Saturday, March 13, 2010

Hey, What are YOU Doing Here?



Sarebear tells us she went to see a new psychiatrist and was surprised when the evaluation was begun by an Energy Healer and the psychiatrist joined at the end of the 90 minute evaluation. See her post, Psychiatry Bait and Switch.

So what's the standard here for psychiatric evaluations? Is there one?
Actually, yes, and here it is: Practice Guidelines for the Psychiatric Evaluation of Adults.

So let me tell you what my experience is of the standards, and we'll come back to the guidelines.

Who does the evaluation, in my experience, is determined in part by the setting. In every private practice setting I've seen, a psychiatrist does the evaluation--- who you schedule with is who you see. I believe that even in private settings, if you're having neuropsychological testing, you may get a more junior person who administers some of the tests. But in terms of psychiatric evaluations--- usually the shrink. Sarebare notes that psych evals are 90 minute events. I spend 120 minutes on them (and oh, I still run over, I gotta work on that)...but for many, many docs, they are 50 minute exams--- it's just logistically much easier on the scheduling, and if you're going to be seeing someone on an on-going basis, it's not that urgent that you get every piece of information on that first day (or you can send out detailed forms to collect info---see my post Please Print Legibly....) . In the Emergency Room of community hospitals, psychiatric evaluations are done by social workers who present the information to a psychiatrist who may or may not see the patient (granted, these are emergency issues only and do not constitute full psychiatric exams for the purpose of on-going treatment). On an in-patient unit, information may be gathered by many people---the nurse, the resident, the attending, the medical student, over and over again until the poor patient is exhausted!

In clinics, it's often the case that a social worker does an intake interview and then a psychiatrist sees the patient. The evaluation team may or may not be the treatment team; at the clinic where I work, one doctor does the evaluation and dictates a long (pages) note, but the patient is then assigned to another psychiatrist for on-going treatment. This was not my idea. In one clinic where I worked, the standard was to have a psychiatrist assigned to "coverage" for each hour and the covering doc was grabbed to do any needed psychiatric evaluations or see any patient who was due for a 90 day review (or med check)-- there was no consistency to care and bless the medical director who changed this and gave every doc a caseload and every patient a doc.

So back to the standards. Regarding the gathering of information, the Practice Guidelines I linked to say:

In many settings, it has become commonplace for the care of psychiatric patients to draw on the expertise of multidisciplinary teams. In the evaluation phase of care, other members of the clinical team (e.g., nurses, psychologists, occupational therapists, social workers, case managers, peer counselors, chaplains) may gather data or perform discipline-specific assessments. The psychiatrist responsible for the patient's care reviews and integrates these assessments into the psychiatric evaluation of the patient and works with other members of the multidisciplinary team in developing and implementing a plan of care.

Nothing at all, not a single word, about Energy Healers, but I'm not sure that a peer counselor would have more training, so I don't know what to say. Here in the Mid-Atlantic, we're not much for Energy Healers, though I did recently have my home sealed and insulated and my energy bills have been remarkably lower. Does this count? Sarebear, I hope it works out.

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And now a word on Shrink Rap logistics. I am going on Vacation ! (am I happy: yes. have I begun to pack: no). Clink and Roy have not been blogging much lately, so I don't know if they will hold up the blog or not. I'm hoping Roy will take a look at proposed changes for DSM5 and write a blog post on these. Please bother him about this. And Clink has adopted podcast editing when she's not hanging off some precipice, so maybe she'll post another podcast....Dr. Barta was kind enough to stay and chat with us even when we stopped talking about telepsychiatry and brains. Finally, we had the odd realization this past week that while our book (Off the Couch, Behind the Couch, Under the Couch?) is due at the end of June, that version has to be finished with review, so the actual finished draft is due in April. Always a fun thing to learn as I'm headed off on vacation. Fortunately, we're in good shape for this, and the first 8 Chapters got a very enthusiastic review. So all good energy at Shrink Rap, but blogging may be a little slow. Please stick with us and check back often!