Saturday, June 23, 2012

Supportive Psychotherapy 101

An article in Psychiatric News on June 15 by Arnold Winston [his book] offers a quick review about the elements of supportive psychotherapy and why it has become the most widely used form of psychotherapy.
Definition of supportive psychotherapy: designed to reduce symptoms, improve self-esteem, and maximize adaptive capacities.
  • alliance building (expressions of interest, empathy, conversational style)
  • esteem building (reassurance, normalizing, encouragement)
  • skills building (advice, teaching, anticipatory guidance)
  • reducing and preventing anxiety (normalizing, reframing, rationalizing)
  • expanding awareness (clarification, confrontation, interpretation)
  • strengthening defenses (as opposed to challenging them)
  • other cognitive-behavioral (identification and examination of automatic thoughts, relaxation exercises, assertiveness training, exposure treatment)
  • supportive
  • empathic
  • nonthreatening
  • affectionate bond between patient and therapist
  • agreement on the task and goals of the therapy
  • patient's capacity to perform therapeutic work
  • therapist's empathic relatedness and involvement

No Place To Go

There is a fantastic article up on the New York Times website, coming out in print this weekend in the NYT Magazine, called When My Crazy Father Actually Lost His Mind, by Janeen Interlandi.  The author tells the chaotic story of how her family tried to get help for her 69 year old father who was ill with a manic episode.  In it, he bounces from hospital to jail to ER, to homelessness, over and over. She talks about the catch-22's with the legal/psychiatric system with a father who is dangerous enough for a restraining order to keep him from his family, but not dangerous enough for civil commitment, and she talks about stories of others families where awful things have happened.  Her love for her father comes through, mixed in with her frustration that there is no place or mechanism to help such people.  Ah, but the story has a happy ending.  It reminded me a lot of Pete Earley's book Crazy: A Father's Search Through America's Mental Health Madness.

Interlandi writes:

And so for weeks, we had been locked in a game of chicken: waiting for my father to do something clearly dangerous; praying like hell that it would not be his suicide or accidental death or the death of someone else. In the meantime, my mother had all but stopped sleeping and had started hiding the car keys and the checkbook. She would tiptoe around their one-bedroom apartment at night, waiting for him to doze off, then call my sister or me to unload her despair in a flurry of whispers. 

Oh, I can't begin to  do this article justice in a blog post, you'll just have to read it.

Friday, June 22, 2012

The High Cost of (No) SuperMax

Recently NPR featured a story on All Things Considered about the state of Illinois closing its SuperMax prison in Tamms. The story talked about the fact that the prison cost twice as much as other prisons to run, in spite of the fact it housed only 200 prisoners. It mentioned human rights organizations that felt control unit prisons or "SuperMax" facilities were environments that inflicted cruel and unusual punishment. The story implied that longterm solitary confinement caused mental illness and that such prisons did nothing to improve safety in the correctional system.

Wow, I wonder which correctional system they were working in.

I work in a system that at one time had one of the highest internal homicide rates in the country. (Internal homicide refers to murders committed within prison, by prisoners.) I have worked in a control unit prison, and I can tell you that the average citizen can't comprehend the level of depravity shown by some of the inmates there. I'm talking about prisoners who have long histories of violence, dating back to elementary school years. When the New York Times ran a story recently about nine-year-old psychopaths, the first people I thought of were some of my SuperMax inmates.

In my correctional system you have to work to end up in a control unit prison. Beds are few, they are expensive, and they aren't given out like candy. SuperMax inmates are people who are repetitively assaultive to their peers or staff, who repeatedly destroy property or set fires, or who actually kill someone at a lower level of security. Single incidents short of murder are rarely enough to warrant a high security transfer.

Even housing in a control unit prison is not a guarantee of safety: control unit prisoners have continued to run gangs and even to kill in spite of that high security environment.

And now advocacy groups want these facilities closed, and these prisoners turned loose upon their peers in lower security settings. Frankly, if I were a parent of a medium security inmate I would be very concerned about that.

Then there is the allegation of mental deterioration. I've, written...about this topic a few times before here on Shrink Rap and also on Clinical Psychiatry News. Briefly, what advocacy groups don't mention---and their expert consultants also sometimes overlook---is that control unit prisoners are a very disturbed group to begin with, even prior to transfer to the facility. They have severe personality disorders which press the limits of our psychiatric diagnostic criteria. They have maladaptive learned behaviors that seem bizarre to the outsider but serve a clear, logical purpose to those familiar with the correctional environment. In spite of this, recent research has shown that solitary confinement can actually improve rather than worsen this psychological disturbance.

Let's assume for a minute that longterm solitary confinement did have detrimental effects for most prisoners, just for the sake of argument. Most systems do have psychological services in place to address this. Prisoners eligible for longterm solitary can be screened for pre-existing psychiatric conditions, and those conditions can be treated with medication, counselling and behavior management even in a control unit environment. Most SuperMax facilities have policies that require regular rounds on segregation inmates, and psychological services are available.

Abolition of an entire facility is an extreme response to a theoretical problem. The violence posed by control unit inmates, unfortunately, is not theoretical.

Wednesday, June 20, 2012

Groupons for Mental Health Care?

So usually they want to feed me dinner, wax my bikini line, or teach me to para-sail.  Today, a Groupon caught my attention: there is one to provide mental health care service to military personnel and their family members-- a contribution to Groupon is met with a matching gift from an anonymous donor.

Somehow, it feels rather sad that our nation can afford so many things, but mental health care for our soldiers gets relegated to Groupon ads.  Still, I contributed, and thought you might like to as well.  

For the link, click HERE

Shrink Rap and Guest Posts

We get a number of unsolicited emails every week from people offering to write guest posts for us.  They would like us to put their tag line on their posts, often links to websites having to do with getting online degrees or dental equipment or what have you.  The same sources often query us repeatedly.

This is just to make our policy on guests posts known: Shrink Rap does not accept guests posts from unsolicited sources.  Our guest posts are either written by people we have asked to contribute, or we've seen something that has been written for another venue and we ask for permission to reprint it here. 

Sunday, June 17, 2012

How to Ask Your Doctor Intelligent Health Care Questions

Going to the doctor can be confusing.  Doctors make recommendations based on what they know, and patients are conditioned to trust their doctors.  While I think it's wonderful that patients trust their doctors, there are times when patients want more input into their health care, and if this is the case, then let me make some suggestions as to what might be important questions to ask.  There is nothing specific to psychiatry about my recommendations, so feel free to have these types of discussions with any doctor or prescriber.

If you go to the doctor for a routine visit and it is suggested that you have routine health maintenance tests or treatments and you are fine with that, then there is not much to ask.  If you have a concern about the necessity of a test or procedure, try to figure out what your concern is so you can verbalize it.  One example might be: Will routine vaccinations cause my child to become autistic?
  • Why do I need this test?
  • What is the risk of this procedure? 
  • If a medication or supplement is being offered to decrease the risk of a specific illness later, then it's reasonable to ask if studies show that this treatment is known to be effective.  This may sound silly, but sometimes we just don't know things: so people took statins to lower their cholesterol, but it was a while before it was clear that they also lowered the risk of heart disease. And now the thinking is that Vitamin D and Calcium supplements may not lower the risk of osteoporosis in post-menopausal women (they may have other benefits however) but they do increase the risk of kidney stones. 
More importantly, if you choose not to follow your doctor's recommendations, ask:
  • What are the risks of not taking this medicine/supplement/having this vaccine?
My favorite personal example-- when one of my children turned three, I took him to a pediatric dentist to start routine care.  The dentist told me it was standard procedure to x-ray a child's mouth at this age.  I wondered why-- if there are no obvious problems, their baby teeth are going to fall out anyway.  I asked and was told that they like to make sure the adult teeth are there.  Hmmm, how many people don't have adult teeth?  I didn't ask that, what I did ask was, "If you do an x-ray and find that there are no adult teeth, what can you do about this?"  The answer was, "Nothing, we just like to know."  So I'm no dentist, but my take on this was that the x-ray exposes my little person to radiation, costs money,  and if a problem is discovered, there is nothing to do to address it.  I verbalized this and the dentist was okay with not getting an x-ray.   

If you go to the doctor with a specific problem, things are a little different.  
  • If the doctor orders a diagnostic test, you may or may not want to ask what he is looking for or trying to "rule out."  The answer may be something scary that is very unlikely and perhaps you may not want to know to worry about something that's not likely to be the problem.  
  • Is it an option to treat a presumed illness without having a diagnostic test first?  If the treatment is something easy or benign or cheap or a lifestyle change, maybe it would make sense to try that before having an expensive or painful procedure.  If the test is being done to rule out a treatable form of a serious illness, then usually doctors do not like to delay a test.
  • If the doctor recommends a specific treatment, it's reasonable to ask "How long it will take to work and when do you want to hear from me if things are not better?"  This is important, if you're supposed to be better in 3 days, you don't want to come back in 6 weeks saying you're still sick or hurting or very much worse.  And if the treatment is going to take 6 weeks to work, he doesn't want to hear that you're not better in 3 days.
  • If you don't want the treatment your doctor recommends (or you're not sure), it's reasonable to ask: Are there other treatment options available?  What is the expected course of this illness/injury/problem if I don't have this/any treatment?  Sometimes the doctor won't know because different people have different courses with an illness and this can be especially true in psychiatry.
 Sometimes people go to the doctor because they are worried they have a specific illness and are then disappointed when the doctor does not order a test to look for that illness.  Sometimes the concern is 
  • It's reasonable to say "I am worried that I have X, how can you be sure that I don't?"
  • You might then ask, "Would it make sense to order X test?"  
  • You might also ask, "If I continue to have these symptoms, are there diagnostic tests or treatment options that might be reasonable to try?"  And then ask for a time frame.
The truth is that doctors often don't have the answers to these questions, but sometimes it's helpful to hear their rationale for a decision or to let them know your concerns.  They certainly don't have crystal balls when it comes to issues of preventative care and risk, and often recommendations are made based on presumptions -- for example, people with sunburns get skin cancer, sunscreen prevents sunburn, sunscreen will prevent cancer-- before we can be absolutely certain that such logic will bear out.  And whether or not sunscreen prevents cancer, it might be nice to not be in blistering pain tonight regardless of long-term risk.

Wednesday, June 13, 2012

Bubbles or Bath Salts

A number of months ago, I had a massage.  It was very relaxing and my massage therapist suggested I take a bath with some special salts later that evening to "remove the toxins.
  In the lull of the moment, I spent $18 on a paper bag full off bath salts.  I used some once, but the truth is, I prefer bubbles.  Recently, there's been a lot of talk about bath salts in the news, a staff member at the Hopkins Press asked if I could talk on "bath salts and cannibalism" and I must say, I was completely confused.  I've finally figured out that "bath salts" have nothing to do with massages or baths tubs.  As I'm sorting this out, I thought I would share with you what I'm learning.

So "Bath Salts" are the street name for a mostly legal drug (now banned in some states, Denmark, the Czech Republic, or Sweden) named Methylenedioxypyrovalerone --MDPV.  MDPV can be purchased in gas stations and head shops.

On the website for the National Institute for Drug Abuse, director Nora Volkow, M.D. wrote last year:

These drugs are typically administered orally, by inhalation, or by injection, with the worst outcomes apparently associated with snorting or intravenous administration. Mephedrone is of particular concern because, according to the United Kingdom experience, it presents a high risk for overdose. These chemicals act in the brain like stimulant drugs (indeed they are sometimes touted as cocaine substitutes); thus they present a high abuse and addiction liability. Consistent with this notion, these products have been reported to trigger intense cravings not unlike those experienced by methamphetamine users, and clinical reports from other countries appear to corroborate their addictiveness. They can also confer a high risk for other medical adverse effects. Some of these may be linked to the fact that, beyond their known psychoactive ingredients, the contents of "bath salts" are largely unknown, which makes the practice of abusing them, by any route, that much more dangerous. Unfortunately, "bath salts" have already been linked to an alarming number of ER visits across the country. Doctors and clinicians at U.S. poison centers have indicated that ingesting or snorting "bath salts" containing synthetic stimulants can cause chest pains, increased blood pressure, increased heart rate, agitation, hallucinations, extreme paranoia, and delusions

The ingestion of bath salts is associated with raising body temperature, which may lead users to take their clothes off.  It was speculated that the man who was found naked and eating the face of another man on a Florida highway may have been using bath salts, though the latest of Googled articles states that this was not the case.  

In any case, the "bath salts" in the tub are different from the stuff in the news.  Stick with the tub stuff, the MDPV variety seem to be doing nothing good and are very dangerous.  

And yes, I'd love to hear your bath salt stories

Sunday, June 10, 2012

Take a Survey on Social Media and Doctor Dissatisfaction

I've written about a number of scenarios where doctors are negatively reviewed on-line, both on rating sites where the doctor knows the identity of the reviewer, and where the reviewer is anonymous.  Recently, we've been hearing about a number of scenarios where doctors get edgy after reading about themselves on line-- on blogs, listservs, rating sites.  I'm planning to write a blog post about my thoughts about these scenarios, but first, I wanted to takes some votes and get reader opinions.  By all means, feel free to add your thoughts in the comment section.

Trauma & Dissociation: Pulling the Cord

From The New Yorker: Black Box, by Jennifer Egan.
... Remind yourself that you aren’t being
paid when he climbs out of the water
and lumbers toward you.
Remind yourself that you aren’t
being paid when he leads you behind
a boulder and pulls you onto
his lap.
The Dissociation Technique is like a
parachute—you must pull the cord at the
correct time.
Too soon, and you may hinder your
ability to function at a crucial moment;
Too late, and you will be lodged
too deeply inside the action to wriggle
You will be tempted to pull the cord
when he surrounds you with arms whose
bulky strength reminds you, fleetingly, of
your husband’s.
You will be tempted to pull it when you
feel him start to move against you from
You will be tempted to pull it when his
smell envelops you: metallic, like a warm
hand clutching pennies.
The directive “Relax” suggests that your
discomfort is palpable.
“No one can see us” suggests that...


MovieDoc tells us that Anatidaephobia is the fear that a duck of being watched by a duck.  See the video he led me to below.  I am so glad this one was not on the Psychiatry Boards.

Friday, June 08, 2012

Double Billing, Revisited

Remember a few years back when I was posting parts of a novel I was working on?  If you don't, that's fine, it was a long time ago. And then I got side tracked writing Shrink Rap and blogging and pod casting and blogging some more. 

Recently, I've started working on Double Billing again, and I got some feedback from a professional on what would make it more marketable.  I've tried to incorporate those suggestions, and part of this involved re-working the story in third person, rather than as a first person narrative.  

If you enjoy fiction, I'd love to get your thoughts on the first couple of chapters, before I once again think about searching for an agent, or maybe kindle e-publishing this.  Oh, please beware, there's no erotica or sadomasochism, if you're a 50 Shades fan, it may be a bit dry.   If you're up for reading, click HERE And Thank You!

Thursday, June 07, 2012

Fifty Shades of Why?

"Have you read it?"

I've been asked that a number of times recently, and no one has to say what "it" is.  The number one bestseller on both Amazon and The New York Times bestseller list, amazingly enough, is not Shrink Rap: Three Psychiatrists Explain Their Work.  The number 1-4 bestsellers are the trilogy starting with the novel Fifty Shades of Gray, by E.L. James.   #1 Fifty Shades of Gray, #2 Fifty Shades of Darker, #3 Fifty Shades Freed, #4 the set of all three as a trilogy.

So I'm sitting at the pool, without sunscreen and my neighbor tells me that she just finished "this awful trilogy."  Why did she read an entire trilogy if she didn't like it?  Her friend, she says, read all three Fifty Shades books 3 times each--- she knows this because her friend's husband announced that fact on her Facebook page.

So I read the first book, Fifty Shades of Grey, when it first starting getting press in the New York Times as the erotic novel that it was okay to read, one people were discussing with their book clubs.  I expected the novel to be something resembling literature with erotica thrown in.  Oh my, I was wrong.  The writing was awful and stilted with dialogue that didn't flow, and...well, just not "literature."  The erotica was graphic sadomasochism.  There was a little 'vanilla sex' and our fifty shades of F*'d up character, Christian Grey, was kind enough to define "vanilla" as meaning there are no props involved.  

I spent over a decade consulting to a sexual behaviors unit.  Nothing shocks me anymore.  Is that true? Oh maybe, but nothing in this book was terribly shocking, except that it's the number one best seller.  It seemed similar to 9 1/2 Weeks, which also had the plot of a woman who was attracted to a man who enjoyed sadistic sex, bondage, and humiliation.   Interesting that the man in that novel was named John Gray (thank you wikipedia).  But 9 1/2 Weeks did not get the hype or best-selling status that Fifty Shades of Grey is getting. The movie did not do terribly well, even with Mickey Rourke and Kim Basinger, though apparently it's done better as a home video.

I'm left with the question of Why?  It's not the writing.  It's not the plot-- there is some pull to know what happened to Christian that he's developed this fetish-- it's not just simple S&M, he has a special secret room called The Red Room of Pain with every form of implement and he makes a big deal of having his women sign a legal contract.  And he won't be touched.  He's fabulously wealthy in a way that pulls on everyone's fantasies--who doesn't want to be helicoptered and chauffeured on their first date?-- young, sexy, charismatic, intriguing, mysterious, brilliant, disturbed, and impenetrable.  Still, not enough for the #1 bestseller along with 2 sequels and so much hype.  

The novel is pulled along by the sex, the build up to the sex, and the vivid descriptions of the sex.  James focuses on the kinky--the bondage, the humiliation, the actual infliction of pain, but she includes all flavors here, including some vanilla, it's not all fetishistic.  I think she covers most tastes, and she does it with a perplexing protagonist-- a freshly minted college grad who happens to be a down-to-earth virgin who is conflicted about accepting her billionaire boyfriend's many (and often intimate) gifts-- it feels like prostitution to her.  It's easy to understand young Anastasia's attraction to Christian, but for someone who's never been interested in sex before, she's an awfully ready, willing, and libidinally-driven character who relishes good sex and tolerates, but doesn't quite crave, Christian's more sadistic desires. 

The sex is the draw, and I'm left to wonder why.  The book, I believe, is selling mostly to women.  It's been called "Mommy Porn" and Saturday Night Live had it's own satirical segment on the book for Mother's Day.  Aside to my co-bloggers: please forgive me for posting the SNL skit video and I hope you'll still blog with me...oy.  Why is it Mommy Porn? There are no mommies in the book, the characters are twenty-somethings.   I'm left to wonder if sado-masochistic sexual fantasies (and I'll stress the word "fantasy") aren't much more common then we assume.  There's something liberating, too, about the fact that Anastasia is not craving her role as masochist; she tolerates it for love, though clearly she enjoys being pushed to this place-- she never refuses, she never uses the 'safeword' that Christian has said will get him to stop.  It's as though she (and the reader) are allowed to enjoy the kinky sex because she isn't looking for it, she's just the victim of love and going along is required to remain in the relationship, even though it seems that Christian is drawn to her by more then his desire for a sex slave.  Perhaps part of the draw is a push away from a world where gender equality is the politically correct, where women now often surpass men as the breadwinners, as the more motivated and driven members of college classes and work places.  

Okay, so you tell me, why is Fifty Shades of Grey selling better than Shrink Rap?

Tuesday, June 05, 2012

I Know What's Good For You

In medicine, we have certain beliefs, and these beliefs guide what treatments we prescribe and, more generally, how we tell people they should live their lives.  Sometimes, we're right-- and I say that mostly because people do live longer and healthier lives then they used to.  The average lifespan is longer than it was 50 years ago, so I think medicine is likely doing some things right.  And while some of the things that we prescribe or recommend are guided by evidence-based studies, some are not, or some of the studies are flawed, equivocal, or just plain wrong.  One can't study every detail of lifestyle, diet, sleep, medication response, chemical exposure, or whatever else there is that might alter healthfulness in a controlled and accurate way, though to read some of the stuff out there, one would think you could. 

We don't know a lot-- this is true for all of medicine, not just psychiatry, but it's true for psychiatry too.  Sometimes we think we do, and we proclaim truths that might just not be. 

So I'm going to refer you to a number of sites to see what you think.

Over on KevinMD, Edwin Leap writes about "When self-evident truth in medicine is systematically ignored."  Dr. Leap writes:

And yet, medicine is filled with situations in which “self-evident truth” is systematically ignored, and those who believe in it intentionally and often viciously marginalized.
For example, after years of being told that physicians weren’t giving enough treatment for pain, and after years of clinicians saying, “yes we are, and too many people are addicted and abusing the system,” the data from CDC says that far too many are dying from prescription narcotics, far too many infants being born addicted, and far too many people, young and old, are using analgesics and other drugs not prescribed for them.  To which many of us say, “duh!”

Today's New York Times "most emailed list" includes  articles which question our assumptions or assert new truths :

1) Gary Taubes writes in "Salt, We Misjudged You," :

While, back then, the evidence merely failed to demonstrate that salt was harmful, the evidence from studies published over the past two years actually suggests that restricting how much salt we eat can increase our likelihood of dying prematurely. Put simply, the possibility has been raised that if we were to eat as little salt as the U.S.D.A. and the C.D.C. recommend, we’d be harming rather than helping ourselves.
WHY have we been told that salt is so deadly? Well, the advice has always sounded reasonable. It has what nutritionists like to call “biological plausibility.”

I add as an addendum that I think I missed the lecture in medical school where salt was the "Public Enemy No. 1."   I somehow got through physiology and pathology believing that if a person has normal kidney function and doesn't suffer from congestive heart failure or have problems with fluid retention, that excess salt gets excreted and isn't associated with shortening your life.  (The issue of CHF was a big one though, for those who had it, a bowl of soup could land them in the ICU).  So Gary Taubes is the same guy who wrote a NYTimes Magazine article 10 years ago that gave credibility to the Atkins diet and challenged our beliefs that pasta and carbohydrates and a low-fat diet are good for you in What If It's All Been a Big Fat Lie?

I think we all have beliefs about what it's healthy to eat, but we don't have real answers and I imagine that the answer is more related to individual biology then anything we've come to entertain as a society with our food pyramids. We'll have to see if New Yorkers live longer when they can't get super-sized soft drinks.

2) Jane Brody writes in Slathering on Sunscreen, Early and Often, about the necessity of teaching children to put on sunscreen like we teach them to fasten their seat belts.  She gives statistics for early sun exposure and the increased risk of skin cancers.  It's all said as a given, and maybe she's right, but commenters wrote in asserting that sunscreens cause skin cancer, that the chemicals in them are toxic, that the evidence is lacking, that sunscreen blocks the light rays needed for Vitamin D production and all the problems associated with low Vitamin D levels, and there were examples of populations that spend more time in the sun but have lower rates of skin cancer.  No answers from me, but I'm not as certain as Jane Brody that the evidence is there to suggest that sunscreening everyone will lead to longer, happier, or healthier lives, and I'm not sure it won't either.  I, for one, don't like the smell. 

3) Exercise is good for you, right?  I actually do believe that.  But Gina Kolata writes in For Some, Exercise May Increase Heart Risk that 10% of people got worse, after exercise, on at least one measure (meaning a lab value or their blood pressure) related to heart disease.

The problem with studies of exercise and health, researchers point out, is that while they often measure things like blood pressure or insulin levels, they do not follow people long enough to see if improvements translate into fewer heart attacks or longer lives. Instead, researchers infer that such changes lead to better outcomes — something that may or may not be true.

4) Finally, in The Trouble With Doctor Knows Best, Peter Kahn writes:

Against the gravitational pull of doctor-knows-best culture, research studies that fail to confirm current practice often have surprisingly little effect on our behavior. Guidelines written by academic types only impact the fringes of our practices. And despite the apparent move toward evidence-based medicine and comparative effectiveness research, most of us still feel that our own experiences and insights are the most relevant factors in medical decision-making. 

What's the take home message?  Question everything, and know that there is a lot we don't know.  We live in a society where we're constantly told what's good for us and what's not, where doctors can be insistent about what's best for patients, where people can be judgmental and self-righteous about the lifestyles they choose to follow.  Now if you'll please pass the butter and salt for my popcorn, and yes, I'd like a beer with that. 

Sunday, June 03, 2012

More About On-Line Doctor Reviews

I wrote about my experience of getting a one-star review of my psychiatric practice on 
I wrote about it on Shrink Rap: Here

I wrote about it on Clinical Psychiatry News: Here
and I wrote about it on Psychology Today: Here.

Some of the responses have suggested that patients/clients should be able to write such reviews and that people should be able to look up information about their doctors.  Well, they are, these sites exist and you can also look up whether your doc has been sanctioned on your state's licensing site.  

 I thought I would address some of the comments in new post

As I mentioned, I Google new docs before I see them, and I would be put off by a bad review.  There are good docs and mediocre docs and bad docs.  I'm not sure how I feel about doctors being reviewed on line.  On my Psychology Today post, a couple of college professors came on and noted that students who get poor grades review them harshly.  I know waiters who have been fired because of gripes put up on Yelp, some of them rather subjective.  The online world is full of pressure.

Should doctors be the focus of On-line ratings?  They are, and maybe that's okay, but I have specific gripes with how this is currently done.  Let me outline those gripes.

1) My information is put up without my permission or consent.  It includes a map to my office.  Some doctors  work alone in isolated settings and may feel unsafe having this information on the internet.  We should at least be asked.  Oh, and the information is wrong, the address listed has not been my address for years.  The websites don't seem to care. They want me to register with their sites and correct it.  I want nothing to do with them, so I'm not registering with them and my information may as well be wrong.  It's public information, you say?  There are lots of things that are "public information"  everything from legal case searches and home addresses.  Does that mean that anyone who wants has the right to put it on their website?    Public information-- would you want someone searching you and putting up on their website every speeding ticket you'd gotten, every DWI, every bill collector's claim, your age, your home phone number and address, and any licensing violation --on their website?  It's all public information but does that give a third party a right to publish it?  Legal, yes.  Ethical--I don't think so.  HealthGrades took my listing down when I requested it., however, tells me that I have no option to not be listed with them.  I'm still chewing on that.

2) Ratings should not be anonymous and there should be some way to ascertain that the reviewer has really been a patient of the doctor, otherwise these reviews are worthless.  Some commenters (I think mostly on the Psychology Today website) feel that being able to write reviews empowers patients, but if someone who doesn't know a doctor (or an angry neighbor, ex, etc) goes in and writes poor reviews, or if the doctor or his friends go in and write great reviews, then there really is no empowerment on either end.  In order for their to be any usefulness or empowerment to these sites, the ratings need to be done honestly. 

3) There should be a mechanism to remove a review if the rater changes their mind.

4) The issues being rated all reflect individual taste and subjective interpretation and don't reflect 
good medical care.  There are no questions about "Did the treatment this doctor recommended cure or alleviate your problem?"   There is a question about how quickly you get seen in an emergency, but what does that mean?  If the doctor talks to you and says "Go to the Emergency Room" is that bad?  He didn't SEE you.  If the doctor is on vacation but his coverage sees you, does that count?  Do we really care about the lighting in the waiting room?  What about, "Did your doctor seek consultation or refer you to a specialist appropriately?"  That's not a question.  How long did you wait?--that's a question. Do you want a doctor who is always on time?  Convenient, yes, but it means that he holds to his schedule religiously-- he doesn't squeeze in emergencies, and if he's telling you that you're going to die of cancer soon, you only get your allotted time to ask questions and don't go over because he's holding to his precise schedule.  Does your doctor listen and answer questions is a reasonable question.  Did he spend the appropriate amount of time with you? Again, isn't this an individual call?  Some people are chatters, some are not.

5) I don't understand why HealthGrades will take down behavioral health ratings.  I asked, they didn't answer.  You can rate a psychiatrist, it's not that they block it, it's just that if the psychiatrist complains, they take it down.  This really negates any value and skews the results in favor of the doctor (at least in theory, I think most doctors believe they are powerless and there is no recourse, and don't actually ask to have their reviews removed). 

Roy, here's a career for you: create a website that provides a public service of rating doctors with some verification of who the reviewer is, with questions that reflect both warm and caring treatment as well as good medical care.  And ask the docs to participate.