Saturday, March 31, 2007
This started out as a comment to respond to some comments in Your Doctor is Making Jokes About You, but it got so long that I thought I'd post it. Midwife's comments (dang, I see she removed them but they deserved to remain) about being able to laugh at tragic circumstances provoked some anonymous comments about insensitivity, which is the other side of the coin to humor (all humor has this Janus quality... it is insensitive to laugh at that poor chicken's difficulty getting to the other side of the street). Mid wife apologized for inciting a riot.
There's no riot. This is a healthy discussion about what it is like to work in a job where one deals with human tragedy on a daily basis.
The problem, I believe, that the anonymous poster has trouble getting his or her arms around, is that physicians (and here I mean all health care "professionals") are not perfect. We do not possess some unique ability that shields us from anger, fear, depression, loneliness, despair. Yet, for some reason, there is an expectation that we are somehow above these human foibles.
We are not.
In the past week, I have dealt with near-lethal suicide attempts, single women who have had their children taken away from them (probably forever) because their brain illnesses currently prevent them from providing adequate parenting, people who have recently lost a loved one, a home, a job, their freedom. I have also dealt with people making more incremental steps of improvement in their life (another week of sobriety, making it to their follow-up appointment, getting a job, making a new friend).
And, I'm afraid, this is a typical week.
Just writing this comment, I feel tears welling up. That's fine. I'm in touch with my pain. I'm down with that. Woo. But I cannot be in touch with it all the time. That may work for some, but for me it would impair my ability to be effective.
So humor is my way of managing these emotions, both in me and in others. And I use it like I use a medication... with a particular dose to achieve a desired outcome (that is, in my work with patients and staff... at home, my humor is much more random... in my posts, it is somewhere inbetween, depending on the topic). (Mind you, I am not talking about "humor" where one laughs at another's misfortune in a way that is intentionally harmful/evil/superior to that person... that is not what I am talking about here.)
My intent is to heal... both myself and others. Just like a drug may have unintended side effects and be harmful, so might humor. I choose medication which I think is uniquely appropriate for a given patient. My patients do not get angry and hurt when a drug makes them have a dystonic reaction. A shot of Cogentin makes it better, and I avoid that type of drug again. They know my intent was to help.
Similarly, I choose the words I use intentionally for a given patient because it is important to use language that they often use. It helps us understand each other. When my humor has an unintended side effect and is experienced as harmful, my patients also do not get angry and hurt. An Apology makes it better, and I avoid that type of humor again. They know my intent was to help.
On the internet, when one stumbles onto a near year-long, extended conversation about psychiatry, mental health, blogging, ducks and fish, it is all too easy to jump right in, read some comments that appear hurtful or mocking, and take offense. This casual blog observer does not know what the intent is, unless they take the time to understand. Similarly, in the hospital, it would be easy to judge me, for example, as insensitive if I am administering one of my therapeutic aphorisms and someone walks past the door, only to hear "You gotta cut this shit out, Joe," or "So your right arm became paralyzed just after your boss told you that you didn't do a good job on the report that you've spent all month working on? I tell ya, it's a good thing it happened when it did, because if that woulda happened to me, I would have wanted to punch him right in the nose."
My approach (in life, but especially on the net) is to assume benign intent. This takes work, because I am, deep down, somewhat suspicious. But at the end of the day, I am convinced that this way of viewing the world makes the world a better place.
> 20% physicians (incl 13% psychiatrists & 7% other docs)
> 9% nurses
> 7% psychologists
> 7% social workers and counselors
> A total of 43% of voters were (mostly mental) health care professionals.
> 29% were patients
> 29% were "others"
Just wanted to share these results with you all. Thank you for your interest in our inspired ramblings.
Friday, March 30, 2007
Saw this on the APA site today. I sorta predicted this in Reality Therapy Vlog...
"A new TLC [The Learning Channel] show is looking for experts in cognitive behavioral therapy and anxiety disorder treatment to take on eight challenging patients in a groundbreaking television series to alleviate their phobias.They are looking for two doctors -- a cognitive therapist and an anxiety disorder specialist -- to go on the road with them for 10 days. Any takers?
Everyone knows what it feels like to be afraid or to feel anxious, but there are some people who can be so debilitated that it interferes with the tasks of everyday life. Their friends and families try to understand, but the relationships are strained. Meet eight individuals who are prisoners of their own minds. In order to take back their lives from their overwhelming emotions, they will undergo a unique treatment directed by two of the country’s top anxiety disorder specialists. On a two-week journey of hope and self-discovery, eight individuals and two therapists will board a bus winding along Route 66, crossing eight states, and 2,400 miles with the aim of curing the neuroses for good. People on the bus will not only face their individual fears, but will also help each other through intensive group therapy.
The show will be an uplifting experience for the participants and the viewers. The patients will be challenged, yet always in a safe but dynamic environment. They will have the guidance and support of two exceptional therapists and their bus-mates, but they will be emboldened to take an active role in their own recovery.
The journey from incapacitating dread to dynamic vitality will be documented for The Learning Channel. The Learning Channel is a network dedicated to groundbreaking programming presented in a sensitive and educational manner. This program will be produced by LMNO Productions for TLC. Eric Schotz, Bill Paolantonio and Kathy Williamson are executive producers."
Thursday, March 29, 2007
You deserve to know the truth. The truth is, your doctor may be telling jokes about you. Well OK, not necessarily about you, personally. But about medicine. About the experience of treating patients with common conditions in common circumstances. Stories about patients with unreasonable demands or unreasonable behaviors who come back repeatedly for repair after refusing to change the very things causing them problems. With regard to psychiatry, doctors who have been assaulted by a patient in seclusion may use humor to relieve the fear and anxiety associated with caring for a potentially violent person. In situations like this it's better to make a joke than to scream, throw up your hands and walk away.
Sometimes in psychiatry you work with patients who aren't very nice to you. They may be angry and they may say things that are hurtful. As professionals it is our responsibility to take this dispassionately and allow the patient to be honest about their feelings. We cannot snap back or be retributive or let this influence our judgement. Psychiatrists must be dispassionate, supportive, sensitive and empathic.
Frankly, that's hard work.
Humor is one way of dealing with this. People who read this blog know that we use humor a lot. We tell jokes about medications, about diseases, about the pitfalls of psychiatric practice and about each other. (Well OK, usually about Dinah but that's just because she leaves herself so gosh-darn open to it. And because she takes it so well. Believe me, she can give it as well as she takes it.) According to our readers' comments one of the things people like about this blog is that it gives them a behind-the-scenes glimpse of the human side of psychiatry. That may be disturbing to folks who don't want to think about their psychiatrists in that way.
Every physician at some point in time has used humor to mediate stress and vent frustration. Heck, even an entire television series was based on this premise. The legendary Hawkeye Pierce used humor and practical jokes to highlight the idiocy of military (and medical) bureacracy all the while giving terrific patient care. I imagine my opthalmologist, my dentist, my primary care doc and even my gynecologist have their own brand of behind-the-scenes humor that I as a patient have never heard. (I have to admit I've come up with a few thoughts on my own while straddling the stirrups. And here's an informal survey: how many of you have gynecologists who post cartoons on the ceiling above the exam table?)
Personally, if it keeps my dentist sane and available for me and helps him be more tolerant of me as a patient I'm all for it.
I'll bet he's laughing at how I walk.
Warning: This blog features graphic scenes of psychiatric humor that may be disturbing to some readers. Reader discretion is advised.
Here are my tangential thoughts about these 10 steps, as they relate to the whole managed care experience.
1. Prearranging some form of contractual obligation, verbal or written, to control the individual’s behavior in pseudo-legal fashion. In Milgram’s obedience study, subjects publicly agreed to accept the tasks and the procedures.
Managed Care (MC) involves establishing contracts with physicians and other health care practitioners, detailing what they can do and cannot do, in a manner which makes them look like poor sports if they do not comply (e.g., being
labeled a nonparticipant versus being part of a network of participating providers).
2. Giving participants meaningful roles to play — “teacher,” “learner” — that carry with them previously learned positive values and automatically activate response scripts.
We health care practitioners strive to provide good care and most are in it to help people, not just for money; so the idea of making health care affordable makes sense. How could we be opposed to this?
3. Presenting basic rules to be followed that seem to make sense before their actual use but can then be used arbitrarily and impersonally to justify mindless compliance. The authorities will change the rules as necessary but will insist that rules are rules and must be followed (as the researcher in the lab coat did in Milgram’s experiment).
Initially, there were rules limiting admissions to only those which were "medically necessary". Who wants to admit someone for a medical problem when it is unnecessary? Now, "medically necessary" is not what you think it is, but what the company defines it to be. Other rules get changed, and many have come to believe that "rules are rules and must be followed". Example: Dinah's previous point that Husband thought he must go to Lab B to get test done (even Lab A told him so), rather than paying the $12.68 and getting it done at more convenient Lab A.
4. Altering the semantics of the act, the actor, and the action — replacing unpleasant reality with desirable rhetoric, gilding the frame so that the real picture is disguised: from “hurting victims” to “helping the experimenter.” We can see the same semantic framing at work in advertising, where, for example, bad-tasting mouthwash is framed as good for you because it kills germs and tastes like medicine.
"Managed care" rather than "managed costs".
"Authorization" rather than "rationed care".
"Medical necessity" rather than "only if we want to pay for it".
"Referral" rather than "gatekeeper".
5. Creating opportunities for the diffusion of responsibility or abdication of responsibility for negative outcomes, such that the one who acts won’t be held liable. In Milgram’s experiment, the authority figure, when questioned by a teacher, said he would take responsibility for anything that happened to the learner.
Care is denied via a Review Committee rather than Doctor Jones. By requiring that patients or physicians jump through hoops, such as getting an authorization, waiting on hold for 15 minutes to speak to a reviewer, or filling out a 3-page treatment plan for 5 more visits, the guilt may then conveniently lie with you for not following the proper procedure, rather than the company for denying or limiting care.
6. Starting the path toward the ultimate evil act with a small, seemingly insignificant first step, the easy “foot in the door” that swings open subsequent greater compliance pressures. In the obedience study, the initial shock was only a mild 15 volts.
It started out as simple as "You accept less of a fee, we will send you more patients." Then it progressed to "You must accept whatever we offer, or we will send you no patients." Now it is "You must practice the way we tell you to, or we will send you less money (and imply that you are practicing substandard medicine).
7. Having successively increasing steps on the pathway that are gradual, so that they are hardly noticeably different from one’s most recent prior action. “Just a little bit more.”
Provide the diagnostic code.
Provide the diagnosis and treatment plan.
Provide the diagnosis, treatment plan, and copies of your progress notes.
Provide the diagnosis, treatment plan, copies of your progress notes, and also various evidence of measures of "performance" to prove that what you are doing can be shown to have a measurable impact on visit-to-visit progress (the equivalent of focusing on quarterly shareholder profits rather the big picture of what is best in the long run).
8. Gradually changing the nature of the authority figure from initially “just” and reasonable to “unjust” and demanding, even irrational. This tactic elicits initial compliance and later confusion, since we expect consistency from authorities and friends. Not acknowledging that this transformation has occurred leads to mindless obedience.
We started out with "medical privacy", which is every patient's right. Then we passed a privacy rule, HIPAA, which makes your records "more private" by removing requirements for you to authorize their release under numerous conditions, and even requiring you to give them up to law enforcement officials, without a search warrant. And, if national security is invoked, y then it is illegal for you to tell your patient that, "Oh, the FBI came by to look at your records." We are all so confused that mindless obediance has been achieved (e.g., annual "Privacy Notices").
9. Making the exit costs high and making the process of exiting difficult; allowing verbal dissent, which makes people feel better about themselves, while insisting on behavioral compliance.
Try "opting out" of Medicare... it means you can't work for anyone who wants to bill Medicare for your service.
10. Offering a “big lie” to justify the use of any means to achieve the seemingly desirable, essential goal.
The Big Lie: We will pay you more for practicing evidence-based medicine, which results in better performance. (The Big Truth: We will pay you less for straying from our population-based, cookbook procedures. As Scott Aaronson says, "The plural of anecdote is not evidence.")
Wednesday, March 28, 2007
[insert photoshopped pic of Egyptian-walking Freud here... anyone?]
Tuesday, March 27, 2007
I watched a comet burn up this week. It was a most impressive flame-out, with raised voices, threats of legal action, hints of physical violence and tears.
The inmates, on the other hand, were relatively well-behaved.
I've seen many health care professionals come and go through the years. As the token employee assistance person (unofficial, uncompensated) I've provided supportive counselling (translation: been ranted at) by some of them. I struggle to know what to say, but over the years I've learned a few general principles.
When you're new to the correctional environment you have to go through an adjustment process that's analogous to the Kubler-Ross five stages of dying: denial, anger, bargaining, depression and acceptance.
1. "I'm working out of a bare cell? No way!"
2. "I'm not going to be treated like this!"
3. "If you want me to do X, you need to give me Y."
4. "Why do I stay here? I should just leave."
5. "It's pretty cool when my patient gets better."
Not all people go through all stages or in the same order, or sometimes it happens all at once pretty fast.
The main thing to know is that you're working in a bureacracy, and bureacracies are notoriously slow beasts to turn. You can't be a fighter pilot in a jumbo jet. Some professionals hit the bureaucracy with guns blazing, making a virtual declaration of war, and burn to cinders in the atmosphere within the first few months. If recent American politics can teach us anything, it's the importance of building a coalition prior to taking action. Your coalition is your team of co-workers. Now, your co-workers may (in your opinion) be inebriated incompetent dim-witted dickheads (I wish I were as eloquent as Shiny Happy Person. She would say this so much better than I could---I believe she'd use the terms 'fuck-wit' or 'git' which just don't get captured by American colloquialisms) but they are your battle-buddies and they're all that you've got. If you antagonize them they will let you go down in a hail of bullets. Or worse, turn weapons on you themselves. Your credibility depends upon tact and restraint. Translation: don't even try to start "writing people up" until you've been there a year or more.
At some point you're going to come to believe (or to witness) that this bureacracy rewards mediocracy and punishes malcontents. Once you hit this stage, you have three choices: you can throw up your hands and walk away, you can bury your head in the sand or you can change tactics. More importantly, you can take time off. You can cool down. You can go home and hug your kids (or your dogs or your cats). But the thing you should never, ever forget is:
We need you. You're smart. You care. And you've saved a few lives while you were here.
I hope that's enough to bring you back.
Monday, March 26, 2007
Here's a quote from the CNN coverage of Anna Nicole Smith's autopsy findings:
His death was ruled an accidental overdose of three antidepressant medications: methadone, Lexapro and Zoloft, according to forensic pathologist Cyril Wecht, who performed a private autopsy at the request of his mother.Ouch. When did methadone become an antidepressant? And how will P4P reimburse for that?
Saturday, March 24, 2007
The idea of pay-for-performance is that doctors will be monitored with regard to various yet-to-be-defined standards of health-care delivery and rewarded (or not) in response to adherence.
First of all, the thing that struck me was that everyone agreed that doctors needed to be measured but so far no one can agree on a ruler. Multiple governmental agencies, health care businesses and professional organizations have a finger in this pie but so far no one has pulled out a plum. There were obvious things discussed like requirements for proper physical assessment or laboratory monitoring, patient education, continuing education and the like but as each aspect was brought up there were parallel problems involved with the assessment. My favorite example: a proposal to make family involvement in patient care a benchmark. OK, sounds good. In prison? The family involvement we get there is the accidental kind, where they happen to meet in a holding cell. Another benchmark: proper referrals for psychotherapy (got any therapists handy over there in maximum security?).
But the main issue as I see it is that the physician becomes the sole endpoint of a very complicated healthcare delivery system. Adherence to practice guidelines could be a useful measure of healthcare quality, but what if the patient doesn't want to take those medicines? Or if you've already been through the guideline decision tree (meant, after all, for the easiest case scenarios which are never the ones I get)? There are just too many 'what-if' scenarios to really tailor one quality measurement system---an inpatient unit is different from a partial hospitalization program, which is different from an outpatient clinic which is different from an emergency room. And none of the guidelines or benchmarks even considered the possibility of a correctional environment.
Consider this: the state saves money by not providing resources to the health care provider. They set the benchmarks, then fine the health care company for failing to meet the benchmarks that they have not provided the resources to obtain. A financial win-win situation for the state. Now comes pay-for-performance, the dynamic now trickles down to the level of the individual clinician. The question that I asked the presenters---and which brought the room to a dead silence---was whether or not the P4P approach would lead to any requirement that publically-funded health care systems actually provide the resources to meet their benchmarks. If so, sign me up.
In the meantime, I can't wait for my final benchmark: the patient satisfaction and quality-of-life survey. Of course, in my situation that would be the quality-of-life-sentence survey.
Friday, March 23, 2007
"I'm a passionate, romantic, sincere friend who has ambitions and goals. I enjoy reading creative writings, studying the law, horseback riding, dining out, and going to museums. I like vacationing and taking romantic walks on the beach. Looking for pen pals..."(link not provided because I'm not trying to encourage this sort of thing)
Theoretically somebody could be printing out my posts every week and mailing them inside the walls to my patients. Frankly, if anybody actually went through that much trouble I'd be rather flattered. And then maybe a bit alarmed.
There are three reasons why inmates express curiosity about someone---for flattery, for intimidation or just out of boredom. They wonder where I'm from when my accent slips out ("Charm City, but not originally."), why I don't wear a wedding ring ("I don't bring jewelry into the institution.") and whether or not to wish me a happy Mother's Day ("Thank you."). Rarely I get a direct personal question, and then I just give a direct response: "I don't talk about myself in here. This is your time." They accept this.
I have run into my patients after release (their release, not mine. I don't see myself being released for quite some time). Usually they recognize me first since once they're out of the standard-issue too-big or too-small jeans and grey t-shirt they just don't look the same. Only once have I run into a former inmate who didn't acknowledge me or seem to recognize me, and I understood that. I doubt anybody would necessarily want a reminder of an unpleasant place.
So I really don't think about it too much. And honestly, when it comes to finding out about someone through the Internet they have a lot more to worry about than I do.
Thursday, March 22, 2007
For those who haven't been here since the beginning to hear about my blogging angst, I started the blog last April after feeling a bit overwhelmed by the winter. I'd returned in November from a brief time in Louisiana with the Katrina Assistance Project, I had a bunch of patients who'd been having problems, I was feeling demoralized with my lack of success in getting my novels published, and I wanted a forum to express some of my thoughts -- more about psychiatry but a little about my own life-- and I wanted to engage interested parties in discussion about topics in psychiatry. My field, it seems, lacks consensus on much of anything, I'm not always very comfortable with uncertainty, and it's fun stuff to discuss. For me, a lot of it is about the writing. I asked ClinkShrink and Roy for help, and have been thrilled that they embraced this project with so much enthusiasm and investment. One of the best things about Shrink Rap is that my friendships with both of these wonderful people have grown, both on-line and in Real Life. Shrink Rap is now a part of my life, it occupies my thoughts in a stimulating way, I love the discussions we have here, and I've enjoyed "meeting" the readers who engage us in both intellectual and entertaining conversation. The blog has been a really good thing.
When we began, I debated using my own name, and initially used my full name. ClinkShrink and Roy were clear on the matter-- they were using pseudonyms. Though, as time and the My Three Shrinks Podcast have moved on, they are both aware that anyone who wants to figure them out, can. I had already published a novel, I'm very active in our local professional organization, here and there I've had a non-fiction rant published that people comment on. In the psychiatric community, I'm not particularly low-profile, and anyone who really wants to Google me can read about my thoughts and my life in a variety of forums. So why not? --and our blog bears my first name.
Wednesday, March 21, 2007
I work in Free Society -- a term I learned from ClinkShrink who works in the jails. My patients are all adults and with few exceptions, they seek my help of their own accord. Often they come with a request for medications, sometimes a request for a specific medication--something that's helped them in the past, something that's helped a friend.
So humor me while I talk a little about medicines.
Medications are prescribed by doctors to target symptoms, to target abnormal laboratory or radiologic findings, or to prevent the development of disease in at-risk populations. Symptoms are things like pain, insomnia, hallucinations, cough, angina, heartburn. The goal of medication is to relieve the symptoms. Abnormal laboratory values are things like elevated glucose levels in diabetics, low red blood cell counts (anemia), elevated cholesterol. Examples of medication given to healthy people might include aspirin to prevent heart attacks, or the ill-fated Hormone Replacement Therapies that were given to women in the hopes of preventing heart disease and
osteoporosis, Lithium for bipolar disorder that is continued between symptomatic episodes. I didn't get it all-- fit chemotherapy for cancers, anti-hypertensives, and a slew of other medications where you will. At any rate, the point of the medicine is to get rid of something bad or to prevent something worse from happening, or both: anti-hypertensives normalize blood pressure and prevent end-organ damage --end organs for high blood pressure are the retina, the kidneys, the coronary arteries, and the cerebral arteries-- so the goal of them medicines is to normalize the numbers and prevent strokes, blindness, and renal failure.
So the good: medications sometimes work. In some people, some of the time, they make the bad things go away and they allow people to live healthier lives longer.
The bad thing about some medications is that they have Side Effects. Side Effects are results of the medications that are nearly always unwanted, kind of the weeds in the garden. Symptoms in their own right, they happen, with some regularity, and sometimes we even use medications for their side effects rather than their primary purpose. So trazodone is an antidepressant, but it makes a lot of people sleepy, so it's used in sub-therapeutic (for depression) doses to help with insomnia. Mostly, though, side effects are bad-- they are uncomfortable for the patient and are often a reason people will stop medications. It's great if that medicine strengthens my bones so I won't break them later, but not if it gives me intolerable Side Effect X now. Side Effects are uncomfortable, they aren't fatal, and they are reversible, they go away when the medication is stopped, and for certain medications, certain side effects are fairly common-- if Ibuprofen upsets your stomach, you're not alone.
What's interesting about side effects is that few of them happen to everyone. So a lot of people will have sexual side effects from SSRI's, but certainly not everyone. Some people will have a tremor from lithium, some will get tired on thorazine. Certain cancer chemo therapies cause everyone to lose their hair, and dry mouth on therapeutic doses of tricyclic antidepressants (at least in my personal observation) seems to be par for the course, but many side effects seem to be fairly random. Many psychotropic medications are known to cause weight gain, and that has been a topic of concern in the comments on Shrink Rap, but I've certainly seen plenty of people take medications that are associated with weight gain who never gain weight. We don't know who will have side effects, kind of like we don't know who any given medication will work for, and because of this, it really becomes impossible to tell patients anything more than a list of the more frequent side effects with this implicit understanding that other side effects may also occur. Pharmacies provide lists, but it's hard to be comprehensive. From the doctor standpoint, there is no guarenteed free ride: when you swallow a pill the possibility of a side effects are there and largely unknown. For the patient who is struggling with a condition that's impeding his life, as many psychiatric patients are, it may be worth taking the risk of any given side effect because that side effect may simply not happen. Since weight gain is a hot topic, I will say that I've seen patients have good responses to Lithium, Clozapine, and Zyprexa (all notorious for causing weight gain) who've not gained an ounce. Other's have inflated like balloons-- the only good news here is that the weight goes on a pound at a time and the medicine can be stopped if the weight starts going on. The problem, of course, is what to do when the patient has a good response to the medicine but also has side effects: unfortunately this scenario leaves the patient with difficult choices.
Side effects are unpleasant, but often anticipated, and reversible. Many medications have really rare and really ugly effects-- these aren't side effects but Adverse Reactions. They can be awful, and they can be fatal and they can be irreversible. So Stevens-Johnson Syndrome, fulminate liver failure, and agranulocytosis are not side effects, they are life-threatening adverse reactions. Tardive Dyskinesia is an Adverse Reaction, though one that takes time to develop. Adverse reactions are the stuff of Black Box Warnings. The usual response to the Ugly is to stop the medication ASAP.
So what do I tell patients?
Mostly, I tell patients the more common side effects and of any black box warnings. I don't know, off hand, every side effect of every medication. If a patient asks in more detail, I open a PDR and read from the list of side effects. I offer reassurance that the medication can be stopped if side effects develop. I can offer no real guarantees about the possibility of catastrophic reactions-- though generally these are less then the risk of getting into one's car and usually I'm left to say "I've never seen that." A friend recently had a patient experience a life-threatening really rare reaction to a medication (one not listed in the PDR) and for a while after I told any patient I started on that medication about this patient's reaction--- no one refused the medication even after hearing the story. My friend says she will never again be able to prescribe that medication. Rational? No, but our own experiences are sometimes more powerful than statistics. In the case of side effects, ultimately the patient is left to decide if the cure is worse than the disease. In the case of an adverse reaction, I stop the medication and don't restart it.
Sometimes, in some patients, the medications simply relieve the symptoms without any ill effects. It's nice when that happens.
Monday, March 19, 2007
Woo-woo! We made ten bucks! Some kind, anonymous reader (I think it is the one who's been yankin' our chain lately... thanks, bud!) made a donation in our virtual tip jar for 10 bucks. I really didn't expect anything to come of this. (Excuse me but gotta go use my steroid nasal spray... allergy time.)
Some of you may have noticed that I added an Amazon Giving button at the bottom of our sidebar a few weeks ago. This is a nifty way for people to contribute to a website they like, even as little as a dollar.
Why do we -- three U.S.-trained, working physicians -- want to panhandle on the internet for pocket change? We can afford $5 per month for the bandwidth costs (Siteground: 900GB per month!! Best deal on the Net!), or a C-note for a microphone (insert affiliate link here). I wasn't really sure why I did it, but I think I figured it out. It's like putting money in the hat of a street performer.
But then I saw this interview on Rocketboom. The two guys who dreamed up lonelygirl15 -- one is an attorney (Greg Goodfried) and the other a surgeon (Miles Beckett) -- left their safe, professional, paying jobs so that they could devote all their time to LG15.com, their new website where visitors can interact with Bree (lonelygirl15) and other not-real characters. For this they expect to eventually be able to cash in bigtime, with their 1.5 million views per week (hey! we get 1.5 thousand, so watch out Greg & Miles).
So I am now in-f'n-spired. I have handed in my resignation as Chairman of the Department of Psychiatry at Bigtime Medical Center so that I can devote all my time to MyThreeShrinks.com. That's right! In two weeks, I'll be unencumbered so that I can spend all my time devoted to improving our $ite for our loyal readers. So start clicking that button, folks. Every 108 minutes.
Oh, sure, Wife was surprised. Even a little upset (I think she's jealous). But then I showed her how just by clicking a button, millions of readers can contribute $1, $2, even $10 each. That really adds up. I could tell by the look on her face that I convinced her that this is the real deal. In fact, she's on the phone right now, even as I'm typing this, calling her attorney (probably to get advice on how to handle the coming tidal wave of cash).
Maybe I'll add some virtual shrinks for visitors to talk to. Like lonelyshrink42. Or Eliza. Or Max. We'll do a daily videocast, like Dr. Anonymous did (but talk faster, with shorter pauses).
This is gonna be big! Look at those visit counters spin.
What's that, Wife? Someone's here for me? Whoa, check that out! There's a car with flashing lights outside... probably my police escort to the bank or something. Man, word gets around fast!
Gotta go, folks. Thanks for the tips! (no, really, thank you) (better not forgot my steroid spray...this stuff is great!)
Stayed tuned for the next post: The Good, The Bad, & The Ugly -- more about medication. But first, I need to run to the store.
Sunday, March 18, 2007
I posted briefly about Pay-for-Performance (P4P) efforts earlier, describing them as the next step in attempts to reduce health care costs while wrapping it up in a package to make it look like an attempt to improve quality.
I remain skeptical that this is the wrong approach. Insurance company bureaucrats will have us "teaching to the test" in the same way that primary education has gone... and with the same disastrous outcomes, I fear. Kids can answer the questions, but can they think? Do we want doctors who just focus on keeping hemoglobin A1C's down, speeding up the time that you get the first antibiotic during abdominal surgery, and counting up the number of cardiac patients they have on beta-blockers? Will we get lost in the forest, just tending to the trees?
Harvard economist, Michael E. Porter, in last week's JAMA, addresses P4P and broader health care delivery issues in a manner which I find very appealing. It places physicians back at the table, while holding us and others accountable for adding value by collaboratively focusing on patient outcome (not process) to improve patient care while controlling costs. In the article, How Physicians Can Change the Future of Health Care, he describes an approach to competitive, cost-effective health care that places the patient back in the center (isn't that what it's all about?), while teams of health care providers work together in parallel (not serially) to address each patient's needs as a connected team, not as an assembly line product. This is apparently what M.D. Anderson and Mayo have been doing for some time.
Take a look at this article and see what you think. If you can't get access to the whole document, email me at mythreeshrinksATgmailDOTcom, and I could send you a few pertinent paragraphs for educational purposes only (for the purpose of comment and criticism). (Or, get his book.)
Dr. Anonymous tagged us with the Thinking Blogger Award. I'm glad we make people think. Or smile. Or laugh. Any of these will do.
Here are my 5 tagees: Omni Brain; Corpus Callosum; NeuroFuture; Health Care Renewal; and ClinPsyc. Tag, you're it!
This whole British MMC thing is just out of control. If you've been following along on some of the UK blogs in our blogroll (like the Psychiatrist Blog or Trick-cycling or DrCrippen) then you know about how the government has set up this new system, akin to the US "Match", to connect young doctors with training sites. However, they've really botched it, and it seems more like the military, where you go where you are sent. Yesterday, twelve thousand junior doctors marched in protest about this crappy system. It is amazing that this many docs got together to do this. It says a lot about how messed up this is.
"They fear the Government's Modernising Medical Careers (MMC) scheme, designed to speed up the training process to become a consultant, will split families, drive some doctors abroad and force others to leave the profession.
Some 30,000 are competing for 22,000 posts allocated under a computer-based system, plagued by technical problems, that critics say takes scant account of the suitability and experience of candidates.
Concerns about the new system, which was introduced in January, came to a head after The Daily Telegraph gave a voice to angry and dismayed junior and senior doctors."
I haven't missed that. Besides being complete and utter poppycock (insert your own international colloquialisms here) it is just rather poor manners to come to a blog purely to insult the bloggers. I enjoy a good conversation but not when it turns to accusatory harangues.
If you don't like psychiatry or psychiatrists you are free to choose another healing paradigm if you wish. If you disagree with the parens patriae role of psychiatry you may go the legislature and change the civil commitment or involuntary treatment laws. Heavens, there are a couple states here in the US that have even authorized physician-assisted suicide.
I'm caring for Max now because he's afflicted with the condition of being a dog. Now maybe being a dog isn't a disease, but he still needs someone to look out for him and I've enjoyed doing it. I scratch Max's butt because that's what he wants. He comes to me regularly for it and I do it even though there is no scientific evidence whatsever that it will be helpful or therapeutic and I can't guarantee there won't be side effects or unforeseen harm from it. I've never forced a butt-scratching on him. I do things to prevent him from coming from harm even if that sometimes frustrates his wishes. These are just the basics of what you do when you're responsible for caring for another living creature.
Being willing to care requires no apology.
Wednesday, March 14, 2007
Tuesday, March 13, 2007
I mentioned a number of things I wish I knew, most didn't draw much attention, but two topics did: The consequences of allowing children to watch video games, and the issue of prescribing novel antipsychotic medications off-label, as opposed to Xanax.
Enough about VideoKid--Spring sports have begun and he'll have gobs of homework as the school year ends, he's looking for a job, thinking about college, learning to drive, it's soon to be a moot point. We're doing our best here and it's an imperfect world, what can I say.
Instead, I'll tell you why I'm more comfortable prescribing a very low dose of a second generation anti-psychotic (usually either 25mg of seroquel or 2.5 my of zyprexa) off label when someone is subjectively distressed---let me call it agitated, it's hard for me to say because I'm not inside their skin. Often these are folks who have bipolar disorder or have an agitated major depression, and the dose of the antipsychotic is given on an as needed basis (determined by the patient) until something else kicks in. I don't think I've ever given this as the sole agent unless the patient has simply refused other medications.
To put it simply, I give these medications instead of Xanax because they are easy to stop. No one gets stuck on them, no one makes me uncomfortable by demanding that I continue to prescribe something that is no longer needed. People take them When Needed (usually a handful of times, or a few times a week). Xanax helps, and people take it a few times a day, maybe it helps so much they take it a few times every day, maybe it helps so much they take it a more than I suggested, and they don't want to stop, and if I refuse to continue to write for it they become demanding, or call repeatedly in distress insisting I MUST give them something, and I'm faced with the issue of refusing to write for it and risking that they'll withdraw and possibly seize, or writing for a medication on on-going basis that I'm not comfortable with, sometimes after it's been escalated to doses where I wonder if the FDA will hunt me down. This just doesn't happen with low-dose anti-psychotics.
Okay, in reality, I never use Xanax, so this has only been an issue when seeing patients that other docs have started and maintained someone on (up to 8mg a day, chronically, ouch!). But if the same patient as above shows up and there is no reason not to, I may use Ativan (lorezepam) or Klonopin (clonazepam) in the same way. I agree, if they can be used in the short term, and if someone doesn't become addicted to them or physically dependent or tolerant, the risks are less. So, I weigh it in my head: Is there a history of addiction? (yes-- no benzos). Is there a history of or current alcohol abuse (punt). Does the patient get distressed when I tell them they can't drink on this medicine? If there is no history of alcohol or benzodiazepine abuse or dependence (they are cross reactive), if the patient has been on a benzodiazepine before and had no trouble coming off, if they drink sometimes but have no history of alcohol abuse, then I feel comfortable prescribing a benzodiazapine. I give a small amount, and I tell them it's a crisis medication, not for regular use. I warn that it can be sedating, that it can be addicting. Most people worry about that: it's a good sign. It's the person who assures me that he won't get addicted that I worry about.
When I use a novel anti-psychotic, I tell the patient that it is a low dose and that the medication is associated with precipitating/fast-forwarding the onset of diabetes, lipid dysregulation, and weight gain. I suggest they take it only when needed and that they stop as soon as possible (there is no withdrawal to low doses). One of our commenters said that even low doses cause difficulties, even "kill" (I assume this means weight gain, diabetes, dyslipidemia)-- this may be, but in my personal experience, I have not seen problems with periodic low dose medication. Maybe I've simply been lucky to date.
I don't insist that anyone take any medication they don't want to take. Nor do I recruit patients, I'm an outpatient doc, people come to me, often asking for medication. I have never said to a patient "If you won't take this medication, I won't treat you." I tell them what the studies show, I tell them what I think they should do, if they don't want meds and they still feel helped by coming to see me, I see them.
We live in a society that values the right to make choices, even bad choices. We allow people to smoke and to drink alcohol, despite the fact that the risks they expose themselves (and others) to are both huge and certain, the cost to society exorbitant. It is unfortunate, perhaps even tragic, that we don't have medications with no side effects or ugly adverse effects and I wish that weren't so, it would make my job so much easier. But given the options we have, when I see someone in distress, I'm faced with what I know-- and that is full of uncertainty . Will this medicine make you sick? Will you have a recurrence of your illness without it? Will you have a recurrence anyway AND get sick if you take it? Given that there is no free ride, the other option is to refuse to prescribe, and that carries with it lots of other risks, the denial of something that often helps, and the message of there is no hope if you can't be patient-- and honestly, therapy alone, even great therapy, doesn't always do it. Mostly, I'm left to share what I know with the patient-- including statistics if I have them and if it's appropriate-- but ultimately the decision belongs to the patient, and when they leave it to me, I cross my fingers and do my best.
So no one wanted to comment on the rise in teenage suicide following the black box warning?
Monday, March 12, 2007
Sunday, March 11, 2007
The case is a complaint to the United Nation's human rights committee filed by an Aboriginal juvenile in an adult Australian prison. The 16 year old detainee was involved in a riot in a juvenile facility and took someone hostage. He was transferred to an adult correctional facility (following a conviction for armed robbery) where he was placed on segregation both for institutional security and for protection from adult inmates. While there he attempted suicide and threatened self-harm if not removed from segregation. While being placed on suicide precautions (which involves removing the inmate's clothes) he kicked an officer in the head. To make a long story short, he had repeated episodes both of self-harm and aggression toward officers. He was given at least two additional prison sentences for convictions related to assault on correctional staff. He was prescribed an antipsychotic medication (what's 'Largactil'?). In the complaint it's alleged that the inmate was prescribed the medication without an examination, and that when the examination took place it did not support any diagnosis requiring medication (or so I'm reading a rather obscure quote). The inmate admittedly took the medication voluntarily after a period of involuntary treatment.
I'm obviously not familiar with the legal procedures for transferring Australian juveniles to adult facilties, but regardless the meat of the claim appears to be that once in an adult facility the inmate had no effective legal means of challenging his punishment or alleged inappropriate treatment. He could follow an administrative appeals process but this apparently didn't provide for damages or any judicial power of intervention. (Correct me if I'm wrong, but that's how I read it.) The human rights court found that most of the interventions did not violate the inmates rights except as regards certain episodes of length of confinement (going more than 72 hours without out-of-cell time) and removal of his clothing. It specifically found that giving an antipsychotic medication did not violate the International Covenant on Civil and Political Rights (see point 9.5 under 'discussion of the merits'). It also doubted the utility of a tort claim due to lack of clear damages.
In free society American physicians adhere to certain protocols when giving orders for the use of seclusion. American prisons also have policies and procedures for this; failure to follow policy has been the ground for Department of Justice intervention.
Saturday, March 10, 2007
I'll leave Dinah and Roy to talk about the free society way of handling that; I can address what happens inside the walls.
The patients I treat get locked up because of persistent misbehavior or persistent high-risk behavior. (I don't call it 'self-destructive' behavior---even though it is---because inside the walls that term has a very different connotation.) I don't really ever have the option of not treating someone. My clinic is never too full to accept new patients and our jail/emergency room never goes on 'fly-by' status due to lack of bed space. So, I get all comers.
That being said, I do have certain limits. By the time I get my patients they are generally ready to accept the idea that their behaviors are getting them into trouble. The biggest issue is how to handle the interventions from that point on.
The biggest trick with treating substance abusers is that there's a big difference between what they say they want and what they actually want. They say they want to be drug or alcohol-free, to give up 'fighting the system' and to get themselves together. But at the same time they want to be in control of treatment, in control of their environment and to have it all done on their own timeline.
This is a setup for frustration.
Fortunately, it's all manageable. The key is to be upfront about expectations and limits and to be true to your word. Inmates can accept a 'no' but it's a very very bad idea to imply you can or will help them with something you have no control over. I don't make housing or cellmate changes, I don't order lower bunks or special diets, I don't make phone calls or transmit messages for inmates. That's pretty much the easy part.
Occasionally inmates aren't happy about that. Very rare inmates may escalate their requests along a continuum that I can pretty much predict: a hint for a favor turns into a direct request which turns into a demand which turns into a threat. Once you reach the demand/threat point treatment stops.
So getting back to the idea of conditional treatment, my only real condition is the requirement for safety. Once a patient gets to making a threat of violence to me, to himself or anyone else, treatment stops and safety interventions begin. That's really the only way to get things back on track.
Thursday, March 08, 2007
We come to day with day with a list of Shoulds we take at face value (--where would you like me to begin? Don't smoke, don't drink excessively, don't be overweight, exercise, take your meds, ingest enough calcium, don't shoot heroin, stay out of jail, don't quit too many jobs, get your screening colonoscopy at 50, yearly mammograms after 40, wear a condom, sunlight is good, sunlight is bad, sunscreen is good, sunscreen is bad, coffee is good, coffee is bad....) only to have them rethought time and again. Roy is now finally off his HRT or so I'm told, he still doesn't look post-menopausal to me.
A few things I find myself wishing I knew the answers to:
Will my children be damaged by all the video-game playing I allow?
Will my relationship with my children be damaged if I don't allow them to play video games and survive the inevitable fights it will cause.
If they go out to ride their bikes instead-- nice healthy exercise--will I wish they'd stayed safely home playing video games if they get hit by a truck?
Why didn't my children come with instruction manuals?
--Inspired by yesterday's snow day and my patient today who is consumed with guilt and a sense of perfectionism with regard to her parenting. Something it's easy to distance myself from during a psychotherapy session, but sometimes strikes a bit close to home.
Will some awful consequence of Gardasil (the new HPV vaccine) be discovered 20 years down the line?
If obesity is so fatal, why, since the 1950's are there so many more obese people and why is the average lifespan 10 years longer?
Why do some people seemed to be unscathed by decades of smoking marijuana?
When my patients chronically misbehave and are completely uninterested in changing (for example, young people who enjoy spending their time drinking to excess in bars, others who repeatedly and without regret sleep with strangers, those who consume large doses of prescription narcotics prescribed by someone else, or people who just won't entertain the idea of abstaining from marijuana)-- am I wrong to continue to treat them on their terms?
If I simply refused to treat them unless they get treatment for their addictions, would they a) stop coming, b) stop telling me about their bad behavior, or c) get treatment and clean up their acts?
When a patient complains of intolerable feelings of agitation or other vaguely defined distress, and gives me the "walk a mile in my shoes" talk, is it wrong that I sometimes offer a prn very low dose of an second generation anti-psychotic, along with the warnings about possible induction of diabetes and dyslipidemia, and let them make the decision about whether to take it? Is it funny that I never ask myself if I should offer that script for very low dose prn Xanax which is what they really want?
And what about the patient whose last depressive episode (of many) lasted nearly a year and who has never been able to tolerate lowering her zyprexa, should I stop it given that her risk factors for diabetes and heart disease are screaming in my face (they preceded the zyprexa, but it can't be helping)? How do we know the worst of two evils?
Were those 250 extra children who died of suicide in 2003 compared to 2004 (see Pediatrics, annual vital statistics, death figures on page 13), children who were not taken for mental health care, or not offered anti-depressants because of the Black Box Warning added to anti-depressants by the FDA?
Sometimes I wish I had a crystal ball that worked, one where I could fine tune it to ask the subtle what-ifs. When it comes to the long-term prognosis for diet Coke and hair chemical abusers, well, there are some things I just don't want to know.