I’m Sorry, The Doctor Is Not Taking New Patients At This Time: The Sad Truth About the Overloaded Mental Healthcare System

I recently saw this article: http://ow.ly/CPei8 associated with the tagline, “Just Try Getting an Appointment With a Psychiatrist.” The link connects to a research study in which investigators phoned psychiatrists’ offices in 3 major cities attempting to set a new patient appointment, and they were only successful in getting an appointment about 20% of the time. Although I don’t live in one of the cities where the study took place, the findings appear consistent with what I would expect here in San Antonio. And I’m sad to admit, I’m a member of the 80% of psychiatrists who cannot take on a new patient.

The 20% accepting new patients are probably newer to practice, or seeing patients for the dreaded 7 minute appointments that have become the norm in primary care. Listening and understanding requires spending more time with each patient, less time means relying on overly simplistic checklists to categorize our patients’ experiences. But there is a clear downside to spending 20, 30, 45, or even 60 minutes with each person in my care: my practice remains small. The total number of patient care contacts would be much higher if each patient was seen for only a few minutes and follow-ups were months instead of weeks away. 

Advocates estimate that one in four of us suffers from a mental disorder https://twitter.com/MarkOneinFour, with many of the most severely ill unable to access care. Even professionals cannot get appointments for those with the greatest need. Just this week I tried to facilitate getting an appointment with a child psychiatrist for the 8-year-old daughter of one of my adult patients. The child had been receiving treatment until her doctor retired. The clinic were she was receiving care, probably the largest children’s mental health care clinic in the city, informed me that they were “unable to accommodate new patients at this time.” Another family looking for a child psychiatrist was told it would be at least a six-month wait. Desperate, parents call the primary care doctor. Although it’s difficult to get an appointment even with the pediatrician (two weeks is now standard for a mental health crisis situation), at least they can see a physician.

But seeing the primary care doctor isn’t ideal either. Two weeks in crisis is not a reasonable time frame. And then their doctor may only spend 7 minutes in the room (sometimes 3 minutes). Or the appointment might be made with the PA instead of the physician, often a surprise to patients when they arrive expecting to see the physician. 7 minutes with the primary care doctor can only offer one kind of treatment for mental health issues: prescription medications. But some patients need treatments other than meds. 

Primary care is overwhelmed, too, not just for the treatment of mental illness, but for the care of general health as well. I have patients asking me to write prescriptions for their blood pressure medicine because they cannot get them filled reliably in the overloaded primary care system. They can’t get through to a person on the phone when its time for an appointment or a medication refill. 

All my doctor friends look exhausted, usually sporting dark circles under tired eyes and chugging coffee to keep up. We all want to provide excellent care, but there are only twenty-four hours in each doctor’s day. Every additional slice in the pie of time comes from somewhere- shortening appointment times, shaving off hours of valuable sleep, cutting in to family time… The system needs more physicians, but training doctors adequately takes many years. Physician extenders like PA’s and RNP’s can help expand access, but have far less training and they seem to be getting thrown into the pool to function as physicians, taking on a percentage of all patients in a practice, not necessarily the most straight forward cases. 

What’s the solution? Many opinions are offered, but as a doctor, I don’t think there’s an end in sight.

Show Your Love by Taking Care of Your Health

Do you worry that self-care is selfish? If you take a sick day off from work, do you feel guilty? Consider the issue from another perspective: Taking care of yourself is a way of showing love for your family. Here are ways to love your family by taking care of you:

1.     If you are sick or injured, rest. Pushing yourself to the brink when your reserve is low will result in prolonged symptoms, burdening your loved ones in the end. You might think you’re being helpful by overdoing it, but taking care of yourself is a better approach.

2.     Schedule your annual check-up. Regular health maintenance prevents you from getting sick. See your primary care doctor, get any recommended screening tests, and make sure your health is ship shape.

3.     Exercise. The research on exercise is strong. If you want to live longer, stave off Alzheimer’s and cardiac disease, and thrive into your golden years, regular exercise is the single most important thing you can do for yourself (and the people you love most).

4.     Keep the vices to a minimum. Don’t smoke, limit drinking to moderate amounts or none at all, and avoid any vices that threaten your long term health and wellbeing.

5.     Mind your mood. Depression and anxiety are extremely common. Even in milder forms, mood problems take a toll on your ability to live a healthy, fulfilling life. If you’re experiencing changes in your mood, it’s best for every one if you go talk to a professional about it.

6.     Eat a healthy diet. The best advice for a healthy diet: Load up on the fruits and vegetables. Whatever your philosophies about food, no one can deny that whole fruits and veggies are the world’s most perfect health foods. Take care of yourself and show your love by getting lots of these goodies everyday.

7.     Talk it out. Work through conflicts by discussing them. Most conflicts come from misunderstandings, so having the courage to talk things through can clear them up. You’ll feel better, and so will your loved one.

8.     Keep in touch. Relationships are important. Stay connected to the people in your life.

Why I Can’t Treat My Friend’s Teenage Daughter

Last week during a supervision session with a psychiatry resident, my text message alert interrupted. The text was from a friend. She said her teenage daughter has been acting-out- breaking curfew and being disrespectful. She knows I work with teens and young adults, and asked if I could evaluate the teenager for depression.

After glancing at the text, I asked the resident, “Why can’t I treat my friend’s teenage daughter?”

Tentative, he guessed, “Boundaries?”

My thought had been: It would almost certainly ruin a good friendship.

Medical care relationships might successfully comingle with friendships. (Might.) But psychological therapies are different. How could I forget if I heard of my friend’s unhealthy behavior in the family from her daughter? And sitting down with my friend saying, “I think you need to learn to talk to your daughter differently,” would not only prove unwelcomed, the advice would likely be ignored. When friends offer unwanted advice, who listens?

The contract with a treatment professional is different. People walk in the door and risk telling their problems to a stranger, hoping to receive sage guidance or sound medical interventions. They walk in the door ready to listen. Friends don’t.

The resident was right. It was an issue of boundaries. Boundaries are a vital part of mental health relationships. But the problem with boundaries is that many people seem confused about what they are. Not just friends who need advice on parenting, even treatment professionals struggle to define “boundaries.”

Recently I was speaking to a colleague who said she couldn’t speak honestly about her own mental health history in public because: “boundaries.” I told her I didn’t think boundaries equated simply to privacy.

Or other professionals will use the word exclusively regarding physical contact with patients or clients by therapists. “I can’t make physical contact with them. I need to have boundaries.” But I know some wonderful, ethical, well-boundaried therapists who regularly hug their clients.

As I began to discuss boundaries with the resident, he referenced both of the above interpretations. He said, “You probably shouldn’t treat her daughter because your friend knows personal information about your life. And you probably hug your friends, you wouldn’t do that with patients.” But I didn’t think he had it quite right. I’m a pretty open book. Nothing my friend knows about me would necessarily have to be hidden from patient families. And I’ve been known to hug a patient now and then, if they ask and it feels appropriate.

I offered him another definition of boundaries:

Boundaries are rules in relationships. Fences. Necessary because, as the saying goes, “Good fences make good neighbors.”

All relationships have boundaries, not just mental health care relationships. Marriages, parent-child, and even fellow PTA members follow a set of rules (often unspoken) regarding the rules of engagement. The rules help us understand what is okay, and what is not, in each relationship. When those rules are broken, conflict, hurt feelings, and misunderstandings result.

If someone is my personal friend, our relationship has different rules than the relationships I have with my patients and their families. My friends listen to my problems, come to my house, and have my home phone number. My patients do not. However, my patients hold a privileged position of a different kind. They are guaranteed my full attention during their scheduled time, no matter whether I am having a bad day, feeling tired, or having a problem of my own. Friends have to take the good and the bad. Patients’ needs take priority over mine.

So, no, I cannot evaluate a friend’s teenage daughter for depression. But I’m sure I can give her the name of a terrific colleague who can.

In Praise of Good Men

Lately there has been an upsurge in the news about terrible men. A public sports figure was caught on camera punching his pregnant girlfriend in the face and knocking her unconscious. Another cruelly abused his child and called what he did “discipline.” News stories are full of men we should fear.

Yet there are probably far greater numbers of wonderful men in the world than terrible ones. I see men in my psychiatric practice, many who come to see me seeking guidance on how they can be better husbands and fathers. There are countless great men in the world. They are terrific husbands. They are amazing fathers. They are caring friends.

How can we remind the good men that we notice? And show our sons which examples we want them to follow? Perhaps we need to acknowledge good men with warm hugs and thank you’s and show them we’re paying attention when they do the right thing.

So for all the terrific men out there, thank you for being strong, patient, humble, and loving.

Ways to Appreciate Gentleness in Men 

1. Hug your dad, brother, husband, or son. Everyone enjoys a nice warm hug and it’s one of the simplest ways you can show your appreciation for the guys in your life.

2. Thank him for everything he does. Many men contribute to families and relationships quietly day after day. They do a lot of heavy lifting in families to keep things running smoothly. Stop and say “Thanks” to the men who give in your life.

3. Draw him a picture or send them a text that says, “I love you.” Don’t shy away from expressing your love for the men in your life. They may not ask, but men need to hear they are loved too!

4. Don’t be afraid to paint dad’s toenails. Every great dad of a little girl lets his daughter paint his toenails when she’s small. Why not, right? Men can be good sports about getting out of traditional gender roles and playing along. Give them a chance. They may be glad to.

5. Treat him like he’s special. Sure it’s Mom who gets breakfast in bed on mother’s day, but why not Dad too? Guys may want to be pampered now and then. Tell dad to put his feet up and let someone take care of him.

6. Cook together. Some households assign all kitchen duty to one person. But it can be fun to spend time together cooking and even cleaning up. If he’s the chef, offer to assist. If he doesn’t know his way around a recipe, welcome him in for a lesson.

7. Ask him to go out for a walk or a bike ride. Spending time together in nature is good for the soul. You can stay connected when by getting outdoors together. Unplug and go out for a bit of fresh air.

8. Let him know all his hard work and sacrifices are noticed. Does your husband work a side job to save for family vacations? Does Dad sacrifice the umbrella so kids can stay dry? Let him know you are grateful when he puts the family before his individual needs.

9. Let dad take on any job mom can. Stop being amazed when an Internet Daddy braids hair. Assuming men can’t care for children pushes them away so they might not participate. Treat men like women’s equals in all things, because they are.

10. Let women take on traditional men’s roles as well. Women can change flat tires, throw baseballs, and read maps just like men. Pigeonholing men and women creates a barrier between to sexes. Erase the stereotypes.