The Myth of the 30 Day Notice

When the doctor patient relationship goes sour medical ethics clearly allows the physician to discharge the patient, but in theory at least the physician must ordinarily make some attempt to help the patient find another doc, and continue to provide care until the patient can establish care elsewhere for a reasonable time, traditionally 30 days.

But what happens during those 30 days?

Although physicians discharge patients for many reasons, such as failure to pay, dishonesty, noncompliance, personality conflicts and others, in my practice at least patients seem to discharge themselves. They miss an appointment and don't return calls to reschedule. With phones and voice mail as they are we often encounter "mailbox full" messages, and of course sometimes we eventually do make contact and discover the patient just lost her phone. But when the patient has really dumped me I want evidence of providing adequate warning of discharge as much for liability reasons, to protect myself, as anything else. While the letters I send do often result in a phone call and continuation of care, for the patient who has left for good the letter becomes tangible evidence that I am no longer responsible for care. If I something bad happens to the patient, but I am clearly not the patient's doc at the time, there is little chance of a successful liability suit.

My standard discharge letter starts out by saying I don't know whether the patient wants to continue treatment, and to please let me know. I inform the patient that I will only continue to act as her physician for 30 days after which I will discharge her. I may also suggest some resources for finding a replacement physician. Often the letters come back undeliverable.

Many physicians seem to accept, but I hereafter challenge, the myth that we must provide a 30 day supply of whatever medication the patient takes. While that may be appropriate in some cases, simply providing a prescription does not equate with medical care, and may lead to increased, rather than decreased, risk. Suppose for example that the patient's condition changes during the 30 days. The responsible physician would want to examine the patient, possibly face to face, to evaluate and explore treatment options. In some cases the patient would be happy to oblige, but suppose the patient refuses. I believe in that situation the physician should consider refusing to provide a refill until the patient has kept an appointment. Not infrequently a patient lost to follow-up will request a refill through a pharmacy. Typically I have by that time given up after many attempts to make contact with the patient. I refuse to fill the prescription and ask the pharmacist to tell the patient to contact me.

But suppose the patient responds to your demand for a face to face visit in order to obtain a prescription or other treatment. Can I demand payment before scheduling the visit or actually seeing the patient? From the perspective of avoiding a lawsuit, the better choice might be to take the loss. But this can be hard to accept, especially when you know the patient will spend much more than your fee on the drugs you prescribe, or on their month supply of cigarettes.

How Many Psychiatrists Does It Take?

In his article in the most recent issue of Psychiatric Times Daniel Carlat, M.D. estimates that we need 45,000 more psychiatrists in the United States. In the article Pharmacists Take Larger Role on Health Team we read that pharmacists could be part of the solution to that problem as they assume roles that were once the sole province of physicians. What is missing from Carlat's article (but may appear in his references) is an estimate of how many patients a single psychiatrist can treat. Carlat advocates at the same time for psychiatrists to do more psychotherapy, but we can't have our cake and eat it too. A psychiatrist who attempts to do traditional psychotherapy and 45-50 minute sessions while also treating patients with medication or other biological interventions will not be able to manage nearly as many cases as a psychiatrist who delegates psychotherapy duties to non-prescribing professionals.

Carlat's solution to the problem of too few psychiatrists, training psychologists in the role of psycho pharmacotherapist, will perpetuate the inefficiency of psychotherapists attempting to manage biological treatments at the same time, though there will likely be more of them. In his article Carlat's justification for training psychologists to do medication management rather than recruiting more advanced practice nurses and physician assistants is his unsubstantiated notion that psychologists will be better able to handle what he calls "tough cases." If by tough cases he means the ones that do not improve with first line treatments, it is unlikely that more psychological training will help. If he means patients whose personalities interfere with their treatment, we need to keep in mind that personalities can interfere with all kinds of medical treatment. Perhaps we should train psychologists to treat diabetes and do knee replacements and colonoscopies, too.

While Carlat and others push for combining psychotherapy with medication management another trend would seem to push in the opposite direction. As more and more prescribers give up psychotherapy some would seem to take on the role of primary care provider (We don't seem to have enough of them either.) for their psychiatric patients. This role arguably demands physical examination of patients which the vast majority of psychiatrists gave up as soon as they finished residency. Of course physical findings have little if any bearing on any psychotherapy, but psychodynamic and psychoanalytically oriented psychotherapists seem to have particular difficulty with the so-called "transference" implications of so much touching and seeing on the psychological treatment.

I believe we have plenty of non-prescribing psychotherapists now and that those professionals are at least as capable as their physician counterparts. I believe physicians remain the most capable of prescribing. I also believe that much of the impetus for psychiatrists to continue providing psychotherapy comes from the psychodynamic school and that for many psychiatric patients such an approach is either completely unnecessary or maybe inferior to cognitive behavior therapy or other psychotherapies. However, I believe that improved psychotherapy skills will make for better psychiatrists. We need to develop greater efficiency in incorporating psychotherapeutic interventions into psychiatric contacts. This will require us to relinquish the traditional 45-50 minute session (Today much of such sessions is already occupied by administrative activities anyway.) in favor of a model that incorporates directed psychotherapeutic interventions into a 5-20 minute medication management visit. Furthermore, all physicians would probably benefit from learning some of these interventions.

Which direction will psychiatry take? Will it return to psychotherapy as a core service or become even more medical with performance of physical exams? Or will psychologists, nurses and pharmacists take care of the psychiatric patient of the future?

Maybe we won't need psychiatrists. If we don't make psychiatry more attractive by eliminating burdens from regulation, low fees and payer contracts we won't have psychiatrists.

Plog My Medical Records

I'm shopping for a new contact management solution. Used to be I would say software. But now it's in the cloud. At least I hope so because my main computer keeps crashing, and the software I use now is old, and the new version is too expensive and won't work on this machine.

The service (ASP for application service provider?) I'm looking at now uses a blog format for working on projects. I thought, "How could I use that?" What about for medical records? (If someone is already doing this, please tell me.)

Suppose you could access the same records your doctor keeps and make changes or add comments. It goes without saying that this would require an audit trail so you could keep track of who entered what. For medico-legal purposes the doc would always have to be able to retrieve and display her records, distinct from any proposed changes or comments made by you the patient. The doc would also have to read and respond to every comment or proposed change. Something like a new phone number might be easy. Rewriting part of the history might not be.

The good part would be the resulting collaboration between doctor and patient to get everything right. Comments added to progress notes (Let's see, progress + log = PLOG.) would take the place of email for updating the doc on changes in symptoms, side effects of drugs. The doc would review and approve each one the way bloggers get to accept or reject comments on posts.

The bad news would be the extra time for the doc. Patients who leave long voice mail messages would probably leave frequent and detailed comments. Patients would also have to understand that urgent or emergent matters would require different methods of contact, like telephone or even 911.

Suppose the doc prescribes venlafaxine and the patient experiences nausea. The patient would send this fact as a comment on the plog post from the last visit. Instead of waiting for the next visit the doc could suggest a change in dosing or when to take the drug relative to meals in another comment delivered to or accessed by the patient. Both doc and patient would be alerted to any change, maybe included incoming lab results.

The plog could also solve treatment team communication problems. For example, in psychiatric treatment, which might involve a non-physician psychotherapist, all three parties might share access.

We just need to see how the HIPAAcrits feel about it.

Pharmacists Gone Wild

(Facts altered to disguise cases.)

• A patient relates that her pharmacist told her if the increased dose of her medication failed to produce improvement in her symptoms after 21 days at the higher dose, she should revert back to the original dose.
• A pharmacist faxes me to ask the diagnosis of a patient, even though the patient pays cash for the prescription, and there is not insurance company involvement.
• A pharmacist tells a patient that a drug I frequently prescribe can be very sedating, when in fact most patients complain that it does not sedate them enough.

Everyone seems to want to play doctor these days, but how much do we want pharmacists to get into that role? There is something to be said for having each of every patient's diagnoses accessible from the pharmacy data bank. For example, it might prevent an asthmatic patient from using a potentially fatal beta blocker. But can we trust them with psychiatric or substance use disorder diagnoses? My patients already complain about pharmacists talking about such diagnoses where other customers can hear.

The first item above appears to clearly involve exceeding the boundaries of a pharmacist's competence and authority. This probably has happened as long as their have been pharmacists, but does the current climate encourage non-physicians to take liberties, possibly to the detriment of patients?

Is Grief Ever a Mental Disorder?

Listen to Kenneth Kendler and others weigh in on NPR's morning edition: 

Is Emotional Pain Necessary?

I see several false assumptions in this debate: 
1) Meeting the criteria for Major Depressive Disorder means you have the illness: Wrong. The criteria are necessary, not sufficient. Just means you may have an illness. 
2) If you have the illness, you must have treatment: Wrong. The patient gets to choose whether to be treated and how.
3) Treatment means medication: Wrong. There is also psychotherapy. And what about grief counseling. A Grief counselor is not likely to kick you out of "treatment" based on the 2 week rule. Neither is a psychotherapist. But the criteria may impact whether insurance pays for them. 
4) Treatment will remove the pain of grief. Wrong. Neither medication nor psychotherapy will prevent the aggrieved from feeling bad about a loss. One could argue that improvement after treatment suggests there is or was an illness. We don't have happy pills yet.
Bereavement and grief by definition involve reaction to an adverse life event. Depressive illness in contrast often occurs in the absence of any connected adverse event, and usually seems to insulate and distance the individual from external circumstances. Treatment of depression may lead to increased sensitivity to loss.