Is It Okay to Lie to Your Doctor?

It's snowy here in Maryland.

First, let me say that it's never okay to lie to your shrink. Therapy is about having an honest interaction, and a psychiatrist probably can't help someone who is hiding a secret life. This post, however, was inspired by Clink's last piece, Rage Against the Machine where she wails on Electronic Medical Records, in a feeble and failed attempt to engage Roy in a fist fight. There she is a punchin' and he's just skating along oblivious as can be.

Why do EMR's make me uneasy? When I'm in the clinic with patients and I can access their medical records, well, it makes life easier. So why don't I like the whole idea? I talked about some of this in the comment section on Clink's blog post.

With an EMR, it's easier to get records, and any doctor in an institution who treats a patient has access to them (oh, the whole institution has access to them, but only those involved in the patient's care are allowed to "peak"). What if a patient wants to withhold some of their information from certain docs? Is that lying? Is that reasonable? Should that be allowed?
If it's about obtaining prescriptions for controlled substances, it's just wrong. But might there be other reasons a patient would want to control the flow of information?

Let's face it, some docs and some patients don't click. A patient may feel the doctor didn't really listen, saw him much too briefly and jumped to a conclusion without hearing all the information, or was uneasy with the doctor's conclusion. The patient comes for treatment of his headaches, and after a few minutes, the doctor says it's "Stress." The patient wants more tests done, the doc feels it's unnecessary, and the patient would like to get a fresh opinion. Electronic Records may hamper the ability to get a fresh opinion. The next doctor may look at the note and agree with the patient that more testing should be done, or he may see another doc's opinion and go with that. And who knows what the first doc wrote, it may continue to prejudice future care. All sorts of human emotions get tossed in here: What if second doc hates/adores first doc, that may prejudice what side he takes. Any way you dice it, if the question is so much as raised that a patient is malingering or that an illness is factious, medical professionals may shut down.

So how does this pertain to psychiatry? Psychiatric patients are often given sub-par medical care. Their medical symptoms are more likely to be attributed to their psychiatric disorders (and sometimes this is appropriate after a reasonable and thorough work up). Perhaps a patient worries that if he tells a doc he's in therapy, his problems will not be considered as valid. I think this is getting better.

Roy would say that the patient should be involved in the evolution of the record. Maybe Roy should say what he wants to say....

And you didn't really think I was going to say if it's okay to lie to your doc!
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So I'm adding this as a next-day addendum: Talesofacrazypsychmajor left us a comment saying that primary care doc who knew of psych diagnosis felt it had to go on every school form that needed to be filled out (presumably for school, work, camp) and perhaps that's a valid thing to reveal to any institution needing medical information. However, it is an example of how the patient is out of control of their information. This example is obviously not an EPR issue alone, but EPR's make the spread of information easier for better or for worse.

Rage Against The Machine

I'm posting this for ClinkShrink at her request. She's in jail at the moment and they block Blogger. This is in honor of the Apple Tablet announcement today, and she's looking to pick a fight with Roy!

Rage Against The Machine
---by ClinkShrink.

With the pending announcement of the long-awaited Apple tablet, and on the heels of my new programming project (an iPhone app), I'm thinking about health information systems. This blog post is a blatant attempt to yank Roy's chain, but I know he's smart enough to see right through it. Nevertheless, if he totally agrees with me I'm going to be quite disappointed.

The fact of the matter is, I'm a geek and I love technology but I really really dislike health information systems. I've yet to meet one (other than stuff I've designed myself) that doesn't drive me screaming into banshee land.

I know all the supposed benefits of healthcare information systems: they're supposed to improve care by allowing communication between providers, they're supposed to reduce healthcare costs by improving efficiency, they're supposed to contribute to medical knowledge by collecting aggregate data about diseases for research.

I also am concerned about the downside of health information systems: potential threats to information security, harmful uses of the data that's collected, breaches of confidentiality and loss of independent medical decision-making.

Fine. That's not why I've hated them. The reason I strongly dislike most systems I've used is because they make it harder to figure out what my patient really has.

Psychiatry is a descriptive art. You make a diagnosis through observation and description. You treat people through language and free communication. Information systems stifle all that. Instead of being able to document that the patient "believed he was the President so he hopped on a bus to Washington, camped out on Pennsylvania Avenue for three weeks, then climbed over the fence of the White House", I only get to check a little box that says "delusional". Now, that really loses something.

Even when the computer programmers give me a textbox instead of a checkbox, I run out of room to document the treatment history of a really complicated patient. I could type for ten minutes about the stuff I want the next clinician to know, only to discover that my keystrokes have been brutally ignored and rejected by the $#@!J$#* healthcare interface.

I am a geek. I want my machines to obey me. Instead, I am forced to let the machine convert my prose into categories, to shave off the nuances and color and "flavor" of the people I treat, all because the system is designed by engineers rather than clinicians. I am peppered by little popup warnings about contraindications and medication interactions that only occur in one out of every 10,000 people. I have ignore these so regularly that I fear missing the one that might truly be dangerous.

Will the benefits of a national health information system outweigh the risks? Better yet, will doctors be able to use them without wanting to smash a keyboard over somebody's head? Only time will tell.

So, that's my take on the 'con' side of the national information system. I'll leave to Roy to be the 'pro'.

******

Flower for Patients: Interview at Noon ET today on BlogTalkRadio (#hcflower)

Today (Tue Jan 26) at 12:00 noon Eastern Time, Gregg Masters (@2healthguru) will be interviewing Dirk Stanley, Tim Sturgill, and me about Flower on BlogTalkRadio.  Flower promulgates the message that we should control our health data and have universal standards for sharing it.

Here's the blurb about it that Gregg wrote for the hour-long live show on BlogTalkRadio:

What is flower? At this time it’s an abstraction — a placeholder for several concepts centering on what would healthcare look like if....? And, more specifically what would personal health information (PHI) look like if....? A flower was chosen as the abstraction because it is easily and universally understood, regardless of language, anywhere in the world — a flower is a flower. Where a flower is flower carries the additional abstraction that there is a common ground — characterized by property and implementation. While a fluid and dynamic idea, this informed panel will provide both history and context for its genesis and diverse unfolding narrative. Join Dirk Stanley MD, @dirkstanley, http://twitter.com/dirkStanley, Tim Sturgil MD, @symtym, http://twitter.com/symtym, and Steven Daviss MD, @HITshrink, http://twitter.com/hitshrink, as we discuss Flower's granularity and transformational potential to make sense of a complex and moving target: informatics, health care and the patient. For additional context and insights on 'Speak Flower' see: http://speakflower.org/, and the threaded discussion on Howard J Luks, MD, blog: http://hjluks.posterous.com/thinking-about-flower-a-concept-is-born-hcflo

Behind the Couch? Please Vote!

We've been quibbling about a title for our book-to-be for over a year now. We've used a working title of Off the Couch: Three Psychiatrists Discuss Their Work. Clink and I like it, Roy hates it, our editor cringed and changed it to Off the Couch: How Psychiatry Works and How Psychiatrists Think. We've toyed with everything from Beyond the Couch, to Psychiatry Demystified, to Set the Couch on Fire. Then HappyOrganist suggested Behind the Couch in one of the comments. Behind the Couch--- I like it, it has the whole behind the scenes connotation. Oddly enough, Roy liked it. Roy liked it. Wow. It's the first title that all three of us have been able to live with. Editor says "we'll see." She obviously didn't love it. So for the moment, our working title is : Behind the Couch: Three Psychiatrists Explain Their Work. Thank you HappyOrganist!
So I want to know: do you like this title? I know it's a complicated question, there's "do you like it" versus "would you buy it?" versus "would you pick it up in a bookstore" versus "Yuck!" So I'm just going to ask as a yes or no poll. Please vote and thanks for your input.

Multi-Tasking To The Max

Okay, picture this: I'm sitting in front of my desktop computer. Swivel to the right and my laptop is there. On the desk in front of me is my cell phone on which I'm arranging a meeting via text message. My left shoulder cradles a phone against my left ear(my home line) where I've been on hold with Medicare for the last 10 minutes because I want to talk about details of the 27 page form that I need to fill out for my office change of address. My left hand holds a second phone (my fax line) to my right ear -- I'm on hold for an insurance company where I'm hoping to talk to someone to help a patient get reimbursement even though I'm out-of-network. My right hand types this blog post. I may explode but I won't have gone down without trying.

Weird Social Situations.

Thank you all so much for your input on my Intrusions post. I'm going to sit with the chapter and your comments and try to get it all put together. Soon. I hope.

So I want to talk about a weird social situation. I have to confabulate this one, you'll bear with me and not get too involved with the details, because they aren't real.

There's this woman I know sort of vaguely. We've had a few conversations over the years, and she has always greeted me very warmly. We were never friends, but I like her, and like I said, the vibes between us were good. She called me at work one day and asked if I'd treat one of her family members. She's not a friend--- I said yes-- but I did make the comment to Family Member that I knew Warm Woman and asked if this was a problem. It wasn't. I saw the family member for a while, the treatment was successful and Family Member has left treatment with the understanding that my door remains open. Nothing that was said in the therapy changed my opinion of Warm Woman....Family Member cherishes her and didn't reveal any skeletons in any closets.

Yesterday I went to a small event for a group I belong to. Warm Woman was there, seems she's also a member of this group. She ignored me. I followed suit and did not approach her-- seems as the relative of the patient, it's her call. And I do know she's been in treatment herself, and that she understands all about boundaries. It felt weird though. I wanted to say Hi, and I wanted to tell her to give my regards to Family Member who has not seen me for a while. I almost felt like I was in the room with my own uncomfortable patient, but Warm Woman was never my patient. I even wondered if I should drop out of the group, but I like going, and I joined, in part, at the request of someone else in the group, someone who has no idea this interaction is happening.

Just thought I'd share a day in the weird life of a shrink.

Intrusions.

I'm working on a chapter for our book. I still like either Off the Couch or Beyond the Couch for a title. Roy wants to name it Set the Couch on Fire. And he's not kidding. What do you think?

Okay, so the current chapter is on real life intrusions-- things that impact care, for better or for worse, in ways we may or may not really understand. So stuff external to the actual treatment. Some examples are--- Money/fees/ not showing up for appointments/ Violence (how does it impact care if you have a suicide attempt? If you threaten or assault your shrink?/ assumptions people make about their patients or shrinks/ drug company influences/ and the media portrayal of psychiatry. A lot of the chapter is about money and insurance companies and fees.

Are we missing anything? The chapter is short---still waiting for Clink to write about violence, still waiting for Roy to chip in. And really, this isn't a real entity in psychiatry, it's something to draw together some unrelated stuff we wanted to talk about and make it cohesive. So is there something you want to know about that might intrude on care?

Doggy Genes and OCD

The timing couldn't be more perfect for an article in the New York Times on the genetics of compulsive behaviors in poochies.

In Scientists Find a Shared Gene in Dogs with Compulsive Behavior, Mark Derr talks about the work of Dr. Nicholas Dodman on doberman's who compulsively suck their flanks (hmm, what exactly does that mean?) and a genetic link:

Dr. Dodman and his collaborators searched for a genetic source for this behavior by scanning and comparing the genomes of 94 Doberman pinschers that sucked their flanks, sucked on blankets or engaged in both behaviors with those of 73 Dobermans that did neither. They also studied the pedigrees of all the dogs for complex patterns of inheritance. The researchers identified a spot on canine chromosome 7 that contains the gene CDH2 (Cadherin 2), which showed variation in the genetic code when the sucking and nonsucking dogs were compared.

Should ClinkShrink be worried? Might she adopt a dog with a psychiatric disorder? Should her would be pup have genetic testing? Derr goes on to write:

Recent rough estimates by Dr. Karen L. Overall, a veterinarian specializing in animal behavior at the University of Pennsylvania School of Medicine, suggest that up to 8 percent of dogs in America — five million to six million animals — exhibit compulsive behaviors, like fence-running, pacing, spinning, tail-chasing, snapping at imaginary flies, licking, chewing, barking and staring. Males with the problem outnumber females three to one in dogs, she found, whereas in cats the ratio is reversed.

Ah, but it's not just the poochies with this problem: other critters have compulsive behaviors, and treatment is available. Mr. Derr tells us:

Other domestic animals, notably cats and horses, as well as some of the animals at zoos, exhibit compulsive behaviors, including wool-sucking in Siamese cats, and locomotion disorders like stall walking and weaving in confined horses and pacing in captive polar bears, tigers and other carnivores used to ranging across large territories.

Although antidepressants, particularly selective serotonin reuptake inhibitors and clomipramine, a tricyclic antidepressant, and behavior modification have proved effective at controlling compulsive behavior in dogs and people, they do not appear to correct underlying pathologies or causes, Dr. Ginns said. Those causes are likely to be as varied as the compulsive behaviors and as complex as the interplay of multiple genes and the environment.

Should ClinkShrink Get a Puppy???

It's your chance to chime in!

Here's the thing:
1) ClinkShrink is allergic to critters and has felt much better since the deaths of her beloved kitties, Elavil and Prozac (aka Zac and Elli, and yes, this was their names).
2) ClinkShrink doesn't want a puppy, or any critter for that matter.
3) A dog would cramp Clink's away-we-go to rappel ourselves down steep cliffs and climb things no one was ever meant to consider climbing.

So why would ClinkShrink get a doggy?

1) A member of her household desperately wants one. Really really badly.
2) They make hypo-allergenic pooches, don't they?
3) She loves my dog Max and takes wonderful care of him when I'm away. (And funny, we've never heard her sneeze).
4) They are sooo cute.
5) Dogs add a dose of passion to life, and passion is good.

Well? What do you think? The puppy in the pic is Roy's, by the way.

Vacation Dreams

It's warm and sunny here. The sand is blue, the water is green, the Dinah is pleasantly pinkish. The Ravens are losing at half time.

I had this dream last night that begs to go on the blog, so here I am.
I was walking down the street with ClinkShrink, and Roy was with us too, but walking a bit slower. We came across a body in the road, face down, and we went to help, Clink and I right there at the scene. It was a woman, and someone else was there, looking for a pulse. She moved, and then she got up. I asked a few medical questions, and we decided it was okay to leave. Roy thought I should have asked different questions.

Then we were in Boston. We'd flown and I had to get back the same day. I asked Roy if he'd bought my ticket, since I hadn't bought it myself and thought I might owe him money. He hadn't. I also didn't recall ever seeing a boarding pass---how did I get on the plane?

We were at a meeting and there was another psychiatrist there as well as some of my neighbors. I sat down and tried to figure out how I was going to get back to Baltimore that day. I pulled out my iTouch and tried to download an AirTran App.

By the time I'm dreaming about i-Anything apps on vacation, well that's when I know that Roy has gotten to me.

The Last Minute Family

I'm headed off for vacation for a long weekend. In my family, we love vacation, but we hate planning it. It's a funny problem. We've left the country on as little as 3 days notice before and this past summer we switched our plans from Montreal to San Francisco on the Monday before we left. Oh, and we're taking vacation now because we never did get our act together to go anywhere over the holidays, but that's okay because the day we were supposed to leave, we woke up to 20 inches of snow and we wouldn't have gotten there, where ever there might have been, anyway.

So I'm writing a blog post when I should be packing. Hours before departure, I asked my husband if they speak English where we're going and he asked me if we can use American dollars. And off to Google we went (:: yes and yes). He's confident he'll be able to watch the Ravens' playoff game which is good----one of the reasons we had so much trouble organizing ourselves over the holidays was that he had Ravens' tickets and there was a push of resistance against leaving town.

Arg! Blogger won't let me put a photo in! Oh, and please do encourage Clink to get a puppy.

Roy and ClinkShrink will hold the fort. See you next week!

Goldstein: Personalized Medicine in 2020

-from Nature

Personalized medicine

David B. Goldstein

Duke University

Over the past decade, powerful genotyping tools have allowed geneticists to look at common variation across the entire human genome to identify the risk factors behind many diseases. Two striking findings will define the study of disease for the decade to come. First, common genetic variation seems to have only a limited role in determining people's predisposition to many common diseases. Second, gene variants that are very rare in the general population can have outsized effects on predisposition.

For example, rare mutations that cause the elimination of chunks of the genome can raise the risk of diseases such as schizophrenia, epilepsy or autism by up to twentyfold. Some researchers view these major risk factors as aberrations. My guess is that as more genomes are sequenced, many other high-impact risk factors will be identified.

If so, here's one confident but uncomfortable prediction of what personalized genomics could look like in 2020. The identification of major risk factors for disease is bound to substantially increase interest in embryonic and other screening programmes. Society has largely already accepted this principle for mutations that lead inevitably to serious health conditions. Will it be so accommodating of those who want to screen out embryos that carry, say, a twentyfold increased risk of a serious but unspecified neuropsychiatric disease?

Some advances will be relatively uncontroversial, such as the development of tailored therapeutic drugs based on genetic differences that are otherwise innocuous. Others will be transformational, such as the identification of definitive genetic risk factors that provide new drug targets for conditions that are often poorly treated such as schizophrenia, epilepsy and cancers. Over the next decade millions of people could have their genomes sequenced. Many will be given an indication of the risks they face. Serious consideration about how to handle the practical and ethical implications of such predictive power should begin now.

Danny Weinberger: Mental Health in 2020

-from Nature

Mental health

Daniel R. Weinberger

Senior investigator, US National Institute of Mental Health

The search over the past decade for genes behind mental illness has led to the realization that mental disorders are not discrete conditions with specific causes. Rather, they are the result of interactions between risk factors that affect development; psychiatric symptoms can arise from many causes and are more interrelated than current disease models allow. By 2020, this insight, which has been slow to take hold, will have transformed how doctors understand and treat psychiatric conditions.

Finding specific genes for mental illness now seems a pipe dream. A more realistic endeavour for the next ten years is to look for genes that code for basic cellular and brain functions that modulate our responses to the environment and that come together in particular ways in individuals at increased risk. Many hundreds of genes may contribute to raised vulnerability, and such defects may affect brain development and function independently of any specific psychiatric diagnosis. There is no straight road to psychiatric illness, but a highly diverse network of developmental pathways.

This approach will lead to diagnosis and treatment based on a proper grasp of the underlying biology, rather than on an interpretation of symptoms. Psychiatric research is poised to realize Sigmund Freud's dream of a biological psychology, but it will require new applications of old thinking (see also page 9).

Can Medicare Make ME Crazy?

I've moved. You know that. The new office is terrific, shabby chic walls and all.
So I'm working on the whole change-of-address thing. I've notified the post office, the bank, sent a zillion notices out. I've notified my malpractice insurance agent so many times that he called to tell me he changed my address weeks ago and I keep notifying him. I called the Controlled Dangerous Substance folks in my state. It costs $50 to notify them of a change of address. What gives with that. And the DEA...no forms, I tried emailing, I guess I'll send a real letter. The hospital gave me a local number, but it's out of service.
And Medicare: have I mentioned the 221 downloadable forms and how to change your address you have to fill out the 27 page enrollment form? I did? I guess I did.
Did I mention that I'm a non-participating Medicare provider? I don't want to 'enroll.' I finally tackled the form, figuring it would have a box at the end where I could check off that I'm not a participating provider....since I have not 'opted out' ...I'm actually participating by not participating. Try explaining this all to a distressed patient.

I surrender. Tomorrow, I'll try calling. I will no longer be blogging. I anticipate the next year of my life will be on hold.

If you have any answers, by all means....

Reasons to go on Living

"The Reasons" is a website devoted to celebrating the decision to choose life rather than suicide.  They are looking for people to tell their stories... of tragic loss... of despair turned to hope...

...about The Reasons to go on Living Project, based at St. Joseph’s Healthcare Hamilton (ON, Canada):  We are collecting the stories of people who have attempted or seriously contemplated suicide but now want to go on living. The project will study and share these anonymous stories for research, education and inspiration. 

I'll add a link to it in the sidebar to make it easier to find later.