Updated: Aug 25
Not long ago a colleague chastised me when I somewhat boasted of my ability to do a 10 minute psych. eval. Being chided, of course, I had to explain myself.
For years I have taken pride in trying to make the best of whatever. opportunity a patient offers me to be helpful. A striking example is the patient who show up late for an initial evaluation leaving me with only a few minutes to try and make good use of the time.
It has always troubled me when some colleagues refuse to see late patients, arguing that that there is insufficient time to complete the evaluation. Such behavior is shrouded, I think, in the doctor's definition of what constitutes an initial evaluation, and whose definition it actually is.
Let's begin by consideration the definition of an evaluation. In a purely clinical sense, an evaluation is a relatively thorough attempt to understand a patient and develop a sound and productive treatment plan. On the other hand, third party payers will tell you that an evaluation is a specific coded event, usually around 45 minutes to an hour, that is reimbursed at a specific rate.
From my perspective, I think it best to prioritize looking at the meaning of 'evaluation' from the clinical side. After all, our professional ethics direct us to put patient welfare first. From the first moment of interacting with a patient I am asking, what can I do to be helpful? As the minutes tick by my impressions deepen. If the patient has only given me 10 minutes I can begin to establish a trusting relationship, I can ascertain the patients risk from symptoms, and sometimes I can even find a helpful medication intervention: imagine a patient for example with acute adjustment symptoms who is judged to be emotionally balanced to the point of self harm being low risk, who has a past response to Prozac under previous stressful circumstances. In such a case the patient might well leave the office with a prescription for Prozac and a scheduled follow up appointment in a week to look further into things.
Diving deeper into the definition of an initial evaluation, here's my take. I am evaluating a patient from the first minute of their first visit and will tell you that in the majority of cases, I consider the evaluation relatively thorough only after 4 or five visits. I like to see patients frequently at first, generally on the order of at least every couple of weeks until a treatment plan has stably evolved. This requires a pretty good understanding the patient's circumstances, his psychological strengths and weaknesses, and likelihood of responding to a particular manner of treatment.
On the other hand, if one confines ones definition to that offered to us by third party payers, we can be in somewhat of a quandary. Should I charge for a full eval. if the patient has only given me 10 minutes, should I bill the first appointment as a med check and schedule the next visit as a psych. eval? In almost all cases there will be creative solutions one can apply to serve the patient and eventually get paid fairly for ones efforts.
The worst case scenario is that a clinician will have unconsciously absorbed the third party's definition of a psych. eval. and decided that in the space of 10 minutes it cannot be done and refuses to see the patient.
This is the very scenario that makes me proud to avoid. My colleague who chastised me the other day seemed satisfied with my response.