Double Agent

 Yesterday, I heard Dr. Glenn Treisman talk at the Department of Psychiatry's  Grand Rounds at Johns Hopkins on "What is a Doctor."  You'd think we'd all know what a doctor is, but Dr. Treisman always has a unique and humorous slant to those obvious slices of life.  His talk was about the forces pulling physicians to look out for the best interests of the patient, while also looking out for the best financial interests of the institution they work for as well as the best financial interests of society.  He threw in some historical references and his talks are always entertaining as well as informative.

At the beginning of any professional presentation, the doctor must "disclose" any conflicts of interest -- in other words, if he receiving any money from pharmaceutical companies.  Dr. Treisman started his talk with a series of Disclosure slides which reflected both his wit and a statement of the problem.  He let me borrow them to reprint here:
 

First slide:

•I am engaged in Doctor-Patient relationships that I was taught ethically constrain me to work in the best interest of my patient

•I work in an institution that was founded by Johns Hopkins to provide care to the poor and indigent of East Baltimore

•I have been instructed to provide “Excellence” in my work

Second slide:

•I am paid by Johns Hopkins which has directed me to:

–Decrease the time patients are in the hospital

–Maximize reimbursement for hospitalization

–Maximize the revenue I generate

I am barraged by “cost-saving” efforts by insurance companies that use bullying insurance reviewers and time wasting paperwork barriers to decrease the delivery of the care I recommend for my patients.

Third slide:

I have been recently informed that I am a “steward of resources” and that I need to conserve medical resources

•I have been recently informed that “Patient satisfaction is the coin of the realm”

I have been informed that my Ryan White funding is contingent on efficient care (shorter visits) and improved measurable outcome targets 

Fourth slide:

•  I have been informed that I am to use “Evidence-based interventions” and follow guidelines and protocols that I find less than optimal for many of my patients

•Some of these conflicts of interest may have affected the views and information presented in this presentation, or perhaps are the subject

  

Ah, Dr. Treisman has a lot of "disclosures," touched with a little sarcasm, but he does a good job of illustrating the conflicting pressures doctors are being put under to act as agents for society and institutions in ways that conflict with being the advocate for the best interest of the patient.  So that you know, he works with AIDS patients in an outpatient clinic, and with inpatients on one of the country's two psychiatric inpatient pain units.  His patients travel from all over the country to be admitted to this unit, often arrive in a state of desperation, and the struggles with insurance companies to permit their care are considerable.

Just a word on the graphic: it's from a show called Get Smart (the 1970's perhaps) about a spy named Maxwell Smart who had his phone in his shoe.  It's where I learned about "double agents."  I figured I needed to explain this one.

  

 

Saying the Right Thing

I just read a very touching article on the New York Times Well blog by an oncologist who talks about a visit with a deceased patient's wife and children.  I finished the article, The Widow's Doctor Visit  and thought, if I ever have that illness, I want this man to be my doctor.  I never think that, but this oncologist's insight into what a grieving family is going through is remarkable, as is his willingness to openly discuss it.  He tells the widow that the patient was lucky to have such a supportive wife.  He tells the son his father wore the same shoes, so he too must be a spiffy dresser, like his dad (oh, actually the writer said 'fancy' but I like spiffy better).  He tells the children that it's okay if they are a little glad that they don't have to watch their father suffer and to have their worlds revolve his medical condition.  He has some sense of what it is that families are looking for,  and that's nice.

But it isn't actually true that I would want this guy to be my doctor.  The truth is, if I had a bad illness, I'd want the doctor with the best outcomes, not the doctor with the best beside manner.  And really, I know the I know this doctor can write a moving article (this is worth a few points in my book) but it doesn't mean that his interpersonal delivery is wonderful -- it may be and I certainly liked him from what I read. But if I had a chronic illness, or one where a bad outcome was virtually guaranteed, then I'd want the best bedside manner and the doctor who could pad the ride with some kindness and sensitivity.

They don't teach you in medical school to tell the wife who has just cared for a terribly ill husband that he was lucky to have her.  They should. 

What do you think?  Oh, and do surf over to the Well blog and read the article. 

Then, if you want, surf over to KevinMD and read this article and let me know if I was mistaken to find it offensive.  I just couldn't get a feel for the author's tone.

Those Privacy-Invading Pediatricians, Silenced!

A while back, Roy blogged about proposed legislation in Florida that would make it illegal for physicians to ask patients if they own guns. What the??? Since when do we legislate what people can ask each other, outside of discrimination issues for jobs? And is there any precedent for legislating the conversation that occurs between a doctor and patient? So apparently this is going to pass, and Greg Allen writes in "Florida Bill Could Muzzle Doctors on Gun Safety,"

Florida Gov. Rick Scott is expected to sign a bill that will make the state the first in the nation to prohibit doctors from asking patients if they own guns. The bill is aimed particularly at pediatricians, who routinely ask new parents if they have guns at home and if they're stored safely.

Pediatricians say it's about preventing accidental injuries. Gun rights advocates say the doctors have a political agenda.

Ah, it's not about us shrinks, it's okay to ask if there is a question of danger. It's about the pediatricians. Personally, I think the pediatricians should fight back: if they can't ask who owns a gun and target their gun safety remarks, they should give extensive gun safety instructions and literature to every parent at every visit. Perhaps as a statement of unity, all pediatricians in all states should discuss gun safety with every patient, no questions asked.

When Hummingbirds Bonk

In cycling and running there's a phenomenon known as "bonking". Bonking is when you just suddenly get overcome by exhaustion and you collapse. To be scientific about it, you 'deplete glycogen stores' and can't go on. A friend of mine tells me that this happens to hummingbirds. They can be found collapsed on the ground, exhausted, which isn't too surprising for a creature whose heart beats up to a thousand times a minute. Fortunately they can be revived with a little sugar water.

There are days when I can really identify with those little guys. On days when I see twenty-plus patients, when everyone is in crisis, when I just can't seem to find a chart (or the medication nurse can't find my order), at some point you hit the wall and bonk. It's that moment when I think to myself that I will just walk out of the facility and never come back.

Unfortunately, sugar water just doesn't do it for me.

This is what to do to revive a correctional psychiatrist in case you ever find one lying on the ground, exhausted, with a heart rate somewhat lower than a thousand beats a minute:

Administer coffee immediately, followed by judicious amounts of dark Belgian chocolate. Don't worry about checking for consciousness first, just hit the Starbucks.

If this doesn't work consider depositing a large, warm, furry and loudly purring cat on the psychiatrist's stomach. This is also a test for consciousness since those tiny sharp kneading claws are bound to get a reaction.

Once revived, deposit the psychiatrist in the middle of a large quiet forest with miles of hiking trails (trail map included). Allow time for staring up at tree branches, listening to the wind whistle, admiring large fungi and searching the stream for minnows.

Repeat, ad infinitum, until smiles return.

I suspect every psychiatrist has their own particular favorite ways to recover from the hummingbird bonk. Dinah is relaxing in a warm, sunny place and Roy seems to find comfort in buying new very large computer monitors (I'm jealous). Regardless of the recovery method, we will all find our way back to Shrink Rap eventually.

Psychiatry's Identity Crisis

Today, the Sunday New York Times has not been inspirational. I suppose I could blog about the pictures they have of the brains of the political candidates, but I just don't want to.

So I surfed around and from KevinMD, I landed on The Medfriendly Blog where neuropsychologist Dominic Carone is talking about how some physicians claim that others-- particularly psychiatrists and physiatrists-- aren't REAL doctors. Dr. Carone goes through the definition of doctor, and his theories on why some docs dis other docs. I added my thoughts to his comment section, specific to psychiatrists, that we may be seen as "less than" because we are less-hands on, our version of an exam is a of mental phenomena and not necessarily of the body, and that part of our treatment is the act of listening/interpreting. Also, many shrinks don't wear a white coat (I'm one of those). Plus we have the Woody Allen view of shrink as psychoanalyst, and pure psychoanalysis can be done by people with several different degrees.

You know, it's a complicated issue because even the term "shrink" is sometimes shared with psychologists, and I generally address anyone with a PhD (even if it's in history, social work, nursing) as "Doctor" and I'm completely comfortable with that, but really, is someone with a PhD in English a "doctor"? No, they have a doctorate degree, but the professional designation is reserved, I think, for those who've graduated from medical and osteopathic schools. Dentists, podiatrists, and vets (and others, for example, neuropsychologists) do the same stuff as "doctors" -- they diagnose and treat illnesses, they have training that's at least as extensive as a people doc, the same prerequisite education, they've dissected those cadavers, they write prescriptions and perform surgery -- in my brain they are certainly doctors, but I bet if you ask them what they do at a party, they say 'I'm a vet/dentist' not I'm a doctor (the podiatrist probably says 'I'm a foot doctor' but hey).

Even without a white coat and a complete physical exam (...ah, I do sometimes check vital signs, ask a patient to walk, hold out their hands to evaluate a tremor, check for cogwheeling, order labs, request that medication vials be brought to the session) ...here's my view of why shrinks ARE docs.

Psychiatrists must attend medical school. To even get into medical school, certain pre-med requirements must be met and back-in-the-day these included: 2 semesters each of calculus, chemistry, organic chemistry, biology (one semester was biochemisty), physics, and all the sciences included lab courses as well. I believe a year of English is now required, my university back then required it for graduation as well as 2 years of a foreign language and some history/social sciences as well.

Medical School entails a two year pre-clinical course of study. I'm not sure I can remember all the courses I took, but here's a smattering: gross anatomy with cadaver dissection, histology (the study of cells), physiology, pathology, pharmacology, biochemistry, neuroanatomy, embryology, microbiology, immunology. With all the talk around about psychologist prescribing legislation which allows psychologists to prescribe psychotropics after taking a 10-week pharmacology course, I want to point out that pharmacology for medical students is a second year course, begun only after years of science prerequisites are met. That's another rant for another day. In the second year, medical students begin learning to perform physical exams and take medical histories.

The two final clinical years of medical school include for everyone (even shrinks): 12 weeks of internal medicine, 12 weeks of surgery, rotations in pediatrics, OB-GYN, psychiatry, neurology, and I maybe missing some other stuff. Surgery for me included a few weeks of cardiothoracic surgery, and electives in neurosurgery and plastic surgery. The fourth year has lots of elective time and time to interview for internships/residencies. I spent some time doing psych research in California, primary care on a Navajo reservation, psych rotations in hospitals I thought I might want to go to, cardiology, a pain service month, and I can't recall what else.

Before psychiatry training formally begins as a specific residency, a year of internship, hands on, being-a-doc is done-- a transitional year may include 6 months of psychiatry, I did a year of pure medicine and did the whole CCU/ICU/renal transplant unit/AIDS units stuff, no psychiatry.

Okay, then there were 3 years of psychiatry: inpatient, outpatient, electives, mostly just psychiatry except for when inpatients got physically sick and needed work-ups begun before the medicine folks arrived.

Many days, I feel like I've forgotten everything that doesn't have anything to do with psychiatry. Actually, I'm pretty sure I have. I haven't heard of half the meds people are on anymore, I forget the details of how lots of stuff works. My father-in-law asked if you pee less if you have one kidney...? does the second kidney double it's filtration rate? And I need to go look up what a mild decrease in T3-uptake means if the TSH and T4 are both normal.

I titled this Psychiatry's Identity Crisis, and if some surgeon or radiologist wants to fight... but really, amongst ourselves, we don't have a "crisis".
--Dr. Dinah