The Patient Who Didn't Like the Doc. On-Line.

KevinMD has a post up today by Tobin Arthur called

Online reputation can have career implications for physicians

Arthur also refers to a post on the AMA's website back in October by Amy Lynn Sorrel,

Negative online reviews leave doctors with little recourse

Good timing because I wanted to post a vignette about a friend who is distraught about the on-line reviews he's gotten from patients. To protect both the innocent and the guilty, I'm confabulating the details & demographics, but the gist of the story is real and I'd like to hear your comments.

Dr. Tom Shrinky (not his real name) is a friend of mine who practices in Sanetown, PA (not a real place). He's an excellent psychiatrist with a great reputation, a packed practice with a long wait for new patient entry, and he's as conscientious as they come: he carries his cell phone everywhere and he returns all calls within the day. Plus, he's a nice guy, though I may be biased because we're friends.

One day, a patient says to Dr. Shrinky, "Doc, you know, I Googled you, and it wasn't pretty." Alarmed, Tom goes to Google himself and discovers that he's got a patient review up on one of these rate-your-doc sites. The comments are strangely personal, they comment on his recent weight loss, and say that he's in bed with the drug companies. There are a couple of other reviews, all 5 star, all saying how he's the best shrink in the world, but his overall rating is 3 star, and you'd wonder if he wasn't dying from the comment.

Okay, you hate a restaurant, you zing it on Yelp and you don't go back.

But Tom believes he knows who put these comments up. He has a patient, a lawyer he sees for weekly psychotherapy sessions. The patient is often hostile towards him, often treats him in a demeaning fashion, and this relationship does not feel good. The patient left treatment once briefly, years ago, but returned because, "You shrinks are all nuts and you're better than Dr. Cashew." Why Tom took him back, I'll never know. Tom tries to get the patient to focus on his hostility as part of the treatment.

So, a drug rep did stop by the office once to drop off samples while the patient was in the waiting room, and the patient had made a comment about this. And Tom had lost a lot of weight recently-- he'd taken up running and before he knew it, he was doing half-marathons. He cut back on carbs, beer and soda, and 60 pounds had dropped off him over 14 months. He looked great, and everyone commented including his patients. This particular patient, however, had said nothing, and one day walked in, looked Tom up and down, and said, "Have you got cancer or AIDS?" So the comment on the review about how he'd lost a lot of weight recently and looked like he had cancer. Tom could think of no one else who was unhappy with him or who would do this.

Unlike the restaurant patron, Tom's patient continues to show up weekly for psychotherapy. Tom feels a bit intimidated by him (this is not new) and is always happy when he cancels. So far, Tom hasn't asked if he wrote the review, but it bothers him. Others have put up counter-reviews, but there is a second bad review, and Tom thinks this is also the same patient. A colleague mentioned that a patient he tried to refer would not see him because of the reviews.

So, my thoughts, and then please do add yours:

--It seems to me that sometimes people have negative feelings in the course of a psychotherapy (ah, we might call this transference, but it would be dismissive to attribute all negative feedback to negative transference). In this case, it's no longer a doctor-patient issue, but one that has potentially included the entire world via the Internet.

--Should Tom ask his patient if he's put up the reviews? What does that get him? The patient may become embarrassed or defensive, or he may say he didn't do it (and maybe he didn't?) and be angry at the accusation.

--How does a psychiatrist (or any doctor) continue to treat someone who publicly struck at their reputation?

--And here's another problem for the doc--- a patient who would do this might also go to the physician licensing board and complain, and so Tom may worry that to terminate this patient's care may incite the patient's anger and result in a complaint and investigation of his practice. The patient is a credible professional and a complaint from him would likely be taken quite seriously. While Tom is certain he's provided responsible care and has not violated any standards of practice, he's well aware that a Board investigation (if a complaint did progress to that) takes years and causes a great deal of expense and agony, and so he may well be worried about fanning any flames.

--And finally, Tom is worried about upsetting the patient. He's been taking care of this patient for years, and he doesn't want this to end badly.

So what should Dr. Tom Shrinky do?

Emotion versus Mental Illness

My favorite commenter, "Anonymous," wrote in to my Duckiness post to say that it was good I could post something totally silly without being told I need more meds. Oh, if life were that simple. And it is true that once someone has a diagnosis of bipolar disorder, not only does the world question their emotions in a black & white "are you sick again?" kind of way, but patients don't trust themselves to feel for it's own sake.

If you're not sick, then being asked if you took your meds is insulting and degrading. And so I thought I'd put together some guidelines for Emotion versus Mental Illness. I'm inventing this as I go, with no evidence-based anything, so take my suggestions at your own risk.

• If you are ultra-successful, rich, brilliant, gorgeous, famous, and comfortable with your diagnosis, you may want to consider telling people you have a mental illness because it decreases stigma and people like being with the ultra-successful rich, famous, brilliant and gorgeous and won't care that you have a mental disorder. It helps even more if you're charming.

• If you're not ultra-successful, you may want to pick and choose who you tell that you've been ill and are on medications. This isn't always possible, especially if your illness is evident to others or if the presentation of your symptoms resulted in a hospitalization. It's good to tell close family members.

• If multiple people are looking at you strangely, or commenting on your behavior, or saying you need medications, you might want to at least entertain the option that you could be sick. Unfortunately, poor insight and judgment are symptoms of mania.

• Tell the people close to you not to make medication jokes. It confuses the issue if you seriously do need medication changes, and it's rude, degrading, dismissive, and disrespectful. There, I said it.

• If you want to be silly, go for it. Be silly when you're well so that being silly is part of your baseline personality and no one equates this with being out-of-character. You'll note the duck invaders did not come after me, rather they said, "There's Dinah posting yet another stupid duck post." If I'd posted about why chocolate should be outlawed and made into a controlled substance, those same duck invaders would be asking "What's wrong with Dinah?"

• Mental illnesses come as constellations of symptoms. There is no "Sending out silly duck stuff" as a symptom. People think about mania when the ducks are combined with more energy, racing thoughts, a decreased need for sleep, increased mood OR irritability, and other symptoms of mania. Know the list and if someone bothers you, say, "I posted about ducks, I do not have any other associated symptoms." Recite them if necessary. If you do have the other symptoms, refrain from posting about ducks. I don't want Posts Duck Blog Posts to show up anywhere in DSM-V and these days you just never know.

• No one controls how any other person thinks of them or judges them and it's not reasonable to live life ruled by a desire to be perceived in a certain way . It's another form of poultry, but Don't Let the Turkeys Get You Down. There are a lot of turkeys out there.

Moods happen on a spectrum. Some people have large variations in their mood---large enough or severe enough such that it causes suffering, and we call it an illness. Some people don't have much variety to their moods and live in a calm, even-keel place, and it's great that we have such people. But, I absolutely promise you that if we lived in a world where everyone had a very narrow range of mood, this would be one terribly boring planet. We should celebrate our diversity, not condemn those who like ducky stuff.

Because I Said So....

I recently linked to an article on the Well Blog about a child with Asperger's Syndrome in NYC. The boy's parents were at odds with their housing co-op about the boy's need for an emotional support dog in the no-pets-allowed complex.

Roy said that's what docs get to do: determine medical necessity.
Commenters on our blog and the Well blog were mixed, and I really don't have enough facts to feel comfortable commenting on the situation.

It did get me thinking about the concept of Medical Necessity and before I start rambling, let me say that I didn't see the term "medical necessity" on anything associated with the kid and dog case. What I read simply said that doctors thought a dog would help the boy, that the co-op agreed to let him have a small dog with many stipulations attached, and the feds, specifically HUD, took on the cause and felt the co-op discriminated against the family. You can read Here.
Medical Necessity is a funny concept, one I'm not always 100% comfortable with. I think the issue here is that when we as physicians deem something Medically Necessary, it implies some imposition, usually financial, but in the case of the service dog--furry-- on someone else. Usually we use the term to mean that it's something someone's health insurance should pay for that they don't (or may not want to) pay for. If there's not a cost (financial or otherwise), then one can leave it at "My doctor said to do ...." and there's not a reason to deem it "medically necessary." That's a term that goes in writing and means someone, somewhere will find it inconvenient.

I don't usually declare that things are Medically Necessary from a psychiatric viewpoint, except for specific medications-- sometimes Name Brands (as opposed to generics) and then because the patient has tried the generic and found that either they don't work as well or they cause side effects. The other Medically Necessary things I recommend are sessions (ie, treatment is medically necessary) or Hospitalization...ah, the joys of managed care. Sometimes I tell people to stay home from work, especially if I feel their behavior during an episode of illness puts them in jeopardy, and I'll write a note saying they need time off, or that they were at a doctors' appointment, but this usually doesn't require a statement of medical necessity, per se, it falls under sick leave. My stationery doesn't even say I'm a shrink, and unless I'm specifically asked, I don't volunteer that in "doctor's excuse" notes.

In the case of the dog and the kid, the term "medically necessary" wasn't used-- it was simply said that the dog might be helpful to the boy. What about another occupant who might require a animal-free environment? How do we determine whose rights trump whose? Maybe this is a bad example, because one can envision that one condo owner could live with a dog in such a way that the other people in the condo aren't disturbed by it and the presentation by the press left the reader feeling that the complex owners are unsympathetic child and dog hating meanies who were being unnecessarily arbitrary. I got curious and did a little googling-- it seems the dog would be going through a training process with the boy. The other issue was concern by the building about the area around the entrance to doctors' offices in the building.

So this is my concern with extending the definition of what is a disabilty and what we should do as a society to accommodate the needs of the disabled: if the issues get too diffuse, then ultimately the laws to protect the disabled hurt them. Don't want any autistic kids here because then we'll have to allow their dogs. Okay, maybe that's silly, but the issue isn't just what one group needs, it's also the fear of being sued because of the perception of injustice, or the fear of having to accomodate. The issue of medical necessity feeds into this unless we hold to a fairly strict notion of what is medically necessary, and as doctors.

If you want to read more about the kid with the battle for the dog:
Try this or this.

And just to be clear, this is a rambling post. Most often, 'medical necessity' is a term that has to do with Medicare reimbursement...somehow I've gone off about service dogs and co-ops and broader implications to society.

My Therapist is a Creep

Pic removed when I looked at it more closely and realized what it was--I am so sorry to all. I will look more closely at what I'm posting...oy.

Vaguely confabulated, but.....

So an acquaintance (let's call her Marsha) mentioned she'd been in therapy with a psychiatrist (let's call her Cruella) I know through professional channels. I shivered, oh did I shiver. "How'd it go?" I might have asked if this really happened. "Awful." No surprise there. Therapy with Cruella sounded to be just as I'd imagined; she was weird, kind of nasty, and just the thought of talking to her about my deepest darkest or looking to her for comfort made me ...well... shiver.

Many people think psychiatrists are weird. Maybe we are. The truth is that most of the psychiatrists I know are at least kind, well-meaning, interested, and want to help people. Cruella does not fit this mold, she's weirder than any TV shrink I've seen, prone to outbursts, and doesn't relate well to people; I've seen her cut people with words, I've watched her hold the room hostage. My opinion, of course, and my best guess is that Cruella has nothing nice to say about me. So be it.

I forgot to mention that Cruella is very smart, and I'm sure she's a very competent psychopharmocologist. But this is the thing-- I would never refer anyone to her. Why? Because she's weird and not nice.

What's this got to do with anything? The truth is that people all have fantasies about their real life psychiatrist-- one is the supposition that the psychiatrist is a nice person who's life is vaguely in order. Did you want to see a marriage counselor who's on his fourth marriage and has three children who've been placed with foster parents for abuse? I don't think so. And while I know many psychiatrists with their own long stories, many of them I would still refer patients to-- they are good at what they do despite the Whatever in their lives.

I think if I walked into Cruella's office I would run the other way at breakneck speed. Marsha stayed for a while, looking for hope or something good. She didn't find it and eventually left, soured by the experience, but it took a while for her to figure out how not-nice Cruella was.
Can you be a mean person and be a good therapist? I don't know, but I don't think so.

Make Me A Nice Person

Written by CLINKSHRINK (she's having computer issues and asked me to post this for her)

Periodically I like to check the search terms that people use to find Shrink Rap. Today I found one that just had to be blogged about: "What medication will make me a nice person?" My first thought was, "How do you know you're not a nice person?" Are you embezzling funds from the company expense account? Do you kick puppies and kittens? Do you park in handicapped parking spaces? Are there bodies hidden under your floorboards (if so, please let Roy out. We miss him.) There are a lot of ways that someone could be "not nice", but I have to say that the majority of seriously un-nice people I've met either don't care that they're not nice or don't have enough insight to even ask the question. If you're willing to recognize you might be having interpersonal problems you can't be all bad.

That being said, the next question is to figure out why someone might think this is an issue that is medication-responsive. There certainly are psychiatric illnesses that could make someone episodically irritable: recurrent clinical depression, premenstrual syndrome ("late luteal phase disorder" in modern parlance), hypomania or mania, the list goes on. Medication can be helpful for these conditions. Other conditions wouldn't necessarily require medication but could be responsive to lifestyle or environmental changes: caffeinism (how much coffee AM I drinking every day nowadays? Don't ask!), sleep deprivation, alcohol abuse or other substance issues.

Finally, there are issues that aren't really your issues at all. I immigrated to Maryland from the Land of Terminally Nice People. It took me a little while to realize that people who change lanes without signalling, who honk for no apparent reason, aren't necessarily being rude---they're just being Baltimoreans. It's how people live out here. There are people who constantly accept and make allowances for impositions that most people would never tolerate. You know the type---they say yes to everything that anybody ever asks them to do, they stay late at work because no one else volunteers to help out, they're usually the ones who finally end up cleaning out the office refrigerator because they just can't take it anymore. (They work in prison because no one else will.) When someone like that grows a backbone and starts saying 'no' and setting limits, they might get accused of being 'not nice' anymore. Good for them.

I have no idea if the googling Not Nice searcher found what they were looking for on our blog, but I wanted to leave something behind that might be useful in case they come back. Good luck.