The Doc and the Cell Phone

I debated calling this The Shrink and the Cell Phone, but I don't think the cell phone problem is unique to shrinks.  Maybe it should be called The Person and the Cell Phone.

Oh, I remember the good old days, before cell phones, before answering machines, before texting, chatting, Facebook, email, and even call waiting.  Okay, I remember black and white television with three stations and you stood up to change the channel and there were no curse words.  I remember rotary phones.  Oh my, just saying this, I feel a million years old.  

Unlike some old folk, I don't think many of these new-fangled inventions are a bad thing.  I remember waiting by the phone for calls, not wanting to leave the house if I was hoping a boy would call, missed connections where I was in one place and my friends were in another, and the general anger that one felt toward a parent or sibling who wouldn't get off the phone when there were important social engagements to be honored.

Almost everyone I know over the age of ten has a cell phone now.  They have their own numbers and you can text or call them and the expectation in our world is that one is available.  Unless of course they don't want to be.  Don't charge your phone? Perhaps you're passive aggressive.  Forgot it again, maybe you've a touch of ADD?   Harry picks up for everyone but me....could I be getting a tad paranoid?

So cell phones have replaced pagers and every doctor I know has a different relationship with theirs.  Some give their numbers out freely, others do not tell their cell numbers to patients.  So the first question is Who Gets the Number?  Is there a line of defense to screen calls and protect the doc from patients who might interrupt them with trivial concerns while they are with patients, sleeping, or simply don't want to be bothered?  Many doctors direct patients to an office number where staff decide what might warrant calling the doc's cell phone.

The second question is what to do about the calls that come?  Is the phone left on at all times, so that it interrupts patient appointments, bubble baths, dinner with the family?   This, I believe, depends on how crucial the doctor is (or perceives himself to be) and his/her individual personality.  If you're the only attending coverage for the ICU and the housestaff is to call you with emergencies, you probably are obligated to leave it on when you're on call.  I know plenty of psychiatrists who leave their cell phone on as an emergency number around the clock, take calls during sessions, and when they are busy with social obligations.   I also know plenty of doctors who don't return calls even if they are identified as being important.

I don't think there is an exact answer to this.  Individual psychiatrists are often their only coverage, besides the obvious, "If this is an emergency, call 911 or go to the nearest ER"....and while many docs feel obligated to take emergency calls, it may not be reasonable to assume a psychiatrist is never going to leave the phone in the other room, go for a swim, or turn it off in a movie theater.  

I think I have the ultimate love-hate relationship with technology.  I like all of it, but I feel compelled to check so many things, so many times.  My sanity hangs in the balance.  I give everyone my cell phone number, but if I don't recognize the number, I let it ring to voice mail -- I get lots of spam calls, I seem to be on every shrink head-hunter's list.  I also don't answer the phone during sessions, while I'm in the shower, when I'm asleep, or when I forget to turn the phone from silent to ring.  I don't answer when I'm at the movies or swimming laps, or in the grocery store, or in a restaurant or anywhere I can't have a private conversation.  I usually listen (except in the movies or if I'm submerged) to make sure it's not an emergency, in which case, I return calls sooner rather than later.  It's a mix, I hope, between being available, and having some control over my life.

I know shrinks who take all their calls immediately because they worry that a patient might be calling when they are on the verge of doing something bad -- and maybe the shrink can persuade them not to? -- or because a patient might be having a crisis or emergency.  Is any given shrink, I wonder, really able to alter an outcome, to talk a patient out of doing something horrible and irreversible, by being available immediately, 100% of the time?  Is immediate availability a standard we should set?  Does it set the stage to say that if only you'd answered the phone, then bad things wouldn't have happened?  

What do you think?  

Podcast #67 : Things Get Flighty.

Podcasting got off to a slow start today.  We haven't done this in a while, and ClinkShrink recently upgraded her computer to Lion and it was not compatible with our MultiMix8FireWire mixer.  It was a long time trying, when Clink realized she'd downloaded a new driver without plugging the mixer into her computer.  She started the process over, and once it actually worked, there was the distraction that Clink and Roy both kept noticing birds at the bird feeder on the deck and Clink would have to stop what she was doing to take photos with a lens that doubles as a full-sized baseball bat.  The photo above is one of Clink's visiting birds.

Now there is some issue with a hat, and who knows what Roy is doing in the kitchen, but we're only two hours behind schedule, and I was late, so what can I say.   

Today's topics include:

Roy spoke with folks at the American Association of Technology in Psychiatry about how Electronic Health Records have not lived up to their promises.  In Michigan, there's a law that makes it a felony for a medical professional to put wrong information in, yet "the software requires you to commit a felony."  Here's a link to the Michigan law.

Roy talked about an Australian hospital where someone got in trouble for falsifying wait times in the electronic health record.

We talk about Rob's blog post: A Funny Thing Happened on the Way to Meaningful Use while we're rambling about electronic medical records.


Dinah mentioned the little bit of research she'd done on e-prescribing.  


We talked about Dinah's novels, past and future, including Monday at the Charm and her soon-to-be released novels on Amazon.  Home Inspection will be available as an e-novel on Kindle, momentarily.  No link quite yet.

We gave a list of our upcoming public talks-- these are in our sidebar.

And finally, we talked about the New York Times Magazine article called When My Crazy Father Actually Lost His Mind by Janeen Interlandi.

The winner of our podcast contest, mentioned at the end of our Jan 7 podcast, was "rossflem".   And now I know what the hat was for-- Roy was pulling a name from it! We'll be sending Ross a signed hardback copy of our book, "Shrink Rap: Three Psychiatrists Explain Their Work." 

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.

Power Outage Disorder, Moderate, Recurrent, With or Without Psychotic Features

Here in the Mid-Atlantic, we've been having issues.   In fact, we've gotten a whole new type of weather event, the wretched Derecho.  And, to think, I believed I'd heard of all types of weather.  Mostly cloudy.  Partly sunny.  Rain.  Wind.  Cyclone.  Typhoon. Toronado.  Tsunami.  Hurricane. Gale-force winds.  Snow.  Blizzard.  Hot & Humid (we do that well).  Fog. Hail.  Wintry mix.  Now we have derechos.

Known as a derecho, the string of storms combined intense lightning and rain with hurricane-force gusts as it swept from the Midwest into the mid-Atlantic Friday night. Meteorologists blamed the violent weather on the prolonged 100-plus temperatures that blanketed the eastern United States last week. 

Derechos typically form when an atmospheric disturbance lifts the warm air in regions experiencing intense heat, causing thunderstorms and hurricane-force winds to develop, AccuWeather meteorologist Brian Edwards said. Traveling at an average speed of 60 miles per hour, Friday's storm took 12 hours to cover more than 700 miles before reaching the Atlantic Ocean. 

Okay, so I admit, I was not here for the event.  I was in the tropics, enjoying sunshine and 85 degree weather (70's at night), far away from the heat of my hometown, only to return north to massive power outages, downed trees, and 102 degree heat without air conditioning.  I spent my first day back in a laundromat, chatting with another psychiatrist while my laundry twirled and my laptop and phone charged.  Funny, I imagined that laundromats would have upgraded since my younger days and have air conditioning and wi-fi, but that was not to be.  

By 10 o'clock last night, I was one of the lucky ones.  My power returned to both my home and office.  It returned before I had cancelled my patients--my office mates were less optimistic and it made for a quiet day in the suite.

The joy of social media, 3G, 4G, and constant connectivity is that one can make interesting observations about how power failures/ cable outages/ and technology failures-- as people post their angst on Facebook.  I will tell you that I've noticed that the symptoms one sees with power/cable outages and the resultant rise in body temperature and withdrawal from technology...well, it all looks a lot like what we see with psychiatric disorders.  Maybe a diagnosis for DSM-5-revised?

• agitation
• marked irritability
• sleeplessness
• restlessness
• pacing
• decreased socializing (especially as the food goes bad and the beer gets warm)
• decreased motivation
• repetitive pushing of power buttons on non-functioning devices
• Feelings of helplessness
• +/- guilt
• boredom
• indigestion &/or nausea
• fear and a sense of impending doom
• anxiety
• frizzy hair

What symptoms do you experience in a power outage?  

WhatsMyM3?

NBC-4 News Clip from Doreen Gentzler (May 16, 2012)

What’s your mental health number?

This is the question that the Bipolar Collaborative is asking, using its WhatsMyM3 screening tool [PubMed]. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.

~from Clinical Psychiatry News

Today's USA Today newspaper ran a story titled, "Screening for mental illness? Yes, there's an app for that," by Michelle Healy.


WhatsMyM3 is a validated, 3-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time.

One of the developers, Michael Byer, approached me about a year ago for my opinions on development and use of the screening tool. Disclosure: After reviewing the research and seeing how useful it is, I have become more involved in the organization, becoming an adviser to the group that was started nearly ten years ago by past NIMH chief, Robert Post MD. (listen to podcast #63)

It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional -- they only measure one domain of symptoms. The M3 is multidimensional, measuring four areas of symptoms. Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83% sensitive in finding true positives and 76% specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety.

Put another way, the negative predictive value of the total score is 89%, meaning that if you score under the threshold, there is an 89% chance that you do not have any mental health diagnosis by the MINI. As with most screening tests, you want the negative predictive value to be high so that you don't have to subject the "negatives" to more specific testing. The positive predictive value, or PPV, is generally lower for screening tests. It is 65% for WhatsMyM3, meaning that if you score positive (total score >= 33 and positive for functional impairment), the odds of you having a diagnosis is almost two-thirds. A clinical evaluation can then help to determine if you do have a diagnosis. (Note: this tool cannot give you a diagnosis; it can only describe your relative risk of having, or not, a diagnosis.)

What people have found to be most helpful is using WhatsMyM3 to monitor their symptoms over time once they do have a diagnosis. This can be done for free on the website, or for $2.99 using the iPad or iPhone apps, or the Android app. For mental health clinicians, they can download the free M3Clinician iPad app and then screen their own patients. For about a dollar per screen, they can register their patients who want to track their symptoms over time and share their scores with the clinician. Primary care providers also purchase screens, and can even obtain insurance reimbursement by billing for an annual health risk assessment. The patient reports can be viewed by logging into m3clinician.com.

A sample report for a fake patient can be viewed here.

I think this sort of tool, or app, is exactly the sort of mHealth thing that empowers consumers to better manage and become engaged in their health care needs. This is happening in other areas, like diabetes, heart disease, and obesity. Mental health is also making great strides in mHealth.

---

I should also point out here that the folks at M3 Information were the only ones to take us up on our offer of a free "advertisement" on Shrink Rap in return for donating at least $200 to our NAMIWalk for Mental Health Month (we don't typically accept display ads). A logo ad will be running soon on Shrink Rap soon for two weeks in recognition of their charitable donations. It will look like this and link to the iPhone and Droid apps. [We received no money ourselves from M3 nor from NAMI. We've never accepted any money from Pharma companies, nor does M3.]

Yet Another Entry for DSM-V: Nomophobia?

From The Indian Journal of Community Medicine, a study by Dixit, Shukla, et. al.


Nomophobia(1) literally means no mobile phobia that is the fear of being out of mobile phone contact. If a person is in an area of no network, has run out of balance or even worse run out of battery, the persons gets anxious, which adversely affects the concentration level of the person. In recent times there seems to have been a transformation of the cell phone from a status symbol to a necessity because of the countless perks that a mobile phone provides like personal diary, email dispatcher, calculator, video game player, camera and music player.(2) Indian market has emerged as the second-largest market after China for mobile phone handsets. Our study was undertaken to find out the prevalence of nomophobia in the Indian scenario considering the tremendous increase in the number of mobile phone users in the past decade. We decided to conduct the study in our college since the younger generation is the latest consumer of the mobile phones, and the under 25 year age group in professional colleges like medical colleges use mobile phones quite frequently since most of them reside in hostels. Day scholar students too want to be in constant touch with their family members and friends since they are out of their homes for the whole day and at nights while studying in colleges and working in hospitals.

The study goes on to say:


A study from United Kingdom on 2163 people revealed that 53% of the subjects tend to be anxious when they lose their mobile phone, run out of battery or credit or have no network coverage. The study found that about 58% of men and 48% of women suffer from the phobia, and an additional 9% feel stressed when their mobile phones are off. About 55% of those surveyed cited keeping in touch with friends or family as the main reason that they got anxious when they could not use their mobile phones.(1) A study conducted by Market Analysis and Consumer Research Organization (MACRO) in Mumbai to study the various patterns and association of mobile phone usage reported that 58% of the respondents could not manage without a mobile phone even for a day.(2)

Podcast 64: Brain Freeze

Happy Holidays, everyone.  We taped this a few weeks ago, but Shrinky Podcasts always make for good holiday chatter.   Today we talk about 
1) Brain Freeze-- inspired by a Well article in the NYTimes for 11/10 on Rick Perry's Brain Freeze.  You'll note that in this podcast, Dinah reads Roy's mind, and no has brain freeze from eating cold ice cream.  We kind of ramble, and so what else is new?  We talk about memory and attention and learning and Dinah explains why men don't take out the garbage during football games.  Clink talks about the scientific phenomena of "brain overload."

2) Siri-- ah, we did this podcast right after I got my new iPhone and it was new and exciting and I was working on an article on Siri and the Psychiatrist.  We ask Siri where we can buy a duck and when the world will end.  Apparently we have 5 billion years.  And Sigourney Weaver was 62 years, 1 month, and 5 days old at the time we recorded.


3) Prison Food-- inspired by a lawsuit in which a prisoner contends that the soy-based food being served in prison is 'cruel and unusual punishment' which caused him cramps. Clink talks about how prison food is handled.  She also talks about nutrient rich Nutraloaf that can be eaten without utensils and she discusses an NPR story which includes the recipe for anyone who would like to try nutraloaf. 


If you'd like to try it:
Special Management Meal
Yield - Three Loaves

• 6 slices whole wheat bread, finely chopped
• 4 ounces imitation cheddar cheese, finely grated
• 4 ounces raw carrots, finely grated
• 12 ounces spinach, canned, drained
• 2 cups dried Great Northern Beans, soaked,
cooked and drained
• 4 tablespoons vegetable oil
• 6 ounces potato flakes, dehydrated
• 6 ounces tomato paste
• 8 ounces powdered skim milk
• 4 ounces raisins

From Clink: You mispelled nutraloaf. Don't worry, I fixed it. Also, by pure coincidence today's correctional nursing topic on Lorry Schoenley's Blogtalk radio show was all about managing food allergies in corrections. For those of you who want to know what happens to inmates with peanut allergies, here it is directly from someone in the know.

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.

Guest Blogger Dr. Jeff Soulen on the Pros of E-Prescribing

Over on our Clinical Psychiatry News website I'm writing about my struggles with electronic prescribing.  The post, "To E-Prescribe or Not? That is the Question" will be posted on December 7, 2011.  In order to write it, I bothered just about every shrink I know, or it least it felt that way.  One of the psychiatrists who was kind enough to respond with a great deal of useful information was Dr. Jeff Soulen, a psychiatrist in private practice, who has had a positive experience.  This is Dr. Soulen's first experience as a blogger. 
------------------------------------------------------


I've been using Allscripts for about 3 years now, and I must say I like it a lot. It's free (no need to sign up for the paid Deluxe version) with a browser-based interface, so I can access it anywhere -- helpful when I'm away from my charts.  I pretty much do 100% of my scripts electronically except controlled substances, for which it's still illegal to e-prescribe. What I like about it:

• I see a list of every script my patient has filled, including those from other docs, though this information is sometimes spotty. It's led to some important discussions about controlled substances I didn't know the patient was taking, drugs that have interactions with the ones I'm prescribing, etc. Kind of wondrous to enter a patient's name, zip and birth date and 5 minutes later the whole list is on your computer screen.

• Patients love it.  Once they are in the system-- which takes a couple minutes the first time-- it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them - no need to bring a paper script and wait.

• For repeat scripts, it's faster than hand-writing - select from the list of scripts you've sent previously for that patient and send.

• No more transcription errors from a paper or phoned script.

• It's been a huge time-saver in that I no longer get calls requesting refills of scripts where I wrote refills, but the pharmacy in their rush put 'no refills' in their computer. This used to happen a lot.

• All the mail-order pharmacies seem to be tied-in at this point, so sending mail-order scripts electronically is as easy as sending to a local pharmacy. Way faster than filling out fax forms by hand, then faxing them. And patients seem to receive mail-order meds about 4 daysafter I send an electronic script - significantly faster than faxed or phoned scripts.

It is true that an occasional script fails to make it through the system to the destination pharmacy. So far that's been well less than 1% of the scripts I have sent, and re-sending a script a few times a
year takes much less time than calling patients/pharmacies several times a month to tell them that yes, the original script did have refills on it.
 
If you want to prescribe from a smartphone, you have to purchase the Deluxe version.  I don't know how much that costs.

Bottom line, for my solo private practice it's been terrific -- faster and more accurate for me, gives me information on drugs my patients are taking and have failed to mention, and patients love it. I e-prescribe for all those reasons, not because of Medicare penalties.
----------------------------

If you surfed over to the CPN article, you'll know that my experience with e-prescribing has not been as happy as Dr. Soulen's.  Of course you're invited to tell us about your experiences...

Podcast 63: The Bystander Effect

These are the topics we talk about:
The Bystander Effect and why people don't call for help when they see violent crimes.  While we don't talk about the events at Penn State, this was the inspiration for this topic.


From this we go on to talk about legislation that has been proposed to make it a crime for health care workers (including shrinks) to not report child abuse.  As is, there are mandatory reporting laws and licensing implications for those who do not report instances of child abuse.


Finally, we move on to happier techy stuff and discuss Depression Rating Apps.

Roy reviewed iTunes apps with the keyword "depression" which met the following criteria: Medical category; a rating of at least 3 stars, and at least 100 ratings. Five apps came up:

• 3D brain (9600 ratings: not a rating tool but a nice 3D map of the brain)
• Sad Scale Lite (800 ratings: uses a Zung depression rating scale)
• DepressionCheck (700 ratings: uses a 27-item validated screen for depression, bipolar, PTSD, and anxiety)
• Moody Me (600 ratings: an emoticon-based mood diary)
• Health through Breathing: Pranayama (300 ratings: not a rating tool, but a highly-rated meditation tool)

[Disclosure: Roy has consulted for M3, the makers of DepressionCheck.]

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.

Technology and The Shrink-- Hello, Siri.

Technology seems to be the theme of the moment here on Shrink Rap.  We're all playing with new toys and trying to figure out what makes them fun and what makes them useful to our work.

For this week's post on Shrink Rap News over on the Clinical Psychiatry News website, I have an article up on Siri and the Psychiatrist.  Some information that might be useful to anyone who is thinking of incorporating this technology into their practice, and oh, a little tongue-in-cheek humor there with many thanks to Dr. Bob Roca at Sheppard Pratt and Dr. Paul Nestadt at Johns Hopkins who both allowed me to quote them during their more playful moments.  There is also a techy post up on  Shrink Rap Today over on our Psychology Today Website with links to some of our past technology posts.
 
Roy is trying to figure out how to use his iPad to interface with Electronic Medical Records and wrote about it last week for our Clinical Psychiatry News SR blog, see iPad: The New Black Bag.  His last post on Shrink Rap was about Depression Apps, and he inspired me to add the Moody Me app to my own iPhone.  I haven't tried it yet, but I'll let you know how it goes, but the colorful smiley faces were more than I could resist.  Depression Apps will also be a topic in one of our upcoming podcasts. 

Okay, so if you read my post on Siri and the psychiatrist, it will make me happy:

If you comment on it, it will make me really happy:

But be nice, I don't want to be sad:

Privacy, Please?

Anon commented on my last blog post about clinical uses for Siri on my new iPhone:

"From the details in your contacts, it knows your friends, family, boss, and coworkers. "

That was from Apple's web site, regarding Siri. If you are using Siri for clinical purposes, know that Siri tells Apple everything. Siri--usly, how do you protect patient confidentiality if Siri/Apple knows so much? Sure, paper files can be stolen, so can cell phones. E files are vulnerable to all sorts of breaches. But what would you do if your iphone 4S fell into the wrong hands with all that clinical related stuff on it? Not quite the same as asking Siri where the closest dry cleaner is.

I find it kind of interesting what people worry about.  I have hundreds of contacts in my phone.  My husband is labeled no differently than my co-workers, than my friends. than my patients.  I'm not sure what it means to have one's iPhone "fall into the wrong hands."  I live in Maryland, so I'm not sure what Apple in Cupertino would do with my information, maybe send iPhone advertisements to my contacts? 


The issue of clinical information is  something I hadn't thought about.  I downloaded an app yesterday specifically for GoogleDocs, and it imported all my documents.  We wrote our book on this, so every chapter and every revision is now accessible on my phone, not to mention my posts for Clinical Psychiatry News and an unpublished novel or two.  I downloaded the app so I would have the option to dictate patient notes.  This would leave clinical information potentially accessible via a cloud or on the phone.  I'm not sure it's all that interesting.  My notes are usually pretty boring.  But I did think that I would print them and then delete, rather than have to deal with keeping charts in order in cyberspace.


I guess I find it interesting that people worry about issues of confidentiality with total strangers in places where it's hard to imagine a use for what is likely to be pretty boring information.  On the other hand, we live in a world where electronic medical records now exist in all types of venues.  I work at a large hospital.  I can access the records of any patient seen there, and if I go to a physician there, his notes about me will go onto the EMR. At this juncture, outpatient psychiatry notes are not on the EMR, just a record of the fact of the appointment (which does say "community psychiatry," and the psychiatrists add their medications, but this will change soon, I'm sure, and psych notes may well be part of the hospital's coming new system.  The patients are not asked, and the doctors they see have access to all records without getting prior permission.  There are very specific rules about whose records a healthcare worker may look at, and people have been fired for looking at their neighbor's records, but someone has to catch you.  This means that a patient would have to ask someone with access to the system to see who had accessed their records, realize that one of those people was not someone involved with their care (Hey, that's my new boyfriend!) and then complain to the hospital and initiate some type of complaint (I think).  There is nothing inherent in the system that prevents one person from looking at the medical records of their coworkers, boss, ex-husband,  or even their doctors, aside from their own conscience and the fear of being caught (and reprimanded).  At this point, and for this reason, I have chosen not to get care at the institution where I work.  


Our state is also working on a system, called CRISP, that lifts medical records from all providers to a centralized system.  You can opt out, but you don't need to opt in: do nothing and your healthcare information goes in.  I opted out, and I got a letter telling me they would keep my information in case I changed my mind.  Wait, so presumably my doctor will be feeding my information into this cloud, without asking my permission?  I don't really know how this will work-- from the shrink standpoint-- because no one has contacted me about putting my professional records into this system, and since my records are all handwritten on hard copy charts, I don't know how this would play out. 


Somehow we've come to think that electronic medical records will mean better care.  I could be wrong, but I'm not really sure why we think that.  It seems to me that the burden this will place on the physician to attend to the devices and the demands of this type of documentation, will consume time and detract from time with the patient.  As is, I've noted it takes about 5 times as long to send an e-script as it does to write a prescription, starting with the fact that the e-system my hospital uses logs me out every 7 minutes.  I'm told this can't be modified, and I'm not aware of any doctor who sees patients faster than every 7 minutes.  Secondly,  an electronic system is only as good as the information it propagates, and I've seen lots of mistakes in the electronic medical records.  The internist notes that the patient is seen by psychiatry and takes Restoril.  Wait, my patient is taking Restoril?  I didn't know this..oh, I think he meant Risperdal.  By my calculation, the number of lives saved by electronic information that is provided when the patient can't provide it himself, will about equal the catastrophes from the propagation of incorrect information.  


So I should be worried that Apple can see my contacts?  My brother, who is an original Caltech computer geek, told me recently that since I have a webcam, it's possible that someone could hack my computer and watch me through my camera.  At first, I was alarmed at the possibility, but then I thought about this for a moment and said, "Why would someone want to watch me type?"  Nothing that exciting is happening here.  Sometimes I don't wear makeup, here and there I stick out my tongue and lick my lips, and okay, in front of the computer, when I'm writing, I kind of talk to myself.  If this might interest someone...

I seem to have my own list of things to worry about.  That someone might hunt my patient information out from the cloud just hasn't yet made my list. 

How Does Siri Help the Mental Health Clinician?

Next week,  it will be my turn to write our article for the Clinical Psychiatry News website.  Over there, we try to have our writing more specifically aimed at an audience of psychiatrists.  I'm going to be writing an article on Siri and the Psychiatrist....in honor of my new iPhone 4s and the "personal assistant" function named Siri.  Okay, I'm obsessed.  Everyday, I find new things it can help me with.  Today, I asked it, "What's the meaning of life."  What, you don't ask your cell phone the finer existential questions?  Siri answered, "All available evidence suggests chocolate."  Wow!  How old is Liza Minelli?  65 years, 7 months, 20 days.  Calculate a tip? No problem.  Convert Celius to Fahrenheit?  A cinch.  And she takes dictation.  "Siri, please text Pt A 'Your lab results are fine.'"  "Siri, please email Jesse, 'Will you write a new guest post for Shrink Rap?' "  Okay, Siri flubs on this....I can't get her to learn that it's Shrink Rap and not Wrap.  I downloaded a Google Documents App so I can dictate....patient notes, my memoir, a few novels, a Shrink Rap post here and there, To Do lists for Roy....  I think I'm set.


So, I'd like your help.  What useful things are you doing with Siri?  How has your iPhone made life as a clinician better? 

Destined to Disappoint?

Tomorrow, I'm going to pick up my new iPhone.  Mind you, I've been an iPhone owner for about 4 weeks now, and I'm returning a month-old iPhone 4 to get a 4s.  I can't wait, the phone arrived today and I've had to restrain myself from going out in the rain tonight and waiting until tomorrow.


I'm looking forward to having Siri be my personal assistant.  For weeks now, whenever I look things up or schedule an appointment or send an email or text, I wonder: Will Siri do this?  Will it work?  Can I tell her to send text messages?  Do I need to switch back to iCal from my Google Calendar?  No big deal, right---I'll just tell her to schedule things and my calendar will be revised and moved in a matter of minutes?  Can Siri phone in prescriptions?  Can she preauthorize my life?   I'm excited as though I'm about to move in with a spouse in an arranged marriage. 


So have I built this up in my imagination? Is it too good to be true? You can bet that if Siri texts, Roy and Clink will be the first to know my new iPhone has arrived.  I'm finally going to be the kid on the blog with the newest toy: it's never happened before!

-----------------------
On another note, I am feeling rather cool.  Our Shrink Rap book was scraped by a Hip Hop site!
 --------------------------
David would like to be credited with the title for this post.  Who knew?

Toys!!!

I think I have officially caught the Toy Disease.  It's taken a long time, but oy, I've got a bad case.  

For starters, after losing my Macbook, I bought a new one and decided I should simultaneously fix all my techno problems.  My phone had terrible reception and many of my calls.  I got a new Samsung phone, a touch screen, and it was awful.  It dropped my calls, it switched to speaker if my face touched the screen, I couldn't cradle it on my shoulder and talk to Camel while I cooked dinner...not good.  I surrendered, and after many years of happiness with my dumb phones, I gave in, risked the last vestiges of anything that might resemble sanity, and bought an iPhone.  Excited, I came home to have teenager greet me with, "Why did you get that, a new iPhone is coming out in 3 weeks."  So, I went back to the phone store (I am now the most-recognized customer), and ordered a new iPhone 4s and am eagerly anticipating the arrival of the new phone.  I can't wait to meet Siri and have her negotiate all my problems. 

Okay, and a while back, I asked Shrink Rap readers to help me decide between a Nook and a Kindle.  I decided on a Kindle, but never got one.  And then I read about the new Kindle Fire.  Oy.  I've pre-ordered one.  

Now I'm thinking I "need" Apple TV.  What is wrong with me?


Finally, I have some questions for our readers:

• Dropbox or iCloud?
• Apple TV: yes? no?
• How's it going with Siri?  What's the coolest thing you've asked it (?her) to do?

• 
  

Podcast #60: On the Verge

Please take our sidebar poll and tell us who you are.
  If you don't know who you are, please guess.  

In Podcast Number 60, we discuss the following:

Questions from readers--

• Sarebear asks: What is a Nervous Breakdown?
• Mary and Max, an award-winning claymation movie about an 8-yo girl and a middle-aged man with Asperger's. Very educational about Asperger's, and extremely entertaining.
• Another reader asks: How are psychiatrists prepared to manage psychiatric disorders in patients with autism?

• The New York Time review of a movie, Beautiful Boy, which led us in to a discussion of guilt and blame and our desire as human beings to believe we have control over what happens to us.  Too bad none of us saw the movie.

• Clink talks about an article that appeared in the Archives of General Psychiatry, National Study of Suicide in All People with a Criminal Justice History.

• Finally, we talk (or perhaps "ramble" is a better word) about the psychology of podcasting.

Thank you for joining us!

****************************

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.

Calling All Would Be Forensic Psychiatrists...&...Wiki Your Diagnosis

Over on our Shrink Rap News blog, ClinkShrink has a post up on how to find the perfect Forensic Psychiatry Fellowship. She'll walk you through what to look for and how to apply. If you have the makings of an amazing forensic psychiatrist, please do apply to Clink's program.

_______________________
Over on Thought Broadcast, SteveMD has some ideas about how to improve on the process of creating DSM-5. He proposes a DSM-wiki. This one made me giggle out loud:

Patients could also upload their own experiences, in YouTube format. Their videos would be cross-referenced to the relevant diagnoses and/or medications. Videos with the most “hits” could win a prize. Maybe we can link terms to their Urban Dictionary entries.

We could add clips from Hollywood movies depicting particular disease presentations. We could add links to Amazon.com to purchase relevant books (and use the Amazon Associates revenue to help manage server costs). We could include a Skype plug-in that would allow users to chat with other people logged on at the same time. We could even sell space to advertisers like Groupon (“10 sessions of psychotherapy for the price of 5 in Chicago!!”) or, for those over 21, porn sites (targeted specifically to readers of the “Paraphilias” entry).

Social media is the future, and the APA really needs to get with the program! An animated GIF logo. An MP3 theme playing in the background of each page. A Flash-based interface (sorry, iPad users). The APA could even create new, edgy slogans for itself and for the DSM. For instance, it’s not DSM-5 anymore, it could be “D5M-ph!\/3″. It’s not just a “living document,” it can be the most 4w3soM3 social media psychiatry destination on the planet! OMG!!!!!!1!

________________

Finally, don't forget to submit your hot-to-trot Grand Rounds Submission with a pic. Roy's coals are hot and he's ready to cook!

Submissions are due on Sunday by Facebook on our Shrink Rap Book page, Tweet to ShrinkRapRoy, or email us at Shrinkrapblog at g mail dot com

Today's Shrink Rapper News

1) Our book is now out on Kindle. Apparently, you can get it in a minute for $10.

2) One of my old posts is up on KevinMD, Predicting How Much Impact Mental Illness has in a Person's Life.

3) In June, we hope to have another component blog up and running---Shrink Rap News-- we will be doing weekly posts on the Clinical Psychiatry News website. Those posts will target an audience of psychiatrists. Oh, we started with that idea here at Shrink Rap, but the readers we found, both shrinks and non-shrinks, have proven to be so much fun!

4) Aloha! We're getting ready to go to Hawaii for APA-- Roy will give you details about where to find us shortly.

5) Frazzled and frizzled, I did what I've never before done today: I blew off my hair stylist! Not on purpose, but I thought my appointment was 3 hours after she thought it was. Ah, you ask, did she charge me? Do hair stylists charge for No Shows? (They should). No, she had time for me later in the day, and Yes, if I can reschedule a patient who has forgotten an appointment on the same day, I don't charge for the 'missed' session. Someone would have asked that, right?

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?

Psychiatry and LiveScribe

I'm not a big toy person (I don't think). I didn't stand on line for an iPhone, I don't have a Kindle---I actually read these old paper things called books, and I don't greet strangers with, "Wanna see my apps?" Roy and Clink like toys more than I do. But yesterday I was reading the New York Times magazine online (because my hard copy never came, but thank you to the judge who brought me hers) and I came across this article on the LiveScribe pen.

Oh, my: I want one. But for what? It would have been great when I was a student. I was an excellent note taker, but to have been able to re-listen to lectures on specific parts of my notes--that would have been really helpful. Now? I take notes during the initial interview with patients, and sometimes I reference those notes, but I can't say I ever have any desire to replay the whole interview, or that there are times when this would help with clinical care. Face it, cool toy, but I don't really need it.

So I started thinking about how a LiveScribe might be useful in psychiatry and this is what I came up with: it could help in psychotherapy supervision. Residents take process notes on sessions, but it would be cool to have them selectively play parts of the session. Oh, why not just record the sessions and play the whole thing? Oh, that would work, too, except that it never works. It's rare that a resident comes in with an audible audio recording of an entire session. Despite all the technology, the residents come with the same little cassette recorders that I used...and never worked...year ago.

Just an idea. What do you think? And will Roy get one???

The Texting Shrink

I like texting. It's a fast and efficient way to exchange information, and I'm a bit prone to yakking, so this allows for a no-nonsense exchange without all the gabbing about how the kids are doing or the latest on someone's ingrown toenails, or the usual assortment of small talk items. Running late, order my salad. Yes, Bobby can get a ride home with us. Or, if you're Roy: "do you have triple sec for the mango margaritas?" Roy makes surprisingly good mango margaritas without using any triple sec. Just so you know-- and I don't mean to brag-- I'm fast with the thumbs.

I text with patients as well. Do other psychiatrists do this? It works well for "Need to cancel my session this week, see you next week." Or "Running 10 minutes late, traffic." Once in a while I'll even text a reminder to someone who misses appointments frequently. I was happy to hear that there is a dentist in town who also sends text message reminders.

Here's the problem with texting patients:
People have taken to texting me with problems. "I feel horrible and like I might want to end it all right now." (This did not really happen). I've done a few back and forths and realized that I'm not good at psychotherapy via text. Usually problem texts get met with "Come in at....." and if .... is not Very Soon, or if the patient says that's not good, I call, or text "call me." I've been texted insurance information, drug reactions, appointment changes, negative biopsy results, "will you call refills in to my pharmacy?" and most notably, "Your office door is locked" after I haven't responded to the knocking, only to find my patient sitting on the hallway floor.

What's good about it? Somehow it feels less intrusive than a phone call, and the time taken up is more predictable. I'm prone to ramble and so are many of my patients-- texts messages take seconds and phone calls can take minutes and involve many phone-tag back-and-forth exchanges. When someone texts their pharmacy number, I can click on it and get through--if it's on voicemail, I often have to re-listen when I have a pen available, and often the number is at the end of a long message. It seems to me that texting is no less documentable than a phone conversation, so I can't come up with any legal reasons it's not kosher.

What's bad? I have taken to telling patients that while I'm happy to try to negotiate appointment times via text, or "running late" messages, that it's not a good way to negotiate problems-- for drug reactions and symptom changes, we should start with the phone. My biggest concern is that if I'm on vacation, there's no way to set a coverage text message, and my voicemail has the names and numbers of covering doctors. I've been pretty clear with people that I'm not blowing them off, and that if they don't get quick reply to a text message, they need to CALL the office.

What do you think? It's a different take on the shrink when there's nearly instant access a good deal of the time.

Dear Roy....Love, David Pogue

There's an article in The New York Times by David Pogue and I think it was written just for Roy.

Roy, in case you didn't know, is a really really smart person. He knows a lot about psychiatry, and maybe more about technology. The only thing is, he sometimes assumes that everyone else knows what he knows and speaks his language, and often that language includes a lot of technospeak. Try writing a book with someone like this! Oh, I did. So glad to be done for the moment.

So Mr. Pogue tells us that The New York Times editors asked their writers not to use the word "tweet" anymore for fear that readers wouldn't understand. Mr. Pogue writes:

“We don’t want to seem Paleolithic,” he wrote. “But we favor established usage and ordinary words over the latest jargon or buzzwords.”

That the Internet’s reaction was so swift and harsh only proves the point: the techno-savvy population can’t even conceive of the existence of a less savvy crowd. If you use jargon every day, you can’t imagine that millions of people have no idea what you’re talking about.

I do a lot of public speaking. And even today, when I ask my audience how many know what Twitter is, sometimes only a quarter of the hands go up.

The article goes on to define the basics for the uninitiated: Facebook, Twitter, Yelp (my favorite), Foursquare (Huh?), and Linkedin. Mostly, though, I liked that it made me think of Roy. So Roy, can you imagine a world where three-quarters of the people don't know what Twitter is?