Getting through to your doctor . . . “hello . . . is there anybody in there?”
I’m going to take a big risk here and, hopefully, not offend my colleagues too much. I hear it all the time that my patients feel that previous doctors have not listened to them when they have tried to communicate about the medication prescribed or the symptoms experienced. This leads, at least, to leaving the doctor’s practice but, at worst, prolonging the psychic pain of emotional distress and can lead to someone hurting themselves or others. After all, if your doctor is not hearing you, how on earth can he or she intelligently prescribe medication. I think some doctors do have that “God” complex thing and don’t want to be questioned. Some are just overworked (hey, welcome to the club!) and don’t feel like they have the time to deal with lots of questions. Some have difficulty clearly articulating what they are trying to do so they come off as not caring when, really, they do care a great deal. Bottom line is, when you leave the office, it should be very clear to you what medication you are taking and why. You should be very clear about what the doctor expects from the medication and what YOU should expect from the medication. My thanks here go out to experimental chimp (see comment on previous post entitled “How much is enough? Getting a good trial of an antidepressant”. He describes an ongoing discussion with his doctor where he is essentially put off without being given adequate information about medication, diagnosis or prognosis. Well, I would not characterize the discourse as a discussion because that would require the doctor to be listening and responding appropriately to his concerns. Anyway, he is back in the office week after week and being told to suck it up and wait. OUCH! That doesn’t feel good at all.
Truth is, most of the medications that we psychiatrists use can have lousy side effects, but they are mostly manageable if effort is made to make them manageable. They can take weeks to begin to work, and recovery, especially if the patient is in a really bad way, can take months. Nothing makes this difficult situation worse than feeling as if your doctor doesn’t know what he is doing or feeling that your doctor is not listening. I try to be very clear with my patients about both the good side and the down side of the medication that I prescribe. I try to explain when they should expect to feel better and how they will feel until they do feel better. I try to go over side effects to expect, including sexual side effects, the unspoken fear of every patient (tho more are being straight forward about this which is excellent). I also encourage people to confront me directly if they feel that I am not listening. I am especially clear to reluctant adolescents who don’t want to take the medication that I think would benefit them greatly. I will tell them that “I don’t make zombies . . . and I don’t keep anyone on medicine that causes alot of side effects or doesn’t work . . . PROMISE”. I also do not see patients unnecessarily. Since most of the medication that I prescribe takes weeks to work or we need weeks to get data to see how well the medication works, I almost never see people weekly or every other week. Every two to three months is typical (remember, in my practice, my patients are seen by therapists on a regular basis). I see patients as often as needed, but as little as possible. They should be saving their hard earned money to have therapy and using their time to do something fun rather than wasting both on seeing me for no practical reason! I write the following specifically for you to print out and present to me or to your doctor when appropriate:
Dear Doctor:
I specifically came to you to receive treatment for a problem in my life. I have found that the methods you are using to treat me have not helped, and have, at times made me feel worse. In addition, when I try to talk to you about this, I feel that you have not taken the time to hear me or understand me. This is not acceptable. I want you to know that I want to continue to work with you as my doctor, but do need for you to take more time with me so that I can understand my illness and my treatment. Please explain the following:
1. What is my diagnosis and how long should I anticipate having symptoms of it? Should I anticipate this being an issue for the rest of my life?
2. The medication that you prescribed is not working and you do not seem to hear me when I say this. How much longer are you going to keep me on this when it is not working and what are the next two options for me?
3. This medication is making me feel like crap. Is there something I can do to stop these side effects? Please explain why I should continue to take it?
4. Are there other medications that I should be using in addition to the ones you have already prescribed?
5. Are there other things I should be doing besides taking these pills?
6. Other (insert your own comments or questions):
Sincerely,
__________________________________
I hope the above is helpful . . . (and I hope not too many of these get put in my face next week!)
–Dan Hartman, MD
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Wow. That’s a fairly impressive response to my comments and is definitely good advice. From a patient point of view, I’ve found it’s often a good idea to sort out expectations (on both sides) from the first appointment. This can be easier said than done with some professionals, though.
I’m sure that part of my experience is pretty cross-cultural, but to clarify a little, I’m from the UK. At least some of my issues are to do with the difficulty of navigating the NHS services here. Seeing a G.P. (probably better known as a family physician in the US) is easy, but seeing a psychiatrist is difficult. G.P.’s are often fairly undertrained in mental health (one that I was seeing had never heard of Seroquel). Due to limits on what they can prescribe and the astonishing unavailability of talking therapies, G.P’s tend to deal with every mental health problem by prescribing an SSRI, but don’t understand the extent of the possible side effects.
That’s essentially what happened to me, even after I informed them that a previous SSRI I’d taken had induced fairly significant side effects bordering on dysphoric mania. What followed was a pattern of rapid cycling, with several episodes of self-harm. After several weeks of being told to wait and see, I found it necessary to graph my moods in order to be believed. The G.P. wanted to refer me to a psychiatrist to get me onto a mood stabiliser. Before this happened, I ended up in hospital having cut through a tendon in my wrist. I then saw a psychiatrist in relation to something else (sleep problems), who told me to taper off the SSRI immediately.
Various threads of treatment are going on (I’ve been seen by a psychologist who’s referring me for cognitive analytic therapy - though the waiting list for this could be up to a year, and also have a psychiatrist who’ll be treating my sleep problems shortly).
To put this in perspective, I’ve been in the system for six months and my entire treatment so far has been one week of sertraline and five weeks of citalopram, with nobody really following up on either. Getting anyone to listen presents problems, but not so many as actually getting to see anyone in a position to listen. It’s free, but it’s not exactly ideal.
Chimp–
I hope our esteemed leaders in the US talk to you before deciding to nationalize our public health service. It is inexcusable that your health system leaves you without adequate mental health care for months at a time. I’m afraid that, in their efforts to fix things here, our own fractured system could get dramatically worse. Our own versions of national health care (mediciaid–aka welfare– and medicare) are such cumbersome systems that many of us do not subscribe to it. Many child psychiatrists in my area (Philadelphia area) have decided to not even take insurance anymore and expect cash only. People complain about the wait to see me (1-2 months for routine intakes) but the alternative is to wait much longer (if you can find someone who is taking new patients) and the insurance co-payment to see me is more reasonable than ‘full-fee’.
Have your doctor look up this site. I do sidewalk consults with colleagues too!
–DH MD
The problem with the NHS is that it’s incredibly patchy in its coverage. For some things it’s incredibly good. When I had to get my wrist repaired, the whole process was fast and efficient. For mental health it sucks, mainly as a result of chronic underfunding.
The NHS seems to suffer from terrible mis-management, which isn’t ideal when it’s the fourth largest employer in the world and has a budget equivalent to the entire GDP of New Zealand. Both the US and UK healthcare systems have problems, but I can’t see either emulating the other as a way to fix things as anything other than disastrous.