Have you had this conversation with your family doctor yet?
“You sent me to see that psychiatrist and I’m no better than before!”
“Look, I’ve already sent you to the specialist, what more do you want me to do?”
There’s a lot of possible things that could have gone wrong to get you to that point. The simplest is that your family doctor mistook a midpoint of an inherently uncertain treatment process with the end of that process.
But I bet you’d be surprised to find out how much could have gone wrong before you even set foot in that psychiatrist’s office.
1. Your Family Doctor Isn’t Fully Aware of Your Problem
Some people are under the impression that when your family doctor says they’ll “send you to a psychiatrist” that their secretary just sends over your name and contact information. Nothing could be further from the truth.
Your family physician will put together a letter to the psychiatrist, detailing the problems you’re having and how they’d like the psychiatrist to help. Yes, doctors have to do a lot of paperwork. Your family doctor needs to decide who to send you to, what kind of help to ask for, how to concisely describe your relevant history and symptoms, and what background information should be sent along.
This can be a difficult task, particularly if they’re not fully aware of all your problems. That’s why it’s important for you to not withhold information from your family doctor, and do your best to communicate it clearly. The presence or absence of certain symptoms may make a difference in preparing the referral, and your doctor may not have time (or remember) to ask about them during your appointment. Consider bringing some notes to your appointment, or someone to help.
Make sure you have enough time to fully describe your concerns. When you call to book the appointment, don’t say it’s for a med refill if it’s really to describe how your life is falling apart, or you’ll be booked too short an appointment. Similarly, don’t leave it as a “oh just one more thing” at the end of your appointment.
Communication being a two-way street, your family doctor may not be doing a good job of listening to everything you’re saying, or not asking clarifying questions. They may jump to conclusions early and cut you off. Or they may have their head buried in their laptop fighting with their Electronic Medical Record software to the point you may need to scream to get their attention.
Not having all the information about a problem can certainly make it harder to ask someone else for a solution. But even if they have all the relevant information, they may not use it.
2. Your Family Doctor Didn’t Send a Useful Referral Letter
The best referral letters contain a concise summary of the symptoms you’re experiencing, confirmed and/or suspect diagnoses, a summary of past and current mental health treatment, a summary of other health issues, current medications, and recent lab results. They also explain why the referral is being made, e.g. clarify diagnosis, medication recommendations, provide ongoing management and therapy, etc.
A referral just saying “please see for depression” or “medication recommendation for anxiety” is less helpful.
Why does this matter? If your real issue is that you’ve got a form of Bipolar Affective Disorder or Post-Traumatic Stress Disorder, and your family doctor has—with great certainty—diagnosed you with simple depression or anxiety, the psychiatrist isn’t necessarily going to ask you the questions needed to clarify your diagnosis. Alternatively, if a thorough medical, psychiatric or medication history isn’t provided, they may well recommend treatments that are entirely inappropriate for your situation.
Generally, the more information that can be sent to the psychiatrist, the better. Doctors are skilled at quickly absorbing large amounts of material, and it’s certainly faster for them to extract what they need from a detailed referral letter than to spend time asking about it all in your appointment. Which brings me to…
3. Your Appointment was Booked for the Wrong Amount of Time
You’ll be booked for an appointment with the psychiatrist for a certain length of time. While every psychiatrist’s office works differently, it’s quite likely that someone sent for a simple medication consultation on a confirmed diagnosis will be booked for a shorter appointment than someone with all kinds of symptoms, on multiple medications and tried many others, where the family doctor is looking for more general guidance.
If it turns out at the appointment that things are a lot more complex than what they appeared from the referral letter, one of two things is likely to happen. First, they may try to rush through and cram everything in, and things will get missed or misinterpreted. Or second, things that really needed to be covered won’t be covered, and the recommendations sent back to your family doctor will be far less useful or reliable. There is a third possibility, that the psychiatrist may realize they don’t have enough time for what you need, and book you an appointment of the appropriate length, within a relatively short period of time, to properly complete the consult. Hey, it happens.
Not every psychiatrist’s office works the same way, and some may just book everyone for e.g. one hour, regardless of what they were referred for, and what gets done in that time is what gets done.
4. The Psychiatrist Didn’t Read the Referral
It’s also possible that the first time the psychiatrist sees your referral letter is when their hand is on the door to the interviewing room. If they’re running behind, if the appointment time is tight, or if there’s a lot of information to go through, that could be a problem. It also does not exactly inspire your confidence, either in them or your family doctor, if they start asking questions showing they don’t have the slightest clue why you were sent to them in the first place!
Not only is this a waste of everyone’s time, but most people are not quick on their feet when thrust into a totally new, unfamiliar environment. This makes giving good answers to the psychiatrist’s questions more difficult. That’s not to say that they won’t deliberately go over some of the things your family doctor provided, to confirm or clarify them.
But while they’ve got dozens or hundreds of patients to see, this is your one chance to get in with this specialist, which you’ve probably been waiting a very long time for. Not having at least a basic familiarity with your situation before they walk in the door shows disrespect.
5. You were Referred to the Wrong Psychiatrist
What else could have gone wrong, even before your appointment? Your family doctor could have sent you to the wrong psychiatrist altogether.
Not to put too delicate a spin on it, like with every profession, there are good psychiatrists and bad psychiatrists. Ones who are more adept at being able to help you with your problem, and others less so. They may have gaps in their knowledge, have difficulty applying it, be poor listeners, poor time managers (see above), and have prejudices or biases against certain groups or problems. They may be highly specialized in the narrow area of psychiatry you need help with, be all-around excellent generalists, or interested in something other than your problem.
And then of course, they may be excellent psychiatrists, but there’s just some weird personality mismatch between them and you, that makes it difficult to really divulge all the highly personal information that may be needed.
Ideally, you’d be referred to the most appropriate psychiatrist for you and the type of mental health challenges you’re facing. But that choice often comes down to other factors: geographical, waiting lists, and your family doctor’s familiarity (or lack thereof) with the various psychiatrists in the area.
Probably more than in any other area of medicine, there isn’t a standard psychiatric consultation, or a standard psychiatrist. With such variation in their approaches, skills and proficiencies, your experience with one may be entirely different than if you were sent to someone else.
If you weren’t satisfied with the visit to the psychiatrist that you had, take heart. You’re far from alone. This post has only scratched the surface of things that could have gone wrong, even before you walked through their door.
In future, we’ll talk about many other things that could go wrong, in your consult appointment, or after your family doctor gets their report.
Get a copy of your family doctor’s referral letter and the psychiatrist’s report. Do they seem completely off the mark? Ask for help interpreting anything that is unclear.
Push for another referral, to the same psychiatrist (if they seem helpful) or another, and get a copy of the referral letter ahead of time.
If you think your family doctor has underplayed what you’re experiencing, ask them why. Alternatively, write up a short narrative describing your symptoms and their effect yourself, and either ask your family doctor to send it along with the referral, or send it directly to the psychiatrist’s office (more on this another time). At the very worst, it will be ignored.
Don’t be swayed by a simple “you’ve already seen a psychiatrist” again. Get them to explain why they think a referral to someone else really wouldn’t be useful.