What's In That Chart?

In Maryland, the issue of patient charts and confidentiality is a heated topic...it's even made it to the state legislature.

I don't write the most exciting of notes. The first time I meet with a patient, I take a full and detailed history and I write the whole time, so my notes essentially say what patient says, ending with a mental status examine, then my impression, diagnosis, and a brief treatment plan. After that, I don't take notes during the session. And I don't generally write about the detailed content of therapy sessions. I may leave it as "Patient talked about activities and family matters." If I change a medication, I say why, especially if it wouldn't be obvious. If I do anything risky or unconventional, I write about why I'm choosing to do this, why other options aren't sufficient, and that I've discussed it with the patient. If I'm worried about someone, I may discuss what measures I've taken to insure their safety. I don't write process notes about the psychotherapy, I don't put in very personal information that isn't directly related to treatment decisions. I view the chart as a legal document and as a clinical reference-- if the patient tells me 3 years later that some medication worked great, I can look up why we stopped a medication that worked great.

Okay, so confidentiality. No one asks for my notes. Rare requests for information from physicians, but a treatment summary does a much better job. No patient has ever asked to see my chart. And if they did, I don't imagine it would be a problem (or a very interesting read).

What do other shrinks write about?

Rethinking My Professional Life

It's time for me to sign a new lease for my office, and I'm not happy with the terms the landlord wants. Add to that how poorly the building is maintained and that the first floor retail space is probably one-third empty, and I'm thinking of relocating.

I've found a found place to go, but it's way too big....I'll need to find some other folks to share with me. And this has me thinking: do I simply want to relocate my practice as is, or do I want to form some type of cohesive group with a shared mission.

So as I think about the office layout with the freedom to create what I want, let me ask for your help. What's important in a psychiatrist's office? What colors do you like? What makes you love a physical space and what makes you hate it?

And if you're in a group or see someone in a group: what makes it works and what really doesn't work.

Harvard Online

Okay, it's not psychiatry, but it's my blog and I'll divert if I want to. So this looks cool, you can take a popular Harvard course for free and in the comfort of your own home. You know I'm there:

http://justiceharvard.org/

[addition by Roy:]

And don't forget iTunesU, which has a slew of full courses from major teaching facilities available free via iTunes. Places such as:
> Stanford
> Berkeley
> MIT
> Texas A&M
> Harvard
> Penn State
> Vanderbilt
> Columbia
> Yale
> Carnegie Mellon
> UNC
> Boston University
> Oxford
> University of Maryland
> Johns Hopkins School of Nursing
[Note back from Dinah] The Harvard "Justice" Course is not just on line, it's being Televised on public TV (there's a link on the website).
Readers: If you try a class, please let the rest of us know what you think of it. [-Roy]

Day Tripping

This is a post for ClinkShrink, but she's so busy lately that I thought I'd stick it up.

So in Maryland, to the best of my knowledge (and I could be wrong) we have this idea that if someone is criminally insane and needs hospitalization, they should probably stay in the hospital. I'm not aware that forensic facilities take people on field trips. Like I said, I could be wrong, I don't treat inpatients and I don't work with designated forensic patients. The piece below caught my attention, it's from The Seattle Times:

On Thursday, Phillip Arnold Paul, who had been committed after being found not guilty by reason of insanity in the slaying of an elderly woman, disappeared during a field trip to the Spokane County Interstate Fair with 30 other Eastern State Hospital patients and 11 staff members. The escape prompted an extensive manhunt that ended Sunday when Paul, 47, surrendered to authorities near Goldendale, Klickitat County, about 180 miles from the fair.

It was the second time that Paul had escaped from state custody.

---------------

The photo, by the way, is of a cow at the Maryland State Fair, and has nothing to do with the story of the escapee from the state hospital in Spokane. I just like cows.

Women Around the World are in a Funk

Victor sent me this. This and cinnamon buns. What more could I ask for?

So in "Blue is the New Black" New York Times columnist Maureen Dowd tells us women have become more unhappy.

According to the General Social Survey, which has tracked Americans’ mood since 1972, and five other major studies around the world, women are getting gloomier and men are getting happier.

Before the ’70s, there was a gender gap in America in which women felt greater well-being. Now there’s a gender gap in which men feel better about their lives.

Did they give everyone Beck Depression Inventories? I'm assuming this isn't an increased incidence of major depressive disorder, but increasing rates of dysphoria, disappointment, disenchantment, and disillusionment, to name just a few dis-able affective states. And according to renown mood authority Arianna Huffington: "Women around the world are in a funk." Apparently women get sadder as they get older and, "They tend to attach to other people more strongly, beat themselves up more when they lose attachments, take things more personally at work and pop far more antidepressants."

More on the Red Book

I got my wish; I got to read the rest of the NYTimes Magazine article, "The Holy Grail of the Unconsious" by Sara Corbett about Carl Jung, on the patio with coffee, a bagel and lox, on a gorgeous Sunday.

The article left me thinking-- perhaps it left me longing-- and maybe this will be more of a journal entry then of a blog post. You'll forgive me for being a bit raw.

I read the article and I was drawn in-- I want to read the Red Book-- the soon to be published work of Jung about his own exploration of his unconscious. Much of Jung's journey occured during a difficult period in his life, and Corbett writes:

Whatever the case, in 1913, Jung, who was then 38, got lost in the soup of his own psyche. He was haunted by troubling visions and heard inner voices. Grappling with the horror of some of what he saw, he worried in moments that he was, in his own words, “menaced by a psychosis” or “doing a schizophrenia.”He later would compare this period of his life — this “confrontation with the unconscious,” as he called it — to a mescaline experiment. He described his visions as coming in an “incessant stream.” He likened them to rocks falling on his head, to thunderstorms, to molten lava. “I often had to cling to the table,” he recalled, “so as not to fall apart.”

I wonder, if I read this will I just dismiss Jung's words as products of an illness, not worth analysis in their own right? Humanity has had a complicated relationship with the ideas of people suffering from mental illness (and it sounds like Jung was indeed tormented)...sometimes they are revered as holy, sometimes they are dismissed as disorganized, other times they are seen as evil. My best guess is that I will feel the Red Book is over my head, too philosophical, too complex for me to understand. The book can be pre-ordered from Amazon, and for $105, well, I'm thinking about it. I'm thinking, too, about visiting The Rubin Museum to see the exhibition with the original Red Book.

But I know very little about Jung, and it's not Jung, or even the Red Book, that really grabbed me about this article. The story included the stories of some people, one of them Dr. Stephen Martin, a Jungian analyst and founder of the Philomen foundation. Dr. Martin has one of Jung's hankerchief's framed in his office. He's devoted himself to Jung, he believes in him with all his heart. Corbet writes:

Just as I had, Stephen Martin flew to Zurich the week the Red Book was taken from its bank-vault home and moved to a small photo studio near the opera house to be scanned, page by page, for publication. (A separate English translation along with Shamdasani’s introduction and footnotes will be included at the back of the book.) Martin already made a habit of visiting Zurich a few times a year for “bratwurst and renewal” and to attend to Philemon Foundation business. My first morning there, we walked around the older parts of Zurich, before going to see the book. Zurich made Martin nostalgic. It was here that he met his wife, Charlotte, and here that he developed the almost equally important relationship with his analyst, Frey-Rohn, carrying himself and his dreams to her office two or three times weekly for several years.

People are searchers, some more than others. Some people are content as is, they look for nothing. Others scour their worlds, looking. Looking for what? I suppose it depends on the individual and I suppose that many who search have no idea what it is they are looking for.

So there is a piece of me that's jealous of Stephen Martin, without ever having met him, without knowing a thing about him (except for these excerpts in the NYT magazine). Why? I suppose because he seems to be someone who is able to believe in something so strongly, so wholly, and with such devotion. I imagine someone who devotes themselves to a cause and a belief with such certainty and reverence, feel sure that Jung had the answers. In Corbett's article, he likens his devotion to a religion, and it's hard for me to imagine ever believing that another human being has something worthy of this kind of worship--if that's the right word. I think I'm jealous of what Dr. Martin believes he has found-- whether it's right or not, he still has the ability to believe so completely in the rightness of someone and something, and presumably it's because Jung gave him something he's found worth having.

Jung is not what I've been looking for. I might might read about his journey, or I might want the book just to have it, because some things are worth having just to be had, even if I never read it, even if I never open it. And maybe Dr. Martin is just one more tormented soul, but for today-- a day which started with a bagel and lox and an absolutely gorgeous morning-- I wanted him to be someone who searched and found what ever it was he was looking for.

Carl Jung in Tomorrow's New York Times Magazine

Ya gotta love the internet--- you get to be "the most emailed" before you're even published. So tomorrow's NY Times Magazine has an article about Jung and the little red book. I started, but I'll save the rest for the joy of Sunday mornings and coffee (and the dream of lox and fresh bagels if anyone would like to drop them by my house). Here's an excerpt from Sara Corbett's "The Holy Grail of the Unconscious":

THIS COULD SOUND, I realize, like the start of a spy novel or a Hollywood bank caper, but it is rather a story about genius and madness, as well as possession and obsession, with one object — this old, unusual book — skating among those things. Also, there are a lot of Jungians involved, a species of thinkers who subscribe to the theories of Carl Jung, the Swiss psychiatrist and author of the big red leather book. And Jungians, almost by definition, tend to get enthused anytime something previously hidden reveals itself, when whatever’s been underground finally makes it to the surface.

Why Psychiatry is a Wonderful Medical Specialty

Dear Medical Student:
This is why you should become a psychiatrist. It's a wonderful career with lots of flexibility and you can pursue a broad range of interests. You love people and their stories? You love feeling helpful in their lives in an integral way? Then psychiatry's for you. What better then being there when a seriously depressed person feels better and gets their life back? You hate people, can't stand complainers, and would like to isolate yourself? Ah, psychiatry has so many unanswered questions and can let you flow in so many different directions: find a lab and isolate genes or look at brain scans or receptors....there's lots of room in the field for basic researchers. You're something in between? Psychiatrists have medication practices, or psychotherapy practices (most have a little of both), they teach, they are administrators (some never go near a patient) they can work with inpatients or outpatients or in residential settings. They can work in jails or with the courts. They write, they have blogs! They work for themselves (I never fight with my boss) or as part of large academic or government institutions. They work with patients with medical illnesses (on transplant teams, in oncology and HIV centers, as consult-liason docs in the general hospital). You can find a job where all you do are evaluations and you never see the same person twice or you can be a psychoanalyst and see one person five times a week.
It's as medical or non-medical, researchy or non-researchy, and people-centered as you want it to be. And you can do pieces of a variety of different things. What could be better?

No big bucks-- sorry.

Who Ordered Psychotherapy?

ClinkShrink and I are working on the psychotherapy chapter for our book-- so far, it's still called Off the Couch.

So Clink doesn't see patients for psychotherapy, her role has been to focus my rambling and to connect the thoughts--- I didn't know she had a talent for this, but she's good!

We started talking about how it is that one person can go to one psychiatrist and be told to come in weekly for therapy, while the same person can see another psychiatrist and be told to return in a couple of weeks for a med check without getting a recommendation for therapy. Clink asked: so where does the recommendation for therapy come from?

Does a patient want psychotherapy and look for a therapist who offers this?

Or does a patient go to a psychiatrist with a problem, get evaluated, and have psychotherapy prescribed to treat their problem just like one gets handed a prescription, as part of the package known as the treatment plan?

And what about those patients who come with preconceived ideas about what they need an unwillingness to entertain other options--so the patient who wants therapy but refuses even a trial of medications, or the patient who calls and says before they're even evaluated that they just want to be seen every three months for meds and aren't interested in talking?

I thought I'd invite you to join our conversation!

A Session With Dr. Whippy

Artist Demitrios Kargotis has invented a soft-serve dispensing machine which uses voice-stress analysis to determine how much soft serve to give to the customer...er...client...er...patient. The more stressed out you are, the more soft serve you get.

But will insurance reimburse?

Make Me A Werewolf

Kind of funny:




Maybe the Shrink Rappers need some Purposal?

Please Pass the Haldol

The atypical antipsychotics are getting a lot of attention lately: they cost a small fortune and they are associated with an increased risk for diabetes and cardiovascular disease. Oh, and they make people gain weight. All bad things.

The older neuroleptics worked fine, they treated psychosis. And with the financial and medicals burdens that come with the new medications, there is now some thought (at least by some people) that we should be re-visiting the old, cheap, and in-some-ways safer medications: Haldol, prolixin, navane, stelazine, trilafon: those guys.

I remember when that's all we had. The medications worked well for stopping the acute symptoms of psychosis. I don't prescribe them as a first line now, because back then, it seemed to me that people hated being on those medications. It was a hard sell to get someone to take prolixin, in a way that it isn't to get someone to try Seroquel. And people constantly stopped their own medications. There were some other problems with the older medications, as well: people had Parkinsonian side effects and looked like they were medicated, they gained weight and stopped menstruating . There was the risk of dystonia, irreversible tardive dyskinesia and fatal neuroleptic malignant syndrome. Someone once told me that being on Prolixin was like have molasses poured into your brain. And there were always the stories of medical students who tried the stuff.

So this post is a question to you:
If you're a psychiatrist: do you prescribe the older medications as a first line? Why or why not?
If you're a patient: if you've taken both, what do you think?
If you haven't taken haldol or any of it's brothers, would you be willing to try it? Why or why not?

Thanks in advance for your responses!

Speed Shrinking

Somehow, I missed this one. Thanks to Buggy for pointing it out!

What do you do when your shrink's away and you've got a crisis? Wait? Call coverage? A group of New Yorkers have set up their own speed shrinking networking service in bookstores and taverns.
From The NY Times, August 31, 2009, Vincent Mallozzi writes "Answers to Life's Worries, in 3 minutes Bursts."

Instead, Ms. Tang went to talk about her fears with a panel of eight psychiatrists and psychologists offering three-minute sessions of what was billed as “speed shrinking” to those whose regular therapists were on vacation or to anyone else needing a very fast dose of advice.

“At first glance, this appears to be a funny, lighthearted thing,” said one of the therapists, Jonathan Fast, who is also a professor at Yeshiva University. “But what I have discovered is that these brief conversations absolutely turn into real therapy. You start with the classic ‘What can I help you with?’ and make a really fast assessment.”

So this is not what I do. I have no super-rapid diagnostic skills and no magical wisdom worth imparting in 3 minutes. I thought they invented grandmothers for this stuff. And Mr. Mallozzi makes therapy sound a little too trite and a little too self-consumed for my liking. Psychiatrists are good at diagnosing and treating psychiatric illnesses, and some are good at psychotherapy. I don't think this conveys any level of expertise for life-decision advise for strangers. Ah, but this wasn't really one we'd pass by on Shrink Rap.

Attention Everyone!

.

In yesterday's New York Times Magazine, Walter Kirn wrote about his own personal, and highly ambivalent relationship with Adderall, a medication he used to help him focus his attention. It wasn't clear from the article if Mr. Kirn actually had Attention Deficit Disorder, if he was simply struggling with a difficult time, or if he wanted an edge.

In A Phamocological Education, Kirn writes:

Adderall, I discovered during the courtship phase of what became our deeply tortured relationship, offers a kind of assistance to the brain that feels just right, at first, for the age of multitasking. The drug might as well have been invented by Microsoft and embedded in the Windows toolbar. It seemed to allow me to do three things at once and not completely fail at two of them. Far more important, however, it helped me do one thing at once and focus on it. If I was toiling at my computer, it sharpened the clicking sensations of the keyboard while lowering the volume of the phone whose ringing might have broken my work trance. It also, for me at least, suppressed emotion, freeing me from the claims of other people (my children primarily, because I work at home) who wanted a piece of my precious, deskbound time.

Julia & Julie: Dinah's Comments.

I went to see Julia & Julie tonight. I've decided it's my job to blog about it because there's no chance that either Roy or ClinkShrink will go to this movie.

The storyline is simple: A young New Yorker named Julie is looking for meaning in her life---she's an unpublished novelist who looks for meaning in being a blogger. I think she might be my soul mate. She becomes obsessed with her cooking blog, and a mission to cook every recipe in Julia Child's cookbook (that would be 541 recipes...Oops...542) in 365 days. We go back and forth with this plot to Julia Child in Paris in 1949 and her role as a bored housewife, also in search of meaning: hat making, bridge playing, and finally cooking. She takes a class, becomes obsessed, and meets two other French chef women and they become a trio, obsessed with writing a book. Well, two of them work on this book....40, 60, 80 hours a week...the third one is not so in to it (---oy...feels a little too familiar!). It takes them 8 years and well, everyone from Julia Child the chef/author/TV personality to Julie Powell the blogger/author and now the subject of a movie, all become famous.

If you take out the cooking and the food, I could totally relate to the obsession of a blog and a book...and to all the innuendo. Both women become fixed on their projects, their lives revolve around them. Julia Child's publisher isn't so happy with her book...again, oy!...and there is some focus on getting the correct title for the book (something we Shrink Rappers are still struggling with.

So, I'm calling Meryl Streep in the morning. I'd like her to play me in the Shrink Rapper movie. My nose is a little different, but we don't have to tell anyone. Suggestions for the roles of Roy & ClinkShrink, anyone?

I Don't Have That!

I'm enjoying asking hypothetical questions these days!
Okay, here's a scenario, tell me what you think the shrink should do.

A patient comes for an evaluation. He's seen a psychiatrist before, but he stopped going because the psychiatrist diagnosed him wrong. Total idiot, that doc. It's clear this diagnosis is meaningful to the patient, and the meaning is very negative. The patient isn't in a place to hear that this is the problem (fill in the diagnostic blank however you'd like). The new shrink does a careful evaluation. He listens to the symptoms, he listens to the course of illness, he gets info from any outside sources the patient wants him to consult. He doesn't call the last shrink because the patient doesn't want him to: the patient doesn't want his diagnostic thoughts colored by information from that idiot, and the new shrink is okay with this. However, the new psychiatrist, with the data he has, has come to a diagnosis: the patient has what the idiot doc said he has. If he tells the patient this, the patient will be gone (yet another idiot shrink)-- the psychiatrist may be "right" but what good is that if he can't help someone who won't come for treatment? So what should the new psychiatrist tell the patient about his diagnosis?

Diagnostic Stability

I have a question: How do people put down diagnosis on insurance forms over time?
Okay, it's easy to start-- a patient walks in with Major Depression, recurrent, moderate in severity. 296.32
The patient takes medications and gets better. No more symptoms. They come once a month. Let's say they come for a 50 minute session once a month because....
But they aren't coming in and spending 50 minutes talking about their symptoms. They aren't having any. Maybe they spend 5 minutes talking about medication-related issues...needing refills, lab work, side effects. And then, they spend 45 minutes talking about the events and activities in their life and their relationships with others. Maybe one of those relationships is having some difficulty and this is what they spend the bulk of the session talking about.
So what's the code? Does it still code as a 296.32 (this is what they sought help for) or does it now go on the wonderful form as Major Depression, in remission. Oh, but they're only in remission because they are on meds.
And the next visit, the primary topic is a panic attack. But they don't have enough symptoms or enough frequency of panic attacks to actually meet criteria for panic disorder. Or maybe they do. Do you change the diagnosis to panic disorder, or do you leave it 296.32?
The following visit, what do you know, the patient is feeling a little depressed. Does the diagnosis change to major depression, mild?

And what about coding those sessions? If the patient doesn't talk about symptoms or medications, is it coded as a psychotherapy session (90806) or as a psychotherapy session with medication management (90807)? I always code a 90807 on the theory that I'm a doctor, and at some level, I always consider from what I hear whether the medications are working...enough, not enough, what ever. If someone's on medicine, there's no way I can know before they walk through the door whats med management and what's therapy. I know one psychiatrist who said he codes therapy sessions as 90806 (no med management and it's often reimbursed to the patient at a lower rate)....I wondered, if the patient walks in and wants their medications changed, does he tell them they have to come back for a different visit? Or does he wait to see how the session goes and then decide what to code (and what to charge?)

There are things they don't ever teach us in a formal way. And there's not a great way to ask (ah, who do you ask?)- I thought I'd ask you!