Podcast #66: The Professional Shrink Rap

Roy talks the top 25 search phrases that lead people to our Shrink Rap blog. 
They include, "Statistics of talking too much on a date,"  "World's largest zucchini,"  "Does Angry Birds make you depressed?"


We talk about when should a psychiatrist call in sick?  How sick is too sick?  How distracted is too distracted?  Are psychiatrists good at self-monitoring?


Roy discusses an article called Professionalism in Psychiatry. 

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Things I'm Thinking About This Holiday Weekend

Happy Presidents' Day.  I probably have 50 blog posts floating around in my head, but I thought I'd share with you some of the stuff I've been reading on line lately.  


The New York Times Op Ed editor doesn't seem to like stimulants these days.   A few weeks back there was an article talking about a study showing that long-term stimulants aren't helpful, and today there is a piece by a writer who finds distraction helpful...told with some contempt towards his friend's son whom he calls Ritalin Boy.  Steve over on Thought Broadcast has his own take on ADD meds.   
 What do you think: are stimulants helpful or not?  I'll stand aside for this one. 


Then there was the article about the business/computer whiz who put hundreds of thousands of dollars of his own money (and all his time) into a kidney transplant matchmaking service.  If you need an uplifting story, this is an interesting one. 


Over on KevinMD,  Dr. George Lundberg is a bit skeptical of SAMHSA's new defining features for the Recovery Movement.  I more or less agree, it feels like it's more about semantics (what does it mean to say recovery is "person-driven"? as opposed to?) than substance, and a lot of it seems to boil down to the idea that patients should be treated with respect and people with mental illnesses should work towards achieving their full potential.  Those things I agree with, for everyone. 


And finally, for the writers among us, Pete Earley has a Before You Quit Your Day Job post up on his blog.  I'm still pondering the $80,000 advance.  The Shrink Rappers need an agent, oh, but we do love our friends over at Johns Hopkins University Press.  


And finally, for my friend ClinkShrink the Introvert,  who wrote a review of a Quiet: The Power of Introverts in a World that Can't stop Talking (---huh, stop looking at me), here is an article called The Brainstorming Myth by Jonah Lehrer in The New Yorker. 


Okay, lots of links.  This is what I've been thinking about.  Aside from that, I made a quick trip to NYC and had my photo taken with Cookie Monster in Times Square, and I loved Jersey Boys.

Physician Online Behavior: Professionalism and Social Media

Mark Ryan, a Virginia family physician, wrote a blog post for Mayo Clinic Center for Social Media three weeks ago, reviewing the many definitions of "professional behavior" for physicians and how that might apply to our social media interactions.

It is apparent to me that what is considered appropriate or not for physicians using social media (eg, should you friend a patient on Facebook?) is still being tested and figured out. However, Mark's post reminds us that there are certain principles that remain immutable, despite the technology.

Weiner Diagnosis?

 

In Shrink Rapper world, we get a lot of email from publicists about books, TV spots, upcoming events.  This was in my spam box today:

Rep Anthony Weiner is expected to resign today after weeks of scandal surrounding his lewd text messages, tweets and photos.  Even in his tearful media conference, Weiner could not explain why he participated in such behavior.  According to NYU Medical Professor and Internist, Dr. Marc Siegel, the congressman’s behavior is systemic of a larger psychological problem, which must be addressed before fixing the addiction to online sexual activities.  

 

Dr. Siegel says, “This seems to be an example of extreme narcissism, inflated self image, depersonalization, loss of contact with reality, addiction, and the power of the Internet as a medium (like the Wizard of Oz you feel you are hiding behind the curtain)”.

 

To discuss the dangers of addiction and steps to overcome the serious illness, Dr. Siegel is available to offer is medical knowledge.  As a medical practitioner and FOX’s House Doctor, Dr. Siegel has spent years diagnosing and treating people in the national media spotlight.

 

If you are interested in speaking with Dr. Siegel, please contact me at .

 

Best,

Rena  

 

Rena Resnick

5W Public Relations

Oh my, I thought.  I read it twice. An internist is going to comment on Anthony Weiner's narcissism, motivations, sense of self, and contact with reality?   Sounds like a shrinky thing to me, but the Goldwater Rule prohibits psychiatrists from commenting on the mental state and diagnosis of someone they haven't personally examined.  Does that mean it's okay for other specialists to talk about the mental state of someone they don't know?  Hmmm...   I guess we'll see what he has to say, but I'm not so sure about this.

i before e, except after w?

I mean we're shrinks, we deal with the weird everyday. If anyone knows weird, it's us.

So I get this email from Roy. Stop spelling it "wierd" it's "weird" you have it stuck in your head wrong. He's right and he gave me a long list of places on Shrink Rap where weird is misspelled as 'wierd.' Only they weren't all me. Clink did it a couple of times. Sarebear did it in our comment section. I did it a bunch. This is weird. But it is "i before e except after c"...right? Why is weird spelled weirdly?

Maybe I need a new word. Strange. Unusual. Unconventional. Odd. That's a good one, even I can't spell "odd" wrong.

From Wikipedia:

Old English wyrd is a verbal noun formed from the verb weorþan, meaning "to come to pass, to become". The term developed into the modern English adjective weird. Adjectival use develops in the 15th centrury, in the sense "having the power to control fate", originally in the name of the Weird Sisters, i.e. the classical Fates, in the Elizabethan period detached from their classical background as fays, and most notably appearing as the Three Witches in Shakespeare's Macbeth. From the 14th century, to weird was also used as a verb in Scots, in the sense of "to preordain by decree of fate".

The modern spelling weird first appears in Scottish and Northern English dialects in the 16th century and is taken up in standard literary English from the 17th century. The regular modern English form would have been wird, from Early Modern English werd. The substitution of werd by weird in the northern dialects is "difficult to account for".^[1]

The now most common meaning of weird, "odd, strange", is first attested in 1815, originally with a connotation of the supernatural or portentuous (especially in the collocation weird and wonderful), but by the early 20th century increasingly applied to everyday situations.^[2]

Enough. It's all too weerd. The chinchilla is for Jesse because his preoccupation with the little rodents is kind of ....different.

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?

Stories From The Office

I'm not sure where I'm going with this story or even why I'm telling it. I've convinced myself that it's okay to tell it, even though it's a real patient story, and I'll confabulate some details, but basically it's true. I haven't seen the patient in over ten years, I don't recall his name, I'm not sure if he's even alive. It's one of those stories, however, that sticks in my head; one I think about from time to time, one that makes me wish I could tell it to the people it involves.

So John (not his real name) was an elderly, but not old, gentleman. He laughed easily and found joy in many things. He and his wife of 53 years had many wonderful things going on in their lives.

He talked about his father who had come to this country from Europe. His father had very definitive ideas about how John should live his life and the rules were spelled out quite clearly. As a young man, John had fallen in love with a young woman and he'd wanted to propose-- his father disapproved and wanted him to put his education first. The young woman married someone else and my patient met his current, and only, wife. He'd long ago lost touch with his first love, but he did know what had become of her-- she'd become quite prominent in her own career and John knew that she still lived in town.

He had spent 54 years thinking about this woman, feeling he'd made a mistake, pining for the one that got away. His wife was kind and attentive, and they got along well, but he'd lived out his adult life quietly wondering 'What if?'

And why is this a blog-worthy story? In fact, I've wanted to write about it for 2 years, I' m not sure what has quite stopped me.

So the patient told me his first love's name. I knew this woman-- she is the mother of one of my friends. I didn't know her 54 years ago, but in the here and now, she's a cranky soul and, if you ask me, my patient is better off with the lovely wife he has. The funny thing is that my friend's dad is a lot like my patient.

I wondered then if I should say something. What would I say and would it help? I didn't, by the way-- I was afraid it might make things worse and that I would regret having opened this door. It's always a little awkward when my worlds intersect.

The N = 1 Trial

[Clink Note: First I put up this post, then Dinah posted over it, then she reposted it at the top of the blog with bookend comments. I've taken out her bookend comments and put them immediately after this post, so please do scroll down to read them or click here. Oy. My Comcast access has been really spotty or non-existant this week so I have to act fast while it's up.]

In the January edition of American Psychiatry News Dr. Glenn Treisman writes a critique of the "fail-first" policies of managed care organizations entitled Promoting The Concept Of The Individual Trial (free registration required to read the article). He begins with a brief case presentation of a patient who was successfully treated as an inpatient with a drug that was nonformulary according to his new insurance company. The patient was discharged and his outpatient doctor, who didn't have access to his previous treatment records, switched him to a different formulary medication which he had previously failed. The patient relapsed and required rehospitalization.

He begins with a critique of the idea of therapeutic equivalence. Therapeutic equivalence refers to the idea that different medications can be shown to be equally effective in treating a given medical condition. Dr. Treisman rightly points out that this evidence is based on treatment response of large groups of patients and may not be predictive for a given individual. For example, SSRI's as a whole may be equally effective in treating depression but a specific patient may find Zoloft more effective than Paxil. There may also be specific individual issues such as co-existing medical conditions that may influence a clinician's choice of medication. (See also Dinah and Roy's posts on How To Choose An Antidepressant, Part 1 and Part 2).

He goes on to attack what he refers to as a perversion of the term "evidence-based medicine". This term originally meant that doctors should base their treatment decisions upon current research, using the best information that is available at the time. He alleges that insurance companies use evidence-based practices as an excuse to deny care and save money:

"At times, evidence-based medicine has come to be used as an excuse to change the equation of medical treatment entirely. The new equation is to start with the premise that treatment should not be used unless it has been 'proven' to work."

The misuse of therapeutic equivalence and evidence-based medicine, according to Treisman, has caused patients to become disillusioned and suspicious of traditional medical care and turn to alternative and homeopathic treatments. And for doctors he feels the nonformulary approval process "wastes the time of busy physicians" and injures patients.

So that's my recap of the article. My reaction to the article is that I agree wholeheartedly with Dr. Treisman that it's good to remember the limitations of large clinical trials when you're treating the individual patient. It's also good to remember that therapeutic equivalence is a regulatory concept not necessarily a clinical truth.

Here's where I disagree:

The nonformulary process and the emphasis upon adherence to treatment guidelines is not solely the fault of the "evil" greedy insurance companies. I think we as physicians need to accept our role in driving these policies.

Health care cost containment is everyone's responsibility. It's easy for doctors to feel bothered by paperwork, to feel threatened by challenges to clinical autonomy, or to be offended by suggestions that one's practice is not up to modern clinical standards. But the fact of the matter is that in psychiatry there are a lot of free-wheeling physicians out there. Indiscriminate use of expensive medications for vague clinical indications (Seroquel for anxiety, anyone?) drives up the cost of health care for everyone. And practice guidelines were not developed by insurance companies. They were created by professional organizations to enhance the overall standard of care and quality of care given by their physician members. The professionals themselves recognized that there were issues with wide variation in patient care, or suboptimal care, long before insurance companies got ahold of these guidelines.

It's a facile sleight-of-hand trick to point to the evil greedy insurance companies for the policies that now nag us. I'd remind folks that we have only ourselves to blame.

What Good Are Psychologists?

So this morning I'm scheduled to see eleven people and an officer catches me at the door, before I even have my coat off, to tell me that one of my patients is down and waiting to see me. I get to the clinic and see two of our institutional psychologists sitting in an office, chatting. I don't think too much of this---it's the usual morning start, they've made the morning coffee---until I happen to see the morning clinic schedule for the psychologists.

Four fulltime psychologists are scheduled to see a total of six patients today.

The thought flitted through my head: "What good are these people?"

The unvarnished truth is that a single correctional psychiatrist will see as many patients in a given year as three fulltime psychologists. This is pretty consistent from what I've learned from talking to correctional psychiatrists in other states. And this makes sense---the vast majority of referrals are medication issues and they can't do anything about that so the referrals get routed directly to me. I also get the diagnostic dilemmas, the unexplained mental status changes that you need medical training to sort out. (Heaven help me if I see another inmate in alcohol withdrawal diagnosed with schizophrenia.) Psychiatrists see more people because they are trained to do things that psychologists can't do, and psychiatric issues come up much more frequently than psychological issues.

That being said, the psychologists I work with are wonderful. They have great senses of humor, they help me keep up my morale and they don't hesitate to step up to the plate to help with what they can help with. They handle the emergency referrals that come up during my clinic. When the secretary is off or out sick (I don't have a clerk of my own, I have to borrow help from the psychology department secretary), the psychologists help traige referrals, set up my clinic schedule and pull charts.

They have their own specific professional duties, of course. They give input into classification decisions (where an inmate is assigned to do his time, what security level he needs) as well as input into program eligibility. When requested they'll do parole assessments and respond to staff needs in case of crisis (suicide response debriefing, mass disturbance debriefing, etc). They provide crisis intervention counselling, substance abuse groups, sex offender therapy and set up behavior plans for inmates who require them.

So this is what psychologists are good for in prison, in case you were curious.

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