’m with you in trying to give the most time I can, but also to use that the most wisely. For-profit managed care companies will try to get us to do the least.

    For those readers who still value what psychiatrists can provide, we need your help to do the best we can.

    • Dr. Moffic,

      I think Dr. Steingard has a much stronger argument.
      Hers sounds like a committment.

      And if psychiatry is going to be open to reconciliation, it must first be committed to reform.

      There is a lot of difference between excuses and reasons. Psychiatry has lots of ‘excuses’ for its behavior – and plenty of people to point fingers of blame – from managed care comanies, to drug company propaganda, to many patients, and few doctors, etc… but it has very few ‘reasons’ for doing what it does.

      Reform.
      That’s the key word here, Dr. Moffic.
      Reform.

      Duane

      Duane

  5. You forgot to mention one huge intervention that you made in our agency maybe 10 years ago, which was to refuse “perks” from drug representatives. You forbade them to lather us with muffins and pastries, and all manner of paraphernalia with their brand names, such as pens, calendars, notepads, letter openers, trinkets, etc.. You directed staff to avoid drug reps who might want to take us (mental health case managers or clinicians) out to dinner (I got offers at some conferences!), and actively talked with staff about striving to not be influenced by or agents of the drug companies. And, no doubt, you have not likely accepted drug money to lecture their party line at conferences. I have always admired your commitment to being as independent of Big Pharma propaganda and financial influences as possible, and recognizing side effects earlier than the published research, such as when drugs caused consistent and excessive weight gain. By keeping yourself and our agency outside of the huge influence of the drug companies, you’ve kept the focus on the individual who is seeking our support.

  6. Another great diary, Sandy.

    I wish more of your colleagues would follow your lead, but I can tell from my representation of people in the involuntary mental health system in Vermont that you are far from the mainstream. In most of the involuntary medication cases I’ve handled in the hospitals I have learned that virtually the entire content of conversations between psychiatrists and their patients is the psychiatrists’ repeated demands that the patient start taking meds. If you’re the patient, and you know that every single day the person who claims to be your psychiatrist even though you never agreed to be treated by that person, is just going to harp on the demand that you take the meds you don’t want to take, why would you want to open up to that person or have any substantive conversation with them?

    As always, thanks for your efforts in behalf of the people who need your help. I wish there were many more like you.

    Jack

    • Thanks, Jack. These are interesting thoughts and I always value your perspective. I do want to try to move the conversation along at least in our small sector of the world. You bring up the role of involuntary treatment. I do not want to hide from that; as you know, I am a part of a system in which involuntary treatment exists. At some point, I want to address this very important topic directly.

  7. Sandy, I enjoyed your article and agree with the need to look at narratives and history, and the reason the person is in our office. You are in a great position to model change. I do need to address an important technical error in your piece which parallels the idea of respecting the consumers as well as each other. As an advanced practice nurse, specializing in psychiatry and substance abuse for many years, I just want to remind your readers that not only psychiatrists prescribe psychotropic medications or do psychiatric evaluations. In many states, including Vermont, Advanced Practice nurses are independent practitioners in their specialty areas, often refered to as Nurse Practitioners. We do “med checks” – or not! …as well as psychotherapy, groupwork, education, and supervision. And as we are all too aware, much of the responsibility for psych care falls on our generalist colleagues, NPs and PAs and PCPS. The credit – or blame- goes to many of us, not just the psychiatrist. I have just signed on to MAD IN AMERICA as I have become interested in the genre of medical narrative. Thank you for all your contributions and I look forward to following you.

  8. I was treated by Dr. Vines who worked under Ms. Steingard from around 2008-2011 and he was the first doctor that didn’t do the standard bipolar ADHD combo with me, often an antipsychotic, one of the ineffective mood stabilizers (anything but lamictal) and either way too high or way too low of a long acting stimulant and neither did well with me.

    I left because I wasn’t fond of the other aspects of the program, like having a case manager and being required to see a therapist that I would want to respect boundaries and in both cases when in with Dr Vines, I would dictate that I felt fine and they’d give me a questioning look. I just left a nurse practitioner and she was flexible and then would get weird. Short acting dexedrine, helped immensely, had to take 6-8 pills and with lamictal and 2.5 mg of haldol for scute moments 2 mg of ativan for the more rage states or 2 mg of klonopin pre thunderstorm… doing the running to make sure you aren’t dying tricks don’t help me at all. I rarely like taking Benzos or antipsychotics but since I deal with mania, I had to come up with a way to make it work because Lamictal helps mania the most preventatively. She wanted me on these more than I wanted though and then would flip and act as if I were drug seeking and now that I recently left there. I have a good physique again with this regimen and it worked and hopefully I can find someone that will allow me similar flexibility. As of now, I am without care and I am off everything although I still have Klonopin 2 mg and Adderall 30 mg tablets in my safe. I also don’t see eye to eye with long acting stimulants. Every one gives you a level and sometimes you need more than others and if it is too much or too little, you are stuck with it until afternoon when the 3-5 hour rage would start from the crash. Adding a short acting dose would feel like a different med and it would still be miserable. Vyvanse felt like taking nothing but I never ate and the methylphenidates were anxiety provoking. short acting focalin would be helpful for setting up events etc. I hate the unorthodox approach that works for me but until I get manic again, I am probably avoiding treatment for awhile. This past experience of asking for smaller quantities of adderall 30 mg tablets and being thought of as drug seeking when it was better than 180-240 pills and the brand of generic was more consistent was just off. And the upset at wanting to use klonopin and ativan minimally. I have been through them all and antipsychotics were horrible and made me fat. This is going to sound odd but the crash from XR meds made me want more and more. However, this kept me the most stable. I am fine… the lamictal abrupt reduction was rough but Dr Vines helped me communicate my needs and not feel unsafe or bullied. He was a good man. I guess if I were to go back to howard, not having similar financial situations and having to live in an SRO that was miserable would maybe but now that I had to end treatment that actually worked with someone who was great and compassionate but odd and probably has me pegged as a druggie, really just makes me pray the next mania doesn’t happen.

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