Guest Blogger Dr. Jesse Hellman: What are the Limits of Psychiatry?

Recently a colleague and I were talking about a question that had been posted on our psychiatric society's Listserv. The question had to do with the age at which a parent would tell their child he had been adopted, and who the birth parents were. This question is quite complex, depending on a multitude of factors. Child psychiatrists responded, as did adult psychiatrists. Is this a question, though, for Psychiatry? One might argue that the question has nothing to do with mental illness. But does our field define itself only as addressing mental illness?

A few days ago in the NY Times there was an OP-ED piece in which the author touted brain studies as showing that we do not just "like our iPhones" but "love our iPhones." When I read it I was surprised, as the idea of whether one might "love" an iPhone (or, for me, my camera or sports car) never occurred to me: Of course I do. What was surprising was the apparent sense of discovery by the author of a phenomenon that Freud had clearly described well over eighty years ago. He invented the word "cathected" to describe that we can "cathect" or imbue any particular thing, or even idea, with erotic energy and so love it with the intensity we have for living things. He explained that that cathected energy can be withdrawn from these things as well as from people, and the formerly loved object discarded instantly.

So psychiatry, to me, includes psychology in its broadest sense as well as the complexities of human interaction. In my own practice the most difficult and important issues are not usually the questions of medication but those that have to deal with all the issues that  beset the patient that are then brought up in their sessions: getting promoted at work, the problems of a marriage, the competitive strivings within a family or its workday substitutes, the losses one faces inevitably in life, and so on. Almost infinite variety.

So how do others address this question? Just what is Psychiatry?

Understanding the Research on Psychotherapy Trends-- a Discussion with Dr. Ramin Mojtabai

For whatever reason, it bothers me when media says that psychiatrists don't do psychotherapy, and lately, it happens a lot.  What am I, chopped liver?
They quote a study by Mojtabai and Olfson in the Archives of General Psychiatry, and say, "Only 10.8% of psychiatrists see all of their patients for psychotherapy."  Is that really true?  Is it really relevant?  I tried to read the article and I wanted to understand how the study was done so I could think about it myself, but I didn't understand how the research was done-- Roy thought it was based on CPT codes, then he said it wasn't.  So why not go to the source?  I asked Dr. Mojtabai if he would have lunch with me and tell me how the study was conducted.

If that got you curious, please read about it on over on Shrink Rap News!  You're welcome to comment there if you're physician, or to surf back here and tell us what you think.  Ramin says he's interested in what people think, and he's been very kind about humoring me, both over lunch and in the many subsequent emails over the details.

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.

Speed Shrinking

Somehow, I missed this one. Thanks to Buggy for pointing it out!

What do you do when your shrink's away and you've got a crisis? Wait? Call coverage? A group of New Yorkers have set up their own speed shrinking networking service in bookstores and taverns.
From The NY Times, August 31, 2009, Vincent Mallozzi writes "Answers to Life's Worries, in 3 minutes Bursts."

Instead, Ms. Tang went to talk about her fears with a panel of eight psychiatrists and psychologists offering three-minute sessions of what was billed as “speed shrinking” to those whose regular therapists were on vacation or to anyone else needing a very fast dose of advice.

“At first glance, this appears to be a funny, lighthearted thing,” said one of the therapists, Jonathan Fast, who is also a professor at Yeshiva University. “But what I have discovered is that these brief conversations absolutely turn into real therapy. You start with the classic ‘What can I help you with?’ and make a really fast assessment.”

So this is not what I do. I have no super-rapid diagnostic skills and no magical wisdom worth imparting in 3 minutes. I thought they invented grandmothers for this stuff. And Mr. Mallozzi makes therapy sound a little too trite and a little too self-consumed for my liking. Psychiatrists are good at diagnosing and treating psychiatric illnesses, and some are good at psychotherapy. I don't think this conveys any level of expertise for life-decision advise for strangers. Ah, but this wasn't really one we'd pass by on Shrink Rap.

How Many Patients Per Hour?

Psychiatrist and former podcast guest Dr. Mark Komrad asks:

As Chairman of Ethics at Sheppard Pratt I have been approached with a question that seems to stand at the border between ethics and "practice guidelines." The question is: "What is the maximum number of patients that a psychiatrist can/should see in an hour to be safe and effective?" In other words, the concern is about certain psychiatrists who are starting to see 8, 9, even as many as 12 patients in an hour (these would average to 7.5-10 min per patient if no breaks). This is an entirely new level of caseload that is emerging, and the question came to me "at what point does it start to become unethical or bad practice." I find this difficult to answer, but thought it a good question to submit for discussion on this list. Afterall, if memory servies, I read somewhere that the typical Primary Care doc is gives each patient an average of 8.5 minutes. Is it possible to do psychiatry with that kind of average time per encounter? Your thoughts?

Forensic Psychiatrist: Job Description

This is a story from a friend of ClinkShrink. I hope she doesn't mind that I stole it for the blog, but her friend suggested it.

ClinkShrink gets home and there is nothing to eat in the house (hmm...ClinkShrink can't make microwave popcorn). So she orders take out sushi to eat with her friend who runs out to get the food. She orders from this place a lot and she usually orders the same thing, so they know what she wants when they hear the name 'ClinkShrink.' The friend goes in to get the order for Clink and the woman behind the register says,
"Oh, take out for Clink?"
"Yes, thanks."
"Are you a forensic psychiatrist, too?" the woman at the counter asks.
The friend is a little surprised and replies, "No, actually, but ClinkShrink is." Then the woman smiles and says, "Oh yeah, she cut up the bodies like on TV." and as she says this, this pretty, demure woman makes a few zorro-like swishing sword motions over the cash register. Clink's friend considered saying, "Actually, she has a clinic in the prison," but realized this wouldn't be as 'sexy' as cutting up the bodies and just laughed and said, "Yes."

Can Black Box Warnings Kill?

I'm going to write about a story I saw on-line about a depressed mother who poisoned her small child. It's a terribly tragic story, and please keep in mind that I only know what I read in the article Here, and I've never examined anyone involved. The question being asked at the trial is that of whether the mother, who was depressed, was legally sane and knew it was wrong to kill her child, and that's not what I'm going to write about. I didn't pick a graphic to go with this blog post, because I couldn't think of any photo that would be appropriate to such an angst-ridden topic.

I'm pulling a few sentences from the newspaper article to use as a springboard for discussion:

They said Sparrow told a nurse practitioner she was considering using sedatives to kill herself, her daughter and her dog, but that medical professional did not contact the authorities or otherwise try to get Sparrow committed to a psychiatric hospital.

After hearing Sparrow had just stopped taking the antidepressant Prozac for fear it was causing the suicidal thoughts, the nurse practitioner let her go home with the instruction to come back if she didn't feel better...

I was struck by two things in the recounting of the story as I read it: that both the patient and the nurse practitioner thought her suicidal thoughts came from the Prozac (and both, perhaps, trusted they would stop with the cessation of the medicine--- obviously I don't know that's what they thought, but it's implied in this particular recounting of the story), and that a homicidal mother was apparently allowed to leave a clinic without being evaluated by a psychiatrist, I think. So my comments are general, because I don't trust a press account to be all-inclusive, and perhaps things transpired that didn't make it in to print.

When Prozac first came on the market, there were some concerns that it made people suicidal, and these concerns were dismissed. With years (oh, more than a decade) researchers revisited this idea and concluded that people under the age of 26 have a low incidence (1-2%) of violent thoughts caused by anti-depressants, and so we have the Black Box Warning about such thoughts. Does all the publicity about how the possibility of suicidal thoughts can arise from the medications narrow peoples' thinking? If we think a medication has caused a suicidal idea, does this prevent people from exploring other options? Perhaps the medication isn't working, or perhaps the depression has gotten worse and has broken through. Perhaps something else has transpired that increases risk. And if the medication is the culprit, what do we know about how long one has to be off it before such violent thoughts stop and the risk is gone? I think the answer is that we don't know.

I don't know if the woman described above saw a doctor the day she was in the clinic, or what exactly she said to the nurse practitioner. I don't know if the outcome would have been any different if she'd been committed to a psychiatric facility. What I do know is that when any story has a tragic ending, it's hard to wonder if more couldn't have been done.

We pass so-called scope-of-practice laws--- should psychologists prescribe? Should nurse-practitioners practice essentially independently? The fuss goes into the legislative battles before-the-fact, one fought primarily by legislators and lobbyists, not clinicians. We don't generally look backwards and ask if poor outcomes are more more likely to occur in settings where we've dropped our standards and we don't seem to ever ask if we should revoke those decisions. I'm not saying we should--- but perhaps we should ask more questions.

Here Ye! Here Ye!!

In medicine we're generally careful not to judge our colleagues harshly on paper. We may report what the patient or another doctor tells us, but we usually hold off on condemning people in a chart-- it makes for messy liability issues, and it's really just poor form to write "Can you believe that idiot prescribed this combo of meds" or "the last doctor never even listened to the patient's complaints."

In real life, I don't believe we're quite so generous. It's not at all unusual for docs to condemn-- in an off-the-cuff manner in casual conversation with friends-- their disdain for the practices of others. Can you believe his former doc prescribed 10 mg/hour of Xanax? Or what about the doc who demands every patient come for weekly therapy sessions even if they don't think they need therapy? Or the doc who only sees patients for 10 minute med checks and never really listens to the patients? How 'bout that doc who gave his suicidal patient a 90 supply of Hemlock? Or how could he start a patient with bipolar disorder on an antidepressant-- of course it de-stabilized him!

I think we're quick with our Can You Believe stories. More in psychiatry than in other branches of medicine? Maybe. Why? Perhaps because less of what we do is clearly defined and even amongst ourselves, we have no full consensus on exactly what it is we do, and in what units. We're certainly getting closer with our use of medications, but still, the guidelines don't take into account what to do if a patient fails many trials of many medications and still has a myriad of symptoms. Sometimes our patients are very sick and we get very desperate. And then too, our label says little about what exactly we do-- one shrink only does med checks, another only does therapy, and we amongst ourselves have not come to a consensus about what is the absolute 'right' thing to do, for whom, in what settings, with what staffing and reimbursement issues, how frequently, and when.

What do you think: are we gentle with each other or not?

You Didn't Even Ask?

Okay, I'm going to ramble (I know it, even before I've started) and I don't quite know where I'm going with this. Please notify me if I get there.

There's an assumption in medicine that the responsibility for pulling out the truth rests with the doctor. Really? I don't know, and I've never seen it stated as such. It feels like it's there, though, in insidious ways that leave us with the sense that if we don't ask the right questions, don't elicit the right information, that the fault (and, yes, I think I mean fault), and the liability, is with the physician.

Let me explain a little better: a patient commits/attempts suicide...people (which people? I don't know: People! Perhaps everyone. Lawyers, supervisors, family members, other physicians) will ask: Did the psychiatrist ask if he was having suicidal thoughts? A plan or intent? In the two clinics where I work, there is a check-off box on the doctor's progress notes regarding Suicidal Ideation. It's a good jog to the memory to remind us always to ask, but it's also intrusive. It must be checked off and the doctor doesn't have the space to decide it's inappropriate to ask that particular question on that particular day. Some might say it's always appropriate to ask about suicidal ideation, but when I'm seeing a patient whom I've known for years, who has never been suicidal, who tells me they are doing well, feeling fine, well, it sometimes feels a little weird for me to ask, "Are you having any thoughts about hurting yourself?" Them's the regs.

But it's not just suicide, or homicide, or any form of violence. It's other things as well. Roy mentions in his Xanax post that the doctor needs to ASK the patient about a history of substance abuse to find out. Oh, but patients can lie, or forget, and doesn't everyone know Xanax is addictive? Shouldn't a patient with a history of addiction volunteer this information to any doctor who may prescribe an addictive drug that will re-activate a past problem?

It's not mental health issues, it's all of medicine, though certainly, each specialist feels an obligation to attend to his organ system. Do internists second-guess themselves if someone walks out and has a heart attack: "Oops, I forgot to ask if he was having chest pain." Do they check their notes and hope they've documented an appropriate assessment for cardiovascular disease?

So what's my point? It's certainly not that we shouldn't ask questions. We should. And there are issues that might not be obvious to the patient, things they might have forgotten or may not know are relevant-- like asking about a past history of mania/hypomania before prescribing an anti-depressant. But, I think, at some level, we've taken on the burden of blaming ourselves (or our colleagues) if something goes wrong and the doc didn't ask. Maybe it's a fallout from the malpractice era: in terms of a lawsuit, it's probably not good form to have a bad outcome about something one didn't ask about. There is also that sense that if you asked, and the patient said No, then how could we know otherwise? It's not that we don't feel sad about a bad outcome, but if there's the sense that all that could have been done was done, at least there's not that feeling of responsibility.

Sometimes, though, it doesn't just feel like a moment of omission, it feels (to me, at least) as though we blame ourselves and each other for a bad outcome if we didn't ask the right question, as though it's our fault, like we've caused something bad to happen, or at the very least, failed to prevent it. We blame ourselves, we finger-point at our colleagues.

I told you I was going to ramble. Well, what do you think?

To Sleep, Perchance To Dream...

Patients frequently tell me their dreams. Part of the royal road to the unconscious, Freud tells us. I'm never quite sure what to do with them. I listen, I comment on how the dream contents relate to the events in the patient's life-- a phenomena known as Day Residue. Simply said, I don't know that much about how dreams are helpful, or why they've come to be.

That said, ClinkShrink had an interesting dream last night, one that she shared with me. She says I can blog about it, so why not?

Clink is climbing a mountain with my dog, Max. Max gets cold. He's shivering, in fact. Concerned, Clink checks Max in to a resort hotel where they offer to give him (my dog!) sherry twice a day. The dream, I'm told, was vivid and in color.

So what does this mean, doctor? I asked Clink if she'd watch Max overnight while I'm away at a party. I will be staying in a hotel, though not a resort. I won't be drinking sherry, at least I don't think so, as I've never before been inspired to drink sherry. There may be some in the cabinet, Clink, but it's cooking sherry, please don't give it to Max and I can't imagine it's much fun to drink. Why is Max cold? He has never complained about the temperature, ever. He does like to eat meat and he likes Mighty Dog, but really, Max is a mutt, and sherry seems way too sophisticated for the pooch. He's never been to a resort. Has ClinkShrink? And Clink does climb mountains these days and Max would probably be happy to go along. He's quite athletic, but he might get freaked by the steep edges. He's not much for vacuum cleaners.

And what did you dream last night?

Should Psychiatrists See Patients for Psychotherapy?

The trend is for psychiatrists to see patients for psychiatric evaluation, treatment with medications, and a medicalized version of psychiatric care, while parceling out psychotherapy to non-MD psychotherapists-- social workers, psychologists, licensed clinical counselors, nurse therapists, pastoral counselors (and anyone else who wants to listen...a bartender or two, perhaps the hair stylist).

Those readers who've been following Shrink Rap for a while know that I work in two types of outpatient settings: a community mental health center where I see people to treat their mental illnesses with medications, and a private psychotherapy practice where I use medications but I also provide psychotherapy to patients who want and need it. ClinkShrink sees patients in forensic settings (name your jail) and she sees a remarkably high volume of patients. She deals exclusively with medical issues-- patients may say or hear things that impact them positively, but the formal setting of therapy to talk, as a process over time, to resolve specific issues, to deal with past events, and to alter patterns of behavior, is not what she does. Roy has worked in many settings, but his current hat is as a Consultation-Liason psychiatrist in a large community hospital-- he mostly evaluates patients and makes treatment recommendations, but he doesn't see outpatients over long periods of time. He used to do that.

Psychiatrists (in the old days) used to see people for psychotherapy routinely, especially before medications were available. I think I was finished with medical school before I even knew that social workers saw clients for psychotherapy. I thought they met with families, worked for agencies, helped with disposition and obtaining benefits, and had a lot to do with foster children and protective services. I believed psychotherapy was the exclusive domain of psychiatrists and clinical psychologists. I simply didn't know.

I've talked here before about why I think, in a totally ideal world, that it's best for patients to see one person for psychotherapy and medications: one stop shopping is more convenient, psychiatric illnesses aren't 'explained' away without the offer of medications, the doc really gets to know the patient and learns to differentiate better what is, and what is not, a symptom of illness or medication side effects, and there isn't a set-up for patients who are prone to dividing their care-takers into good guys and bad guys.

The reality of the world is that psychiatrists are the most expensive mental health professionals, and in the shortest demand. They are more expensive to train, they often finish school heavily in debt, and there aren't enough to go around. And psychiatric residency programs, for the most part, don't emphasize psychotherapy training-- the resident has to pursue it. A psychiatry resident was recently telling me about a patient who wanted insight-oriented psychotherapy and the resident said, "We just don't have time in residency to do that." For those who know they want to pursue a career in research, spending a lot of time learning to do psychotherapy may not be a wise use of limited time. Some people might go as far to say that it's wrong to have psychiatrists doing psychotherapy, especially in shortage regions where there aren't enough shrinks to go around--- a lot more patients can be seen for quick med checks than for 4 times/week psychoanalysis (-- I'm not a psychoanalyst, by the way).

I believe that people should do what suits them, given the realistic constraints of their environment. I'm even okay with the psychiatrist beauty queen. With regard to psychiatrists doing psychotherapy: I like the work and there seems to be a demand for it. I also work in a clinic where the option does not exist to do this kind of work, but it does afford me the opportunity to see a different population of patients and to work as part of a team.

(Roy made me proof read this; my first draft was a disaster.)

After the Data: More on the Phone Therapy Study.

Okay, if you read my last post, you know I ranted (who me, rant?) about Tara Parker-Pope's NYTimes Well blog post where she asserted that phone therapy is effective for Depression-- as effective as real life therapy with less attrition. People wrote in to talk about their feelings about phone therapy, but really my gripe was with the idea of presenting a conclusion without any details-- I had a lot of questions about how this conclusion was reached, and I thought perhaps there were only 12 patients in the study.

So I emailed the author of the study, David C. Mohr, pH.D. at Northwestern, and within hours, I had a reprint of the study. It was a lot of data and I only did a quick read, but my questions were all answered, and here's the scoop:

This wasn't a research study: the journal article is a review of the literature of ALL phone therapy studies done, and 51 such studies were identified. All but 12 were excluded because they did not meet the authors' specific criteria to be included-- for example, some were surveys, not therapy trials, and any study that had ANY face-to-face contact was excluded. Mohr goes into detailed discussions of therapist training, treatment orientation, co-morbid illnesses, treatment format, and other variables. Mohr discusses how many of the patients and control subjects may have been on medications prescribed by primary care doctors or oncologists (--some of the studies looked at phone therapy in patients suffering from specific illnesses). I couldn't find any data from these studies that revealed that phone therapy worked as well as the traditional in-person stuff in a face off controlled trial.

The Well blog said: "The researchers also found that telephone therapy was just as effective at reducing depressive symptoms as face-to-face treatment."

Actually, the researchers wrote:
We also want to emphasize that it is premature to generalize the results of this meta-analysis broadly. Individual studies suggest specific uses under specific circumstances; for example, telephone therapies may provide added benefit compared to care for depressive symptoms by a primarycare physician or to no care at all. However, because the depression symptom outcomes used in this meta-analysis were self-report instruments, the generalizability of these findings to clinically diagnosable depressive disorders is limited (Kendall & Flannery-Schroeder, 1995). Furthermore, the measures of depression used in this study had a wide range of specificity and sensitivity (Minami, Wampold, Serlin, Kircher, & Brown, 2007). Thus, the aggregated effect size estimates for depressive symptom severity should not be used as any sort of benchmark. In addition, the level of heterogeneity across studies suggests that we do not yet understand the characteristics of patients for whom such telephone interventions may be effective, and those for whom telephone intervention may not be appropriate. The heterogeneity in the severity of depressive symptoms and in medical comorbidities in the samples also limits generalizability.

AA noted in his/her comments that we here at Shrink Rap sometimes make statements without fully backing them up or giving a full assessment of the literature. I have to agree. We're rambling for fun, we try to be accurate, we look up and link, but psychiatry is sometimes vague, still a mix of art and science with more questions than answers and the it never ceases to amaze me that how differently individuals react to the same intervention-- be it a word muttered or a medication prescribed. We try to be careful, but we can't be exact and some of this is about ducks and chocolate and us just venting about our days. I promise, however, that the moment the New York Times wants to pay me a salary to do this, I'll become really really careful about the conclusions I draw!

Thanks to Dr. Mohr for providing the paper:
The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta-Analysis David C. Mohr, Northwestern University, Hines Veterans Administration Hospital Lea Vella, San Diego State University Stacey Hart, Ryerson University Timothy Heckman, Ohio University Gregory Simon, Group Health Cooperative

What Didn't I Tell You?

It's not specific to psychiatry, but this caught my eye, first in the Wall Street Journal, and then through their link in the Boston Globe.

So a woman in her 70's is getting chemotherapy. She is also on painkillers and complains to her doc that she's dizzy. Fourteen times. She then has a car accident and kills two people. The relative of one of the people who was killed sues the doctor who prescribed her medications for failing to tell her not to drive. The claim is that if the doctor had specifically told her not to drive, she wouldn't have. A similar case went to court last year.

I don't know the details of the case, it's just what I read in the on-line articles, and we all know the press sometimes presents things in interesting ways. The question gets to be, however, what exactly is the doctor responsible for when a medication is prescribed? Side effects may or may not happen: bottles are labeled by the pharmacy, should everyone be pre-emptively told not to drive? And once some does have a side effect, and knows they have it, is it still the physician's responsibility to state the obvious: you're sick, you're on a sedating medication, it's making you dizzy, don't drive or operate heavy equipment? Is it the physician's responsibility to even ask if the patient drives, or to absolutely ascertain that he doesn't? Is saying "don't drive" enough? Should the family be brought in and the keys be taken away? What about the not as obvious: the doctor never said to give up gymnastics on the balance beam. Or not to rock climb (...ClinkShrink!) which may be hazardous, meds or not.

So the striking thing about this story is that the suit wasn't filed by the patient, but by the survivor of the victim's behavior. So, like, if an engineer takes a medication and has an accident, can the family members of every one injured on the train sue the doctor who prescribed the medication that the engineer took? And what about the pharmacy? It's all kind of confusing.

Another Thing to Ponder

Thanks for the lively discussion in the post below. If you missed it, Click Here.

So Gerbil tells us she never refers patients to therapists she doesn't know personally.

This got me thinking: How much responsibility does a referring doctor bear for the treatment of his patient by another doctor, one he's referred the patient to?

Okay, so in this wide world of psychiatry, when a patient asks me for a referral (gay/straight/Republican/dog-owner, whatever), I often give names of psychiatrists I know personally whom I trust. In this realm, I'm pro-Gerbil. If someone wants a referral for someone in their insurance network, I tell them to call the insurance company: I have no idea who is in what networks. And sometimes I can even give people the name of a good primary care doctor (one I know and think highly of). If they go, and if the doc does wrong by them, how much am I held responsible for this? Most readers seem to feel it's not cool to "out" a gay doc, but am I obligated to tell a patient that someone I'm referring him to has been the subject of a malpractice suit? Or 5 malpractice suits? Or that decades ago he's been sanctioned by a professional board or banned from a hospital? Or that I happen to know he's cheated on his wife? If I don't just happen to know it (via the grapevine or whatever), am I obligated to research the past of another physician before I give out a name? Am I more obligated to do the Googling than the patient is?

So you say Why Would I Refer anyone to someone with an unseemly background? And actually, I wouldn't if I knew the doctor had these issues and if there were other choices. But what if one lives in a small town and the patient needs a specialist, and there is only one such specialist (...oh, say a retinal surgeon or a hand specialist... or a cosmetic surgeon who specializes in...name your body part) and that specialist is known to be competent despite his unsavory past.

I know, I know...therapists are different.

Chime in:

Should Doctors Scold?

Okay, first I was scrolling through KevinMD's blog, and this caught my attention:
In Whoa! an Er Doc talks about psychiatric, pain, and obese patients in his ER. Regarding the obese patient in the ER, he writes:

However, many, many people are obese because they simply eat too much unhealthy food and do not exercise enough. Many of these people live in subcultures within America where obesity is not only tolerated (mostly in women), but is praised, despite the well known health hazards. Obese patients are treated with respect in my ER - however, if they are disrespectful to the staff, demanding, and make a nuisance in my shop, they will get rebuked,just like any one else. Additionally, just like with smoking, I feel it is a doctor’s duty to reprimand patients for unhealthy behaviour - and this includes unhealthy eating and subsequent obesity.

I'll refrain from rambling about people who blame overweight folks for their condition. Another post, another day. What grabbed my attention was this doctor's use of the word Reprimand. It's not just that he reprimands, oh my gosh, no, he feels a duty to reprimand. I think I missed that part of medical school.

Perhaps it's just the harsh terminology. He's talking about behaviors here: over-eating, under-exercising, smoking. Can I add drinking alcohol and using illicit drugs to the list? I do, however, sometimes feel a need to remind people that smoking is bad for your health (it seems to be one of the few behavioral issues we're fairly certain of) and it may well be that using illicit drugs makes it harder to stabilize one's mood. So far, very few people have changed their behavior simply because I've suggested it would be healthier. And fortunately, so far, very few people have left treatment when I've repeatedly suggested they change their behavior. Sometimes I add that if they don't do so, I may be limited in my ability to help them.

I do feel kind of obligated to state the obvious from time to time. I don't think I scold, and sometimes I wonder if I was firmer, more insistent, or more threatening, might I be more successful in getting people to change their behavior? The fact is, I don't have that in me, I don't really believe it would make a difference in anyone's motivation to give up their addictions, and I believe a physician's role is to treat illness and be compassionate, not to reprimand.

ClinkShrink, of course, just puts them in Lock Down.

Here's When You Need A Psychiatrist

Have we written this one yet? I seem to think that Roy, our Consultation-Liason Boy, may have done this.

This is just my opinion, it's written with the non-shrink doc in mind, and it assumes access to psychiatric care:

So when should a patient be referred to a psychiatrist for care?

• When their distress due to psychiatric illness is such that they can't contain it and are driving the primary care doc nuts.
• Any patient with the new onset of a psychotic illness should initially be stabilized by a psychiatrist (this is just my opinion) if they are willing to go. Psychotic illness: any illness accompanied by hallucinations and/or delusions. Psychosis is frequently seen in Schizophrenia and Bipolar Disorder, but can also be seen with depression, delirium, and a host of other non-psychiatric illnesses. If the patient's hallucinations are caused by a brain tumor and they resolve with removal of the brain tumor, then the psychiatrist may not be necessary. Maybe Roy can write us a "causes of psychosis" post.
• For depression: my conservative rule would be to refer after the patient fails one antidepressant medication given at a therapeutic dose for long enough. What's a therapeutic dose: I go as high as a) the patient will tolerate or b) to the highest recommended dose (which ever comes first). If a patient can't tolerate more than 50mg of zoloft, well, this isn't a full trial. Switch to another med and try to get the patient up to a full dose. Wait AT LEAST four weeks (the mantra is 3 to 6 weeks) on a good dose. It's not uncommon to get a patient who has been on small doses of many anti-depressants, none for very long. And primary care docs aren't the best at augmentation strategies.
• Any patient with Bipolar Disorder needs a psychiatrist to stabilize them, and a psychiatrist available for management of episodes. If someone has been stable on Lithium for the past 8 years, they don't need a psychiatrist to prescribe it.
• When prescribing that first antidepressant, ask every patient with depression if they've had a manic episode: "Have ever had a time when your mood was too good, when you had excessive energy and needed less sleep, when you talked faster than usual, your thoughts raced, you were more impulsive than usual with regard to spending or sex?" Anyone who doesn't look at you like you're nuts for asking this needs to be questioned in more detail about manic episodes. If the patient has a history of even one manic episode, you're dealing with Bipolar Depression and prescribing antidepressants could be very risky-- not a bad time to refer.
• Don't prescribe Xanax for a chronic anxiety disorder. It's hard to treat patients who get dependent on xanax and it's hard to refer them if they end up on high doses.
• Any patient with a recent serious suicide attempt or recent psychiatric hospitalizations should be stabilized by a psychiatrist.
• Any patient with any psychiatric disorder that is compromising their ability to function, who does not improve after two to three months of treatment, should be referred for psychiatric care-- so OCD or Panic Disorder that is not getting better quickly.
• If a psychiatric disorder puts anyone's life at risk, it's probably more than a primary care doc wants to or should deal with.
• Any patient who is being treated by a primary care doc for a psychiatric illness should be asked if they want to see a psychotherapist (a shrink or a psychologist or a social worker or a nurse therapist). The patient may say that the pills have cured their depression and they don't need to talk. In the absence of information, this should be respected. But the gentle offer of a psychotherapy referral should be made early.

Sorry, a little haphazard, maybe Roy can come in and add an addendum....

Everybody Doesn't Need Psychotherapy

There, I said it. And primary care docs do just fine at treating many cases of depression. Everybody doesn't need a psychiatrist. There, I said that, too.

So, with my years of experience with my psychotherapy practice, here is my bullet-point formula for who needs psychotherapy:

• Oops, I don't have one.

I have no idea. Some people find that psychotherapy is essential to dealing with mental illness. Some people find it helps them sort out their maladaptive behavioral patterns and enables them to stop doing the same things over and over. Some people...oh I could go on and on. I touched on this in my post You're Supposed To Get Better, back in July, when I did go on and on (so what else is new?). The bottom line: there are people who come willing and readily to therapy, they talk openly about their problems, they do the work of therapy, and they don't get better, they don't change, but if they get comfort from it and it helps sustain them through their suffering, that's good. Only some people don't even find therapy comforting. Other people resist coming, "My primary care doc's been telling me to call you for two years now." They come in begrudgingly and filled with skepticism, talk about their problems, often for not all that long (a few weeks, a few months, maybe less) and they get a lot out of it. "I wish I'd come sooner."
Some people come, don't say much of anything, but still get better, feel comforted, or find that it's helped them to change.

My next post will be When To Refer. Maybe later? It's a holiday, so we'll see.

And finally, the Shrink Rappers met yesterday to do a couple of podcasts. They were both themed, though apparently Roy plans to post the second one first, so we had the pleasure of talking about the "last podcast" before it was done. So, if I have this right, Dr. Chris Kraft joined us for the "first" show and we talked about the Sexual Re-Orientation treatments. If ClinkShrink is our walking encyclopedia of Prison History, well Chris knows an awful lot about the history of Sex! The 'second' podcast is a discussion about the appropriate and inappropriate uses of Benzodiazepines. Essentially, the show consists of the three of us Screaming at each other. So I promised a series of posts on benzos, perhaps I do short ones as a prelude to the My Three Shrinks bloodiest podcast ever.

The best part was going out for Indian food after. I am the type of person who always enjoys eating a good meal with friends.

Dropping By

My office is in a building with lots of other offices and some stores. It's not uncommon that friends will mention they've been in the building for a reason, or they might say they're going to be there and might drop by. I generally suggest that they not do that-- I see patients back-to-back most days, it's more than a bit awkward to have my personal life intrude on my professional life, though I don't want my friends to think I don't love seeing them, just not during the work day.

Yesterday, between sessions, I got this text message from a friend, "I'm in the building. U there?"

I called and said, "I have to see a patient quickly, come up in a little bit."

It felt like a funny, meant-to-be sort of thing set up by the cosmos. I didn't tell the friend all the details, but I did have a patient scheduled that hour only the night before she'd called and said she forgot what time the appointment was. I told her (same time as friend showing up), but as an afterthought I added that I had another time available later if that was more convenient. It was, she took it, thereby freeing the cosmic time slot. And you know I don't do "med checks" but the patient I'd scheduled into that time is the only patient in my entire practice that I see for brief med checks-- a patient who came to me completely stable with no symptoms or side effects, no desire for psychotherapy, who could easily be managed by an internist (and has been told that) but he wants a psychiatrist to write his prescription.

Friend came up and we chatted. He sat where the patients sat, I sat where I sit. I'm not the quietest of therapists, but when I'm doing psychotherapy, it's all about the patient. I got to talk about me. He looked around, asked about the position of the clocks. Why doesn't the patient get to see a clock? Why don't I have a desk? We talked about some other stuff. I didn't ask if he needed more meds. He left when the hour was up. I wondered if he felt funny that the patient in the waiting room must have thought he was a patient.

It was nice to see you, Roy.

Roy: Healthcare Truth & Transparency Act

I've been a lax blogger (working too hard). SHP inspired these thoughts.

This from the APA today:

RE: New APA-backed U.S. House Bill Attacks Consumer Confusion about Physicians and Non-Physicians

We are pleased to let you know that today Representative John Sullivan (R-OK) and Representative Gene Green (D-TX) introduced bipartisan legislation to help safeguard patients from misleading claims by healthcare providers about qualifications and training. Representatives Sullivan and Green were joined by Representatives Michael Burgess (R-TX), Joe Schwarz (R-MI), Charles Bass (R-NH), Michael Bilirakis (R-FL), and Pete Sessions (R-TX) as original cosponsors.


The bill, the Healthcare Truth and Transparency Act, will promote patient safety and informed choice by better distinguishing between physicians and non-physician groups who create confusion by their apparent efforts to cloak themselves in the medical or physician label. As an example of the potential for consumer confusion, your DGR provided our congressional leaders with examples of the growth in the use of "medical psychologist" -- a misleading and frankly meaningless term that is the creation of those in organized psychology who seek prescriptive authority by state legislative fiat, not by virtue of medical education or training. The Sullivan bill says that:


‘It shall be unlawful for any person who is a licensed health care service provider but who is not a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine to make any deceptive or misleading statement, or engage in any deceptive or misleading act, that deceives or misleads the public or a prospective or current patient that such person is a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine or has the same or equivalent education, skills, or training. Such deceptive or misleading statements or acts shall include advertising in any medium, making false statements regarding the education, skills, training, or licensure of such person, or in any other way describing such person’s profession, skills, training, experience, education, or licensure in a fashion that causes the public, a potential patient, or current patient to believe that such person is a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine.’


As part of our ongoing efforts to deal withnon-physician scope issues, the APA has also joined a coalition of medical specialties and the AMA in foundingthe Coalition for Health Care Accountability, Responsibility and Transparency (CHART), which is committed to promoting and supporting the Sullivan bill.


Both the Sullivan bill itself, and APA's membership in and support for the CHART organization, together with APA's founding role in the AMA scope of practice center, are concrete examples of our continuing efforts to proactively respond to the psychology prescribing struggle. We hope theapproach taken by the Sullivan bill willoffer our District Branches and State Associationsa template for relatedefforts in the states. At a minimum, enactment of the Sullivan bill will provide a means at the federal level of addressing efforts by non-physician groups to use tactics that may mislead and confuse the public. As part of our ongoing campaign to assist our District Branches and State Associations, APA is also working on other legislative "templates" that we hope will be of use in playing offense as well as defense in the states.

Trick-cycling's post about nurse practitioners and physicians, along with today's well-timed announcement, made me think of posting this. I do find still that many folks don't know their ologist from their iatrist. Now there's the urse actitioner. The legislation would require these non-MD providers to correct patients, when asked the question, "What's up, Doc?"