Thinking About Bellevue

Little did I know as I was writing that last post on Sunday that just a few days later some of the same docs I was listening to and learning from would end up evacuating their hospital. When I read about the desperate conditions at Bellevue Hospital in New York as the storm struck and the remarkable efforts to evacuate every one of those hundreds of patients---without any loss of life, to my knowledge---I was impressed and humbled.

Every hospital and institution theoretically is supposed to have emergency policies and procedures, and is supposed to run occasional disaster drills to make sure everyone is aware of them, but who ever really believes they'll be needed or used? Those kind of large scale, potential mass casualty events seem to horrible to think about or really imagine could happen. Until they do.

There's not much I can do from a distance, but from my brief contacts with the Bellevue docs I know that those seriously mentally ill patients and prisoners received the best care possible under the worst possible conditions.

Let's hope that when the storm clouds clear and the rubble is swept away, the hospital that re-emerges is a newer, better and brighter one. The patients and staff deserve it.
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Addendum from Dinah: there is an article on the Bellevue evacuation here. 

The Violent Patient

On the New York Time's Well blog recently, nurse Theresa Brown wrote a piece entitled "Feeling Strain When Violent Patients Need Care," in which she talked about caring for a very threatening, potentially dangerous patient suffering from cancer. This patient, a large 300 pound man, had a reputation for causing havoc in the hospital. He had been banned from one ward for tearing a light fixture off the wall and fighting with hospital security. He had "slugged" a family member at the nursing station and threatened to kill a nurse. In spite of all this, he apparently was not in custody at the time that Ms. Brown was caring for him, which meant that he was not a prisoner in shackles and there was no dedicated law enforcement professional watching over the situation. Understandably, Ms. Brown was afraid.

What some people might not appreciate or been aware of, was that she was also embarrassed about being afraid. Working in the health care field, and in nursing in particular, meant that one could be exposed to volatile situations at any time. Being a professional meant being able to stay calm and poised enough to manage these situations, and this is where the author of this piece felt lacking. She felt she should have been tougher, more unflappable, or somehow invincible to this very concerning patient's intimidating demeanor. Ultimately she was replaced on the case by a male nurse. We never find out what happened to the patient, whether he actually did commit acts of violence during that admission, or whether he calmed down with the male nurse and cooperated with the care he needed. We also don't come to any resolution about what a health care professional should do in a situation like this. This is not a question the narrative was meant to answer, apparently.

As always in story like this, the most interesting part to me were the comments that followed. Over the next two days nearly one hundred people wrote in, mostly nurses and doctors and other health care professionals, to talk about the multiple incidents in which they were bitten, scratched, spat upon, cursed, hit and kicked in the emergency room, on the psychiatric unit, and in the intensive care unit. Half way through the comments I found myself wondering what the incidence of post-traumatic stress disorder must be among health care professionals after a few years of routine work. (I don't know the answer to that question.)

I was also impressed by the range of thoughtfulness that some commenters brought to the situation. Some quickly speculated that the patient might have been a veteran or someone equally traumatized, who would naturally have responded with aggression when startled awake in the middle of the night by a stranger. Others speculated that he might have been having an unexpected reaction to a medication, or been in the midst of a delirium. Some suggested that a CT scan should have been done to make sure his impulsivity and temper weren't due to a malignant brain metastasis. Clearly, these health care professional readers were setting aside their own personal experiences to consider the cause of the patient's emotional reaction and behavior. This was heartening to me.

Other comments were less sympathetic, implying that hospitals should be more liberal in their use of physical and chemical restraints and that assaultive and threatening patients should be prosecuted consistently.

I felt rather fortunate after reading this piece. I've worked with patients known for this kind of violence, but I've been comfortable doing so knowing that safety and security were a necessary and essential condition to providing treatment. I've always felt safer in most correctional facilities I've worked in than in some more traditional clinical settings. Even so, I rarely have had to deal with patients who were so angry or potentially dangerous that I wasn't sure I could treat them even in the correctional setting. That's not good because in most cases there is no one else to turn the patient's care over to when you're the only shrink in the building. This is how I've managed to handle it:

If the patient starts the appointment calmly but escalates during the interview, the first thing I do is slow down. I want time to listen, to think, to make sure the patient knows that I'm hearing him and am concerned about what he's saying. This also helps me listen better. I set my pen down and stop taking notes. I look at the patient. I make sure he knows he has my full attention. If he allows me, I will ask questions to get more information or to clarify something he has said. I repeat what he's told me, and ask him if I am understanding him. If and when he says 'yes', things chill out immediately and we negotiate a treatment plan.

If this doesn't help, or if I start to feel I can't listen safely, I tell the patient I feel uncomfortable or worried. It's not waving a red flag in front of a bull to admit that you're scared. You'd be surprised how many temperamental men (I only treat male prisoners) have no awareness whatsoever that they are talking way too loud or gesturing too broadly or behaving in a way that attracts attention. The nearest correctional officer usually notices first. If I see an officer glancing in to check on me that gives me a nice opportunity to point out to the patient that his behavior is arousing the concern of custody. That always works.

I'm surprised how often an angry inmate will suddenly pull himself together and calm down once you tell him you're scared. Some of them are quick to apologize, or emphasize that---in spite of what they might have done in the past---they have never laid hands on a woman.

Lastly, I know when to recognize when I need to take a break. If I find myself wanting to cut the patient off or getting annoyed---too annoyed to listen---I know it's time to call it a day and try again another time. These are the times when mistakes get made. I can ask the patient if we can take a break and come back to the discussion later in the clinic session, or on another day. I explain that things have gotten heated and I really want to make sure I'm taking the time to think about his care.

If none of this works, I still keep trying. I will make sure I have any necessary security in place, and explain to the patient why it's needed. If someone is available, I may ask another health care professional to sit in the room with me. And make sure an officer is outside the door. In extreme cases, it might be necessary to put the person in handcuffs and a waist chain for the appointment.

Hospitals aren't used to doing any of this, or can't. But when 15% of all US nonfatal on the job injuries take place in health care settings, through patient assaults on staff, it's time to take de-escalation training seriously.

Please Don't Tell

Earlier, we were talking about an ethical dilemma in The Very Badly Behaved Health Care Practitioner-- What should a therapist do if he's treating another therapist who confesses he's been having an affair with a patient?  Should the treating therapist report his patient to their respective licensing board?  Of course, the comments are the most interesting part of that post. 


It got me thinking about two things:  Doctor-Patient Confidentiality and What is a Patient? 

From the Encyclopedia of Everyday Law:
The Oath of Hippocrates, traditionally sworn to by newly licensed physicians, includes the promise that "Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." The laws of Hippocrates further provide, "Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated into the mysteries of the science."

Doctor-patient confidentiality stems from the special relationship created when a prospective patient seeks the advice, care, and/or treatment of a physician. It is based upon the general principle that individuals seeking medical help or advice should not be hindered or inhibited by fear that their medical concerns or conditions will be disclosed to others. Patients entrust personal knowledge of themselves to their physicians, which creates an uneven relationship in that the vulnerability is one-sided. There is generally an expectation that physicians will hold that special knowledge in confidence and use it exclusively for the benefit of the patient.
  
Most psychiatrists I know (at least in Maryland) do not violate their patients' confidentiality unless 1) there is an issue of child abuse and this is because state law mandates it be reported, and 2) there is an imminent risk of danger to self or others.  There may be reasons other physicians break confidentiality, for example the mandated reporting of contagious diseases or driving issues with epilepsy, but these do not generally happen in psychiatry.  The thinking behind doctor-patient privilege is that no one would trust a physician if they worried their problems would be repeated.  When I am not sure what to do, I will ask a trusted colleague, but there are clearly times when what is in a patient's best interest is not what's in society's best interest (such as prescribing an expensive medication or ordering an expensive test or revealing information learned in treatment) and I generally feel that my job is to keep my patient's best interest in front of me.  It's hard to be everyone's agent.


For the most part, I don't endorse laws that mandate the reporting of past child abuse against the wishes of the patient (--not that anyone has ever asked me, but hey, it's my blog so you get my opinion) --at least not by psychiatrists as an after-the-fact event. In an Emergency Room with an injured child victim it's a different story and it's hard to imagine that it would ever be in the best interest of the patient to send them home to a violent setting.  For psychiatry, I believe that such laws prevent people with problematic behaviors from getting help, and they prevent victims of abuse from having therapy if they do not want  the scrutiny of the legal system or the turmoil that may bring if family members were involved. If a patient reports an active urge or plan to commit a violent crime,  taking action is generally in that patient's best interest as well as society's and violating confidentiality may be the clear right choice.   


In the vignette given in the Badly Behaved Behavior Health Care Practitioner, the situation asked whether a therapist should report a patient who is also a therapist who is having a sexual relationship with an adult patient.  There is no "law" about reporting such behaviors (at least not in our state), though some Licensing Boards  make statements that professionals are required to report colleagues who are impaired or incompetent.  Some of our commenters wrote in to say that the therapist should be reported-- that patient safety should come first.  My thought was that when a patient walks in the door for treatment, she is a patient and not a colleague and such licensing mandates do not pertain the way they would if the therapist in the next office knew illicit sexual activity was going on.  It seems to me that the spirit of such mandates is to get the licensee help, something she is already doing by seeking care, and that these mandates were probably not made in the spirit of trumping confidentiality with patients, but I could be wrong.  Reporting the therapist might help prevent future harm to patients, but in the big picture, it means that badly behaving psychotherapists can never get help in a confidential setting. 

  I suppose one way to get help for a misbehaving therapist to get help would be to seek care from a therapist in another specialty-- there is nothing in the Licensing Board mandates that suggests a licensee needs to report an incompetent member of another specialty or profession, so a social worker who is having an affair with a patient could perhaps seek treatment from a psychologist or a psychiatrist?    And the other thing I wondered about-- does reporting the therapist necessarily help the current victimized patient?  An adult patient, after all, is free to report her abusive therapist.  If she chooses not to, perhaps there is a reason-- perhaps it would blow apart her marriage, or perhaps the inquiry that comes with such events would leave the victim feeling even more victimized.  These aren't easy scenarios-- one can imagine all types of configurations-- the victim could deny the abuse/affair happened,  the victim could be thrilled to hear that a confession occurred which will help with the prosecution, or the victim could feel not at all like a victim, but like someone who chose to have a consensual relationship and does not want the attention of the therapist's disciplinary proceedings.  

These are really difficult situations.  I'm not sure what the rules are for psychologists or social workers, but for physicians the default requirement is for confidentiality and there needs to be a really good reason to violate it, and revealing a patient's secrets may leave the psychiatrist open to his own scrutiny, disciplinary action, and lawsuits.  We treat people even when they have behaviors or beliefs that are deplorable to us.  I hesitated, however, to write this, because I can think of scenarios where confidentiality in the doctor-patient relationship might warrant a breech, and I'm happy I've never been faced with one of these situations. 

Like Looking in a Mirror

Sometimes, I treat people who have the same problems I have in my personal life. It's hard. Oh, it's really hard. If I'm really distraught about something and a patient calls seeking treatment with a similar life circumstance, I will sometimes turn them away and recommend another shrink. But I don't always screen so carefully on the phone, and often "I'd like to make an appointment," will simply get a time and date.

The feelings get really complicated here.

If I feel I've had a role in creating my circumstances, then I wonder as my patients seek my counsel, Who am I to be making any suggestions, much less giving advice? Why are you looking to me, I've screwed up the same situations. Oh, you say, Dr. Jeff said on KevinMD that Psychiatrist's Shouldn't Give Advice, but you know, some of us do, and even when we don't, our feelings are often relayed through the questions we ask or the comments we make or don't make, or perhaps by the expressions on our faces, even if we don't say "You should do X." I told a friend once that I feel uneasy, guilty even, in these situations, and he replied, "How do you think I feel?" Did I mention he does family work and was in the midst of a stressful divorce? And I have yet to ask a colleague who also does family work how he managed during the years his own children wouldn't speak to him. Oy, life can be tough, for shrinks just like everyone else.

So perhaps I listen to someone talking about his most personal feelings about a situation, and you know, if I've been there before, perhaps it's good that I can empathize. If I'm in the middle of it, sometimes I listen and the patient's words seem so unreasonable, so unjustified, and yet I recognize them as being exactly my own--it's like having my own anxieties bounced off a wall only to ricochet straight back into my face.

Do I tell the patient that I've been in the same place before? Generally, no. Therapy is about his problems, not mine, and I think in these situations my empathy is clear. I say things that are more poignant and resonant than I might in circumstances where I feel removed. And patients never ask if I've been in the exact same place. On some of the harder things-- things that have no precise quick and easy answer-- I've taken to saying, "Not only don't I know what will fix this, I don't know anyone else who does have the answer." This I can say because I've done my own searching.

I hope I'm reassuring and comforting to people who find themselves in the same places I dwell. Certainly, tripping over a few stones on the path makes one walk a little more gingerly and judge a little less harshly those who walk more slowly. Mostly, though, I worry that I'm a little bit of a fraud just for being in the room.

My Assorted Thoughts on Tara Parker-Pope's Wellness Blog Today

I feel this funny kinship with The New York Times Wellness blogger, Tara Parker-Pope. I don't know her, probably never will, and I'm jealous that her blog is so much more widely read than mine. Why hasn't The New York Times hired me?? Maybe it's because she's a blogger, I think she's a mom, and "Tara" is the name of my college roommate who has journeyed around the country collecting advanced degrees and remains a beach-ball of energy (there's something 'round' about my Tara, I don't know why, she's petite, slim and runs miles a day, but she's energetic and hard to grab on to, nonetheless). More simply, though, Tara Parker-Pope often writes about things we like to address on Shrink Rap, and for the second time recently, we've "known" in some sideline way, the same people. Not long ago she wrote about headaches and referenced my neighbor, the Johns Hopkins migraine king-- a man with beautiful gardens, a lovely wife, who run circles around our neighborhood for exercise, but my conversation with him has been limited to mutual nods.

So the Wellness Blog of 2/8 came to my attention this morning because it's on When Doctors Become Patients. That was ClinkShrink's post!! There Tara Parker-Pope goes, stealing from Shrink Rap again. We got to do something about this!

So I click over and there's a photo of Bob. Who's Bob? you say. Well Robert Klitzman certainly wouldn't remember me, but he pops up in the media now and then so I remember him. When I was a third year medical student doing my much-anticipated psychiatry rotation (for Bob's sake, I won't say where), Bob was one of the four PGY-2 residents on the fourth floor unit I was assigned to. Only I wasn't assigned to work with him, I worked with Beth. Beth was great, the thing I remember most about Beth was she told me she didn't like to go to the movies on a first date; she wanted a chance to meet a guy, get to know him a little, so she could dump him right away (she eventually married a musician, don't know what happened to the marriage, but my feeling towards Beth remain fond).

Bob wrote a book about his residency training experience: In a House of Glass and Dreams. I stumbled upon it in a bookstore. I knew the author so I bought it, and while he never named the program, I knew all the details. I remembered the lock that stuck outside the hallway to my supervisors office. He talks about his first day going to therapy, and I remembered being in a conference and a bunch of the residents saying "Where's Bob?" and someone replied "Bob went to therapy!" "Bob went to therapy???" I didn't really know Bob but I assumed that wasn't expected. This was in an institution where the chief resident posted on a black board what times he'd be psychoanalysis, don't beep me then. At some point, many years ago, I chatted with Bob briefly when I accidentally ended up at the wrong reception at APA, and I told him how much I liked his book. I think he was flattered. The book, which I read well after completing my own residency at an institution where one certainly didn't announce that they were going to psychoanalysis, resonated with me and and left me feeling understood-- it was during a time in my life where I was having a hard time feeling like anyone understood. I'd had enough wine to be at the wrong reception, so who really knows what we talked about, maybe 15 years ago.

At some point, and I'm not sure why, I learned that Bob's sister had died in the September 11th attacks. My heart went out to a man I hadn't ever really known, and the Wellness blog is about Bob's experience of being a psychiatrist with depression in the aftermath of his sister's death, and how his own journey has made him a better, more considerate doc. I don't doubt it.

I guess the other thing I wanted to comment on, since this NYTimes post hit on so much for me, is that Bob initially experienced his depression as physical symptoms and didn't recognize them as a mental illness. This is not uncommon. I've had patients lose tremendous amounts of weight (50 pounds anyone?), have severe pain (usually GI) and have extensive cancer workups. One tells me frequently "No one ever told me this could be depression." Another is only now getting to be a little better after his zillion-dollar work up. When I heard of the case, as he was being referred, I said to the internist, "Hmmm, sounds like cancer." He agreed, said they were continuing to look for the elusive tumor. One look at the patient and I rethought, "Looks like depression." Patients, unfortunately hear this as "Your Pain Is All in Your Head." I' rephrase this as "Sometimes depression is expressed as pain. It doesn't mean the pain isn't real." I want it to not be insulting, but the reality is that the prognosis for pain as a symptom of depression is a whole lot better than the prognosis of pain as a symptom of lots of other things that people are wishing will be found.

How This Psychiatrist Thinks About Psychological Tests

First a big thank you to Gerbil for giving me the idea for this post. In a comment on my post "What Good Are Psychologists?" she mentioned psychiatrists who refer patients for diagnostic psychological testing. It got me thinking---this is a good thing---about why I do (or don't do) what I do.

I have to say I hardly ever request psychological tests. Even before I started working in prison, it just wasn't something I routinely did with my patients. When I was in residency we had lectures from psychologists about the different types of tests and what they're indicated for and a few things about interpretation, and later psychologists I've worked with have told me that I have a better understanding of testing than the average psychiatrist, but I'm not sure what that means.

For the lay readers among us, there are some general categories of psychological tests. There are personality tests that measures different character traits. There are intelligence tests that measure IQ. There are projective tests that are used to get an understanding of the person's interpersonal dynamics and style of thinking. There are neuropsychological tests that measure a person's cognitive capacity---ability to learn and remember, use language, coordinate eye-hand movements and so forth.

In general, when thinking about tests you have to consider what it is you're trying to figure out. If you have a patient who is failing in school you might want to order IQ or other achievement tests to see if the personal has a developmental disability or learning disability. If the patient has had a head injury or you think he or she might be getting demented you'd order neuropsychological testing. If you have a patient in therapy and you want material that might be useful to help the patient understand his own inner workings, you'd request projective testing and/or personality testing. Some tests are used as tools to predict certain things: whether or not someone would perform well on a certain job or whether or not they will re-offend as criminals.

It's important for tests to be used as part of an overall patient assessment. Test results fit into a whole database of information that a psychiatrist considers when making a diagnosis or putting together a treatment plan, in addition to a good patient history and a review of available treatment records.

It's also important to know whether or not the given test has been validated for your particular patient because 'normal' test results can be different for different groups of people. A test is only as good as the patients it's been based upon. For example, normal results for the original Minnesota Multiphasic Personality Inventory (MMPI, a test used to diagnose psychiatric disorders) was originally based upon only 500 people living in Minnesota. Much as I would like to think that Minnesota should be the gold standard for normalcy, this just isn't realistic. I mean really---Baltimoreans would end up looking pretty depressed compared to them. This is where a big limitation comes into play for me working in prison---many psychological tests have not been validated for use in prisoners.

Similarly, predictive tests only give group predictions and aren't necessarily reliable for the individual. A certain score on the Hare Psychopathy Checklist might give you a result that the patient has a 15% chance of re-offending, but that just means that out of 100 people with an identical score 85 will not re-offend and 15 will. The score doesn't tell you which of the two groups your patient will actually be in. The other trick with using tests to predict things is that many tests used for prediction have never been proven to have predictive value---there is no test to predict 'good parenthood', for example, yet psychological tests are used constantly in custody evaluations. It's important to know the limits of the test.

So...which tests do I actually use?

In prison the most common test I use is the Mini-Mental State Examination (MMSE). It was invented by two psychiatrists as a quick bedside test of cognitive functioning. You can give it in about ten minutes and it's a great way of measuring how brain impairment changes over time. You use it to check to see if someone's delirium is resolving, or as a screening tool for problems that should be investigated further.

In free society the most common tests I used, besides the MMSE, were general symptom inventories. For example, the Beck Depression Inventory (BDI) is a nice tool for measuring the severity of depressive symptoms. It's used to screen people for depression and also to monitor reponse to treatment.

I never use projective testing, mainly because I've never found it particularly useful for anything---maybe I would if I had a psychotherapy practice but even then I don't know too many psychiatrists who use them. I'd probably use neuropsychological tests if I could, but these are very specialized tests that have to be administered by a neuropsychologist (a subspecialty of psychology) and I don't know of any prisons who have one of those.

So that's my take on psychological tests. Thanks, Gerbil.

Let Me Tell You About Myself

After our last podcast, Shrinks on the Take (now what does that even mean?), we received the following comment/questions.

Can one of you comment on this?OCD can make you feel like a weirdo and so I hid it through most of my treatment b/c it wasn’t to bad, even though I didn’t expect my therapist to judge me for it. When I finally brought it up I was somewhat shocked when my therapist said she too had it, but insisted it was well under control, except in situations she doesn’t encounter much where she’ll sometimes carry out a mental compulsion. She mentioned I should add paxil to my wellbutrin, and I said I thought I heard about a lot of paxil withdrawal problems, and she said “yeah I went thru that”. She rarely talks about herself. Though I was shocked I felt really relieved and un-selfconscious afterward. I guess even though I know you are trained to not judge, I think ocd is a hard thing to understand unless you have it and have actually felt that repetitive irrational doubt and those maddening urges- but since I knew she knew the feeling- I think it helped a ton. Still what do you think of mental health professionals who admit to their patients a shared mental illness, or what medications they were on? Does it also depend on the illness? (-note from Dinah: I shortened the question a bit)

What a great question. I've been thinking about this one for days.
The issue of self-disclosure in psychotherapy has a number of meanings. The uni-directional flow of information is one of the boundaries that differentiates psychotherapy from friendship. Boundaries, as we've noted before, are important for keeping the therapy safe, and more specifically, it's important that the therapy be about the patient and not the other way around. Self-disclosure in psychotherapy gets a particularly hard rap because of psychotherapy's underpinnings in Freudian psychoanalytic theory where the therapist is required to be a "blank slate." In this school of thought, the treatment requires that the patient know little about the therapist, and so to self-disclose isn't just imprudent, it's actually considered to be harmful to the treatment.

And if this isn't a good enough reason for a therapist not to tell a patient about his own psychiatric disorders, perhaps the therapist's desire for privacy is.

Okay, that said, the reality is that no one is a totally blank slate and no one gets complete privacy. Sometimes the only reasonable thing is to tell patients about a medical condition the therapist is coping with. It's hard to hide a pregnancy, and perhaps patients are entitled to know if their therapists are anticipating a prolonged medical leave for any reason. Full details, full disclosure? I suppose that depends on how personal the problem is (Let me tell you about my prostate?) and the therapist's own desire for privacy.

What about in the case where the therapist has a psychiatric disorder, as in the case our reader describes? Our reader makes the point that the therapist does not usually self-disclose, that the therapy is usually about the patient and we might assume that the therapist considered carefully whether to disclose to the patient her own experiences with OCD.

There is nothing inherently wrong, immoral, or illegal about a therapist telling a patient that she suffers from a psychiatric disorder.

If the therapist doesn't mind the loss of privacy and doesn't then use the sessions to talk about her own problems, it's not wrong, but it can be powerful and so there are risks. As in any conversation, whether something said is helpful or harmful is subject to Monday morning quarterbacking and interpretation, and we don't always control how information is taken or used. A patient can have many responses, including the thought that it's troubling to know the therapist has a mental illness or feels burdened by a therapist's problems.

If the patient is distressed by a therapist's self-disclosure, then it was the wrong thing to do.

If the patient is comforted by their shared condition (especially where the therapist can offer hope and a good outcome), and the patient says, as our writer did, "I think it helped a ton," then it was the right thing to do.

And life would be so much easier if we always knew before we opened our mouths what the exact right thing to say is. I'll call when I get there.

(And don't forget to tell us who you are on the sidebar vote!)

Time With A Patient

My good friend and once med school roommate had a letter published in today's New York Times. Quoted in full:

Re “A Stubborn Case of Spending on Cancer Care” (Business Day, June
12):

Despite recognition of the problem, the fact remains that our current
system of health care reimbursement values procedures and volume over time spent with patients.

The time spent talking with patients and families is an
investment that pays for itself many times over. Carefully eliciting a history,
reviewing records and communicating with other health providers, assessing
patients’ values and weighing them into decisions regarding complex treatment
options cannot be done in 10 minutes, but it can provide better and more humane
outcomes.


Technologically advanced and costly treatments save lives, but
their allocation needs to be made sensibly and not to the detriment of
old-fashioned talking and listening between doctor and patient.


Patients want and deserve this time-intensive care, and although it
can often be ultimately cost-saving, it will not be the norm until the financial
incentives reverse themselves.


Susan C. Kalish, M.D. Boston, June 12, 2007

I have a nice friend, she is a warm and caring doctor with an enormous heart and wonderful values, even if she isn't a psychiatrist (she's a geriatrician). Sometimes I'm not sure exactly what medicine is about--we allocate our resources in idiosyncratic ways, some of which don't make sense in terms of cost-benefit but do in terms of emotion. We've come to see physicians as precious resources, whose time needs to be meted out in cost effective 10-minute doses while the humanity of medicine is doled out to less expensive professionals-- nurses, physician assistants, social worker therapists. Susan says, and I'll agree, it's a mistake.

Compliments of...

Speaking of livers....



So Camel and CamelMan went out to dinner the other night. They're sitting alone eating their dinner in peace because CamelChild is off at a national oratory competition where she's leaving the rest of those orating children behind in the dust. The waiter brings them drinks and declares they've been sent over as compliments of another couple in the restaurant. Camel looks around and sees one of her patients. How nice? How awkward. Camel called me from the restaurant....What should she do? It's not really a question, it's more of an I-need-to-tell-this-to-someone moment. CamelMan wants to buy the other couple drinks back (CamelMan is not a physician or mental health professional). Camel knows the sender of the drink, sitting there with his own, is an alcoholic, but even if he weren't, she still would feel uncomfortable reciprocating.



What to do? Thank the patient and move on? Sometimes this is the only thing to do. Tell the patient she can't accept this, and risk that the patient will feel rejected, or start a whole back-and-forth "I insist" scene? Quietly tell the waiter to transfer the charge to their bill, hope it happens as quietly as intended and the patient doesn't leave feeling insulted? Perhaps there is no perfect answer. Generally, though, shrinks hate it when this happens.



-- Happy Memorial Day weekend. ClinkShrink is playing scrabble with her family. This I know because she sent me a cellphone pic followed by an email asking for words with 3 u's. Roy is doing yardwork and thinking about ducks. And I will be cooking dinner tonight for Camel and CamelMan.

--It's not too late to observe National Duckling Month!

--Double Billing will continue on Tuesday.



--And Hi to Elise: I've just learned that my mother-in-law reads Shrink Rap.