Psychiatric appointments have become short. A twenty-minute medication check is adequate for a stable patient on a stable regimen and inadequate for almost everything else, particularly when the question is whether the problem is psychiatric at all.
The first appointment
The first appointment is 120 minutes. It covers the psychiatric history, the full medical history and problem list, every medication and supplement you take, prior psychiatric treatment and how each trial ended, family history, and relevant laboratory and imaging results if you have them. I will ask you to send records in advance where they exist. That is important because I will do a thorough record review before you ever step foot in the practice.
By the end of it you should have a formulation you can repeat to someone else, an explanation of what is being ruled out and why, and a written plan.
What I look at that may not have been looked at
- Whether the presentation is fully accounted for by a psychiatric diagnosis, or whether a medical, neurological, endocrine or medication-related contribution remains unexcluded.
- Interactions across your entire medication list, not only the psychotropics.
- Cardiac conduction risk, including QTc, where the treatment under consideration warrants it.
- Dosing adjusted for renal and hepatic function rather than for an average patient.
- Whether prior treatment failures were true failures, or trials that ended too early, at too low a dose, or for a side effect that can be managed.
Ongoing appointments
Follow-up appointments are 45 minutes. Interval is set by what your care requires.
This practice does not offer brief medication-check appointments. A patient whose care can be managed in fifteen minutes is being managed well by someone else, and does not need this practice.
Reading the record
Patients who arrive here have usually been treated before, often by several clinicians, and the record of that treatment is frequently the most informative document in the case. Prior medication trials, the doses actually reached, the reason each was stopped, laboratory values over time, and the notes of the internist or cardiologist who was managing everything else — that history determines what should happen next, and it cannot be reconstructed accurately from memory in a first appointment.
Where prior records would materially change the assessment, we contact your previous clinicians, assist in requesting the documents, and follow up until they arrive.
For voluminous records, an hourly charge may be required, but you will always have the option to agree to it in advance, and will never be billed by surprise.
Working with your other clinicians
Complex psychiatric care done in isolation from the rest of a patient's medicine is the problem this practice exists to address. With your consent I correspond with your internist, cardiologist, oncologist, transplant team or therapist. That correspondence is part of the work, not an extra.