Dr Yao @ Blue Shield of CA: 999 refills of Suboxone

I just want to express my grattitude to Dr John Yao, MD, MPH, FACP, Senior Medical Director of Blue Shield of California, for his extraordinary generosity in authorizing Suboxone film with 999 refills for his subscriber in his "Authorization Confirmation Fax" dated 12/05/2011. The authorization is "valid from 12/5/2011 to 3/5/2012."

I am confused, however, as in the next paragraph Dr Yao writes, "The authorization has been entered with 99 refills to allow for titration purposes." Maybe that's 99 for titration AFTER the 999 are used up for a total of 1098.

Yay Dr Yao!

(If this was all a mistake at least I have another addition to my blooper collection.)

What Would Psychiatry Be Without Psychoanalysis?

How might the practice of psychiatry have evolved without the close association with psychoanalysis? I don't know the history of how the two fields became so intimately intertwined, but I might imagine that at the time psychoanalysis gained acceptance it seemed to compare favorably with what little else we could offer those who suffered from mental disorders.

I would attribute several elements of the practice of psychiatry during the past 50 years or more to the influence of psychoanalysis:

• The term "shrink," short for head shrinker, probably generalized from psychoanalysts to all psychiatrists. 
• Likewise the practice of referring to psychiatrists as "therapists" probably would not have occurred without the nearly universal incorporation of this modality into psychiatric practice. 
• Psychoanalytic/psychodynamic theory probably continues to form the basis of psychotherapy training in most residency programs. 
• Then there is the 50 minute hour. What other medical specialty has fostered an expectation that so much time would be spent with the patient at each encounter? And what other medical specialty refers to these encounters as "sessions?"

What other medical specialty emphasizes "getting to know" or "understanding" the patient? Did this not originate with psychoanalysis?

Had it not been for psychoanalysis would other psychologies or psychotherapy methods have taken hold in psychiatry to the same extent? Keep in mind that many of these evolved out of or in reaction to psychoanalytic theories.

Will psychiatric practice some day return to what it might have been as the impact of psychoanalysis diminishes over time? Will that impact eventually disappear entirely? In the end will we say that psychoanalysis has damaged psychiatric practice or enhanced it?

Hands Free Mic for VR

Having to don the headset has always tended to discourage me from using voice recognition software like Dragon Naturally Speaking even when the software performs well, so when I purchased a tablet PC with phased array mics a few years ago the completely adequate performance was like a breath of fresh air. This year though I put together my own desktop, so I reverted to the dreaded headset that came with my new(er) version of the software. I could hardly believe a mic costing less than $40 could handle the task, but the Andrea Array 2-S convinced me otherwise.

I mounted the mic atop my monitor, and my Web cam atop the mic. It recognizes my speech as well as any headset I have used, and works well with Skype, too.

You plug the mic into an included USB sound card. I plug my speakers into the card too. I still do not understand how to use the audio software that comes with the package, but neither do I seem to need it.

Controlled Substance eRx: Is it live?

According to this Surescripts press release "a select number of certified and audited vendors and their users located in states where EPCS (E-Prescribing of Controlled Substances) is legal" have "begun the initial deployment of EPCS." When this trial period is complete, possibly January 1, EPCS will be made available to all.

Is your eRx live with EPCS yet?

If so, please reveal their identity.

Forms R Us

I think I'll design a T-shirt or bumper sticker that says:

Physician

Will Fill Out Forms

For Free

Any Forms

All forms

I tend to like forensic work, even evaluating workers for risk of violence, at least as much as clinical work, for, among other things, the inherent ability to evade the constant stream of people -- often not the patient, and institutions, who demand that I fill out forms and sign agreements, usually unrelated to my role as physician. 

I can hear the conversation in the human resources department now:

"Do we need this form filled out before we can send the retainer check?"

"Gee, I dunno. What kind of supplier is it?"

"I think he's a doctor."

"A doctor? Don't worry about it. Just tell him he has to fill out. Doctors always fill out whatever form you shove under their noses."

Regardless, yesterday a potential forensic client told me I would have to complete, in addition to the usual W-9, an "Approval" form, and a "Supplier Classification Form" before the local employer (my client) would cut a retainer check for me so we could schedule an independent examination of a worker who may pose a threat of violence.

Approval Form

As far as I can tell the only items I know are my address and phone number on this spreadsheet. I guess they're short-handed in the typing pool. Other items include: "Does this supplier have a relative working for [Company]?" and "Does this supplier h" [?]. My favorite: "What is the reason an existing supplier cannot be used?"

Supplier Classification Form

If you have not seen one of these, it consists only of a bunch of check box items where you indicate whether you are a small business, a large business, a "Service Disabled Veteran Owned Small Business" or any of several others. Since I'm a physician I thought maybe I should check "Small Disadvantaged Business." (I'm not sure which is worse: provider or supplier.)

But this is no joke. If I get it wrong, according to the "PENALTY" section I may face "fine, imprisonment, or both."

So let's look at the whole enchilada. I will be paid a reasonable fee to examine someone who may be dangerous, and who I may make even more dangerous, potentially to me or my family, if he doesn't like my determination. And add to that risk of fine or imprisonment for claiming I'm a small business when in fact a prosecutor might prove that I'm actually a HUBZone Certified Small Business. (I have no idea what that is.)

I think I'll pass.

You might correctly object that it is quite possible that these are well-meaning folk, just trying to make sure they keep out of trouble with all the gumment regulations, and have a physician and his malpractice carrier share the risk if the worker goes postal. That's fine. They -- and the gumment -- can do so to their hearts' content -- without me. Thank you very much.

Waking Up Is Hard to Do

Inundated with new, and often unproven, biological and psychological treatments for mental disorders whose causes remain mysterious, psychiatrists should welcome any promising treatment. This CME article appearing in the October, 2011 issue of Psychiatric Times describes just such approaches involving treatment of depressive illness by keeping the patient awake all night, followed by sleep phase advance and bright light therapy, with or without initiation of medication.

At first glance you might think you could do this at home with minimal professional support, but a person suffering from major depressive disorder might find it challenging to stay awake all night unassisted. Could a practical nurse provide such a service with minimal training?

For answers to other questions that came to my mind regarding protocols refer to the programs outlined at Chicago Psychiatry Associates Program in Psychiatric Chronotherapy and Columbia University's Light Treatment Center.

• What signs and symptoms predict greatest likelihood of positive outcome?
• What contraindications exist?
• How can staff keep a resistant patient awake?
• Can stimulant drugs be used to prevent sleep?
• How can you tell whether the home and family are adequate for the task?
• How should treatment emergent mood elevation be managed?
• Are there other risks?
• Are there risks for those who stay awake with the identified patient?

Is the novel treatment approach ready for prescription by the office-based psychiatrist for use at home, or should we amass more experience in hospital settings?

What's making more Greeks kill themselves?

According to a piece I heard on NPR a couple days ago suicides are up in Greece. Is this because of reduced availability of psychiatric treatment or factors more directly related to the country's economic problems?

In psychiatry we have a tendency to associate suicide with mental illness. Since we believe we can treat mental illness we have promoted the myth that we can prevent suicide, but with unintended negative consequences. For example, wrongful death represents one of the top claims in psychiatric malpractice suits. Because of this, those of us in a position to do so shun risky patients, making it more difficult and costly for them to find care, and possibly increasing the risk they will kill themselves. If we get stuck with caring for a risky patient the focus shifts from optimizing treatment (assuming there really is an illness to treat) to desperate attempts to control the patient's behavior.

We should accept that suicide arises almost always out of free choice and focus our efforts on treating illness instead of pretending that we can control behavior. Even when patients who suffer from mental illness choose to end their lives the motivation may have little or nothing to do with the illness.

The Birth of Managed Care

I recall a meeting of the private practice committee of the Manhattan District Branch of the American Psychiatric Association at the Payne-Whitney Clinic more than 25 years ago. I guess nobody was worried about the future of private practice back then. Only about three of us attended. We talked about psychiatrist Jay Reibel, MD at Four Winds psychiatric hospital and his attempts to cut costs for the State of New York by reviewing cases in what may have been the first "behavioral carve out."

We love to hate managed care in psychiatry as much as anywhere in medicine, but to help keep it all in perspective think back to the months long hospital stays and years of four sessions a week psychotherapy. Ask yourself whether we could ever be wealthy enough as a society to sustain such benefits for more than a privileged few. You can read more in this 1985 article from the New York Times:

http://www.nytimes.com/1985/12/01/nyregion/new-effort-seeks-to-insure-quality-of-psychiatric-care.html

Managed Care Bloopers

I had to read it several times to make sure my imagination had not taken over:

"All pregnant women should be on generic Subutex (buprenorphine)."

This bold statement appears fittingly in bold letters near the top of a Columbia United Providers Follow up Suboxone PA Form.

I think they meant to say something like, "Pregnant women taking buprenorphine should not be taking Suboxone, the preparation that also includes naloxone." So why did they not say what they meant? The gaffs continued:

Substance abuse program the patient is attending? ________________________

That was a question? I think not. How about,

Current dose of Suboxone for PA approval?

Again, not a question. When you (patient? physician? bus driver? It does not specify.) sign, you agree that:

I have read the CUP Policy on Suboxone Treatment and attest that all criteria and limiting conditions have been satisfied. [followed by boxes for Yes or No]

Do we really need those boxes? For more fun the Policy statement follows. See if you can guess what the writer meant by "criteria and limiting conditions":

TITLE: Columbia United Providers Suboxone Therapy Policy

Is it not kind of Columbia United Providers to let us know that what looks like a title really is in fact a title. I kid you not. "TITLE" really appears at the top. Now follow the criteria and limiting conditions (apparently):

Patients will NOT be able to purchase their own medication during or after treatment.

Makes me wonder how they (we?) can stop them. Does the statement refer to all medication? I suspect it just applies to buprenorphine preparations.

Patients will also be required to have a signed pain contract that includes random urine drug screens.

Apparently just any old pain contract will do, provided it is signed -- by somebody. The contract has to include a drug screen. Do you suppose they mean that the contract must obligate the patient to submit to drug screens? And here I thought we were talking about treating addiction, not pain.

I'm starting to feel like Andy Rooney here.

Providers will need to indicate the type of narcotic that was prescribed prior to Suboxone: and mg dose.

There we see a novel (and gratuitous) use of the colon, but yes, we providers will certainly need to indicate that, and hope that we do not have to figure out who "prescribed" the heroin. I have no idea what they mean by "type of narcotic." If you can guess, please comment.

No patient will be prescribed more pills/day than they actually take

The writer probably could not decide whether to end that with a question mark or a period. Maybe they just did not want to assume that it was in fact a sentence. Think about how to comply with this "limiting condition." In my experience prescribing has to take place before "taking," so compliance could be a challenge.

Patients that violate their contracts with providers will not have their prescriptions filled.

OK, but pharmacists fill prescriptions. How can the physician or the patient commit to what the pharmacist will do?

I hope this will help CUP rewrite their agreement and policy, and give you a few laughs. The intention here is to mock, make fun of, and otherwise ridicule bureaucrats, legislators, executives, and just about anyone else who reveals their ignorance or stupidity with respect to behavioral health care or any other aspect of medical care by gaffs, bloopers, grammatical blunders, and malapropisms. I solicit your contributions which will soon collect on a page attached to this blog.

If you're suicidal hang up and call the crisis line.

Despite the ubiquitous "If this is an emergency, hang up and dial 911" message I wonder how many patients who are sufficiently ambivalent about ending their lives to call their psychiatrist would call 911 instead. There seems to be an expectation (standard of care?) that psychiatrists can somehow talk them out of it over the phone, or attempt to stop the patient by involving 911 or other resources. I find it ironic that many argue that video conference (eg, Skype) is inadequate for even routine psychiatric encounters and yet expect psychiatrists to, on the spur of the moment, handle a life or death situation over the phone. Why not send these calls to the people who handle them all the time, crisis lines, and stop trying to be the hero like one of those movie psychiatrists? In Sybil Dr. Wilbur goes to her patient's apartment to rescue her. How far should one go to stop the patient from killing herself? Why stop with a telephone call?

Should we pretend to do something we cannot do? Does providing access outside of an appointment encourage or reward dysfunctional and potentially dangerous behavior?

"If you're suicidal, leave a message and you'll get a free telephone session with your physician who wants to be your hero and rescue you and provide you with attention and make you cared for, warm and fuzzy."

I am challenging an irrational myth which has become to some degree standard of care, at the very least an expectation, just because we perpetuate the illusion, a myth that interferes with providing appropriate after-hours assistance to patients. Does the fear of malpractice suits force us to do what may not be in the best interest of the patient, practicing what I call make-believe medicine?

As a physician I want to provide access by telephone after hours, but talking to me by phone is no substitute for going to an emergency room. I don't pretend to be capable of talking anyone out of any kind of bad behavior. Is there any evidence that any of us is capable of doing that? (other than in the movies)

Are all medical jobs created equally?

Guest blogger: Elizabeth O’Malley

Elizabeth graduated with a degree in Public Health Administration before relocating with her family to Seattle. She is currently writing, and her favorite topics include health care, work-life balance, and travel. Thank you Elizabeth.

In prestigious medical careers that require years of education and experience to climb the ladder of success, people of lower socioeconomic (SES) backgrounds, often ethnic minorities and women, may face disadvantages in their pursuit of a career in medicine. I am a firm believer that most people can achieve their dreams if they work hard. However, countless studies have shown that persons from low SES backgrounds have more difficulties in their paths to educational and professional success than persons who come from more affluent families.

Medical professionals are some of the highest earners in America, especially the professionals at the top of the medical earnings scale, including anesthesiologists, surgeons, and other medical doctors. Becoming a successful medical professional costs more than even most from upper-middle-class backgrounds can afford without taking out loans. People from a low socioeconomic background may not have the resources or time to consider going to college or medical school because of the expense and other factors such as family responsibility. The psychological consequences of socioeconomic status may prevent people from considering a high paying career as a viable option.

Instead, the lowest paying jobs in medicine are often the options most available. If someone has a GED or high school diploma, for example, they can become a certified nursing assistant or registered nurse assistant. Usually this requires a certification program that takes much less time than a degree. However, in a hospital setting CNA’s and RNA’s often work long hours of overtime and often do the most menial and labor-intensive tasks on their floor, such as cleaning bedpans and changing soiled linens. Nursing assistants generally have to spend much more time with patients than RN’s or MD’s. At times this can be enjoyable if they are able to develop relationships with their patients, but it can also put them at more risk of violence in some circumstances. Working as a nurse assistant also offers little opportunity for upward mobility.  

Is it really fair that those who do so much labor are also the lowest paid? Inequality in opportunity to achieve success extends beyond the medical profession. It rests on the class bias and wealth stratification of our country’s social structure in general. But more people are taking notice of the stratification of work that exists within the medical profession itself, and between medical career paths.

The bigger question remains: how do we solve these inequalities? The issue of work distribution inequality deserves more attention from health care professionals and researchers. Professionals such as Paul Fischer have recently suggested that within the medical profession itself should advocate for a more level playing field. Perhaps it is time to encourage more people to join the medical profession for the work itself, as opposed to the money. This solution might involve lowering the already exorbitant pay of some health care workers to discourage those who have no interest in helping others from going into medical professions, and considering whether a medical career might not be the right choice for them. Distributing information about medical careers to schoolchildren in low income areas so that they are encouraged to consider the medical profession a viable option and increasing the cultural competency of medical education might also help lower these barriers to equal opportunity over time.

How do you rule out ADD?

Seems like it's almost as easy for adults to get a diagnosis of ADD and a stimulant these days as for Bipolar Disorder and a mood stabilizer. Probably the easiest way is to go to someone who claims to be an ADD expert, maybe get a brain scan with pretty colors. The more expertise the clinician has the more likely they will bestow the diagnosis.

But it also seems to me that an expert should excel at determining you do not have the disorder.

To further this discussion let's borrow some concepts usually applied to laboratory pathology. We call a test, like a thyroid function test, positive when it confirms the presence of the disease and negative when it rules the disease out. So if certain thyroid hormone levels in your blood exceed the normal limits we might call the test positive for hyperthyroidism; otherwise the test is negative. But like a psychiatric diagnostic examination, even including the brain scan de jour, laboratory tests can mislead, in which case we call them false:

• False positive: The test suggests the disorder is present, but it is really absent.
• False negative: The test suggests the disorder is absent, but it is really present.

You may then ask, "But how do we know for sure whether the disorder is present or absent?" This presents more of a problem for ADD than for hyperthyroidism. We can confirm or rule out the latter illness with further objective tests, but there exists no such gold standard or objective test for ADD.

What difference does it make?

One reason experts and amateurs alike tend to diagnose ADD so readily is that a false negative deprives the patient of a potentially very helpful treatment. We tend to like to avoid that by applying looser criteria. But that approach leads to more false positives.

The downside of a false positive usually involves proving someone a potentially addictive or abusable drug they may share with others or use to get high. Having such a diagnosis, even just in an old record, might also prevent you from obtaining something, like a job or insurance. Absent this downside we might just throw stimulants at everyone, and if they like them diagnose ADD, or if they don't tell them they don't have it. But we know that doesn't really avoid the false positives and negatives either. Many people who do not suffer from ADD likely experience stimulants as pleasurable or improving their cognitive functioning and alertness (false positive).

Clinicians still face this person who claims to have a problem and want help. Sometimes we can diagnose an anxiety disorder and treat that, and sometimes we feel confident the patient just wants drugs for the wrong reasons. Maybe we don't pick up a clear history of ADD dysfunction in childhood. But it's hard to say, "You don't have ADD. Go away." unless you can be very confident that you are not looking at a false negative.

I like to think the real experts should have more confidence when they rule out the disorder, but do they? 

How do you rule out ADD in adults?

or

How do you rule out ADD in adults?

Who ya gonna call?

Got a problem? No budget to solve it? Need someone who will jump when you snap your fingers? For free?

Find a doctor. And hold hostage the care and welfare of the patient.

This is exactly the tactic a pharmacy at Group Health Cooperative (@grouphealth) tried to use on me when (they claim) a controlled substance I prescribed got lost "in mail." I received this note by fax five days after I ordered the refill by telephone:

"Prescription wrote on 9/7/11 was mailed to patient which has been lost in mail. Confirmed with USPS. Please write a new Rx and fax to Bellevue Pharmacy where patient will come in to pick up. -- Thanks"

(I hasten to point out that, from what I have been told, the prescription -- not the patient -- was lost in the mail. I guess pharmacists can get by these days with limited writing skills.)

Maybe HMO pharmacists are accustomed to ordering employee physicians around. It may have been a shock to them when I reminded them that I had already ordered the drug, that I only wanted the patient to have that one refill, and that so far they had failed to comply with my order, causing the patient, their subscriber, distress. It may have been a shock when I refused, but instead reported the incident to DEA and the state pharmacy board. I plan to give them a few more days to see whether they comply with my order before filing a formal complaint with the Department of Health.

My telephone contacts with the pharmacy board and DEA disappointed too. A representative of the pharmacy board failed to provide a definitive answer to the question of how the pharmacy should have handled the loss, and DEA has yet to provide clear guidance as to whether I might be in violation should I write another prescription.

Sadly, third parties of many kinds exploit physicians and their wish to protect their patients every day, and in numerous ways. I hope this example will discourage the cynical practice of exploiting physicians' instinct to protect patients, but I believe that only when physicians stop enabling by giving in will this shameful practice stop. If you the physician ultimately choose to cave in to protect your patient, at least look for ways to punish those who exploit you. For example, in the case I describe above I can refuse to order through that pharmacy, possibly forcing the patient to find a different payer or a different physician or to forgo reimbursement. I can also specify that the drug must be dispensed directly to the patient.

Doctors: Push back!

Attracting Easy

To get  ideas for a new logo for BehaveNet I viewed a dozen or so Web sites related to behavioral health care, mostly a variety of providers running the spectrum from psychotherapists of all kinds to drug rehab residential facilities.You can probably guess what I found: birds and butterflies, flowers and trees, waves and water, brains and molecules, happy, fulfilled appearing people, some with their arms in the air, and a variety of abstract shapes. You can probably imagine the marketing people pushing positive images depicting happiness and light, growth and fulfillment. Avoid reference to pain and suffering, failure and defeat. Avoid reference to reality. Talk about issues instead of symptoms and dysfunction.

I wonder to what extent this approach to marketing reflects the fact that most of us prefer to work with low risk patients, the worried well. And who could blame us? We want to help, but who wants to (or can afford to) accept responsibility for the too numerous horrible outcomes? Certainly not our society, always looking to blame the professional when someone who may suffer from a mental illness does something shocking.

To survive we may strive to shun the people who need our help most, even if only by the subtle means of attracting cases that allow us to sleep at night.

I hope the disclaimers will suffice to keep the judges and juries from holding BehaveNet responsible for bad outcomes. So when I started the logo design process I said no birds or butterflies, no smiling faces or flowers, and I mentioned Mr. Loughner. We pursue serious professions, and the serious problems exist. I welcome suggestions.

Contingency Fee for Physicians

"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw

The debate rages: Should physicians charge a fee for non-clinical tasks such as completing FMLA and disability forms, utilization (peer) review, and prior authorization for reimbursement for drugs, tests and procedures? As physician reimbursement plummets physicians increasingly wonder how they will pay the overhead, much less take home enough to pay off the student loans and still make a living. Many physicians now charge a nominal fee, maybe $50, or an hourly rate which barely covers the loss of time entailed.

Keep in mind that in many cases a third party like a disability carrier or pharmacy benefit manager exploits the physician's wish to help the patient in order to obtain free service from the doc. Physicians rarely obtain payment from the third party, and billing the third party raises ethical and role questions. The physician should work for the patient, but the third party foots the bill. Who does the physician work for anyway? And yes, the same question arises when the physician accepts money from insurers for rendering ordinary medical care, especially under contract.

Plaintiff's attorneys can collect as much as 30% or more of damage awards as contingency fees when they win a case. Not only does this practice assure an income, it also provides an incentive for them to take a case and spend their own money on trial expenses, like hiring expert witnesses, that many of their clients cannot afford.

Why don't physicians do the same? Let's say a patient applies for disability, and the policy allows for $1000 per month. If the physician completes the application, but the carrier rejects the claim, no one pays the physician either. But if the policy is awarded, the physician takes 30%, or $300 per month. It could work the same way for prior authorization for an expensive new atypical anti-psychotic. The physician would take 30% of the retail price as a reward for having obtained reimbursement.

This could change the game, giving physicians an incentive to increase skill at obtaining reimbursement. Experts with proven track records would sponsor courses. Physicians would publish their success rates on their Web sites. Patients would choose physicians, not by bedside manner or quality of medical care, but instead by how well they perform to obtain reimbursement.

What? You say there may be an ethical problem with this approach?

"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw

Voir Dire and HIPAA

Yesterday I presented myself for jury duty for the first time. It did not surprise me that the attorneys for a personal injury case rejected me after subjecting all the candidates to the process known as voir dire. The other prospective jurors, however, did surprise me by their willingness to discuss their medical histories openly in court. Not one refused to answer questions about injuries and treatment.

Truth be told, during the voir dire we identified ourselves only with large numbered placards, but the jury attendants had previously assigned numbers with names announced to as many as 100 prospective jurors, and selected jurors would likely introduce themselves during deliberation. I planned to refuse to provide what in any other venue would qualify as protected health information (PHI) under HIPAA, but neither judge nor attorney ever asked. I admitted only that I have never sustained an injury in a motor vehicle accident.

I still wonder whether the court can compel a prospective juror to reveal medical information. If so this would seem to represent a double standard of sorts and would seem to conflict with or even invalidate medical privacy safeguards.

All prospective jurors also dutifully stood, raised their right hands, and said, "I do," when ordered to swear the oath. (No one seemed to notice that I did not raise my hand or say, "I do.") In that situation most seem to accord great authority to judges, sometimes assuming judges possess authority they may not really have. I doubt that a judge can compel me to swear an oath. If this is true, and if judges lack the authority to compel release of medical information, they should inform prospective jurors of this fact.

Need Help With Drug-of-the-Day Tweets

If you had to think of two or three words to remind a potential prescriber or even a patient about some important aspect of a drug, what might they be?

Every day (repeating on the same day annually) I will tweet a different CNS drug with a link to the drug's page and a few words to remind of a key property of the drug or aspect of it's use. This is intended as an educational tool.

Yesterday's tweet: 

"BehaveNet® Clinical Capsule™ #Drug of the Day: #risperidone #prolactin http://bit.ly/nFJZbN"

I am soliciting suggestions. More examples lithium: kidney, thyroid; bupropion: seizure. 

What might you suggest for amineptine? trifluoperazine? The list currently contains more than 365 drugs including many from the DEA controlled substances list. I am also looking for suggestions on which drugs I should drop to get down to one drug per day.

twitter.com/behavenet

You can view the list at the link below. You may need a gmail account. Please mention suggestions with comments here or at facebook.com/behavenet.

https://spreadsheets.google.com/spreadsheet/ccc?key=0AmhtA4iuvrWpdHNCTFQ0TkNRQ09QS3o1NDA1NU50TlE&hl=en_US

Hung Up on Drug Classes

This WSJ article on increasing use of antidepressants illustrates at least part of the problem: Readers naturally start thinking about patients with depressive disorders, and the article alludes to recent media attention to possible lack of effect on mild cases. Only near the end of the article does the author remind us of the wide variety of uses of these drugs beyond treatment of depressive illness, some of which enjoy FDA approval. Bupropion helps with smoking cessation. Fluoxetine gained approval for Bulimia Nervosa. I frequently prescribe mirtazapine, off label, for insomnia. FDA has approved various SSRI's for anxiety disorders like Panic Disorder and PTSD.

Did I say SSRI? Here comes another dimension. SSRI refers to a mechanism of action, or just action. SSRI's (starting with fluoxetine in the US, fluvoxamine in Europe) represented an apparent improvement over the older tricyclic antidepressants. But tricyclic, like tetracyclic (trazodone) refers to chemical structure. Other chemical classes include benzodiazepine and barbiturate.

Had enough yet? I struggle with yet another category of drug class. Even if you leave out chemical class and action, and attend to what I call clinical class, which clearly includes antidepressant, anxiolytic, and anti-psychotic, several other classes seem distinct. These include sedative-hypnotic, psycho stimulant, and neuroleptic. To my way of thinking clinical implies illness or symptom. Antidepressant means attacks depression, a symptom. But neuroleptic refers to no illness or symptom, even though we usually use that class of drugs to treat psychotic disorders. I propose calling these "effect" classes and separating them from the clinical classes. Should clinical classes be a subset of effect class or a separate class on the same hierarchical level?

Clinical classes also suffer from the too frequent assumption of all or none status. Once FDA grants approval for treatment of depression few would argue with membership of the drug in the antidepressant class. Enter the controversy surrounding the evidence that antidepressants can precipitate mania in patients with Bipolar Disorder, and take for example the anti-epileptic drug gabapentin. Anecdotal reports in the literature describe cases of apparent antidepressant effect. Should we classify the drug as an antidepressant based on such scant evidence? Does inclusion in the antidepressant class imply risk that the drug may precipitate mania in Bipolar? Just how should we determine whether a drug deserves admission to a given clinical club? For many drugs it seems the original category sticks despite evidence for inclusion in other categories.

We can see the same problem with action. We may call a drug a dopamine antagonist because that action seems to dominate, but the same drug may have histamine antagonist (anti histamine) action, and others, as well.

Sometimes the context determines the category. FDA first approved divalproex for treatment of epilepsy (Think clinical class.), but when discussed in psychiatric circles we usually classify it as a mood stabilizer (Think effect class: There's no direct mention of illness or symptom.).

Separating effect classes from clinical classes will not solve the problem. Ultimately we must maintain awareness of the limitations of the designations. The need to categorize and the complexities of the task permeate human psychology and language. For an exhaustive and fascinating exploration read:

Do you know how your patients use social media?

When I participated in a typically frantic Tweetchat discussion on Health Care and Social Media (#hcsm) last Sunday (9PM eastern) the subject of patient use of social media came up. Some tweeters focused on communication among patients and providers using, for example, Facebook and Twitter, but several voiced concerns about HIPAA compliance and privacy. Although I use both in connection with BehaveNet, as far as I know none of my patients even knows that I am Moviedoc or that I publish BehaveNet.

It has occurred to me that the ability to discuss patient care in a private and secure forum might enhance that care. I envision a virtual place where all providers involved can collaborate with the patient and even significant others or other caregivers, all with the patient's consent of course. Google Wave seemed to provide the right kind of platform, but if it has not already departed it may be on the way out. It appears though that the cloud based contact management service I use might allow me to create and host invitation-only spaces where we could hold conversations and collect and share resources.

Then it occurred to me that I don't even know whether or how any of my patients uses social media now, especially whether they use these technologies to communicate with other patients or providers about illness and treatment. I resolve now to start asking with the next patient to find out whether any might want to jump in. Next I will have to pole a few primary cares and psychotherapists.

Traveling sick? WA beats MD beats MA.

As patients continue to move or travel in different states I have the opportunity to update my table of information on legality of practice of medicine across state lines.

Massachusetts gets an F

In two voice mail messages a representative of the Board of Registration in Medicine on June 30, 2011 explained, "If the patient is in Massachusetts, you would need a Massachusetts license." This applies not only to patients moving to the state, but also to patients traveling in the state. They even consider calling in a prescription to a pharmacy in MA to constitute practice of medicine, requiring a license to be legal.

Maryland gets a C

In a series of emails on July 18 and 19 a "Public Policy Analyst" at the Maryland Board of Physicians cited: Code of Maryland Regulations (COMAR) 10.32.05.03 which specifically addresses "telemedicine" in stating that even a phone call with no fee would require a MD license, but she also pointed out that the Board would not likely know and that investigation might only occur after a complaint.

In a followup message, however, the Analyst told me that MD has a reciprocity agreement with DC, so physicians and patients located in or licensed in either jurisdiction might pretend it's just one state.

But there's more: In her final message she cited: §14–302.  Health Occupations Article, Annotated Code of Maryland:

"Subject to the rules, regulations, and orders of the Board, the
following individuals may practice medicine without a license:
(4)   A physician who resides in and is authorized to practice medicine
by any state adjoining this State and whose practice extends into this
State, if:
(i)   The physician does not have an office or other regularly
appointed place in this State to meet patients; and
(ii)   The same privileges are extended to licensed physicians of this
State by the adjoining state..."

As I read the map this covers: DC, VA, DE, PA, and WV. I know of no other state with such a rational statute. Every state should enact a similar law.

Washington gets an A+

I still have to pinch myself to make sure I'm not dreaming. Yesterday a representative of the WA Medical Quality Assurance Commission repeatedly assured me that WA considers the practice of medicine to take place where the physician -- not the patient -- is located. At least for purposes of patients traveling to other states I believe this is as it should be. I have a feeling this policy will not last, but until then, if you are sick, come to Washington! Or at least if your patient plans to travel, and you the physician want to retain your status as a non-criminal, encourage all your patients to choose WA as the place to vacation or travel on business.

Government sanctioned deceit on hold

According to this NY Times article feds have postponed planned deceitful survey of doctors:

Administration Halts Survey of Making Doctor Visits

Let keep up the pressure to abandon the idea completely.

Government sanctioned liars

New York Times: U.S. Plans Stealth Survey on Access to Doctors

According to the article factitious federal "shoppers" plan to call primary care offices to assess relative availability based on payer, like Medicaid, Medicare, insurance or direct (cash) pay.

Physicians should look at this as an opportunity to send a message to Washington: Starting now or in a "few months" stop accepting Medicaid and Medicare patients. Apparently docs can avoid the calls altogether by not accepting or returning calls from ID-blocked numbers.

Or send them to the ER.

Go Ahead and Die!

Health care financing: The Lounge Lizards tell it like it is. Do I see the jolly roger coming up over the horizon? (What's the proper spelling of aaaarrrrrgh?)

Shiver me timbers.

Progenitorivox

Enough is enough! Stop the me-too drug explosion now.

Ask your doctor.

Did Danny Carlat write this song?

Gotta get me some of this.

Do med schools select for wimps?

I have this pet theory that part of the reason medicine is in such a pathetic state today is the failure of docs to stand up for themselves and their patients. On the wimp spectrum I see psychiatrists at one end and surgeons at the other. To get into medical school you have to comply, comply, comply. Conform. Don't assert. Rebels and mavericks need not apply.

What If Psychotherapy Required Physician Referral?

I didn't think much of it when my own physician wrote me some kind of order or prescription for 12 sessions of physical therapy a couple months ago, maybe just whether my medical insurance would claims for additional sessions differently. But a few days ago I was surprised to read in a physician forum a discussion of possible ramifications if physical therapists were allowed to treat patients directly, that is without referral from a physician. I had always assumed that patients could self refer to physical therapists in much the same way they can to psychotherapists.

This led me to wonder what it would be like if one could only engage the services of a psychotherapist with an order from the physician, maybe not necessarily even a psychiatrist. Maybe this would only apply to reimbursement. In other words you could self refer at will provided you paid cash, but perhaps there would be reimbursement from healthcare payers only with physician referral. Maybe it already works this way for some carriers.

How would this impact a typical psychotherapy practice? How would physicians determine whether to refer for psychotherapy? Would they get to know better the psychotherapists to whom they referred? It already seems to me that even psychiatrists might find it difficult to find a local psychotherapist who provides the type of psychotherapy best suited to a patient's particular problem. I suspect most physicians lump it all together as psychotherapy or counseling and don't know the difference between psychoanalysis and dialectical behavior therapy or between family system psychotherapy and primal scream. Certainly it would seem that physicians might be inundated with marketing efforts by psychotherapists clamoring for referrals. Maybe physicians would thus learn something about psychotherapy methods. Or would busy physicians just ignore it all and blindly authorize whatever treatment they are patients requested?

Under such a system might there be more communication, real collaboration, between physician and psychotherapist? Would it be easier or more difficult for patients to get treatment? What would be the impact on health care costs overall? Would such a policy solve problems or just create new ones?

Apps for Psychiatry

Robert Post, MD started publishing paper charts for tracking mood, meds, events and other information relevant to Bipolar Disorder years ago, but Optimism here is the first I have discovered that might handle the task digitally. I hope they come up with an Android app.

I have not tried Optimism or recommended it to patients yet, but I have started tracking my own moods with the T2 Mood Tracker from the National Center for Telehealth and Technology. I find the free Android app easy to use. It produces a graph to track mood, anxiety, PTSD, and head injury related parameters. A patient could show it to his provider during visits, but I would like the capability for providers to view the chart in real time with a browser which would allow more accurate viewing via Skype/Tango. When the app detects out of the ordinary entries, it suggests you make a note, which you can also save in the app for later viewing.

A patient actually introduced me to the idea of an (iPhone) app for monitoring sleep. I downloaded the free Android app Sleep Graph. To use it I must activate it, then leave it on the corner of my bed all night. (I wonder whether it can produce separate graphs for each person and animal on the bed.)

Two apps from Apple appear to allow you to address sleep problems:

ResMed appears to focus on breathing related sleep problems.

Sleep Hygiene seems to record total sleep time and other parameters for overall sleep monitoring.

What other apps have you found useful for addressing psychiatric problems?

Web Therapy

If you thought the 15 minute med check was bad, wait'l you see Fiona Wallice (Lisa Kudrow) conducting 3 minute Web therapy sessions:

Upcoding for Cash

Well Mr. Jones, that's the end of today's visit. That will be $95. Wait a minute. I asked you about that cough. That counts as a partial review of systems, so I can tack on another $7.50. I also checked your med regimen for interactions. That gets me $9.99. And I did establish that you know who I am, where you are, and the time and date. Partial mental status exam counts for $12.75.

You probably cannot imagine doing that to a patient who pays cash for psychiatric treatment, but that is exactly what happens after many physicians and other providers wrap up a patient encounter when a third party payer foots the bill. If the physician fails to squeeze the maximum blood out of the reimbursement turnip in a hospital or a large enough group practice, a coding specialist will jump in.

Don't get me wrong. I dislike Medicare and private insurance companies as much as anyone, but there is something particularly disengenuous about sticking it to them when we would never approach a patient with the idea of attempting to squeeze every penny we can out of them. Quite the contrary, I tend to look for ways to charge my patients less for more. For example, I could have increased my fees to cover all the phone tag with patients and pharmacies, mostly related to refills and cancelling or rescheduling appointments. But a few months ago a patient had the audacity to text me, I texted her back, and now I save countless minutes over lower tech communication by texting with patients, easily enough to allow me to defer a fee increase for a few more months.

It's fine for physicians to make sure someone pays them adequately, especially when financial incentives lead to improved care, but when you stick it to the payer, whether it's a big guy like Medicare or a little guy like your patient, you ultimately stick it to all of us who pay premiums.

Patient Falsely Claims to Not Have Medicare. Doctor Goes to Jail.

Sounds absurd, doesn't it? And of course it really hasn't happened. Yet. As far as I know.

But it could happen in your lifetime. Here's how:

Patients regularly call my office asking whether I "accept Medicare." Until about a month ago we politely explained that I opted out of Medicare. This means the patient must agree in writing that neither of us will ever bill Medicare for services I provide and that the fee I charge is between me and the patient. We are not bound by the Medicare fee schedule. About a month ago, however, I decide to stop treating patients who are covered by Medicare altogether. (Why is another story.)

Many of the patients who call my office, when we tell them I do not accept Medicare, tell us they cannot find a psychiatrist in the area who does accept Medicare. The obvious solution? Lie. After all, what physician or office staff would suspect someone of claiming NOT to have coverage? What might we say? Prove it. I suspect not. And besides how could the patient prove he does not have Medicare coverage?

Why would a physician want to make sure the patient is not covered by Medicare? There may be stiff civil or even criminal penalties for failing to file a claim with Medicare unless the physician has opted out. So adopting a "Don't ask. Don't tell." approach involves considerable risk.

How would the patient know the physician does not accept Medicare patients, and thus must lie? My practice Web site front page clearly states that I do not accept patients who have Medicare.

I contacted the Office of Communications/Media Relations Group at Centers for Medicare & Medicaid Services and inquired whether any such cases have been prosecuted. Ellen B. Griffith, Public Affairs Specialist, responded:

"As to whether a physician would be prosecuted for failing to submit a claim for services to a beneficiary who lied about his status –  CMS is not an enforcement agency.  Prosecutions of violations of Medicare law are handled either by the Office of Inspector General or the Department of Justice.  I would suggest you contact them directly."

I then asked, "Is there a way a physician can confirm that a prospective patient is not a beneficiary by accessing a database at CMS or other agency?" So far no response.

I admit this hypothetical situation seems unlikely, but its very plausibility suggests Medicare badly needs fixing, and soon. You can join the conversation with seniors at AARP.

What About Treatment?

To considerable fanfare (press release) last week the Obama administration announced an action plan for addressing the "prescription drug abuse epidemic." Along with ONDCP, FDA, HHS, and DEA will lead the effort. Notably absent from the alphabet soup of federal agencies are CSAT and SAMHSA, or indeed any mention of treatment. The plan just lays out more of the same old supply side war on drugs that will make it harder for physicians to manage pain with narcotic analgesics in the patients who really need it, and likely restrict supply which will lead to higher black market prices, more crime, and more cartels. And more job security for DEA agents.

You might think professional organizations like APA and ASAM would raise the issue of treatment, but no, that does not seem politically correct from their point of view. In a press release treatment barely achieves afterthought status. When I asked ASAM's government relations representative, Alexis Horan, she responded with this:

"ASAM has been working with the DEA since last March to have them issue a guidance to all prescribers re: what to expect from these audits, how to prepare, etc.  We’ve also suggested to the DEA that their agents be better trained on how to perform these audits, how to work with the providers and their staffs, etc.  In fact, we’ve facilitated some meeting between local DEA agents and ASAM chapters to have an open dialogue about audit experiences.  We are also working with SAMHSA and other HHS agencies to offer prescriber training and other ways of education people about these issues.  I promise you, ASAM cares! "

In other words, "comply, comply, comply."

I wrote back:

"ASAM seems to care more about compliance than the rights of members and their patients. What keeps ASAM from demanding that DEA schedule the audits to minimize disruption? What keeps ASAM from demanding and publishing an "Administrative Warrant?" How can ASAM educate if it cannot provide such a document to its members? Is it not politically correct? What repercussions does ASAM fear if it takes a stand?

"Many of my readers believe their professional associations have failed to advocate vigorously enough where they believe their rights have been violated. Is this not a legitimate role for such an organization?"

No response to date.

What are these organizations afraid of? Why are they shaking in their boots when they hold an excellent position from which to advocate not only for treatment, but also for freeing physicians to do their jobs without gratuitous interference from law enforcement disguised as auditors. While paying lip service to "caring," ASAM, with this cowardly approach, misses the opportunity to call DEA on the carpet for discouraging treatment, thus working at cross purposes with agencies charged with encouraging treatment.

The federal government must deal with its ambivalence toward treatment if it really wants to solve the prescription drug problem, and professional associations like ASAM must keep up the pressure rather than rubber stamping failed policies.

The Good Med Check IV: Getting Physical

(Continued from The Good Med Check III: Time Is Money)

Critics of the med check often equate the abandonment of psychotherapy by psychiatrists with tragic abandonment of the biopsychosocial model, viewing psychotherapy as a necessary ingredient of every patient encounter (if only for psychiatric patients). You might think they were invoking the bio-psychotherapy-social model. But in fact when psychotherapy in the form of psychoanalysis stuck it's foot in the psychiatric door a hundred years ago was it not the "bio" that was abandoned? Back then  few drugs competed with non-"biological" treatment modalities, but as the model of psychiatrist as psychotherapist (or just "therapist") evolved psychoanalysts pronounced the physical examination, so long an integral part of patient-physician encounters, incompatible with analysis, and eventually any psychotherapy, citing potential boundary violation: talk, but don't touch. (Thankfully, we do not hear protests that psychotherapy should accompany electro convulsive therapy.)

To be sure physicians of many specialties have abandoned the physical exam in favor of laboratory tests and imaging studies. If your non-psychiatrist physician lays hands on you at all, she will likely limit or direct the examination to only that which relates directly to your complaint or diagnosis. Admittedly, at least at first look, few aspects of the physical (other than the mental status exam) seem directly related to psychiatric complaints or disorders, unless the psychiatrist assumes the role, as some do, of primary care provider. But a psychiatrists probably could do a better job by attending to a few physical findings, whether part of a med check or a psychotherapy session. A few examples follow:

• Monitoring blood pressure in patients taking venlafaxine, and some other drugs
• Weighing eating disorder patients or patients taking drugs that affect weight
• Pupil diameter when you suspect unadmitted drug use
• Examination for cogwheel rigidity in patients taking dopamine antagonists
• Neurological examination to rule out neurological causes for psychosis or conversion

One could argue that the psychiatrist needs to "see" the patient more than the patient needs to see the psychiatrist. In some ways physical examination of a psychiatric patient stands at the opposite end of the spectrum of clinical tasks from psychotherapy, but it is at least as legitimate.

The Good Med Check III: Time Is Money

(Continued from The Good Med Check II: Getting to Know You)

Shorter visits to the psychiatrist translate into more than lower cost to the patient and higher income for the doctor.

Blogger Steven Balt commented on my first post in this series: "And be sure to get it all done in the 15 minutes you're allotted for each patient!!" Come to think of it, the usual pejorative label actually reads "15 minute med check." Steve refers to this as a "cookie-cutter treatment mentality" and tells us he works part-time in a community mental health center. I surmise that means sicker patients with fewer resources and less discretion on the part of the psychiatrist in determining the schedule. More likely than not many if not most patients could use more than 15 minutes even for a med check. In my practice, however, I have the luxury of determining how often I schedule patients. Maybe I'm spoiled. Even if I schedule a different patient every 15 minutes, many of the visits take less than five minutes, so I can spend more time with others. And we all pray for late cancellations and no-shows on busy days, so we can get some (administrative) work done.

The tradition of the 50 minute hour has raised expectations in psychiatry more than any other medical specialty that patient and doctor will have time to chat. It's not just about psychotherapy. Both patient and psychiatrist complain that loss of such relaxed visits resulted from a need to limit payment. As psychiatrists have moved away from the 50 minute hour because of financial considerations patients have questioned the now standard practice of charging almost as much for a medication management encounter as they might have to pay for full session psychotherapy, or the converse, from the psychiatrist pointed view, of getting paid little more for what really occupies an entire hour than they can charge four (or more) times in that same hour. But what does the psychiatrist really get paid for? Not just time.

Consider treatment of two patients for an entire year. One patient gets 50 minute sessions weekly while the other gets four 15 minute medication management encounters during the same year. The psychiatrist still likely spends equivalent amounts of time with administrative work like prescription refills, and each of the two cases represents similar risk of a professional liability lawsuit. Yet the annual revenue for the two patients differs dramatically. This should explain to some degree the apparent discrepancy in the two fees charged. And while some patients still want to spend lots of time talking to the doctor, or actually doing psychotherapy, others resent having to present themselves more than once a year just to get that prescription renewed. After all, if something goes wrong they know they can always schedule an earlier appointment.

Shorter visits make for more flexible scheduling too. Double booking full session psychotherapy means someone has to reschedule or sit it out for an hour in the waiting room. But when you double book medication management encounters accommodating both patients requires only that one wait for an extra 10 to 15 minutes. This makes it more feasible to schedule an encounter earlier to address a problem that cannot wait the usual interval. The same applies to phone calls. Some psychiatrists still seem to interrupt psychotherapy sessions for "emergency" phone calls (a bad idea in my book), but a fifteen minute med management encounter means postponing that call fifteen minutes at most, making interruption unnecessary.

(Continued in The Good Med Check IV: Getting Physical)

The Good Med Check II: Getting to Know You

(Continued from The Good Med Check I: Checking the Med)

Critics of the now nearly ubiquitous medication management encounter frequently recite the mantra that psychiatrists who use this procedure  do not "get to know" their patients. They would have us believe that spending 45'-50' for psychotherapy once or twice a week in an artificial setting subject to numerous restrictions on verbal and other interactions allows the physician to really know the patient. They would also have us believe that only psychiatrists need to know their patients. They rarely complain that endocrinologists don't know their diabetic patients or gastroenterologists the patients on whom they perform colonoscopy.

I believe the better any physician knows his patient the better care she can provide. But don't equate psychotherapy with getting to know the patient. Many psychotherapies probably interfere with really knowing the person in treatment. One of the first things a psychiatrist should do when embarking on a medication management practice: Dump all the psychoanalytic dogma about blank slates, boundaries (no, maybe not all of those), and self revelation, and relate to your patient like any other physician, like a human being.

You can get to know your patient even in a 10' med check. Here are some ideas:

• Ask the patient about new developments in his life since the last encounter.
• Talk about an interest or concern you share with the patient, something the two of you have in common.
• Establish an interest in a matter you know is a priority in the patient's life.
• Discuss sports, hobbies, entertainment.
• Follow up on the patient's evolving relationships with significant others.
• Ask the patient what has changed most in her life since the medication started to work.
• Inquire about the patient's pets. Even encourage them to bring one to a visit.
• Chat about current events, religion, politics
• Encourage dialog about health care reform.
• When (if) you conduct encounters via video-conference you may see the patient at home, at the office, or even in a vacation spot. You may see a family member, pet or other element of the patient's life you would never see in your office. Ask about what you see.
• Google your patient and tell them what you discovered.

Look for a subject that will evolve over time. Make a note in the patient's record to remind you to inquire about change in that subject during every encounter. Even one or two minutes devoted to such dialog will enhance the effectiveness of your services.

(Continued in The Good Med Check III: Time Is Money)

The Good Med Check I: Checking the Med

The much maligned "psychiatric medication management" visit, sans psychotherapy, pejoratively labeled the "med check," has become standard for many if not most psychiatrists. Contrary to the mantra, everyone does not need psychotherapy, but all med management encounters are not created equal. My concept of the elements of a good, even great, and comprehensive, med check follows. Don't expect to cover every one of these on every visit. Feel free to suggest additions to the list:

• Inventory of target symptoms and behaviors
• Assessment of success or failure of treatments
• Discussion of dose adjustments and adding or removing medications
• Monitoring of substance use emergence or relapse and use of recovery tools such as 12 step groups and sponsors
• Reassessment of working diagnosis and safety
• Review of status of psychotherapy or other treatments provided by other professionals
• Inventory and management of side effects
• Prior and emerging medical problems
• Review of medications for other conditions started since last visit and potential interactions
• Overall assessment of treatment status
• Review of long term goals and plans
• Education about the illness and its treatment
• Education about new related developments and treatment alternatives
• Referral to other services or professionals
• Laboratory and other tests: drug screen, medication levels, thyroid, liver function, renal function, imaging
• Administrative matters such as reimbursement, refills, appointments, changes in practice policies and procedures
• There's no law against throwing in one or two brief and carefully selected psychotherapy interventions, especially CBT or systemic
• Getting to know the patient (next post)

How many of these items might we apply to almost any patient-physician encounter, not just psychiatric, even perhaps including the psychotherapy interventions?

(Continued in The Good Med Check II: Getting to Know You)

"Self Abuse" Redefined

Consider "child abuse": Who gets hurt? The child.

Now consider "Drug abuse." Who gets hurt? The drug? Hardly.

One who "abuses drugs" hurts oneself.

"Self abuse."

I propose we abandon the old use of the term. Who uses it that way anymore anyway? The light bulb flashed on in my head as I became embroiled in yet another dispute over the notion of "self medication," once more misapplied to an individual using drugs and alcohol in the context of another separate (presumed) psychiatric disorder.

As in most such cases the drugs and alcohol more likely hurt rather than help the patient, as I argued in my earlier post: A Working Definition for Self Medication

So when you hear or see the term self medication in the future think self abuse and see if it doesn't lead to more accurate conceptualization of the case.

Sleeping for Fun and Profit

The recent New York Times article describing the psycho pharmacotherapy practice of Pennsylvania psychiatrist Donald Levin, M.D. garnered considerable negative attention from the psychiatric blogosphere, mostly from advocates of psychotherapy and detractors of psycho pharmacotherapy. Desperate to garner support for what I call sporkiatry, the practice of combining psychiatric medical treatment with psychotherapy (sporkology when performed by psychologists with prescribing privileges), they all seem to have ignored an article published in New York Times Magazine only a few days prior in which the author describes his multiple experiences of psychoanalysts falling asleep during his sessions.

Although I cannot recall ever having fallen asleep myself during a psychotherapy session I came close on a few occasions, and I know that the problem is not peculiar to psychoanalysts. However, regardless of how you feel about Dr. Levin's short patient encounters, I would be surprised to hear that he ever fell asleep during one of them, regardless of how "boring" (Danny Carlat's suggestion) or "unfulfilling" he may find medication management. (If you know of a psychiatrist who fell asleep while administering electroconvulsive therapy or transcranial magnetic stimulation, please report below.)

Blogger Carlat places more importance on the psychiatrist's job satisfaction than on what best serves the patient: "doing therapy is fun--it's involves getting paid for having interesting and intimate conversations with people." Or interesting dreams?

Blogger Steven Balt accuses Levin of "selfishness." [correction: Dr. Balt in his comment points out that the article, not Dr Balt himself, accuses Levin of selfishness.] Is Dr. Levin selfish to sacrifice the "fun" of psychotherapy? Balt still seems to think it's all about the session: feeling good about what goes on during the 50' hour rather than relief from symptoms outside the psychiatrist's office. Or maybe it's whether the psychiatrist reaches REM sleep.

According to blogger 1 Boring Old Man, "Days like Dr. Levin describes change you into a machine, and you become kind of brain dead." Might this result from sleep deprivation?

In contrast blogger Reidbord at least understands the proper purpose of psychotherapy:  "I’m a huge advocate of psychotherapy, yet I don’t recommend, much less provide, it for everyone.  It’s a treatment..."

It is not so much that these (we?) fallible professionals fell asleep in the course of their (our) work, but as the author points out, at least one psychoanalyst writing in a professional paper appeared to blame the patient. And it took the author's mother to raise the question of whether he might not have needed psychotherapy to begin with, underscoring the fact that almost no professional providing psychotherapy will likely tell the patient after the first interview, "Get outta here. You don't need treatment."

Everyone makes compromises and mistakes, and there is no perfect psychiatrist or psychotherapist, but I'll take a Dr. Levin, awake, alert and responsive, over a somnolent psychoanalyst any day.

How $MUCH.00 for the Psychiatrist?

Pennsylvania psychiatrist Levin sounds like he's working very hard to make money for retirement (Talk Isn't as Cheap as Drugs), but is he making too much? How much should I psychiatrist make? Yearly? Weekly? Hourly? Remember even a newly minted board eligible psychiatrist has completed four years of college, four years of medical school, and a four year residency.

Keep in mind what attorneys charge per hour, automobile mechanics, accountants and neurosurgeons. Physical therapists. Chiropracters.

Psychotherapy or medication management.

Also, include overhead: vacation, sick leave, malpractice insurance, office staff, office rent, furnishing and maintenance, continuing education, telephone and information technology.

What's it worth to you?

Now think about insurance. How much would you be willing to have your monthly health insurance premium go up to pay for psychiatrists to do unlimited psychotherapy. Four days a week, five or more years. Not just you paying higher premiums. Everyone.

What am I worth as a "therapist" and as a physician? How much?

Talk Isn't as Cheap as Drugs

This article in today's NY Times has generated considerable discussion.

Here's my take:

• 39 patients in a day: too many for me
• Dr. Levin has a right to practice as he chooses
• Dr. Levin's wife's role counts. She's appears to do things many psychiatrists would incorporate into their own roles. This makes the 39 patient count more reasonable.
• Dr. Levin must be doing something right to attract so many patients.
• Dr. Levin may be a lot better at psychopharmacotherapy now that he is doing so much of it.
• Dr. Levin needs to get a... blog. Or maybe tweets would suit his practice better.
• Sometimes 15' is more than enough time.
• Sometimes 50' is not enough time.
• Dr. Levin should have told his drinking patient to stop, if only because of potential interaction with prescribed drugs, and recommended appropriate help if needed. He could even have prescribed a drug to help him stop drinking.
• Many patients just don't want psychotherapy and shouldn't be forced into it.

It's not all about the money:

• Dr. Levin's patients get to choose their psychotherapist. They are not stuck with him.
• Dr. Levin's patients can get the type of psychotherapy best suited to their diagnosis, not just the kind that he happens to practice.
• Dr. Levin's patients don't have to get psychotherapy at all unless they want it.
• Dr. Levin's patients get to start and stop psychotherapy independently of medication.
• Dr. Levin's patients get to start and stop medication independently of psychotherapy.

My related posts:

• The Real Reasons Psychiatrists Want to Provide Psychotherapy
• Who Wants to Be a Sporkiatrist?
• The Sporkiatrist Tries to Do Psychotherapy