At some point, you may find yourself in need of a good psychiatrist. There are three critical rules in doing this. Understanding the terminology in distinguishing between a psychiatrist, psychologist, and psychiatric mental nurse practitioner is the most important step.
Know the Rules
Setting your expectations appropriately and not sabotaging your approach is second. Third is the rule of not forgetting your ultimate goal.
Rule 1: Know the Terminology
If you are in need of general mental health medications, approaching your primary care physician (PCP) is a good first step. These tend to be general practitioners or family practice doctors. The advantage is one of accessibility; chances are, you already have an established relationship with your doctor and they know a little about you already. However, they may be limited in their specialty or be cautious in terms of dealing with in-depth psychiatric disorders. If you are dealing with run of the mill depression or anxiety, it can’t hurt to start here.
When you need more in-depth experience or are dealing with issues relating to medication side effects, it’s time to seek out a specialist. This generally falls into two different types of prescribers: Psychiatrists, and Psychiatric Mental Health Nurse Practitioners (PMHNP). Here’s where the difference becomes essential.
Psychiatrists are highly specialized and tend to know mental health issues and psychiatric medications inside and out. If you are concerned that you have been misdiagnosed, or are dealing with competing and unwanted side effects from your medications, you can’t go wrong in choosing a psychiatrist. It’s not uncommon to describe a psychiatrist as someone who can tell you that if you take medication A while spinning on one foot during a full moon on a Thursday, backwards, then you can likely expect results B and C. The disadvantage is that there aren’t as many psychiatrists around who are accepting new patients and, if you do find one, it may be several months before you can actually secure an appointment! Psychiatrists have an M.D. (Doctor of Medicine) or D.O. (Doctor of Osteopathic Medicine) degree.
Another specialized type of prescribing provider is a Psychiatric Mental Health Nurse Practitioners (PMHNP). They do not have as much in-depth training or education as a psychiatrist, however there tend to be more of them available and they can be easier to get in to see (and often sooner!). They often practice independently and have a good blend of skill and approachability. If you need specialized help but can’t get in to see a psychiatrist, a PMNHP is a good bet.
Rule 2: Set Your Expectations
Remember the vintage combination TV/VCR? It was relatively uncommon; you usually had a TV (for watching shows) and a VCR (for recording). The same is true in seeking psychiatric medications and therapy. Medical doctors, psychiatrists, and psychiatric mental health nurse practitioners are good at prescribing but often have limited training in counseling per se. Psychologists and therapists are good at providing counseling (talk therapy) but they cannot prescribe medications. Where we get into trouble is when we confuse the two roles.
I have had a number of patients who have fired their psychiatrist or PMHNP because they weren’t personable or only offered short, 15 minute sessions. Others have made appointments with therapists hoping to get a prescription but did not understand the limitations of what such providers can do. Don’t confuse the roles. Just as a TV is for watching and a VCR is for recording, a prescribing provider is for prescribing medications and a therapist is for talking out your problems to. This doesn’t mean that your prescribing provider won’t talk with you; in fact, they likely are interested in this and want to be able to help. However, it’s not their primary role.
Rule 3: Know Your Goal
When you try to make an appointment with a prescriber, you’ll probably get a list of names from your insurance company. Your need to remember that your goal is to make an appointment. Prescribing practitioners tend to be overworked, understaffed, and it can take a while to coordinate with them to make an appointment. You want to go through your list, calling each provider. Speak clearly, be specific, and to the point. Mention that you are looking to make an appointment as a new patient and tell them what your insurance is. If you don’t get an answering service, they may ask you want you are seeking treatment for; this is not the time to provide a full autobiography of your life story. Simply state what you are looking for help with (e.g., depression, anxiety) and anything significant that should be known (e.g., if you are at risk or have a history of suicide attempts). Again, be brief unless asked to explain further. Above all else, if you are leaving a message, make sure to clearly spell out your name and provide a single phone number for them to call. The goal is to make it easy for them.
One of my colleagues once remarked that he decided who to return calls to depending on how the message sounded when someone called. If they complained, slurred their words, were argumentative, or did not follow basic instructions from the voicemail message, they never received a call back. Another described a voicemail he received where a prospective patient criticized their inability to reach a live person and then complained about not knowing why no one was returning their calls, all before leaving the main part of their message (they never got a call back). While many would consider these to be of questionable practice on the part of a provider, it does happen and it is a reality. Finding a prescribing provider is much like applying for a job: You need to put your best foot forward (just remember not to hide your symptoms and issues).
If you’ve gone through your list, call your insurance and get another list of names. Call these as well. Lather, rinse, and repeat. Since your goal is to get an appointment, you need to put as much effort into getting an appointment as you have in other important areas in your life. Follow up with any returned phone calls promptly, however it’s best if you can be immediately accessible to avoid voicemail tag. If you haven’t hear back from anyone, call again after a few days and inquire again, without complaining.
When you finally get an appointment, verify that they can take your insurance. Know ahead of time if you have a deductible and what your out of pocket expenses will be. Make an appointment even if it’s months away. Ask to be put on a waiting list if they have one, and call back once a week to gently inquire if any openings have appeared. If leaving a message, leave your phone number again, even if you’ve already provided it.
When you have your appointment, remember that this is an appointment for psychiatric medication. You should have with you a list of your current and previous medications, including dosages and who prescribed them. Remember that now that you have an appointment your goals have changed; initially, it was to get an appointment. Once you actually have the appointment, you now have two new goals: Leave with a prescription (assuming you’ve been accepted as a patient), and do not leave without scheduling your next appointment.
Remember, prescribing providers are people too. If you treat them well, chances are you’ll receive the same. If you get upset that some aren’t personable, remember that the goal isn’t to find a best friend; it’s to get a prescription. By reframing your approach in terms of tasks and goals, you will keep yourself from getting frustrated by a system that can be confusing and overwhelming even at the best of times.
In choosing a good psychiatrist, Most people focus on their interpretation of the word “good” and neglect the word “choose”. Hopefully, this has helped narrow down your approach and made it more manageable for you with real-world suggestions.
How NOT to Talk to Your Doctor
In order to understand how to best talk with your doctor (or psychiatrist, psychiatric mental health nurse practitioner, or other medical provider), you need to know one very important concept: Your doctor wants to help you!
However, as healthcare costs continue to rise, there is a push for doctors to see as many patients as they can. This can frustrate even the best doctors, and happens more often than not. Also, doctors are human beings and despite our expectations, they tend to dislike displays of unpleasant emotions, disorganized patients or those that make them feel as if they must “fix” everything, “or else”.
As a result, it is not uncommon for doctors to be limited in the time that they can spend with you. Because of this, we often leave our appointments feeling unheard or, occasionally, unwelcome. We end up putting off additional appointments, minimizing our symptoms or simply not presenting well when talking to our doctor.
Well-meaning patients can end up making things worse, despite our best intentions. Our expectations and frustrations with the healthcare system can end up making us anxious and, as a result, a “poor storyteller” of our problems and symptoms. Sometimes our fears of being judged or being thought of as a “terrible person” or being seen as “weak” or even “difficult” can keep us from sharing important details.
Or, as is often the case, we are simply exhausted by our suffering. We hold things together until our appointment, and then we end up “falling apart” in front of the doctor. Without presenting things in a straightforward and direct manner, we often run into problems getting adequate help for our symptoms.
So WHAT can we do to fix this? As with all things, you can only control the things you can control. We can try to “fix” the system, but this is difficult even in the best of times and would take longer than we want. When we need help from our doctor, the last thing we need is another problem. Since we can’t control the system, we can at least control how we talk about things with our doctor.
What follows, then, is a list of things that you should NOT to do when working with your doctor. Your mileage may vary, however these “rules” have been found to be true over and over again, both by patients and medical professionals.
Whimpering or Whining
When we’re sick and in pain, sometimes our voices take on a whimpering, whining quality. No one likes to listen to whining. If you have children, you know that you’re more apt to ignore the pleas of a whining child than one who makes his requests in a normal conversational tone. Even though we may not realize it, we tend to give less credibility to someone who whines – be it a child or an adult. You may not even be aware that you sound whiney at times. If you have any doubts, ask a family member who will be honest with you. When you talk with your doctor, you want your voice to sound calm and rational.
Stay Away from Exhibiting Behaviors
These are the behaviors that we do to show we are suffering, hurting or in pain. If we’re extremely depressed, we end up being very quiet and withdrawn. If we’re full of panic and anxiety, we tighten our muscles and start breathing rapidly. Those suffering from chronic pain end up rubbing their back, groaning, moaning or walking with a limp. While it is normal and natural to want to do these things while you are suffering, it gives less credibility to your illness.
However, this does not mean that you should hide your symptoms. The goal is to avoid making your doctor sorry that he or she stepped in the room. Overly excessive displays of emotion and pain take the focus away from the conversation and end up hurting you in the long run.
Don’t Over-Do It
Since your symptoms are invisible, it is important to remember that the physician is looking for ways to make the problems real. One of these ways is to ask you how you are feeling on a scale from one to ten: Typically, one being low and ten being the worst thing you have ever experienced. This can be done for depression, anxiety and even chronic pain.
Now, before you think this is a simple question… it is actually a test to bring credibility to your symptoms. Proceed with caution when answering this one. Ten should only be reserved for “can’t breathe, barely alive” types of symptoms. Many people will rate their symptoms above a ten… say, a fifteen. This is a red flag for your doctor because research shows that those who rate their symptoms at ten or above may be exaggerating how they feel.
On the reverse side of things, don’t over-think things. If you choose an answer of, “6.5” or “between a six and a seven,” your doctor may think that you are over-analyzing and may wonder if some of your symptoms are “in your head”.
What we often forget is that using numbers to describe how we are feeling is very useful when talking to a medical professional. Saying that you have been feeling “very sad for a while” is not as effective as saying, “on a scale of one to ten, I’ve been feeling about a 6 for the past two weeks.” Some patients even use an old- fashioned paper calendar to write down their numbers (whether for depression, anxiety, chronic pain, etc.) each day and then bring this in with them to their appointment for “show and tell”. Surprisingly, this is very effective and gives you both credibility and prevents you from not adequately describing how you’ve been feeling.
We all know that when we are suffering, we tend to become more moody, irritable and emotional. As true as this may be, the more emotional you are when talking with your doctor, the more he or she may label you as “histrionic” and discount your story. You deserve fair treatment, and to ensure this, practice deep breathing so you don’t cry during the office visit.
This can be especially difficult for those suffering from severe depression. If it can’t be helped, then it can’t be helped. However, it does take valuable time away from being able to tell your doctor about your symptoms so that he or she can give you the best type of care. Ask yourself, would you rather walk away with a hand full of Kleenex or a revised prescription that might be of help.
Your Doctor is not Your Best Friend
Even though you are getting to know your doctor quite a lot lately due to how often you see him or her, remember, they are still not your therapist or friend. This also holds true for psychiatrists and psychiatric mental health nurse practitioners. You are paying them to be your “medical professional”.
Worse, you end up putting them in an unrealistic position. They have a job to do, and if you start treating them as your “best friend,” chances are that they will disappoint you and you will end up with a “bad feeling” about the relationship as a result. Your doctor does care about your well being, but they are not in a position to be your “best friend”.
Explaining and Talking Too Much
As it was told to me by one doctor, “When I ask a patient about his or her symptoms, I am not looking for a long story… I want a short, to-the-point answer.” Just like the old show Dragnet, it should be, “just the facts Ma’am, just the facts”. This is where coming in prepared will help.
This also is important in providing documentation. If you walk in to your appointment with a five-page, single-spaced and typewritten description of your symptoms, how they have made you feel and how unfair all of this is, your doctor’s eyes will start to glaze over. Keep it simple and straightforward.
Keep your list just like a resume: It should be no longer than one page. Perhaps filled with single-sentence bullet points listing the important parts. You should assume that whoever reads it will spend on average only about 10-15 seconds on it. Your writing style should reflect, and not challenge, this reality. This can mean the different between walking out of your appointment with nothing changing and the doctor saying, “Hmm… I had no idea your symptoms were still bothering you. Let’s increase your medication.”
Another aspect of this is the “handwritten on the back of a napkin” approach towards documentation. NO ONE wants to be handed a napkin with potentially illegible writing on it. It looks rushed, as if you just made up your list of symptoms on a whim. Your doctor may consider this evidence of disorganization and approach you differently.
Finally, a new trend is for people to keep their list on their smartphones. While convenient, handing your doctor your phone doesn’t help him or her as well as a printed out piece of paper. Chances are they will glance at it and the majority of what you’ve written down won’t end up getting across.
What to Do Instead
After reading this, you might be asking yourself if there is a list of things that you should do with your doctor. Indeed, there is. It’s a short list, given that many of these items have previously been covered here. Some of the essential highlights to keep in mind are:
- Patients with the most success in working with their doctor tend to be the ones who are more “scientific” about their situation. They keep track of their symptoms, are organized, and are able to provide concrete and specific information without a lot of extra “jibber jabber”.
- Bonus points to those who bring this documentation with them to their appointments to show their doctor, whether this be in the form of a diary or simple markings on a calendar. Be organized, be inquisitive, and above all be honest with how you are feeling.
- Doctors tend to be encouraged when a patient is curious and inquisitive about their condition. This shows that you are taking ownership of your situation and are willing to do whatever it takes to make things better.
- Finally, if you have difficulty remembering what your doctor tells you, take notes. Again, bonus points if you bring your own pad of paper and pencil with you rather than having to ask the doctor to find one for you. This shows, you guessed it, ownership.