Good Psychiatry: The First Meeting
This is the first in a series where I hope to describe the care I offer to my patients. I have thought a lot about what it is to provide good psychiatric care, because interestingly, I do not believe I was trained with this in mind. In my time as a psychiatrist, I have painstakingly and deliberately developed the practice I have now. One I am happy to say I am very proud of.
Even before the first meeting, good psychiatric care starts with the family physician. It starts with a diligent family physician who will make sure that there are no medical reasons behind your mental health concerns (for example thyroid and autoimmune illnesses can first present with mood and anxiety symptoms). When these have been ruled out, a good family physician feels comfortable diagnosing common mental illnesses and treating those that are of mild to moderate severity. I am very lucky to work with excellent family physicians who have made attempts at a diagnosis and tried several treatments before they consider referring a patient to me. This means the patients I see are of more complexity and severity, a good use of my expertise!
When you first meet me, it is for an initial consultation. In my training, I was taught this needs to be 50 minutes long (the final 10 minutes is to gather your thoughts and write your notes). In my experience 50-60 minutes has only been enough in very simple, straight-forward cases. This has made up less than 1% of my practice. In order to do a complete assessment, while also leaving time for giving patients feedback and the discussion that follows, I have found 90-120 minutes is more realistic. I will detail what goes into the initial consultation to give you further justification for this lengthy first meeting.
In the first meeting I am gathering A LOT of information about you. Not only do I want to know about your current difficulties, I need to know how you were before these difficulties and the details around how your difficulties began and evolved. I need to know your current living situation and support network, and what you have noticed makes your symptoms better or worse. I need to know if you have sought other help and what medications you have tried and their effects. I need to know your medical history, allergies to medications and any psychiatric history. I will ask you about past suicide attempts, thoughts or self-harm, and if you use any recreational drugs. I will ask you about any legal history and spend quite a bit of time on your social history.
A social history is one of the most important parts of the assessment. It entails a series of questions about your upbringing and what you remember about your first attachment figures, usually your parents. I will ask about your academic performance and how you did socially in school. I will ask about important romantic relationships and friendships and any significant losses you had in your life. The reason why this is so important is because I need this information to better understand how you may perceive the world, what you have grown up to expect from other people and how you feel about yourself. We are learning more about how adverse childhood events like neglect and abuse have significant impacts on people and their mental and physical health in their lifetimes. Trauma is a topic that was never covered in much detail in my psychiatry training, but is pervasive in society and over-represented in patients seeking mental health care.
A psychiatric assessment is also unique in that a "safety screen" must also be incorporated into each new consultation. This means knowing if there are children in a patient's home or firearms, and when necessary if there are concerns about driving. I would also need to know about whether or not a patient may be at risk of harming herself or others. Very sensitive, life-saving topics that need to be assessed accurately as they have significant implications.
So the above is a snapshot of what I will try to cover with every patient who sees me for the first time. The last thing worth mentioning to help you better understand the breadth of what needs to be established in this meeting is that I fully realize that while I am trying to better know the person in front of me and how to be helpful, the person is also sussing me out, and asking himself if I am trustworthy. Learning how to be a good psychiatrist has been very humbling because unlike other medical specialties, where I can order a scan or bloodwork to tell me what is wrong, the best source of information I have comes from what the patient feels comfortable telling me. In order for that information to be reliable, I have to first earn the confidence of the patient. I am not entitled to it. There are no short-cuts here. Good Psychiatry takes time.