I recently posted an early view of an approach to look at the treatment planning discussion that occurs at the end of a psychiatric interview. I thought that the next step would be to see if this approach works in the real world. My current real world involves doing 1 hour evaluations with anywhere from 15-20 minutes of that time focused on a discussion of the treatment plan and that does include the option of no psychiatric treatment and in many cases other suggested treatments. For example, some people seek treatment for acute stressors including grief that generally resolve spontaneously or are more adequately treated by individual or group counseling. In most treatment settings where there is a triage system, these people are frequently screened out and do not see psychiatrists. That consideration directly applies to the treatment planning discussion because it affects the discussion of diagnosis, medical complications, and suggested treatments.
The graphic above shows the results of 10 interviews and the distribution of what was discussed (indicated by the orange cells) varies with individuals and general headings. The graphic is more readable if you click on it and zoom. For example there were 13 bullet points that were covered in all 10 discussions and those points have to do with a diagnosis and specific treatments are expected. Some topics were less frequently discussed and that generally means there were less applicable or the discussion time was reduced by a more lengthy diagnostic interview. I have found over the years that the length of an interview depends on getting the necessary transfer of information that can lead to a working diagnosis so that treatment planning can be started. The information necessary can be compromised by a number of factors including the patient's emotional state, their ability to describe a history with enough detail, the ability to be relatively concise, and the ability of the physician to communicate based on eliciting the necessary information and empathic listening. That can vary significantly from physician-patient dyad to dyad.
In terms of coverage of all 50 bullet points, 30-58% of them were covered in the discussions with patients. I don't think there is an ideal number. The people I talked with all have unique needs and there is no cookie cutter approach to either the diagnostic process of treatment planning. In some cases my discussion may run a little over the 15-20 minutes but that is rare. I have received some feedback that this seems like an ivory tower approach that can only be used by psychiatrists who have unlimited time with patients. All of these interviews were conducted the same way I have interviewed and talked with people for the past 30 years. The interview was not modified in any way. This is not research (yet) it is real world experience.
I am in the process of modifying the form based on suggestions from other psychiatrists so this is not the final version. At some point I think it would be useful to consider research using this kind of format to document that points covered by setting, diagnosis, and time constraints. A basic skill that all psychiatrists need is knowing when to depart from the original reason for consultation to a more urgent need - like the need for assessing an acute medical problems, a medical problem that might represent the cause of the psychiatric presentation, or a complication of treatment.
For now, I think it works as good evidence that psychiatry is not as easy as it has been depicted. The original depiction was by the federal government when it suggested the structure of psychiatric evaluations and treatment were not like the rest of medicine. There were separate codes and reimbursement for psychiatric treatment that did not take into account even one section of the above template. The adaptation to that government and insurance company practice has been to reduce discussions to the amount of time congruent with the devaluation of the cognitive process. That also led to clinics scheduling patients too close together and for briefer appointments. There is a lower limit to the time necessary to assess and treat patients. I don't think anyone who is doing new evaluations every 20 minutes while they are talking to patients and checking off templates in the electronic health record is going to be having lengthy treatment planning discussions. This form suggests that psychiatrists need time to do what they were trained to do.
The form when it is completed with provide not only a good estimate of what was discussed with the patient but will also provide guidance on what is relevant to document.
George Dawson, MD, DFAPA
