Rethinking the First-Visit Prescription

"Somewhere along the way, behavioral health adopted an unspoken rule: the first visit ends with a prescription. Not because it is always clinically appropriate. Often, simply because it is expected. Understandably, patients want immediate relief. Systems expect productivity. Employers may expect "decisive action." And clinicians, caught in the middle, are left trying to meet a stranger, understand a lifetime of context, assign diagnoses, and initiate treatment, all within a single appointment."

"Even in systems that encourage or require prescribing at visit one, liability is not transferred upward. Organizations share responsibility, but the prescription still bears the prescriber's name, license, and ethical obligation. Yet we continue to hear from clinicians who feel pressured, directly or indirectly, to prescribe the first time they meet a patient. This should give our field pause. Prescribing is not a productivity metric. It is a clinical judgment that must belong to the provider, full stop."

"The reality is that many clinicians feel they must choose between doing what feels thorough and doing what feels expected. That tension erodes autonomy and, over time, contributes to burnout."

Mental health systems have adopted an unspoken expectation that first visits conclude with prescriptions, driven by patient desires for immediate relief, system productivity demands, and employer expectations. However, this norm is not always clinically appropriate. Providers face ethical tension when pressured to prescribe despite insufficient time to establish rapport, gather comprehensive history, evaluate risk, and synthesize symptoms. Liability remains with the prescriber despite organizational pressure, creating autonomy erosion and burnout. A two-step model—prioritizing rapport-building first, followed by data-informed treatment planning—offers greater clinical precision. Immediate prescribing should be exceptional rather than default practice.

Read at Psychology Today