What is Ideal Medication Management?
At Proliance, people often call our office and ask if we provide “medication management.” In fact, I provide what I would like to call Ideal Medication Management. Simply put, medication management occurs when a medically trained doctor closely monitors all the medications the patient is taking to ensure that they are taken as intended, working as intended, not interacting with any other medications, and most importantly, not harming the patient. Often new patients will call and say they “just need medication management.” I know what they really mean. They may already have a therapist or don’t want one. However, to be clear there is no “just” to medication management. Medication management is extremely complex and dangerous in the wrong hands, despite appearing to be simple. It is for this reason there are several important aspects to Ideal Medication Management.
First of all, the medical doctor needs to monitor all the medications the patient is taking, not only the ones he is prescribing to the patient. This monitoring involves documentation of all prescription medications (alternative ones included), over-the-counter medications, herbal supplements and vitamins that the patient is actually taking. The doctor must confirm that the patient is complying with a medication regimen, and compliance cannot be assumed. While many people intend to take things as prescribed, they may actually not be doing that for a variety of reasons. These include being afraid to take the medication, not believing it is really needed, forgetting to take it, having stopped it due to perceived ineffectiveness, and the list goes on. To be effective, the doctor must establish a sense of comfort for the patient, which I often do as a gentle guide, or “paid suggestor,” as I often tell my patients. The reason for this is that most patients relate to their doctor as an authority figure (dad or mom-like), and they may not want to tell the truth for fear of being chastised by the doctor. “I was afraid you’d get angry with me… fire me as your patient… “ and so forth. This is why feeling comfortable with your doctor and not having a rushed-through-an-assembly-line feeling is very important. This is where TIME comes to play. Many fine doctors can provide excellent medical care. Often, however, doctors wrongly assume they have all the information that they need. If the patient feels rushed or feels that the doctor doesn’t care about them, the patient won’t give the doctor all the information. The one who suffers is the patient who is seeking healing and happiness.
At Proliance, rushing does not occur, because as a private pay office (non-preferred insurance provider), I am not under the time constraints forced upon many of my excellent colleagues. This allows me to give my patients the time they need to give me “the whole story.” Patients can tell me that they accidentally forgot to take their medications without feeling badly. They can also openly tell me if they do not agree with my advice. I say this, because while I may have gone to medical school, residency training and fellowship (many years of training after the undergraduate university) to get where I am, in the end I am there to serve my patients. Yes, I am the doctor, but my patients know themselves the best. Only when they see me as a partner will the two of us (the patient and I) be able to help the patient. By forming an alliance with my patients I help them understand why various medications are being prescribed, why they need to be taken in specific doses at set intervals, and why missing doses or timing doses incorrectly can cause complications. patients understand why things are done, they are free to agree or disagree; their compliance with treatment will improve; and they will get better. In addition to the above, I also remind patients about whether or not drugs need to be taken with food, and warn them about potential side effects of medications.
The sad reality is that too many times people come to me after years of ineffective treatment. It often isn’t their former doctors’ fault, but the system those doctors must work under if they want to survive. Those psychiatrists do help a great many people, but when patients suffer from multiple or complicated medical or psychiatric problems, and the doctor needs more time than is available under the system, important details can fall through the cracks. This is where I come in. While I see some of the simplest conditions that cause people to suffer, I often see complex ones others have either missed or failed to treat. Why? Time. I spend more time so I can get more accurate results. Over the years I have found that treating patients is like heading down a road with numerous forks in the road. Each fork in the road of treatment leads to a different path and more forks to more paths. With that in mind, can you imagine what would happen if you repeatedly pick the wrong road to treatment because you or the doctor was rushed?
Here at Proliance Center I often tell my patients “if you are going to be taking a medication, it better work!” This may sound like common sense, but it is a crucial aspect of Ideal Medication Management that many people miss. Is the medication you are taking working as intended? You are better, right? What is better? Twenty percent is better, but it is not the same as 80 percent! All too often people return to their doctor after starting a treatment and report they are “better.” “Ok”, the doctor may say, “let’s leave things the way they are.” Failing to quantify how much better often means the difference between a tolerable quality of life versus an excellent one. I want the best for those who entrust me with their hope for a happier life. I do not want mediocre results, but results approaching the ideal.
Another aspect of medication management is ensuring that the patient is avoiding potentially dangerous drug interactions and other complications. It is extremely important that the doctor who prescribes the medication has gone to medical school. Why? Keep in mind that all medications, even psychiatric ones, can have an effect on the whole body, not just the mind. Medical training, not a quickie few month crash course, prepares a medical doctor for all possibilities. It is not just about checking how the prescribed drug typically interacts with other drugs the patient is taking. It is also about how the medicines affect each particular patient. Each patient is a unique individual and may have special medical circumstances that must be taken into consideration when prescribing drugs. Not everyone has identical physiological responses to medicine. There are patients that have faster metabolism and require a greater amount of medication than others. Some have very slow metabolism and need much less. How does the doctor know? He explores with the patient the expected results of the medication versus the actual results. I often tell my patients, “I know how the medicines are supposed to work, but how they actually work is up to your unique physiology, which we will determine over time.” This is where a medical education comes into play. Some non-medically trained individuals take a quick few months crash course to prescribe medicine. They learn what to prescribe and what to do, not why. The “why” is a critical factor. A robot can do what it is programmed to do as long as there is no deviation from the normal (like with a unique individual). Ideal treatment must be tailor-made to the specific individual. This is the essence of personalized medicine, and while it is not for all, it is what I do at Proliance Center.
Lastly, Ideal Medication Management, as I see it, involves having the patient on the least amount of medications that do the most good. This involves a complete knowledge of all the medications someone is on, how they interact with each other, what each of them treat, and if any can be removed due to the presence of other medications doing the same thing. The practice of taking numerous medications is known as polypharmacy, and it is particularly common among older adults, as they are more likely to need medications to manage an array of chronic conditions. It is also a reflection of complex medical conditions that unfortunately cannot be treated with a single medication. Despite this, I have observed that many people being treated for a variety of psychiatric symptoms are often overmedicated. In fact, some psychiatrists routinely treat mental health problems with complex medication combinations that are not evidence based. That kind of treatment can be costly and debilitating, exposing the patient to side effects without any therapeutic effect. At Proliance, I specialize in identifying polypharmacy in my patients and systematically eliminating unneeded medications, together with the patient or her family member.
What Is Involved in Medication Management for Adults?
At Proliance Center, the process of medication management occurs as described above under Ideal Medication Management. It begins with a one-hour initial evaluation. At that time I will review any former relevant records, including an extensive questionnaire that is exclusive to Proliance Center. I will conduct an initial psychiatric evaluation of the adult patient to identify key problem areas, put together a customized treatment plan of action with the patient and finally, after the evaluation ends, I will write up a report. During the evaluation, adult patients are usually interviewed alone. Time may be provided to speak to the family at the discretion of the adult patient. It is very important that the patient or his or her family member bring not only all relevant records to the appointment, but have the initial questionnaire filled out prior to the appointment. That allows me to get to the core of what is bothering the patient and use the majority of time to teach the patient or his family about the condition, how I intend to treat the condition and why I feel it is best to do it that way. I believe that by forming an alliance with a well-informed patient, the chances of success are much greater.
After the initial evaluation, follow up visits will be scheduled to ensure that the treatment moves in the direction and speed desired by the patient, within allowable limits. I often tell my patients, “I cannot guarantee results, only maximum effort, in the quickest time we can get it done as a team.” Follow up visits are always scheduled in at least 30 minute time slots so the patients never feel rushed by another person in the waiting room. Sometimes the visits are quicker, as the patients achieve and maintain improvement, and other times they can take the full 30 minutes or longer if scheduled that way. I will generally decide in advance with the patient or his family how much time to schedule each subsequent visit. This will depend on the complexity of the problem. The frequency of the visits will depend on the severity of the problem. More severe problems may require more closely spaced visits (in one week or less), and less severe ones can be spaced out to a month or more. As patients improve, they will not need closely spaced visits, but are welcome to have them more often if they would like to do so for their own comfort. I generally say “you can follow up in ___ days/weeks/months; you are welcome to come back sooner if you like, or if you run into a problem you can call for an earlier appointment.” While I cannot guarantee last minute request for appointments, as I am generally booked several weeks in advance, I will do my best to accommodate. With that said, I take a preventative approach to treating my patients and believe that regularly scheduled visits will ultimately ensure greater patient comfort by indentifying potential problems before they arise.
What Is Involved in Medication Management for Adolescents?
As with adult patients (see: What Is Involved in Medication Management for Adults?), the process of medication management at Proliance Center occurs as described under Ideal Medication Management. Because the evaluation of an adolescent involves more time, more time is scheduled for the initial evaluation: a two-hour period. The extra hour allows me to speak to the family members, parents or guardians of the adolescent, and then time to speak to the adolescent alone. The party who is not with me will have their own room to stay in, where they can watch television, play video games, etc. (They will not return to the waiting room.) Because this initial evaluation takes about two hours, the family will often have the choice to schedule the two hours back-to-back or spaced apart. Everyone has their preferences and reasons for each, but what is important to note is that due to the length of these evaluations, with rare exception, they will generally occur during the school day. Further, if the evaluation time is scheduled back-to-back, I will often ask the adolescent for his or her preference to be interviewed before or after the family, and time will be separately and privately allotted to both the patient and the family. Either way, I will always meet with the family of the adolescent prior to the conclusion of the appointment to formulate a plan. If the initial evaluation is scheduled as two separate one-hour visits, the initial hour should generally be with the parents or family members, and the second hour should be with the adolescent. The second hour would then include a shorter visit with the family toward the end.
Follow up visits occur as with adult patients (see: What Is Involved in Medication Management for Adults?), though greater frequency of visits may be needed because there are more individuals involved in the treatment process. Occasionally, the family may need to contact me between appointments. If these contacts are more than a quick question or concern, they will be billed as a phone appointment, at the same rate as an in-office visit of the same duration. This allows busy families greater access to me without the need for frequent in person appointments. However, with rare exception, these phone appointments must be scheduled in advance so I don’t need to rush the family making the call or the patients with previously scheduled appointments for that day.
What Is Involved in Medication Management for Children?
At Proliance Center, the evaluation and follow-up procedures in managing the medication of children is similar to that described for adolescents above (see: What Is Involved in Medication Management for Adolescents?). The one major difference really depends on how old the child is. It is clearly more difficult to evaluate a 3-year-old who is anxiously clinging to his or her mother than it is to interview an 11 or 12 year old. I have a lot of experience with all age ranges of children, as well as the flexibility to adapt to whatever the situation calls for, whether it involves an interview with a child in the hands of his or her mother or with the child alone. Regardless, I have two rooms (not including the waiting room) available at all times. This allows parents the privacy they need and deserve, while simultaneously shielding a young child from things she doesn’t need to hear.