Mental Health Is too Valuable for a Drive-Thru

Your mental health is far too valuable for a drive-through experience. For me to even have to say this is a sad sign of our times.

Like my patients, I too have experienced the phenomenon of the production-line: prescriptions are rubber stamped with endless refills and the patient emerges from the appointment without feeling heard by their physician.

I know I was not trained to look at patients this way or to speak the economic language of targets, revenue streams, efficiency , billing, coding, co-pays, deductibles and other patient metrics. Nor am I accustomed to the “fifteen-minute med-check.” What can you really decide about medication in a 15-minute conversation?

And I was certainly not trained to think of advertising, pharmaceutical reps, generics or brand names: just the appropriate medication or range of medications for the condition I was treating, along with sound principals of prescribing, No incentives, no gimmicks, no arm-twisting—just the pure wisdom of how medications actually work and what their benefits and risks are.

So what happened? In a nutshell two things: the business and bureaucratization of our healthcare. Time with the patient comes last, but those endless, dreaded, checkbox forms come first! It’s not just me or my colleagues who say this, it’s practically all of my patients.

I naively emerged from training into a corporate and bureaucratic maze of rules and regulations that have little to do with patient care, but dictate to healthcare professionals what they can and cannot prescribe, while incentivizing them to churn through many patients a day, as if we were literally all part of a drive-thru line.

How does this affect your treatment? I’ll give you examples from my own experience:

1. Patient and physician agree on a one-month generic medication and dose to continue to see how it is tolerated. The physician calls in the prescription. Shortly after, the pharmacy calls to inform the physician that insurance has authorized three months’ worth at $10, but that one month will cost over $200!
   Aside from the absurd pricing differential is the more concerning notion that the physician is being forced to prescribe three months’ worth, otherwise the patient will have to pay more. What happens if they need a different medication/new dose in the following few weeks that doesn’t match the medication/dose denomination?This is a classic example of corporations inserting themselves into the middle of the sacred doctor-patient relationship and dictating what they think is best without assessing the risks of having extra unused medication lying in the home. In order to appeal such a decision, the physician has to call the insurance company (even if not in their network), and yes (you guessed it), fill a form for them to approve it.
2. After a thorough discussion with their psychiatrist, changes are made to the formulation of a medication (longer acting/shorter acting etc.) to another form because of side effects. It is simply denied by insurance, just like that. No explanations. No care. Just no.
3. The way most physicians are paid is dictated by the volume of patients seen in a given unit of time. This is usually dictated by managed-care entities that the majority of practices or hospitals are beholden to for revenue. The consequences of that? Less time to discuss and review choices and considerations, implanting a quick-fix mentality akin to a tune-up at a gas station. No matter what the medical specialty, that is never a safe way to treat patients.
4. Piecemeal prescribing. I have spoken to this at length in another of my blogs. With the time pressures on physicians, I have seen countless examples of this. There is never any explanation of how medications work and the rather crude strategy appears to be a different medication for every different symptom. That was never how it was supposed to be. Such prescribing practices can lead to dependence and even dangerous consequences. And then there is the sheer number of misdiagnoses and all the serious implications that flow from that.

Do I want my practice to think of me as a just revenue generator? I don’t think so. Our society still appears to respect the medical profession, but there is no doubt that our public standing has been eroded by the drive-thru mentality as well as the ensuing detrimental impact on patient care.

Don’t get me wrong. I’m all for businesses being able to manage their bottom line. But does that have to be at the expense of proper patient care? Could we, for example, incentivize health care entities to provide high quality clinical care, rather than just rewarding volume?

I can summarize my own approach as a psychiatrist akin to Frank Sinatra: I’ll do it my way. But with the caveats that my patient should never have to unfairly suffer and their dignity as a human being should never be compromised. I need to ensure that I can be the patient’s guiding light and educator in a system that is all too confusing and overwhelming on top of the suffering that they have to endure from their mental disorder.

For me, time spent with the patient is crucial. That way, I can tease apart symptoms from side effects, not leap to a diagnosis or rubber stamp what they were previously diagnosed with or prescribed. I can also meet their clinical needs. Sometimes, it’s understanding what they are going through or simply education about how common symptoms and the way they cope are all related. In turn, this builds an alliance between myself and my patient, something which allows for deeper communication. If that means bringing in their therapist or family into the conversation, I will call them into it, with their permission. It’s not usually difficult if the physician instills a can-do mentality. It just means making the time to do something that simple, yet that powerful.

That way, my patient feels genuinely supported, which is another crucial ingredient in their recovery. My surprise is that the system does not emphasize any of these basics.

That is because my way does not include being beholden to a system that makes me prescribe the quick and easy and usually addictive fix. It’s not the patient’s fault, but ours as a collective healthcare system for conditioning patients into expecting instant results. Advertising no doubt has a role to play in that, but we already know the motives behind commercials for medication. Therein lies the invaluable education piece in pushing back on common myths and misconceptions about mental illness and medications.

How do I work around the inevitable bureaucratic hurdles? I go back to the older, tried and tested and long-term medications, on the principal of proper dosing over time. They tend to be way less expensive, are usually approved by insurance plans and, I have plenty of examples of successfully using them on hundreds of patients over the years.

Most importantly, I encourage my patient to realize that medications cannot and will not do it all. When combined with therapy, the quality of their lives could be radically transformed.

This is my experience of treating real patients in the real world. I hope it inspires you to seek out help, in spite of all the system’s flaws, and to rightly expect your treating professional to be your true partner in your recovery toward lasting mental health and wellness.