Sunday, August 30, 2009

How Many Patients Per Hour?

Psychiatrist and former podcast guest Dr. Mark Komrad asks:

As Chairman of Ethics at Sheppard Pratt I have been approached with a question that seems to stand at the border between ethics and "practice guidelines." The question is: "What is the maximum number of patients that a psychiatrist can/should see in an hour to be safe and effective?" In other words, the concern is about certain psychiatrists who are starting to see 8, 9, even as many as 12 patients in an hour (these would average to 7.5-10 min per patient if no breaks). This is an entirely new level of caseload that is emerging, and the question came to me "at what point does it start to become unethical or bad practice." I find this difficult to answer, but thought it a good question to submit for discussion on this list. Afterall, if memory servies, I read somewhere that the typical Primary Care doc is gives each patient an average of 8.5 minutes. Is it possible to do psychiatry with that kind of average time per encounter? Your thoughts?

Saturday, August 29, 2009

Freud Goes to Hoboken

Here's an op-ed piece from the New York Times about Freud's visit to the United States 100 years ago. It's an interesting historical perspective.

Friday, August 28, 2009

My First Voice

I entered the yard and started cleaning up a bit. I pick up the end of the hammock that had fallen, shook it out, and reattached it to the tree. I finished and reached for my keys to go inside.
I turned. No one was there. But I'd heard the "hey" distinctly, though my ears, really. I waited, no one said anything. I looked up at the windows, maybe one of my kids had called out. But, no, the windows were closed.
My first voice, I thought. This must be what it's like. There wasn't really anything to do, it was just a simple "hey" loud and clear. It was a bit disconcerting, but I went inside and promptly forgot about it.
My cell phone was on the counter. I picked it up and saw a message. Roy had texted. "Got here early and I'm sitting on the patio." Ah! My voice! It was Roy, of course, lurking in the bushes.
"Why didn't you say anything else?" I asked.
"I didn't want to scare you," he said.
Oh. And of course there's no one else whose voice I'd rather hear!

Wednesday, August 26, 2009

Forensic Psychiatrist: Job Description

This is a story from a friend of ClinkShrink. I hope she doesn't mind that I stole it for the blog, but her friend suggested it.

ClinkShrink gets home and there is nothing to eat in the house (hmm...ClinkShrink can't make microwave popcorn). So she orders take out sushi to eat with her friend who runs out to get the food. She orders from this place a lot and she usually orders the same thing, so they know what she wants when they hear the name 'ClinkShrink.' The friend goes in to get the order for Clink and the woman behind the register says,
"Oh, take out for Clink?"
"Yes, thanks."
"Are you a forensic psychiatrist, too?" the woman at the counter asks.
The friend is a little surprised and replies, "No, actually, but ClinkShrink is." Then the woman smiles and says, "Oh yeah, she cut up the bodies like on TV." and as she says this, this pretty, demure woman makes a few zorro-like swishing sword motions over the cash register. Clink's friend considered saying, "Actually, she has a clinic in the prison," but realized this wouldn't be as 'sexy' as cutting up the bodies and just laughed and said, "Yes."

Sunday, August 23, 2009

Covered or Not?

Here's an article about a private health insurer and how they dealt with an out-of-network referral. I'm still trying to figure out how you know what you're getting with health insurance. Some of it sounds like the coverage is great, but when a patient needs a service or goes to get a medicine, it's not covered. The one good thing about HMO's is that there is no pretense: you know you're not getting out-of-network care, you know the formularies are limited. This is from the wife of a cancer patient and the struggles they had getting the care:

Tuesday, August 18, 2009

Can We Teach People How To Avoid Mental Illness?

Prevention is an interesting word in psychiatry. It's hard to prevent mental illness-- we believe a lot of it is about genetics-- and when we think about prevention, we think about things like avoiding drugs and excess alcohol, getting enough sleep, growing up in a kind, safe, and loving environment with a reasonable amount of stability. Those are good things. When it comes to preventing Post-Traumatic Stress Disorder, we think about avoiding trauma, to the extent that we are able. Roy has written about the hypothetical idea of giving people medications to prevent the hard-wiring of traumatic memories and we talked about it in our My Three Shrinks Podcast #46 :Fugetaboutit!

But can you teach people not to get ill -- an insurance plan, if you will, or extra-protection-- before they get exposed to extreme trauma? Can you teach them not to get depressed? Not to get PTSD? It's a great idea, but as far as I know, people vary in their vulnerability and resilience, perhaps even tempermentally, and I'm not aware of research that shows you can teach people resilience in the fact of horror. It doesn't mean it can't be done, it just means I don't know of any research proving it. And if you can teach this, I want to be in the class, and I'd like to invite all the folks who live in the inner city to join me.

So Benedict Carey writes in today's New York Times about how the military intends to require emotional resiliency training for every soldier. Wow!

The new program is to be introduced at two bases in October and phased in gradually throughout the service, starting in basic training. It is modeled on techniques that have been tested mainly in middle schools.

Usually taught in weekly 90-minute classes, the methods seek to defuse or expose common habits of thinking and flawed beliefs that can lead to anger and frustration — for example, the tendency to assume the worst. (“My wife didn’t answer the phone; she must be with someone else.”)

Carey goes on to note:

“It’s important to be clear that there’s no evidence that any program makes soldiers more resilient,” said George A. Bonanno, a psychologist at Columbia University. But he and others said the program could settle one of the most important questions in psychology: whether mental toughness can be taught in the classroom.

So what's the downside? I'm not sure there is one-- except the price tag-- $117 million dollars for an unproven experiment? Couldn't we do some pilot studies first? Obviously I'm a bit of a skeptic-- perhaps we can teach people to be more adaptive in mildly stressful places, but I'm wondering if anything shields you from the extremes and the trauma our soldiers experience in combat. Funny to be spending so much for an unproven intervention in an arena where there aren't funds for treatment of those who give so much and come back so damaged.

Saturday, August 08, 2009

Shrink Rap: Grand Rounds is up at Emergiblog (& Happy 4th Bday!)

Kim at Emergiblog celebrated her 4th blog birthday earlier this week amidst much congratulations. For blogs, that's probably like 57 in human years.

How does one celebrate a birthday? Host a Grand Rounds, of course.
Interesting shrinky-links:

Friday, August 07, 2009

First Date

I'm awake, my kid is not. I'm in the wrong time zone, so I'm up early for vacation, and the other half of my family is scheduled to arrive tomorrow, so it's teenage girl and me for the moment.
I want to talk about our dinner last night. It's not about psychiatry. Oh, except I think the woman was in the mental health field and her dog was raised in a mental institution (her choice of words).

So tired, jet-lagged teenager and I grabbed a bite at the grill at our hotel. Wine, cheese, calamari, chocolate...what more could you ask for? At the table next us there was a couple on a date. A first date, and not listening wasn't an option....the tables were close, they spoke loudly, it was a get-to-know-you, tell-you-about-myself, trying-to-make-a-good-impression place. She ate half her entree and he ordered a wedge salad which looked like the whole head of lettuce was just dumped on the plate. They shared brulee, after declaring that chocolate molten cake would be too much (we had the chocolate molten cake and it was not too much!).

We weren't there for the very beginning, we were seated as she talked about how her mother was upset that she'd traveled alone in India. Mom doesn't like that she also is always covered in white cat hairs or that she wouldn't go to church with her in high school. Mom is an artist. She is/was a professional belly dancer and spent the Millennium dancing in some golden bird outfit for elders in a Indian tribe in Colorado. I believe she worked at a state hospital in Southern Colorado where everyone worked there or at the prison (ClinkShrink?) and she dated a co-worker who took her for Chinese food. She's glad to be away from Southern Colorado because they have no ethnic food and people ordered hamburgers for you get get Vietnamese and other ethnic foods. (Calamari and chocolate brulee, too, apparently). She has a dog (he was raised in mental institution and is good with all sorts of people) and a cat, one sleeps on the bed, the other does not.

And the gentleman...he's from Scotland where his linguist mother drew attention to him by talking to him exclusively in German. Her family is Jewish, his father's is Christian, and he went to Christian schools. He works in the film industry and has read hundreds of bad screenplays. His favorite movie is Looking for Bobby Fisher (it has soul) and when you see a good screenplay, the writing sings.

It was a nice place for a date and he paid.

So daughter and I both thought it was an Internet date--- two people interested in finding someone who are worldly and want to meet another worldly soul. My teenager thought they spend too much time talking about themselves and the woman talked too much about people she's dated before. Conversation seemed to flow, and I found them both likable and interesting. This may have been the best meal I've ever eavesdropped on. We were both dying to know if there would be a second date-- conversation flowed, and he was thrilled to hear she liked Indian food-- but it was a little, oh...trying? I thought he liked her better than she liked him, and my kid thought it was the other way around, maybe slanted by the fact that we were seated facing different members of the couple? I thought, my daughter thought eHarmony.

Wednesday, August 05, 2009

Treating the Cosmetic

I wrote a post about the hurdles one of my family members had getting insurance authorization for a medication for an infected nail. He surrendered and bought the medication at Walmart for $4 as the insurance company would not pay for the medication: the doctor had not indicated that the infection was causing pain or discomfort and so treatment was not approved-- of note, this doctor had never been denied this preauthorized medication for a patient before and was not aware he needed to specifically say the infection was causing pain or discomfort . Blog reader and physician Midwife With a Knife commented that onychomycosis (fungal nail infections) are really a cosmetic issue: should insurance even pay for such things?

It's an interesting question as to what constitutes distress and discomfort. ClinkShrink and I had a series of posts on the Worried Well and who deserves care-- we got close to bloodshed a few times, actually. Is one state of subjective distress more worthy of insurance-treated medications than another? Evidence-based medicine, FDA approvals for specific illnesses, and all that jazz, but as psychiatrists we sometimes see patients who don't do the best job of articulating their distress-- is it only real and worthy of certain treatments if you can articulate your torment in the right words (and perhaps the answer is yes)?
If your groddy toenails bother you, or leave you feeling self-conscious in your designer flip-flops, should insurance pay for your meds? Since there's a $4 Walmart option, maybe it shouldn't. And how does Walmart get all those meds so cheaply?

If you have a huge and ugly-- but benign-- lesion on your face, should insurance pay for its removal? And what constitutes "discomfort"? Many people suffer from psychiatric disorders where the result is subjective distress, but not dysfunction or impairment. If you're quietly having panic attacks, but they don't impair you, should your insurance pay for the treatment? What about a nose job if your nose is really ugly and attracts a lot of attention? How about breast or penile reconstruction for cancer survivors (or landmine victims, or the relatives of Ms. Bobbit?)? And what if you have pain, and repeatedly present to a doctor or the emergency room, and no anatomical cause can be found? Just thought I'd ramble about the lines of where we think about sticking our health care dollars...

Sunday, August 02, 2009

Missing parts of the paper

And from today's Sunday New York Times Magazine.....
Oh, my paper came today without the magazine section. I should complain. It's summer and I'm in slow motion, much too lazy to even figure out who to complain to.
The Shrink Rappers have slowed our pace lately--- 13 posts in July, this may be our all-time low month. I'm getting ready for vacation, Clink is hanging from cliffs, Roy...has anyone seen Roy? He posted last, so I think he's lying around soaking in the rays.
Just to say "Hi." I'll check out the NYT magazine on line.....