The Psychiatrist as Therapist

[by dinah]

I started this discussion when I agreed with Shiny Happy Person and her frustration with NP prescribers. Maybe I started this discussion with Perception vs. Reality where I referred to a NY Times article titled "Making Patients Happy Doesn't Make Them Well."

First let me say that I work in two settings: I have a solo private practice which is a bit of an idealized bubble-world where I practice psychiatry exactly as I want and I make all the rules (and I never argue with the boss!) and I work as an outpatient Community Psychiatrist, where split therapy is the rule. In this setting, patients are seen for psychotherapy by social workers, sometimes they also have case managers, and the psychiatrist sees them to assess symptoms and prescribe medications. If all is going well and no one is complaining, the patient is seen by a doc every 3 months. If things are not going well, the patient is seen more often, and in the clinic where I work now, the therapist usually is present during the medication management sessions and communication is good. This helps. I started my private practice so I would be able to see patients for psychotherapy, and keeping with my bubble-world wishes, I don't see patients who have another therapist. I've never told someone who is happy with their therapist to stop seeing them, I simply recommend they consult a psychiatrist who has a working relationship with their therapist.

The reality of the world (bubbles aside) is that there aren't enough psychiatrists for everyone in every income bracket in every locality to see a psychiatrist for psychotherapy. That's just how the world is and that's fine. The other reality is that often people in split therapy like their non-MD psychotherapists (and as many have pointed out, often they like them much better) and get good symptom relief from medications prescribed by a doctor who sees them for 15 minutes a month, and they are pleased with their care and have great outcomes.

So why do I think that the best care comes from having one practioner do both therapy and prescribe? Really, it's not the politically correct thing to believe, but I do anyway.

Here are some reasons:

• One-stop shopping is more convenient.
• It's probably cheaper than seeing a psychologist and a psychiatrist (most PhD level psychologists I know charge as much as psychiatrists).
• A psychiatrist who does psychotherapy really gets to know the patients--they aren't just a compilation of symptoms listed on a page. Psychiatric symptoms are often very similar to normal reactions and a psychiatrist who knows a patient well gets a much better feel for when a "symptom" is something other than an indication that a medication needs to be adjusted. Similarly, people often explain away their symptoms and a psychiatrist who follows a patient closely gets familiar with symptoms that could easily be written off and not treated appropriately with medications.
• Being in psychotherapy with a psychiatrist encourages the patient to look at the relationship; in split therapy the patient may avoid looking at important feelings, and if the dynamic gets set that the therapist is the good guy and the psychiatrist the bad guy, the therapist may collude with this in a way that stymies the patient's ability to progress.
• Non-MD therapists (and alas, some psychiatrists) may overlook or explain away episodes of major mental illness such that the patient never gets an appropriate referral for medications. Here lies the risk of Perception versus Reality: a patient may have a perfectly good, caring, helpful relationship with a therapist, feel comforted and understood, but not get Cured (or managed, or have symptom reduction, or optimize their ability to function) because a diagnosis is missed.

So the comments last time, when I agreed with that Shiny Happy Person, talked about how psychiatrists are lousy therapists. Some psychiatrists are lousy therapists. Some psychiatrists have no interest in doing psychotherapy. Many psychiatric practices are not set up for the psychiatrist to do psychotherapy. Some psychiatrists are creeps.

Medications are sometimes helpful when prescribed by a creepy psychiatrist with the social skills of an iguana. Psychotherapy, however, requires some degree of connection, some sense that the therapist can empathize, and without this it simply doesn't work as a treatment modality. There's not a therapist out there who is the perfect therapist for every one, and some people don't like even the best of psychotherapists.

So for my ideal, politically incorrect bubble world: Patients get the best of care when they see a psychiatrist (one they like and are comfortable with) for both psychotherapy and medications.

What A Meth!

I'll say up front that I'm not in favor of government-sponsored addiction. When I was a medical student I did some of my rotations at a local veteran's hospital. It was the only hospital I've ever seen that had a bowling alley. It also had vending machines for cigarettes, which was very convenient for my patients with COPD (emphysema). One town I lived in sponsored a municipal liquor store. The proceeds from the liquor store went to pay for the local alcohol rehabilitation program. And then there's the issue of slot machines to pay for government services, like treatment for gambling---don't get me started.

Thus, we come to the issue of methadone. Methadone is heading our way. Methadone maintenance, long known as a staple of addiction treatment in free society, is expanding to prisons. An American survey of state and Federal prisons showed that only 48% of systems currently provide methadone to prisoners, and then only generally for detoxification or for maintenance therapy of pregnant women. However, a Canadian court recently ordered that a prison provide methadone maintenance to an inmate. Fearing that additional litigation might cause different standards for different facilities, the Canadian Correctional Services took a proactive approach and created a policy to provide methadone maintenance to those already enrolled in maintenance programs. Pressure is on to expand treatment by offering it to prisoners who were not previously on it prior to incarceration.

At this point there is little question that methadone maintenance decreases heroin use and needle-sharing behavior in free society. Preliminary evidence suggests this may also be true in prisons, although current studies are limited by the small number of available programs to study and limited program enrollment. The question remains open whether or not methadone maintenance reduces new cases of HIV and hepatitis in prisoners.

As with any healthcare program, it will add to the expense of incarceration. The cost of this program in one American facility housing 50 inmates was $5000 according to one report, although this report doesn't clarify if this is per inmate per year or an annual total program cost. In Canada the cost is $1700 per year per patient ($1500 USD). In Australia the cost of prison maintenance therapy is $3234 ($2400 USD). Assuming an average cost of $2000 per inmate per year, and a very conservative estimate of 25% of state and Federal inmates who need treatment, this would add approximately $700 million to the annual cost of incarceration in America. The true cost of drug abuse in prison, or the benefit of treatment for drug abuse, is difficult to calculate. Supporters of methadone maintenance often balance the cost of the program against the cost of therapy for HIV or hepatitis contracted within the system. Treatment costs also apparently now have to be weighed against the costs of litigation filed by inmates seeking treatment, or suing for damages for drug-related illnesses contracted while incarcerated.

I've yet to see a cost-benefit analysis on this issue that addresses the effects of methadone maintenance on institutional culture and civillian safety, or even mentions the possible unintended negative consequences of introducing a controlled substance---a free controlled substance---into a correctional facility. This is what this post is about.

Here are my concerns about prison methadone maintenance:

• I don't want to be a drug pusher.
  

  When programs like this get started, administrators usually take it for granted that clinical care will be provided by existing health care professionals. I'm not a substance abuse specialist and I don't have any particular training for the prescribing and supervision of methadone. I'd be willing to bet the cost of the program will not include on-site subspecialty services for this, and the medical providers will consider this a psychiatric responsibility. For once, I'd rather not have prescribing privileges if the expectation is that I will prescribe methadone.

  
  
• Methadone given without rehabilitation or addiction counseling
  

  Similar to mental health services, substance abuse treatment often requires counseling in addition to medication. A correctional system should not point to a methadone maintenance program and say they are providing substance abuse treatment if they are not also providing the relapse prevention counseling and other therapy to go along with it.

  
  
• No expectation that inmate will ever come off maintenance therapy
  

  After seeing some methadone maintenance patients continue on the drug for over ten years, I think the term "maintenance" is a misnomer. At this point users see the drug as an entitlement, not a pathway to abstinence.

  
  
• Decision-maker safety
  

  Programs generally have guidelines for inclusion and exclusion criteria, but these are not necessarily "bright line" rules. There is usually some room for clinical discretion. It will fall to the decision-maker or the decision-maker's representative to tell the inmate whether he is 'in' or 'out' of the program. I've seen what happens when inmates are turned down for programs or services. I don't want to be the one telling the inmate he can't have the free opiate he wants. I already have to deal with inmates who act up or make threats to act up in order to get the sedating medications they want. If inmates make threats now over Thorazine and Elavil, I don't want to think of what they'll do for methadone. I'm not goin to put my personal safety at risk over this.

  
  
• Risk to non-enrollees
  

  When you work in a correctional facility, you have to remember that anything you prescribe will end up in the hands of others in the facility. It's inevitable, even for "watch take" or "directly observed" therapy. Even in free society methadone users have been known to "cheek and spit" methadone for resale. Circulating methadone will pose a risk to non-enrolled inmates and could lead to overdose deaths. It will also enhance the institutional black market.

  
  
• Complication of psychiatric diagnosis and treatment
  

  I don't really need to dwell on point. Drug addiction is a common complicating factor when it comes to making an accurate psychiatric diagnosis. Up to now, one of the nice things about working in a correctional setting was that you could get a relatively good diagnostic snapshot or your patient while abstinent. I could use lower doses of medication because I wasn't fighting against illicit chemicals. And yes, I did know when my inmates were using.

  
  
• Risk of new addiction
  

  Inmates have been known to experiment with lots of unusual things---anticholinergic medication, asthma inhalers, and in a worst case scenario even "pruno" (homemade alcohol brewed in toilets). Some inmates begin abusing substances while incarcerated. Circulating methadone could lead inmates to broaden their repertoire of abused substances if they get a chance to try it while they're locked up.

  
  

Of course, I could be wrong about all this. Methadone maintenance may be the answer to drug-related violence and public health problems, but within the correctional system the jury is still out. I hope I'm just watching for a falling asteroid. I just want to make sure that all of the potential consequences get considered.

Disclaimer: The opinions expressed in this blog are my own and do not represent those of my employer or the state government. Please don't shoot me.

Happy (Belated) Birthday, Canada

Congratulations On Your 139th Birthday!

My blushes for being late. I was busy thinking about an asteroid. I hope your celebrations were terrific.

The Good Breast

[posted by dinah]

This one doesn't get a graphic.

From the opinion section of today's New York Times, "About Breastfeeding..."

If you want to start an argument, mention breast-feeding. A two-year federally sponsored campaign caused a rumpus when it compared a mother who fails to breast-feed with a pregnant woman who rides a bucking mechanical bull at a local tavern, or, in one official's formulation, with a woman who smokes while carrying a child. Recently, a Times article on the campaign incited a new debate that kept the report in the paper's most-e-mailed list for days. While we hesitate to stir things up again, it seems as if this is one issue where the middle ground makes the most sense.

The original article, Breast Feed or Else, by Roni Robin, was published on June 13th and states:

Ample scientific evidence supports the contention that breast-fed babies are less vulnerable to acute infectious diseases, including respiratory and gastrointestinal infections, experts say. Some studies also suggest that breast-fed babies are at lower risk for sudden infant death syndrome and serious chronic diseases later in life, including asthma, diabetes, leukemia and some forms of lymphoma, according to the American Academy of Pediatrics.

Both the original article and the opinion piece it inspired discuss some practical reasons women can't breast feed: the logistics of expressing milk at work, or the mother's inability to produce enough milk to nourish her infant.

From a psychiatric standpoint, breastfeeding is a good thing; it helps with the mother's bonding to the infant while creating an environment of closeness, warmth, nourishment, and comfort-- what could be better?

Neither article, however, mentioned what happens when a mother must take medications. The trend is to not only encourage mothers to breastfeed, but to demand it, and now to create the dictate that to not breastfeed is yet one more form of (granted, not yet indictable: sorry Clink and Foo) child abuse. The issue comes up in psychiatry over and over again in the treatment of Post-partum depression. In this condition, the depressed mother is already questioning her competence, she is prone to feelings of guilt, she may be struggling with remorse and distress if there was a separation due to her psychiatric hospitalization, and she may well need to be treated with medications. The last thing she needs is to hear she's harming her infant by not breastfeeding and that her inability to do so is akin to exposing her neonate to cigarette smoke or riding any kind of bucking broncho thingamajiggy.

While one jury's still debating the precise wonders of breastfeeding, another is debating the safety of exposing neonates to psychotropic medications via breast milk. I won't go into those studies here-- most of them look at the immediate effects, or those effects that occur up to age 2 so even if it's found to be safe, the utility of these studies is limited: I want to know how the exposed infants are doing at age 20.

Maybe we will find that early exposure does good things for the infant, maybe it will protect against future episodes of mental illness in a new human being who is already at increased risk (remember, this is my rambling, there is no evidence at all anywhere that this is the case!), maybe we will some day realize that prozac should be in the water supply. In the meantime, however, I'll continue to assume that psychotropic meds might do harmful things to the developing brain. Most of the women I see have stopped nursing before they've crossed my threshold-- it's just been too much to handle in their compromised state. All of them feel guilty. And while I agree that breastfeeding is the ideal, our worlds aren't always ideal or anywhere near it, and I'm left to say that generations of people were raised on formula and people turn out as they will. Zooming asteroids, terrorists, bird flu, and all those known & unknown toxins we drink and breathe, mostly we're just doing the best that we can in a world with no guarantees.


In case I messed up the links:

post partum depression: http://www.womenshealth.gov/faq/postpartum.htm
Breast Feed or Else: http://www.nytimes.com/2006/06/13/health/13brea.html?ex=1151985600&en=4bd49310078f89a1&ei=5087%0A
About Breastfeeding from today's opinion section:http://www.nytimes.com/2006/07/02/opinion/02sun2.html

[Pic per ClinkShrink]

Do Not Be Alarmed

As I was driving to work this week I learned that a giant asteroid was hurtling toward Earth and would be visible to the naked eye sometime tonight. The radio station I was listening to then switched immediately into a chirpy, cheery commercial for Glad ziplock sandwich bags. Asteroid? Giant asteroid? Near miss? No big deal as long as your sandwiches are fresh. I'm sure Homeland Security has this covered.

The asteroid, 2004XP14, was originally discovered by an observatory in New Mexico in 2004. It is about a half a mile (0.8 km) in diameter. The Jet Propulsion Laboratory's Near Earth Orbit project can trace out its trajectory and we've been assured it won't actually hit the Earth. You can even watch a cool little Java animation of the asteroid's path. (Maybe it's me, both those little moving dots labelled 'Earth' and '2004XP14' do seem to touch.)

All these measurements and predictions are made by very smart people with degrees in astronomy and physics and other relevant stuff. Personally, I'm a little reluctant to believe that anything with the term "XP" in its name won't crash at least once.

The reason why I'm bring this up is because it got me thinking about Death and Hot Fudge Sundaes. And about my prisoners, of course. So often I get parole violaters coming back into the system who say: "Why did they pick me up? I shouldn't be here. I was doing everything right." And all I can say is: "Sometimes bad things happen even when you do everything right. Sometimes bad things happen because you do the right thing."

Asteroids happen.

Roy: Psych Notes for Smilies

Inspired by Carrie's comments...
Carrie had wondered why her doc never put her on an antidepressant. She wrote: "God knows most days I wonder why not. LOL "
I replied: "It's because of the 'LOL'. If you couldn't LOL then maybe he would. Of course, if you were ROFLYAO, then he'd probably reach for the lithium."

This exchange got me thinking... hmm... how would a psychiatrist manage someone who could only communicate via emoticons? Below are the resulting progress notes...

:-)	stable. cont prozac 40mg. f/u 3 mos.
:-))	reduce prozac to 20mg. f/u 1mo.
:-))))	d/c prozac. add lithium 300 tid. check TSH, creat. f/u 1wk.
:-D	add depakote. check lithium level, LFTs, CBC. f/u 1wk.
:-|	stable. cont prozac 40 mg. f/u 1mo.
:-(	increase prozac to 60mg. f/u 2wk.
:'-(	add wellbutrin SR 150mg. f/u 1wk.
X-(	call 911. send to ER. check for OD.
:*}	check breathalyzer. refer to AA.
%-}	weekly tox screen. refer to AA/NA.
:-&@?	add haldol 2mg bid.
|-0	d/c ambien.
:-#	d/c elavil. use hard candies.
;-P	d/c haldol. add clozapine. AIMS exam. vitamin E 800 iu bid.
:-)~	reduce haldol. add cogentin to reduce sialorrhea.
8-~	reduce dose of seroquel.
(:-)	reduce depakote. add zinc, selenium.
;-)	establish boundaries. do not schedule at end of day.
;-x	see with chaperone only.
=^..^=	give Ativan 1mg IV to relieve catatonia. (thanks, ClinkShrink)
:-o	(on seeing the bill for 1st appt.)
>:-O	(on seeing the bill for missed appt.)

Roy @ Shrink Rap (http://psychiatrist-blog.blogspot.com) and mythreeshrinks.com

[thanks, SmiliesUnlimited, for the emoticons]

Flight of Ideas

The Red Sox are losing (bottom of the 7th inning) to the Marlins. They've been on a 12 game winning streak.

Question of the Day comes from my daughter: Why do old people wear ugly underwear?

Note to my son away-from-home: Feel free to speak to me in just one full sentence, though I do so love it when you grunt.

My husband wants to know why Fat Doctor says nice things about her husband and I never say nice things about him on my blog. Like Fat Doctor, I too have a wonderful husband. He's charming, smart, funny, handsome, and he doesn't overpay for his haircuts. Does it get any better than that?

My dog, Max, never complains.

Roy: the final post of the month is yours. Don't blow it.

Chomp, Chomp

No, this isn't another cannibal post. That's the sound of me eating my words. From a recent New York Times article, "Market Forces Pushing Doctors to Be More Available":

In Dr. Gerdes's office, the innovations include daily clinics at lunchtime called QuickSick, in which patients who have phoned up that morning can come in for routine problems requiring immediate attention, like an upper respiratory infection, and are guaranteed they will be examined, treated and on their way within a half-hour.

After a nurse checks the patient's temperature and blood pressure and types the symptoms into a computer, the doctor follows up with a brief exam. If medication is warranted, Dr. Gerdes can e-mail a prescription that will be ready when the patient arrives at the pharmacy.

"I can see three patients with acute needs every 15 minutes," she said.

The charge is $52 to $60, which is coverable by insurance and similar to prices at many of the new clinics springing up in places like CVS pharmacies and retail chains like Wal-Mart.

We have now entered the fast food age of medicine. QuickSick sounds like the Golden Arches of health care. Quick math check: one patient every five minutes at $60 a pop = $720 per hour of revenue. Guess I'd better take back everything I said about the spiritual gardening consultant. But do they charge for missed appointments?

I Quit

I've been hearing these words quite a bit lately. To a certain extent it's a seasonal thing. Many of our facilities were built before air conditioning was invented. When the indoor temperature starts pushing 90 degrees, people rub on each others' nerves and tempers flair. The work is difficult enough, but dealing with these challenging patients gets even harder when you need to look after your co-workers' well-being. Battle fatigue can strike anyone, from the top administrator down to the scheduling clerk.

I try to remind people that the problems are temporary. I encourage them to take time off or think about ways of changing the job to make things more bearable. In a worst case scenario, I even suggest looking at other job options just to reassure yourself there are always alternatives available. Sometimes that's enough, but it doesn't always work. Sometimes people need to leave for their own mental health.

I don't want my colleagues to leave. The average length-of-stay for a new correctional doc seems to be six months to a year at the longest. "Lifers" are rare, at least among us non-inmates. I'm blessed to be working with a dedicated young doc now who is called to public psychiatry and is very, very competent. I've watched her grow in her correctional experience and learn, both with and without my help. She has reached the critical stay-or-go point that comes with the adaptation process. I'm keeping my fingers crossed.

Roy: Psychiatry declared a "religion"

I suppose some of you may find this story amusing; this Onion-like site has declared Psychiatry to be a religion, not a medical science.

"If you dressed up a parrot in a doctor’s smock and taught it some Latin phrases, it wouldn’t be a doctor. It’s the same with Psychiatrists."

If the God of Psychiatry for the last century was the Supreme Superego, it is now the Cosmic Chemical.

"The matter of faith in a deity was also a sticking point but a study of Psychiatric scriptures reveals that Psychiatrists believe in an invisible entity known as “chemical imbalance”. The existence of Chemical Imbalance is stated as fact in the texts though there is no proof of his existence, analogous to a Christian’s belief in God or a Muslim’s belief in Allah."

Now all they have to do is declare Scientology a real religion, and then I can truly deem The Spoof editors to be the Ra of Rhetoric.

I'm Still Thinking About Fat Doctor!

We started Shrink Rap in April. By early May, I'd become addicted, writing blogs, reading other peoples' blogs: blog, blog, blog. Even the word is ugly. In my post What's Happening To My Life, I mentioned that Roy had introduced me to Fat Doctor.

So, let me tell you about Fat Doctor. She is a family doctor, married to a minister. She works on the same unit as her mother, a nurse. She owns two dogs, one of whom has been treated with Elavil (can't remember if that was Big Dog, aka Spot, or Little Dog) and has a son, a toddler whose exact age I can't quite recall. Her sister recently had bladder surgery. Fat Doctor has been having a rough time of it lately-- this spring, while at a medical conference, she suffered multiple frontal lobe strokes and spent some time in the NICU being stented. She suffers from depression (she was on Prozac which she stopped when she was trying to get pregnant), restless leg syndrome, and sleep apnea. Following her strokes, she went back to work oh-so-soon, and has recently had neuropsych testing. Her pantyhose drooped in a rather horrifying way as she spoke at the end-of-year Residency dinner.

Oh my gosh, it's its own illness. I check in everyday, waiting to see what's happening next. It's like a Soap Opera, only I hate Soaps, and it's not a Soap Opera. Maybe it's like Tony and The Sopranos where I'm waiting to find out what happens next, but this is a real person's life. Except, this is a real person I don't know. Why do I care? It's not like I don't have enough people's lives to follow. I drop in, a session at a time, to my patients' lives and often I'm eager to hear what's happened with the same wonder and anticipation. Only, my patients are real people, and I have some small degree of control-- if something heated is going on ( for example, waiting for biopsy results) I'll ask a patient to call between sessions and let me know how it turned out.

I worry about Fat Doctor. Only weeks after her CVA, she was complaining about being tired, lethargic, lacking motivation. Her brain, I think, was telling her to rest, and yet she pushed herself and returned to work. She's getting better, in leaps & bounds, or so it seems and so I hope, but I do wonder if she should have taken it a bit more slowly.

My husband wonders if Fat Doctor is real.

"What if someone's just making this stuff up?" he asks.

No, no, no. Fat Doctor is real, she has to be. She likes Diet Coke.

"And, so, how fat is she?" my husband wants to know. I think he, too, might get sucked in.

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?"

No Show

I hate it when patients don't show up for their scheduled appointments.


I have a solo private practice, it's just me-- no partners, no staff, no secretary. I run on time and I don't double book. Patients know that the time is theirs, I tell them this before the first appointment: The time is reserved for you, if for any reason you're not going to keep the appointment, please call and cancel. I tell patients on the first day that I bill for any appointment not cancelled at least 24 hours in advance, with the exception of weather emergencies or the sudden onset of an illness (in other words: I don't want to be infected or vomited on). Any appointment that is simply not kept is billed in full and the cost of a missed visit can't be passed on to an insurer. I've said it, and a few years ago I wrote it and handed it out on a sheet of Office Policies.

My first few years in practice, I was lax about enforcing the late cancellation/ no show policy. I hate charging people for a service they don't receive, especially since it seems that most of my patients struggle a bit financially. At some point, I realized my schedule was mayhem. People didn't show up, or they called asking for a different time-- I like to be accomodating and would shift when I could, but I started to feel like each day was a juggling routine, and the number of No Shows and Late Cancellations escalated, often for reasons such as conflicting Karate lessons, or I Forgot. I quickly figured out that if I value my time at Nothing, the patients do as well.

I still am a bit ambivalent about it and often debate with myself what to do. If I call and find the patient, we can develop a plan -- to reschedule or for him to come in for the remainder of the time-- and at least I can do something else with the time. If not, I am held hostage in my office, waiting to see if the patient is simply caught in traffic or enroute. I could rant about why is it that I have to repeatedly call patients on their mobile phones to ask if they're coming, only to be told at 15 minutes after the hour that they're almost there-- they couldn't phone first to let me know they're running late/? Another post for another day.

I still sometimes let the Late Cancellation folks slide, though my neighbor told me she still puts it on their statement with a notation "Fee forgiven due to..." and I've adopted this practice, even if it's just to write "Fee forgiven, one time only." The repeat offenders, I bill, even if I feel badly about it.

So yesterday, I left the clinic and went to my office. My first patient did not show up. He's done this before, several times, and I was unable to reach him on the phone and the bill is in the mail. The background is that in the past, I've spent the better part of a weekend worrying about him and ended up having someone go to his house when I could not reach him anywhere for days: he was busy and hadn't checked his messages in some time, but was alive and well. My next patient also didn't show up. This gentleman has been in treatment with me for years, and has only once or twice missed his weekly session. He always comes on time, and he called last night saying it was important that we meet and he came in today at a time that was convenient for me-- I let yesterday's missed visit slide with a One Time Only notation. Today, I had a late cancellation from someone who had switched work shifts to help a desperate colleague-- the catch: she'd switched shifts several days ago and had exhausted her One Time Only (which I believe was actually two or three times) pass several missed visits ago. Still, this patient works several jobs and struggles to keep up-- I feel badly charging for the missed visit.

In the public psychiatry clinics where I've worked, No Shows are always a problem. The clinics get the bulk of their revenues from Medicare and Medicaid and billing is not allowed if the service isn't rendered. In effect, the therapists' time is valued at Zero, there is little disincentive for patients to come, or even to call, if they can't come (or if they oversleep or if something better comes up or if they don't want to talk about the yucky things going on in their life). In some clinics, patients are discharged if they miss three appointments, but that's never been the case in the clinics I work in, and across the board, Community Mental Health Centers sport a 30% No Show rate (sorry, I should have a reference and a link, plus I think it was actually only 29%).

It comes up with Pro Bono patients as well, and when I've offered free care through Maryland's Pro Bono Counseling Project, I've taken to adopting a No Show fee-- if you show up, care is free, if you blow me off, there is a nominal fee meant to discourage people from abusing my time.

Do these measures work? Mostly, I think so-- it's much less of a problem than it used to be, though I did just write about 3 patients who didn't come in the last two days, and I didn't even mention one of the patients at the clinic who didn't show....

Teach Them A Lesson

According to the Bureau of Justice Statistics, as of mid-year 2005 over 6000 juveniles were incarcerated in adult detention centers* pending trial. This number has actually been declining after reaching an all-time high in 1999. While there is no constitutional right to public education, many states do have laws that mandate the provision of education to juveniles housed in adult jails, or prison policies that mandate participation in GED programs for juveniles serving time in adult prisons. About a quarter of all state prison inmates get a GED while incarcerated.

The issue that brought this topic to mind was a recent CNN story commenting on restrictions to juvenile education in the Cook County jail. Specifically, this jail has banned hardbound textbooks and also regulates juvenile access to pencils. The article portrayed this as unreasonable or unnecessary, however this is pretty standard correctional stuff. Most facilities have restrictions on hardbound books because they can be used to store or transport contraband. And pencil-stabbing is certainly not unheard of. The fact of the matter is that when it comes to constitutional rights, there is an uncanny resemblance between the restrictions placed on students and the restrictions placed on inmates. In public schools the restrictions are justified by the fact that the school is acting in the place of the students' parents, meaning that the school has an obligation to supervise and safeguard their juveniles. Correctional facilities have the same obligation.

I actually had a different topic I was planning to blog about, but the recent reference to the gansta-wannabe son changed my mind. When he gets home you should greet him at the door wearing a sign saying "Geek Mom".

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*A bit of explanation for our foreign readers and those not familiar with the American correctional system: detention centers, or jails, are run by local county governments and house pretrial detainees. Prisons are facilities run by the state or Federal government, and are used to house convicted and sentenced offenders.

To My Son...

My gansta-wannabe child has left home to try his brain at a college course this summer. Never a camper, this is the longest he's been away from home.

So far, life without you:
I've been thinking about you and wonder how you are. I liked talking to you last night, but a little more info would be okay. Say Hi to your roommate, John, from the unknown place. I hope he likes watching The World Cup and you find someone up there who isn't a Geek. I'm glad they found your luggage and you got to bring your clothes with you. I hope you wear it. If you send me your email address, I'll write to you.

Even your sister misses you. Dad tried to give her your seat at the dinner table (why? ask Dad...he thought she was too far away at the end of the table) but she wasn't interested.
Love,
Mom

I should have something more interesting--from a psychiatric perspective-- to say about my oldest child growing up, but it's too hard to think about the fact that soon he will be leaving for good.