Should Psychiatrists See Patients?

Today's Wall Street Journal has an article on a new model of psychiatric care: the psychiatrist serves as a consultant to the primary care doctors and the psychotherapist.  The psychiatrist hears about the patient, but if my read is right, the psychiatrist has a large caseload and never actually sees the patients.  

In Getting Mental-Health Care at the Doctor's Office: Providers Take Integrated Approach, With Patient Numbers Set to Jump Under New Law and Psychiatrists in Short Supply,

Melinda Beck writes:

As the consulting psychiatrist for four primary-care practices, Dr. Ratzliff confers weekly with 10 care managers who follow the patients closely, provide counseling and chart their progress in electronic registries. She helps devise treatment plans and suggests changes for those who aren't improving.

"I get to touch so many more lives than I would if I were seeing these patients in person," she said.

I'm speechless.  The article goes on:

In some practices, psychiatrists and psychologists work alongside primary-care providers on cases. In others, primary-care doctors prescribe antidepressants or other medications, and care managers—typically licensed clinical social workers—confer weekly with patients to monitor progress, often using a standardized nine-question depression quiz.
Many care managers also provide cognitive behavioral therapy and other counseling. "The goal is to give patients the skills to approach problems differently," said Jürgen Unützer, a University of Washington psychiatrist, who has helped more than 1,000 clinics nationwide adopt the model.

Many studies have shown that integrated care can reduce patients' depression and cut costs. One University of Washington study of 1,800 patients found that providing a year of integrated care cost $600 a patient but saved an average of $4,000 in lower medical bills over the next four years.

Still, integrated care is a big adjustment for psychiatrists, whose training typically focuses on one-on-one relationships.

It's good that more people are able to get help.  It's good that money is saved and that this is so economical ($600/year for mental health treatment, wow!)  And primary care providers already prescribe for the majority of patients, so adding a therapist and a psychiatrist to consult with may well be an improvement, but shouldn't patients with serious mental illnesses still see a psychiatrist?  

The Hired Gun

I know I'm going to get nudged to talk about this article so I'll beat Dinah to the punch. Today's New York Times has a story entitled "Witness for the Prosecution" about a neuropsychologist who frequently is retained to testify on behalf of the state in criminal trials. The expert witness gets criticized for slanting his opinion in favor of the prosecution by ignoring previous history or making certain presumptions about the defendant's previous education or experience. You can read the article yourself, I won't repeat it here.

The article quotes questions from the doctor's cross-examination about the assumptions he based his opinion on: how do you know the defendant took a psychology class? Why are you ignoring or not considering his mental health history? Why are you disregarding DSM diagnostic criteria?

All of this sounds pretty horrible, but the fact of the matter all the questions asked by the cross-examining attorney at the beginning of this article are routine questions that will get asked of any testifying expert. As I mentioned at our recent talk at the Johns Hopkins Odyssey lecture, these questions are designed to make the expert look incompetent or foolish. They are an attempt to undermine the credibility of the expert in the eyes of the judge or jury and to get him flustered and confused.

This is predictable, and to a certain extent it's a choreographed dance. When you express an opinion you will be asked the basis for that opinion---what information did you consider, did you have all the information, why do you rely more heavily on one source of information than another, did you consider the credibility of the information?

The next step is to alter all the details slightly in an attempt to get your opinion to waver or even change: what if this piece of information weren't true, or you found out a certain fact was different from what you assumed? How would this affect your opinion? This step of the process could go on for hours. It can be painfully boring for a jury, so when the NYT article talks about the importance of "presentation" and communication for a good expert witness, that's why. You have to hold a jury's attention for hours in spite of excruciatingly detailed questions, a court room that is either too hot or too cold, and chairs that you can't quite get comfortable in no matter how you twist.

Once all of this is exhausted the last stage is to attack you, personally. If you don't have the guts for this, if you have an issue in your professional past you'd rather not have public, this is the stage that will weed you out of the expert witness field. I note that the NYT article mentioned the expert's appearance on his Facebook profile, and also mentioned he had a Twitter feed. I plan to send this article to my students to remind them that anything they write, anywhere, could theoretically end up on the New York Times web site. I certainly keep this in mind when I blog and tweet. This is the chance you take when you do forensic work, whether or not you are forensically trained.

The last point I'm going to make using this article is the fact that this particular expert is retained as a prosecution expert. There are both advantages and disadvantages to being retained by one side or another, as opposed to working as a neutral court evaluator as I do. A defense expert has the advantage of being able to get in to see the defendant as soon as possible after the offense. This is good because you're more likely to get an accurate picture of the defendant's mental state at the time of the crime. A state or court's expert sees the defendant weeks or even months later, after bail review and arraignment and after the defense expert has had a chance to advise counsel on the likelihood of a viable insanity defense. Experts acting in a neutral court-appointed role have to work harder to gather the data to put together a retrospective picture of that mental state.


I could go on and keep rambling about this but that's enough for now. The NYT's point about the expert being a hired gun as an old one I've talked about before. Ironically, the NYT just made my point about this---if you are a hired gun everyone will know it, it will undermine your credibility and make you less useful as an expert. Being a hired gun is bad for business so most experts know you just can't get away with it over the long term. And that's one of the standard cross-examination techniques as well---trying to paint you as a hired gun.

Enough.

Guns, Again (--another broken record shrink rapper)

Apparently,  if the shooter is dead, I can talk about it (a little).  I don't know any facts except what I've seen in the paper, and I've interviewed absolutely no one, so I'm not going to say much, but I am going to use what I've read to write a post on the on-going issue of the role of mental illness and gun control.

Per today's New York Times:

But several senators, like Senator Richard Blumenthal, Democrat of Connecticut, who has pushed for tougher gun laws since last year’s elementary school massacre in Newtown, Conn., see mental health policy as a way forward.

“Mental health is really the key to unlocking this issue,” Mr. Blumenthal said. “I’ve become more and more convinced that we should establish the mental health issue as our common ground.”

  So you know, I have read approximately eight news articles, mostly in the New York Times, a couple in the Wall Street Journal, and I listened to the transcript of the interview with Dr. Ritchie and Dr. Torrey on PBS.  And ClinkShrink already wrote about this in Speaking Ill of the Dead, because she's a broken record.

Here are the "facts" I have seen reported.  Note that some of these "facts" are conflicting:
--the shooter went to the VA ERs twice in the past month and got medicine for insomnia.  He was reported not to be suicidal, depressed, or anxious, and was given Trazodone, an antidepressant used for sleep. Trazodone is not an SSRI, and I say that because there have been questions about whether SSRI's can cause violent or suicidal thoughts.
--he had a "decades long history of mental health problems" with no clarification as to what that meant or consisted of.
--the VA has no history that he ever sought mental health treatment
--on August 7th, he was in Rhode Island and called the police because he was paranoid that people were following him and there was something to do with microwaves.  (Sounds psychotic, but the psychosis is due to what? No clue but possibilities might include ?schizophrenia, ?delusional disorder, ?DTs, ?bad drug trip, ?mania, ?brain tumor, ?malingering, ?psychotic depression, ?neurosyphillis, ?hypothyroidism aka myxedema madness --I have no clue, though Dr. E. Fuller Torrey calls this "classic paranoid schizophrenia" and he may be smarter than me.).  
--The police faxed a report to his employer
--The police did not fax a report to his employer .
--The police did not take him to the ER (that we know of).
--Nothing has been said (that I saw) about any offer to take him for a psychiatric evaluation, so we don't know if he 'refused' care that day or any other day.
--His father said he had PTSD from being a first responder on 9/11
--There is no record that he was a first responder
--There has been no mention of psychiatric hospitalizations
--He had VA benefits and access to care and was actively employed and working, rehired by a prior employer this summer and had a security clearance.  To me, this implies that his work for that employer during the previous stint was satisfactory.
--His discharge from the military was honorable.
--His discharge from the military was not dis-honorable.


So with regard to mental health issues being the key to gun control, I ask:
--What's the line?  You hear a voice and everyone's head is wired such that the voice goes directly to a databank so that your guns are removed and a magical shute pops up to wisk you to a state hospital bed?
-- You tell a doctor you are having trouble sleeping and you can no longer own a gun? This would be a huge help in either keeping guns from people or cutting down on sleeping pill prescriptions.  And it would be fun to watch the drug companies go bonkers.
--Everyone who sees a therapist is exempted from owning a gun?  Or just people who see psychiatrists?  What about people who get psychotropic medications from their family doctors?  Or do we weed people out by their psychiatric diagnoses?  Or specific symptoms?  And how do gun-limiting databanks and law enforcement agencies discover those symptoms or diagnoses?  Insurance forms?  Mandatory reporting by therapists?  What about self-pay patients?  Perhaps we should require anyone with psychiatric symptoms to self-report to a database?


With regard to looking at behavior, instead of imprecise labels like "the mentally ill," I've seen the following reported (again, just what I saw in the press):
--two weapons violations for discharging a gun, no convictions.
--the shooter reportedly claimed he had an anger-induced blackout (not an official diagnosis) as an explanation for firing shots
--two days in jail for a bar fight 
Legal records are not confidential, so it might be much easier to ban people with a history of criminal impulsive behaviors from owning guns and cast a wider net.  


When someone has committed a tragic, senseless crime and has complained, ever, of a psychiatric symptom, it's easy to say mental illness is the common denominator and that's where we should target our gun control.    If you shoot strangers, we don't understand that behavior (at least I don't), so we say someone is severely mentally ill, and in retrospect, they may well have been.   But until that time, it may not have been obvious that they were dangerous and the question is how big a net should we drop?  Mental health professionals  see people every day with psychiatric symptoms, insomnia, violent thoughts, and sometimes psychotic symptoms.  It is so easy to see the 'red flags' in hindsight, but so many people have these symptoms who never go on to hurt anyone, that our predictive powers are sometimes limited.  I certainly think there should be a mechanism to report someone who a therapist is clearly concerned about as being at high risk for violent behavior, and in our state, there is a mechanism to get someone in the hospital, but not to keep them from owning or purchasing a gun.  I think we need to base such gun control on actions -- people who've been violent or people who have had suicide attempts serious enough to require medical admission, or those with stated intent.

Finally, at this point, we don't know for sure that mental illness was the motive for this action and maybe we should wait to hear if anything indicates that it was before jumping to that conclusion.

Speaking Ill of the Dead

I'm moving this discussion to its own post since it has little to do with mandatory employee health screening and I think it deserves its own section.

Jesse put up a link to a PBS news interview with Drs. E. Fuller Torrey and Elspeth Ritchie regarding Aaron Alexis, the alleged Navy yard shooter. This has spurred discussion about what, if anything, psychiatrists should be saying in the media about specific individuals with rumored mental illness.

I've gotten on a soapbox about this a number of times before and I don't want to be repetitive, so if you feel inclined you can search the blog for the labels "shooter psychology" and "spree killing." You can also read my Clinical Psychiatry News column about a similar situation, "Use of Psychological Profile to Infer Ivins' Guilt is Prolematic". (Titles are not my strong suit.) I wrote a followup column about this just last month when the president of the APA tweeted out a statement regarding the legal sanity of the Fort Hood shooter.

Honestly, at this point I feel like a broken record. (Oh dear, some of our readers have probably never played a record!)

In my opinion, no mental health professional should be making public statements about the legal sanity or mental state of a living criminal defendant prior to trial. Presently our APA ethical guidelines do not expressly forbid this, unfortunately. The guidelines make a generic caution against public statements regarding people we haven't personally examined in a principle known as the Goldwater rule. This has been interpreted to mean that public statements are OK as long as the professional makes an initial disclaimer that they have not personally examined the individual they're talking about.

This guideline was written and adopted before the Internet was invented, even before there were personal computers (back when people knew what 'records' were and what happened when they cracked).

I felt the time was ripe to bring this so-called Goldwater rule into the modern age, and I also felt strongly that we should include a specific caution or prohibition against public statements regarding criminal defendants. I drafted proposed language in an action paper which was later adopted by the APA. To my knowledge, the Goldwater rule is being revisited (and hopefully revised) right now.

But back to Aaron Alexis and the PBS interview. This is where it gets tricky. In contrast to the Fort Hood shooter, Jared Loughner and the Aurora theater shooter, this is a situation where people are making statements about a dead suspect rather than a living defendant. The impact on a dead person is, well, moot.

Nevertheless, there are ramifications to consider. Media statements may reinforce the notion of guilt in the public mind when the deceased was never actually tried or convicted, or any of the evidence put to the test. This was the case in the situation of the late Bruce Ivins, the anthrax mailing suspect. In that case the only physical evidence linking him to the crime was the genotype of the anthrax bacillus. This evidence was weak enough that FBI investigators were concerned it might not be admissible. He might have been innocent. The situation is slightly different for Aaron Alexis given that he was definitely at the scene of the crime and presumably the evidence of guilt might be stronger than in the Ivins case. But does that change our professional obligation to maintain respect for persons? At what point do we need to balance the real need for public education about mental illness, violence risk assessment and the pro's and con's of involuntary treatment against the distress of a surviving loved one? While public opinions about won't impact a dead suspect, they will impact the suspect's wife, children and siblings. Just ask the mother of the Columbine shooter.

This post is getting a bit long and I have other things to do, but I thought I'd spew out an initial reaction. There are also state laws about medical confidentiality which address the maintenance of confidentiality after death, but that's a topic for another post. Some confidential information might have become available to investigators when the suspect was still alive, in the heat of the incident when danger was imminent. Given that there will be no trial, we likely will never know. But these situations are bound to come up again so we should be prepared for these discussions.

Staple a Kid's Head and Eat a Few Knives?

~ There's an article on mental health stigma in The New York Times by Pauline Chen, worth the read: Caring for a Mind in Crisis.

~Since I like to gripe about electronic records and privacy, I'll add this to my list of you-don't-want-to-believe privacy issues: On Campus, A Faculty Uprising Over Personal Data.  

Penn State administrators quietly introduced the plan, called “Take Care of Your Health,” this summer in the deadest part of the academic calendar. But that didn’t prevent some conscientious objectors from organizing a protest online and on their campuses, culminating last week in an emotionally charged faculty senate meeting. The plan, they argued, is coercive, punitive and invades university employees’ privacy.

The plan requires nonunion employees, like professors and clerical staff members, to visit their doctors for a checkup, undergo several biometric tests and submit to an extensive online health risk questionnaire that asks, among other questions, whether they have recently had problems with a co-worker, a supervisor or a divorce. If they don’t fill out the form, $100 a month will be deducted from their pay for noncompliance. Employees who do participate will receive detailed feedback on how to address their health issues.

On KevinMD, Sanjay Gupta has an article on one of our topics of interest, Medical Marijuana, and there was  a Weed special on CNN featuring Dr. Gupta the other night.  Interesting that he comes out "Pro" MMJ, even though his article doesn't mention that the little girl with seizures was using a varient of marijuana that was so low in THC that it was unsellable, and that she was taking it orally, not smoking it with a high.  I found the CNN show more enlightening than the article but I'll link to the article here.

If you're getting mental health care from an agency in  New Mexico, sounds like things may be rough.  A number of agencies providing care to many patients are being investigated for Medicaid fraud. The state's response: shut them all down.  Apparently it's leaving patients without access to treatment and inpatient admissions are rising.  Here is a an article from the New York Times but I'm sure there are many other local pieces on line.   I have to say, I don't understand the photo that went with the article, but I borrowed it for my graphic here because it was so perplexing to me.  What are they doing to that kid's head?

From the Shrink Rappers, over on Clinical Psychiatry News:

I continue to make noise about how psychiatry needs to question our assumptions and to talk about how Dr. Insel's blog post on the NIMH site questioning the effects of long term antipsychotics should shake up the risk/benefit discussions we have with out patient.  Read more in Questioning Psychiatry's Assumptions about Life Long Medications.

And, finally,  ClinkShrink gets annoyed about the idea that everyone thinks the really sick patients should be someone else's responsibility in Locked In, Eating Cutlery.  Yes, she is talking about a patient who eats their forks.  Why?  Just read. 

So why did the font change color in the middle of my post?

What are You Afraid to Ask About Psychiatry?

On Thursday, ClinkShrink and I will be speaking at the Johns Hopkins University's  Fall Odyssey Program.  It's a lecture series, and we'll be speaking at the kick-off reception for a program called Mini-Med School.  We were asked and, flattered, we said "Yes!"  I didn't ask what they'd like us to speak about, and I started hearing details from people after the brochure came out.  Our talk is titled,   "Everything you always wanted to know about psychiatry but were afraid to ask."  One hour.  Two speakers.  Please leave lots of time for questions.  Okay, so I'm tasked with condensing my 12 years of higher education and 20 years of experience into 20 minutes (10 minutes for questions), then ClinkShrink gets her go at it.  

So I have a question for our Shrink Rap readers: What do you want to know about psychiatry that you're afraid to ask?

If you'd like to come, we'd love to have you.  I have no idea if there is still space, last I heard (back when I asked what I was talking about and where I should show up), I was told there was a good response, so I don't know if there are seats left.  

Here's the link to the brochure: http://advanced.jhu.edu/wp-content/uploads/2013/07/Odyssey_Fall2013_final_singles3.pdf 
If psychiatry isn't your thing, there are many other choices.  

Can I Be Your Doctor If....?

Last week, ClinkShrink wrote an article about a heinous criminal who committed suicide while in prison.  She titled her post: Your Patient Died. Who Cares?

Such a post begs the question of whether all people deserve equal medical care, equal physician devotion, and equal medical resources.  I think we all have our own beliefs about such things.  Some of us can minister to the physical and mental disorders of those who've done awful things, some of us can not.  I guess you could go further and say what's an awful thing?  Can you treat Hitler?  His bodyguard died a few days ago, having made it to the ripe old age of 96.  Can you treat someone who only killed 5 people, and not 13 million?  Can you treat someone who drove drunk and killed a single young child?  Can you treat someone who beats their children?  Who cheats on their wife?  Who causes their own illnesses by drinking, drugging, and eating pizza (~I ate pizza and ice cream at the beach today, it was sooo good, but I do know this is not good for me).  Who has religious beliefs that your own religion deems unacceptable?  And if your father ends up in jail because he drove while intoxicated, committed some sort of financial fraud, or there was a weird case of identity confusion that took a little while to sort out, would you want him getting reasonable medical care during his stay in jail?

Does everyone deserve the exact same medical care?  Is is wrong if one person can afford to pay out of pocket for more attentive care or better doctors or more expensive medications if those things aren't allowed by the Blue Insurance that most people get?  What if the person who says he can't afford such concierge type care puts in granite counter tops, wears designer clothes, and drives a luxury sports car, while the person who opts for high-end concierge care drives a used Chevy and shops at Wal-mart?   I've found that even in our world of haves and have nots, that often those with private health insurance are the have nots because certain treatments are deemed 'not covered' and there is no rhyme or reason as to who can get what.

Questions of how we divvy up our medical resources are difficult.   

But I'm going to move us back to the question of treating Clink's prisoners.  A doctor doesn't have to work in a jail, but if a doctor does  choose to work in a jail, or in an ER that happens to service the drug dealers who shoot at each other,  then that doctor is obligated to provide the best possible care to those patients.  Sure, people quietly judge, but if a doctor can't turn that off and offer the best they have to offer any patient, then they have no business being a doctor in that setting.  Should prisoners get the same care as model citizens?  No one's asking me, so I won't bother with an opinion, but I do think that those carrying for the prisoners need to be their agents, they need to advocate for reasonable standards of medical care for their patients.  Just like those taking care of the medical needs of those who are obese, mentally ill, or smoke, doctors need to offer the best care they have available, without stigmatizing the patient.

So Clink, I don't care that your patient died, but I'm glad you do. 

Your Patient Died. Who Cares?

 

 

I thought I'd share what I saw on my Twitter feed as soon as I got up this morning. I immediately felt a blog post coming on, particularly after reading the Twitter comments as they rolled in. I felt a bit sick, knowing what some of my colleagues in Ohio must be going through right now. This post is for you.

When it comes to patient suicide, correctional psychiatry is probably one of the higher risk subspecialties within psychiatry. The average prisoner has three risk factors for suicide before he even steps into the facility: he's male, young, and has an active substance abuse problem. There's even a recent study to suggest that being charged with a crime increases one's risk of suicide, even if that person is never incarcerated.

Considering this, if you practice correctional health care for a few years it's pretty likely that at some point you will experience a patient suicide, either as a health care first responder, as an administrator or as a mental health clinician. I feel like I need to write this blog post to warn you about something:

Don't expect your friends, family and colleagues to understand why you're upset that somebody died.

I know that sounds counterintuitive, but that's just the reality of correctional health care. The general public---and even some physicians---are going to instinctively give you a "who cares? He's just a criminal" response even if they don't know the person or what he was locked up for.

Let's consider the responses I've seen just today regarding the suicide of Ariel Castro, the man who kidnapped three women and held them prisoner for several years (comments drawn from a network news site):

• Great news! Seriously, it's great that Ohio taxpayers won't have to pay to house and feed this scum bucket.
• He did society and himself a favor....good thing he's gone!
• Too bad that he didn't live to be locked up and suffer for a few decades.
• Too bad he couldn't have been chained to a wall while the inmates he was being protected from got rewarded for taking turns demonstrating the receiving end of his version of the universe. Can't exactly hang yourself when your chained to a wall. Cruel and unusual? If it's not cruel and unusual, it's not punishment.

Yeah, that could be your patient they're talking about. And all your patients watching the news or reading a newspaper will see this public reaction and know that the rest of the world truly could care less about them. Your job, temporarily, is about to become much harder. Fingers will be pointed, armchair psychologists who have never set foot in your facility will "know" how the system or you as a clinician must have failed, and new redundant policies will be created that will make your health care delivery system less efficient.

This will pass. Eventually, people will grasp the fact that this man who successfully hid multiple felonies for several decades probably also had the skill to hide a planned suicide attempt. Your colleagues in other parts of the country will step up to the plate to remind the media, and the general public, that correctional and forensic psychiatrists are taking an active role to implement suicide prevention policies and training that have dropped the correctional suicide rate substantially in the last twenty years.

And maybe, just maybe, it will lead people to recognize the importance of what you do.

Just a few thoughts from inside the walls, given that next week is National Suicide Prevention Week.

Deeds, not Diagnosis.

Here on Shrink Rap, we've talked at length about the implications of having a psychiatric diagnosis on one's future occupational endeavors.  For example:

We've talked about whether you can have bipolar disorder and be a doctor.
We've talked about the fact that a psychiatric diagnosis prevents you from being a pilot.
We've talk about psychiatric disorders and being in a powerful political office.
We've noted that the New York Times recently ran an article on psychiatric diagnoses and how it affects one's ability to be admitted to the Bar Association.
We've discussed mental illness and gun legislation. 

 What the DSM does for us is it gives us a list of symptoms that go with every diagnostic category.  It means that if a patient presents at a given time with a specific set of symptoms, and they are examined and a history is taken, that different psychiatrists at that point in time, with the same data, will come up with the same diagnosis.  It's actually good for that, and we call this inter-rater reliability.  

What the DSM doesn't do is tell us which patients with a given disorder will get better with medicines, will get better without medicines, will respond well to therapy, will do better without medicines, or will be hopelessly sick and disabled no matter what is done.  Schizophrenia is often a poor prognosis illness to have, and nothing about diagnostic criteria tells us who with schizophrenia will become a law professor, like Elyn Saks, and who will end up living in a cardboard box under a bridge.  

Given this fact, we need to stop using psychiatric diagnoses for anything to do with occupations or gun ownership or drivers' licenses, or much of anything else aside from the treatment of psychiatric disorders.  It's silly anyway: Why should you be prevented from being an attorney because you have a history of a mood disorder, but it's fine for you to be a school bus driver with dozens of children depending on your mental stability?  

We need to judge people's competence based on their deeds.  If you run naked through the hospital, you can't be a surgeon there (not this week, anyway).  If you're so depressed you can't get out of bed and you're always late to work, perhaps you shouldn't be President of the United States, because I hear it entails being at a lot of meetings and press conferences.  If you're behavior when ill leads you to do illegal or dangerous things, then you should be barred from doing things that one needs to be a safe and law abiding citizen to do.  But it's the behavior, or the expressed potential behavior that counts.   So if you've quietly been depressed, gone to tell this to a psychiatrist who prescribed you a medication that took that depression away, and a pill and some therapy keep you well, then why shouldn't you be running the country or driving those kids to school?  Oh, there's risk, you could get depressed again.  But you could also have a heart attack or get cancer or epilepsy or Alzheimer's Disease.

When I'm on a plane, I want a pilot who does a great job of flying a plane.  Perhaps there are some objective measures of what we want to see in a pilot -- things like reaction speed which could be impaired by depression or by medications.  Instead of stopping someone from flying because his depressive symptoms are adequately addressed with an antidepressant, perhaps we should be checking his reaction times on a simulator.  If a pilot does a great job of flying, then I don't care that he's on an antidepressant, and I don't care if he's thinking about his grocery list, or anything else that I have no control over.  But  I do care that he flies well, that he's not impaired, and since history may repeat itself, then I care about his past behaviors: if he's had close calls when flying for any reason, or a history of a suicide attempt, then I'd like another pilot, please.

And I personally don't think anyone should own guns, but since no one cares that I think that (yes, yes, 2nd amendment...), well then what say we prohibit the following people from owning guns, at least for a period of time: anyone with a history of assaultive behavior, and anyone who has had a suicide attempt serious enough to require medical attention.  Both imply that the person has a level of impulsivity where a gun could be a problem.  And, yes, I think that someone who gets in a bar fight and throws some punches shouldn't have a gun, at least for a given period of time -- say long enough to age into some brain maturity or get some treatment for their alcohol problem. 

 I don't care what the diagnosis is: no diagnosis precludes any type of employment, and no lack of diagnosis is any guarantee of safety.  What matters is behavior, and that's what people should be judged on.  Oh, you're going to say I think this means it's okay if the pilot tells his co-pilot he's thinking of crashing the plane: and I'm going to say No!  The act of telling another that you have violent criminal intentions is a behavior, that pilot should not be permitted to fly.  Silent thoughts which one never intends to act on are one thing (we all have weird thoughts from time to time), expressing such thoughts can be a cry for help, or it can indicate poor judgement, or it can be an expression of a symptom of serious mental illness, but once expressed, it's a different animal than a quiet fantasy.  

We need to change the questions.  'Do you have a diagnosis of X,Y, or Z' is not relevant.  Have you ever been convicted of a crime beside a minor traffic violation?  Have you ever filed for bankruptcy (I don't want you running my accounting department, thank you, anyway)?  Have you ever been treated in a psychiatric facility for violent behavior or a suicide attempt?  Have you ever been committed to a psychiatric facility involuntarily for dangerous to self or others  ("committed" implies that you were not just observed for 72 hours, but that a hearing was held where you were determined to be dangerous by a judge).   And for many of these things, there should be a period after which it's no longer an issue.  A single suicide attempt at age 15 following a break up with a boyfriend, followed by years of mental stability as an adult should not haunt one forever.  Maybe 7 to 10 years without troublesome behavior is enough.    But a diagnosis of Bipolar disorder?  Now what does that mean?

Okay, rant.  And please tell Clink that "twerk your giblets" is not something that normal people say.

When Patients Don't Pay

Before we start, some housekeeping issues:

First, I want to say that I was misled.  I was told that gazpacho freezes well, and following such advice, I can say with impunity that fresh gazpacho is far better than defrosted gazpacho.

Second, I want to say that when I deactived my personal Facebook account, I lost access to the ShrinkRapBook Facebook account where I post new Shrink Rap articles and other links to Shrinky Things of Interest.  Instead, please follow us on Twitter: ShrinkRapDinah, ShrinkRapRoy, and ClinkShrink.  I'm slowly transferring my social media addiction.  

Third, ClinkShrink and I will be doing the kickoff lecture for the Hopkins Odyssey Mini-Med School Series on the evening of September 12th.  There is a reception, followed by our talk where apparently we will be teaching everything you want to know about psychiatry in one hour, with time for questions.  While I speak, Clink will be fashioning the shingles in the back of the room, so you'll be ready to hang them soon after.  While Clink talks, I'll be distributing the new Psychiatrist shingles.  It should be a fun evening, so if you're in town, do register.  

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Now for the post.   Before I start rambling, let me say that it's rare that patients don't pay.  It happens in every business, and some people are more aggressive about being sure they are paid, but I am not.  I ask for payment at the time of service before the first session, and maybe half of people pay at each visit.  If someone doesn't pay, at the end of the month, I send a statement.  The large majority of people then send a check.  Some don't, and the following month, I send another statement.  Some people let them build up and send payment irregularly, but most people stay up to date, and nearly everyone pays at some point.  Since I'm not living on a pay-check to pay-check basis, it doesn't bother me if someone waits a bit -- perhaps they're waiting for the insurance to reimburse them to have the cash available, or perhaps they are lazy about bills, but I'm not a stickler for this, I hate nagging people about payment because I don't want them to feel like all I care about is the money (and that is what people think) and that I don't care about them.  Talking about money is the hardest part of psychiatric practice, especially if I'm the one to bring it up and not the patient.  Much harder than  talking about sex or suicide, or the routine stuff of psychiatric sessions.

So I'm not a stickler for being paid at a precise time, and I would never send a patient away who forgot their checkbook (in some practices: No payment, No treatment) and for the most part, it's not a problem, most people pay, if not now, then later.

But this is a post because sometimes people don't pay.  Sometimes  keep coming and building up a balance, and acknowledge this and say they intend to pay.  Sometimes they disappear with an unpaid balance, never to be seen again, or later they want to return and send in the check for the unpaid balance before calling for another appointment.  But every few years there is someone who just doesn't pay, doesn't address it, and continues to request services, emergency care, repeat requests for medications to be called in, or duplicate statements to be sent for insurance reimbursement (which does not turn in to payment for the doctor).  Rare-- I could probably count on my fingers how many times this has happened in 20 years, but still, I find it troubling on several levels:
-- I feel I can't turn someone away if they are in distress.  Actually, I'm not much for turning anyone away once they are an established patient.  As one psychiatrist told me, "Once a patient, always a patient."  Forget 'in distress.'  If someone requests an appointment, I'm not good at saying, Hey you owe me big bucks, what's the deal?
-- If the patient is submitting to insurance and then not paying me, this is insurance fraud. They are turning a profit on coming to treatment.  Even if the money is going to pay their mortgage, it still feels wrong.
-- At some level, the issue starts to impact care: there is a large unpaid, unaddressed bill, and then a call with a crisis on a weekend.  To me, it never feels right to say "I'm sorry you're suicidal, but you know you last paid me 6 months ago."  I deal with the crisis, but I'm not happy about it.
-- I'm not in insurance networks, so people have the option of getting less expensive care by going in-network; I'm no one's only option for treatment.

So what is reasonable?  I don't want to say to people, if you haven't paid by the 15th of the month, then I won't see you until you pay up.  Some people pay irregularly, but I've seen them for years and I know they will pay and there is no issue.  Others, I just don't know.  And sometimes I will agree to a reduced fee for someone in a rough place who has been in treatment with me for a time, but ironically, these are the people who are most likely not to pay. I suppose they figure that if I can afford to discount the fee, I must be rolling in the bucks.  Which then might beg the question, should a wealthy physician who doesn't need the money to survive because he inherited a trust fund from grandpa be charging people with financial problems for necessary medical or surgical care?  Well of course, his time/training/expertise have value, but patients sometime resent paying rich doctors.  (P.S. I didn't inherit a trust fund, but I wish I did, and I'm still open to being a beneficiary). 

What's your experience been?  Psychiatrists: what rules do you have for collecting payment: Pay at the door? Pay when you get your bill? And when do you start saying you won't schedule another appointment -- when a bill is unpaid for one session? One month? 90 days?  Six months?  What overdue balance can you live with and not feel taken advantage of?  $100?  $500? $1,000? $1,500?  If someone is in a regular on-going psychotherapy, it's not hard to get to those numbers.  Patients/Clients/"Consumers": How does your shrink deal with this?