November 2010  << Back  

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Prime Time. Maximizing the Therapeutic Experience. A Primer for Psychiatric Clinicians

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Frederick G. Guggenheim. New York, NY; Routledge (Taylor & Francis Group); 2009; ISBN 978-0-415-80109-6; pp 227; $24.95 (paperback).

The pressure to do more, to see more patients, and to push productivity is increasing in all medical specialties. Unfortunately, increased productivity does not necessarily mean better work. It is frequently measured by numbers, akin to car companies during the “good old times,” when focus was on the volume of cars produced. Because our day is naturally limited and cannot be stretched, ultimately we end up squeezing in more patients per hour or day. This volume provides advice and guides us on how to increase the number of patients effectively. The focus of this book, as Frederick G. Guggenheim postulates, is “to assist the time-pressured clinician to do more (quality work) with less time” (p ix). He adds that “all too often the 50-minute hour gets shrunk to the 20-minute hour for follow-up appointments” (p ix) and that his “primer” provides a variety of shortcuts and experience-tested ways to maximize those 20-minute (or so) sessions.

The book is divided into an introduction, preface, 2 parts (total of 26 brief chapters), and an appendix containing a list of useful references. The preface, “The 20-minute hour is new, where did it come from?” provides a historical review of the changes in our practice over the past 4 decades—the origins of the 50-minute hour (Freud suggested to “chill out or cool off for a few minutes between therapeutic hours” [p xi]); non-parity for mental health; the arrival of managed care with its management of access, requirement rates, and documentation requirements; the concept of health care as a profit center from the corporate and the clinician’s perspective; the impact of managed care on psychiatry and psychotherapy in particular; the changes in reimbursement rates (psychotherapy is reimbursed significantly less per minute than the rest of the psychiatric practice); and the positives of managed care. Access to mental health has increased and the costs have decreased (almost no inpatient care!) but there has been a huge increase in the administrative costs for the entire health care system (mine: almost another industry!).

Part I of the book, “Ways to make the 20-minute hour work for you,” consists of 8 chapters—1. Beginnings—not a moment to spare; 2. Measuring symptoms; 3. Setting the contract; 4. Decisions, decisions; 5. Psychoeducation/teaching; 6. Shortcuts; 7. Early and later pitfalls; and 8. Terminating treatment. The focus of these chapters is to provide shortcuts, from using small talk to enhance rapport, to measure symptoms and changes quickly, to jump start education, or to end a session on time without much problem. Some of the advice is good (ie, list of office supplies for the initial interview), some advice points out that shortcuts also mean cutting and focusing on money. The chapter on measuring symptoms advocates using a visual analogue scale (not bad advice), and a small scale for rating depression from 0 to 10 with sad or smiley faces is included. The chapter on contract includes a solid handout concerning practice information for the patient. Some advice is questionable and seems driven by the idea of just cutting. I personally would not wait 6 weeks to see a patient who was started on selective serotonin reuptake inhibitor “unless there are unacceptable side effects.” That is too long and does not foster a therapeutic relationship, even if the patient sees a therapist in the meantime. The discussion of psychoeducation is good. It correctly points out that interest in teaching psychoeducation to residents and students is minimal or non-existent. I missed the resources (handouts, etc.) for psychoeducation here, but fortunately they are listed in the following chapter. The chapter on shortcuts provides some tips on talking to patients effectively (but pointing out that one should never interrupt and never tell someone who is talking that his/her time is up). This chapter also points out the importance of documentation and includes a table on “how to avoid malpractice problems.” The last 2 chapters of this part, on early and late pitfalls and termination, are again a mixture of the author’s empirical advice, opinions, and occasional material supported by the literature.

The second part, “Quick-grab chapters,” includes 18 chapters discussing specific clinical situations, encounters, and troubling issues with chapters on: 9. The depressed patient; 10. The bipolar patient; 11. The anxious patient; 12. The traumatized patient; 13. The angry or violent patient; 14. The somatizing patient; 15. The patient with mild schizophrenia; 16. The questionably psychotic patient; 17. The adolescent patient; 18. The elderly patient; 19. The borderline personality patient; 20. The mildly mentally retarded patient; 21. The suicidal patient; 22. The depressed patient that is or wants to become pregnant; 23. The divorcing patient; 24. When your patient (or you) is stalked; 25. When tragedy befalls you or your patient; and 26. The clinician’s vulnerability to violence. Similar to the first part, some chapters present useful information (ie, the chapter on the “anxious patient” includes a table on the amount of caffeine in various drinks), while others present less useful and not very clear information (ie, the chapter on mild schizophrenia includes a non-useful and non-critical review of the CATIE study). Some chapters are just short blurbs (questionably psychotic patients, adolescent patients) while others cover their topics fairly well (the elderly patient, the depressed pregnant patient). The most readable chapters are the ones covering topics not frequently found in other texts or not taught well in residency training (ie, working with the divorcing patient or with the mildly mentally retarded patient).

I am not against shortcuts and/ or increasing productivity in a good sense. However, the focus should not be on numbers and should not be measured exclusively by negative outcomes. The focus rather should be on quality of outcome and quality of care we provide. The amount of our paperwork should be reduced and the approval procedures by insurance companies simplified. Some of these concerns are touched upon lightly in this volume and some are not. There are some factual mistakes and at times the author writes about persons who had done something important, yet does not provide proper reference (ie, introduction to somatization disorder patient). Those are probably fixable and at times tolerable flaws. The main issue I have with this book is its unclear message. Do the proposed shortcuts enable us to maintain good quality of care? What is the purpose of shortcuts—good care or an easier life for treating physicians? I am not exactly clear, although I recognize the importance of both. In summary, this is a mixed bag of useful information and not so useful or not much information at all about certain topics. Some beginners may find this book useful and some may find it simplistic, not very informative, or will question the way some topics are covered (or better, not really covered).