Rethinking the 15-Minute Medication Management Visit: Does it Work?

The 15-minute medication management visit has become one of the standards of psychiatric practice. But is it as effective in helping patients as it could be? Does it engage all the skills a psychiatrist brings to patient care?

And is anyone—patient or physician—happy with the current “med check” model?

William Torrey, M.D., a professor of psychiatry and vice chair for clinical services at the Dartmouth Geisel School of Medicine, said that the answer to those questions is a resounding no, and he argued, in an Open Forum article posted March 1 in Psychiatric Services in Advance, for a reconceptualization and redesign of the medication management visit. Torrey’s co-authors were Ida Griesemer of the School of Global Public Health at the University of North Carolina, Chapel Hill, and Elizabeth Carpenter-Song, Ph.D., a medical anthropologist at Dartmouth College.

Torrey and colleagues also proposed a team-based redesign of the psychiatric visit based on research he has conducted through the Patient-Centered Outcomes Research Institute (PCORI). According to PCORI, its mission is to fund research that can help patients and caregivers make better-informed decisions about health care choices.

“As professionals, it is our job to sort out how to organize care so that when people are experiencing difficulties, they walk into a system that actually addresses their needs,” he told Psychiatric News.

Torrey said that he believes the term “medication management visit” should be scrapped. “Even the way we talk about the work, as a ‘medication management’ visit or ‘med check’ frames the process in a way that isn’t helpful,” he said. “If you start by framing the visit as being all about medicine, you miss much of what psychiatrists can offer—real connection and the ability to help people be more hopeful and get on with their lives.

“Instead of thinking of the work as providing medication management, we should emphasize ‘care’ and call it ‘psychiatric care’—just like ‘primary care.’ As in a primary care visit, what really matters is the expert care you receive, whether or not you leave with a prescription.”

Based on ongoing research Torrey has conducted with PCORI comparing different team-based approaches, the authors of the Psychiatric Services paper proposed a redesigned visit in which much of the essential history gathering—symptoms, side effects, and vital signs—is done prior to the psychiatrist’s and patient’s meeting.

“The redesigned visit might look more like a smooth-running primary care office where history taking, basic assessment, and measurements of vital signs are gathered before the physician enters the room and where designated team members are prepared to put the treatment plan into action at the end of the visit,” they wrote. “Common clinical scenarios can be anticipated, allowing psychiatric care clinicians to design effective and efficient clinical pathways … that can be ordered with the check of a box when indicated. … With well-designed workflows, psychiatric care providers can use their limited time for the essential health-promoting work: connecting therapeutically, integrating patient-specific aggregated data with what is known from the scientific literature, and partnering with each patient to develop a practical shared biopsychosocial plan.”

Torrey said he believes a redesigned basic “psychiatric care” visit should incorporate principles from the best trends in recent years: the movement toward evidence-based care and recovery-oriented treatment. “The more the individual can understand about the illness and be activated to manage his or her own illness and be part of the health care process, the better he or she does over time,” Torrey said. “People who do the best are those who move from being passive recipients of care to active participants in co-creation of health. We can help people build the knowledge, skills, and confidence to play an active role. This is what the psychiatric care visit should be focused on.”

Concern about the “med check” and a corresponding drop in psychotherapy provided by psychiatrists is not new, and the phenomenon is supported by research: a 2008 report in the Archives of General Psychiatry by Ramin Mojtabai, M.D., M.P.H., and Marc Olfson, M.D., M.P.H., found that between 1996-1997 and 2004-2005, the percentage of office-based visits to psychiatrists involving psychotherapy decreased by 44.4 percent.

Eric Plakun, M.D., chair of the APA Psychotherapy Caucus, commenting on the Open Forum article, agreed that the 15-minute med check pleases no one. “We already know the doctor/patient relationship predicts whether medications will be taken, and, independently, whether they will work,” he told Psychiatric News. “How does this trusting relationship get created in 15 minutes or even when using an efficient team of providers, as proposed in the editorial?”

Plakun is the associate medical director and director of biopsychosocial advocacy at the Austen Riggs Center in Stockbridge, Mass.

“There is clear evidence that the combination of medication and therapy is superior to either alone for many disorders,” Plakun said. “How does it make sense for psychiatrists to [be forced to] pick only one of these demonstrably powerful tools that are effective and associated with brain change? The 15-minute med check is a reductio ad absurdum of the biomedical model that threatens to supplant the biopsychosocial model for the etiology and treatment of mental disorders—especially when a third to half of the time is spent interfacing with an electronic health record.”

Plakun said the Psychotherapy Caucus stands for “the importance of psychiatrists thinking beyond meds alone, and for ensuring that psychotherapy remains an essential part of the training and skills of psychiatrists.”

Grayson Norquist, M.D., chair of the APA Council on Quality Care and chair of PCORI’s Board of Governors, said the reform proposed by Torrey and colleagues is thoughtful but requires buy-in and collaboration from multiple stakeholders. “This is a ‘system’ problem and will require new models for organization of care and financing before anything changes,” Norquist said. “It’s not clear that much will change until these models, especially those that focus on team approaches to patient care, are implemented in local and state systems.”

Torrey acknowledges that the market and social forces that have made the 15-minute med check a prominent feature of the mental health landscape will not be reversed easily. But he said psychiatrists with whom he has spoken are energized by the idea of transforming care, and he invites APA members to contact him with their thoughts and perspectives.

“Doctors get excited about this, and they feel demoralized by the 15-minute visit as it is practiced today,” he said. “People feel diminished by being called a ‘prescriber,’ and we know that as psychiatrists we can offer much more. Therapeutic engagement—being a force for health—is possible and very important even in brief visits. If learning what medications to prescribe at what doses were all that I needed to learn to be a psychiatrist, my residency would have been one year rather than four years.” ■