Transcription
Hi, I'm Dr. Joseph Woodring, and today I wanted to talk about how the, I guess, the dysfunctional medical system can lead to something called prescribing cascades. Um, and okay, so what are, what, you know, what is a prescribing cascade? A prescribing cascade is when someone comes in with something that's relatively benign. Let's say that they're depressed or anxious because they're going through a divorce, or they lost a job, or something like that. And they get started on a medication. And it just snowballs. And then they have side effects of that problem, they get another medication, they have more side effects, and eventually they end up on like five different medications, and they're just a mess.
And so, um, this is what we do in our practice. We, we untangle prescribing cascades. And so we talk to a lot of people about, I guess, how they started. And, um, I'm going to share my perspective on, on this, on this topic. And so, um, you know, our medical system is kind of set up in a way, especially if you're going to like, you know, the kind of insurance-based system. It's set up in a way where, I guess, the physicians that are seeing you, that go into the profession, they just want to, they want to help. The next kind of, uh, I guess, I don't want to say naive, but once you kind of see the way medicine's practiced, it, it can be very different.
So, um, so why is this relevant? Um, physicians can be incentivized to see more patients per hour because they get a higher payout from the insurance company. So, you know, if you're a psychiatrist and you do, you know, four 15-minute visits in a session as opposed to say, you know, a 15-minute, a 15-minute like med check plus, you know, an add-on of like maybe, you know, 50 minutes of psychotherapy, although they're like roughly the same amount of time, you make way more money by doing the 15-minute med checks. That's just how it's reimbursed. You know, um, you know, the insurance system and the way billing and coding is done, it's, it's not set up in a way that, uh, I guess encourages a lot of therapy, especially for prescribing physicians. There, you know, it kind of incentivizes them to just, you know, do an evaluation for 15 minutes and move on.
And so why is this a problem? Like, obviously, you don't get that much information in a 15-minute appointment. And so then what do you do? And then I guess what a lot of people do is, is what leads to prescribing cascades. So you have someone that comes in going through a divorce, something bad is happening in their, in their life. And, you know, they get started on an antidepressant. This is a good one. And then they take that medication for a while. Maybe they've been on it for about six months or something. And then they, maybe it's working, they're not really sure. You know, something else is happening and they get the gulp on the dose. Shortly thereafter, they become, they become very agitated. Um, and, um, they end up in the hospital because they're really irritable and their family is worried about them. And then the physician who evaluates them, you know, again, only kind of either in the emergency room, you know, they've got a million other people to see, they want to just kind of figure this out pretty quickly.
I was sorry, okay, so you're in the emergency room, you get sent to the psychiatric hospital. And, uh, if any of you have been in, in some of these county psychiatric hospitals before, um, you don't spend a lot of time with your physician. I would say on average, um, you know, maybe it's like, you know, 20 to 30 minutes for the intake, and then for like the follow-up visits while you're there, it's like five minutes. So anyway, you go in there, you know, the, the physician just goes, you know, what if I can, you know, see these, you know, 10 people before noon, I'll take off and I'll go home. And then I'll just, um, um, you know, respond to any calls, you know, you know, from home because, you know, there's, there's not a big incentive to spend, you know, two or three hours with someone, you know, that's going to start eating into their time with their family and things like that.
Okay, so they come in, okay, yeah, you're understanding depressant and you, uh, okay, and now you're agitated. Instead of even like going and doing that history and just saying, okay, tell me, tell me about about your background, you know, when did you, you know, when did this happen? When was it in relation to your medication changes? Okay, maybe they don't know that antidepressants can cause mania. And they go and they pull up the drug label and they look at it and they go, okay, that's interesting. Uh, but instead of that, they go, okay, well, he's agitated and he has depression and he's in his early 20s. Oh, this could be bipolar disorder. The most conservative thing that I could do right now is to put this person on, um, let's say, you know, Depakote. You know, they, they've, this, this, uh, antidepressant may have unmasked some bipolar disorder. And so without taking a history, they just grabbed the person's clinical symptoms, diagnose them with a new condition that fits, and and write a medication. And that's, and and that's like a lot easier than taking a history or calling their family and getting, you know, collateral information of, you know, what, what happened when you see these changes? Tell me about your, um, you know, what, what the patient is like normally. So a lot easier to just, you know, okay, symptoms, it's bipolar disorder, let's throw another med on there.
Okay, now this person's, uh, out there, maybe they're on Depakote and they're, they're having difficulty concentrating at work. Um, and maybe they go to a place that's doesn't do a very good job. They go in there and, you know, they say, I'm having difficulty concentrating. Again, without kind of going through this process of saying, you know, tell me about where this emerged from, not all doctors, but some of them, they might start them on say, um, a medication for ADHD, whether it's Strattera or, um, maybe an amphetamine medication like, um, like Adderall. Um, and so now you've got someone kind of on these two different medications that they don't really need to be on.
And then, you know, life happens. You know, someone may all of a sudden run out of that Depakote one day and then they start having, uh, withdrawal. And then they go back into the hospital because they're suicidal and they're really irritable because they're in withdrawal from Depakote. And then they could kind of get an antipsychotic thrown on top of that to cover it. Again, it's the same thing. Someone doesn't kind of look at the, the history and how these medications started and how the symptoms are related to the temporal course of the medication.
You can also have someone, you know, get started on this ADHD medication and now they develop paranoia or maybe even some hallucinations in severe cases. And then it becomes kind of like a, I guess, you know, you know, bipolar disorder can turn into schizoaffective or something like that. And yeah, and so you can get these, these cases where, you know, you have these people and they're on like five different medications and it's just a mess because the initial problem was something that may have just been contextual. And now they've kind of been chewed up by the system and spat out because everyone was incentivized to see the patient in the shortest amount of time and they didn't do a really good job. And it's kind of harmed the person for the worse. Um, so that's my perspective on, I guess, prescribing cascades and how that can happen. I mean, sometimes you do bump into good doctors and they'll say, hang on a second, just stop. Why the hell are you on this? But, um, sometimes you don't, and that's when these real, really bad cascades happen.
So, did this happen to you? You know, what was your experience like seeing physicians in the, I guess, in the public system, I guess, you know, you know, with insurance and things like that? Um, or, um, I mean, did you have a great experience or have you seen kind of similar behavior to this where it's not so much interested in your history, the clinical course, and all of that, but more just, you've got these symptoms, take this medication, see you later?
So, yeah, let me know your thoughts on this. Thanks.