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Feds Should Respect State Legalization of Marijuana

As of today no Washington state law prohibits possession of less than an ounce of marijuana by an adult. Prosecutors in several jurisdictions have already dropped pending charges based on such possession. The state has started work on establishment of regulations to govern commerce in marijuana. Federal law, however, still prohibits associated activity.
The federal government should stop wasting lives and resources and let state law prevail where conflict exists. No good will come from a legal battle over states' rights or from continued enforcement of existing federal law in Washington or other states where adults can possess, grow, sell or use the substance (or hemp) legally.
Alcohol and nicotine should be classified as Schedule I drugs before marijuana, and none of these substances should require authorization or prescription by a medical professional.
Stop the real "reefer madness" now. Let us start dealing with marijuana problems with treatment instead of punishment.

Shame on this Jury

According to this article out of Syracuse, NY, a jury awarded $1,500,000 to the survivors (and their attorneys) after the suicide of teacher/coach Joe Mazella. The plaintiffs argued that Mazella's family doctor prescribed paroxetine for as long as 10 years and that he was negligent in doing so with little or no contact then abandoned the patient who killed himself without even telling his wife of his plan and after hospitalization and change in medication.

Anti-drug "reform" psychiatrist Peter Breggin wrote here about his testimony for the plaintiffs:

• The family doctor had increased the dose of paroxetine to 40 mg and added olanzapine after a telephone consultation.
• He criticized the family doctor for not warning Mazella about the "serious risks" associated with the drug (despite that fact that he had been taking the drug for 10 years!)
• "I also concluded that a hospital psychiatrist was negligent in not recognizing that Mr. Mazella was suffering from adverse drug effects and in discharging him without proper followup two weeks before his death."

In neither article could I find any basis for establishing a causal link to the suicide either with the admittedly negligent prescribing or the drugs themselves. Apparently Dr. Breggin finds it sufficient that one has taken such drugs prior to the suicide: post hoc ergo propter hoc.

Even the widow is quoted as saying, "He’d given no hint that he was suicidal, but he was complaining often about the effects of his medications, Janice Mazella said."

I might have testified for the defense:

• There is no evidence that any of the medications contributed to the suicide. Mazella's suicide resulted from his own wish to die, and nothing else. We will never know what motivated him to such a tragic choice.
• Nothing the family physician did or did not do contributed to the suicide. The hospital physicians assumed responsibility for his care after the family doctor discharged him. Even if this discharge somehow constituted abandonment his hospitalization obviated further need for involvement by the family physician. Mazella had apparently stopped the paroxetine prescribed by the family physician prior to killing himself. Perhaps he should have continued the drug.
• The hospital physicians could not assure that Mazella followed up at the appropriate interval with another physician after discharge. That was the responsibility of Mazella and the physician of his choice.
• If the drugs made Mazella feel so bad he should have stopped taking them on his own or at least sought consultation with another physician.
• For anyone to have stopped Mazella from killing himself required that they have contact with him during the time between his first thoughts of suicide but before the act, and that he tell them he intended to kill himself. Perhaps Dr. Breggin could have saved him had he been living with him 24/7!

According to the first article, "Janice Mazella said she hopes the verdict sends a message to patients and their loved ones to be careful about doctors overmedicating." It certainly does. It sends the message that if you kill yourself while taking the right medications, prescribed by a doctor with a good malpractice insurance policy, your survivors may be better off financially than they would have been had you remained alive.

Breggin calls Mazella's death the "tragic outcome" of use of prescribed antidepressant drugs. We may never know how many suicides occur among those who people like Breggin has frightened away from getting the treatment that could have saved them. But if your loved one kills herself after reading Breggin's propaganda and failing to get treatment, I want to be your expert witness.

Drug Screens and Insurance as Subsidy

Several months ago I started a quest for a new laboratory for oral fluid drug screens to conduct in my office, and got a lesson in medical economics in the bargain.

Oral fluid offers advantages over urine, particularly since we can observe collection with the patient in the waiting room. Also, since we mail the specimen to the laboratory for analysis, we do not have to worry about CLIA compliance.

I had hoped I could use Labcorp, which integrates with my electronic medical record, reporting results electronically, so I started with Labcorp. I connected with my representative there with some difficulty, but at first she evaded questions about pricing, assuring me that insurance would pay for the testing anyway. Eventually I discovered the analysis would cost more than $50, at least 4 times higher than what I had expected. The next few laps I contacted provided similar responses.

I had liked using the Quantisal collection device in the past, so I contacted them directly. They provided a list of laboratories using their technology, and I contacted each. Eventually I found several labs with much better pricing (under $10) and no run around. I chose J2 Laboratories whose service allows me to test for 6 drugs including buprenorphine, and I feel like my cash patients will get good value for their precious money.

Not that I like medical insurance companies, but with attitudes toward reimbursement examplified by Labcorp no wonder they push so hard to control costs. Let's hope Obamacare will bring improvements.

Earth to AMA: Substance Use Is Not Social

According to Wikipedia, the social history section of a medical history documented by a physician includes "living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets."

In learning more about the Current Procedural Terminology published by the American Medical Association I was shocked to discover that even after decades of acceptance of addiction as a disease CPT still relegates this critical element of history to "social," a throwback to the days when physicians minimized use of tobacco, alcohol and other drugs by identifying it as a social activity.

Substance use deserves a heading of its own for documenting past, as well as current, drug use, including tobacco and alcohol, including sufficient data to establish presence or absence of a substance use disorder.

Prepare for the Coding Cliff

Meeting with a bunch of psychotherapists in my building the other day I asked how they planned to prepare for the changes in Current Procedural Terminology (CPT) codes scheduled to take effect on January 1. (CPT codes allow payers to reimburse for medical claims based on a numerical code.) None of them acknowledged any awareness of the change and its likely impact.

CPT codes have become one of the few remaining reasons for existence of the American Medical Association, which profits considerably from their publication, still a monopoly despite the fact that only a small minority of physicians still belong. Do not expect AMA to help you unless you belong. They make money selling the information you need.

I understand that new codes will replace all the old psychiatric codes, including initial evaluation, psychotherapy, and medical management. Do not expect payers to help you. If you submit an outdated code, they get to delay payment.

Psychotherapists may have it relatively easy. Just figure out what new codes replace the old codes.

Psychiatrists who provide what we used to call medical management will, however, start to use the same evaluation and management (E/M) codes internists and other primary care physicians have used for years. More complex than psychotherapy coding, each level of "procedure" requires performance of different services. For example, you may expect a sudden explosion in psychiatrists checking vital signs (pulse, blood pressure, etc.) at every encounter with patients who somehow survived all those past years without.

The devil may be in the documentation. Someday a payer may audit your records and have you sent to jail for fraud if your notes fail to support the procedure you claimed.

The American Psychiatric Association seems all excited at the prospect of psychiatrists obtaining reimbursement more commensurate with services provided. I will believe that when I see it. Do not expect APA to help unless you belong. APA retains few other benefits of membership. Notice I wrote reimbursement, not payment. This change means nothing to patients who pay you directly for your services. Do not expect them to jump for joy at the prospect of paying you more for the same service so your insured patients get better reimbursement. Ask them how much they want to pay for you to check blood pressure on every visit. Will we risk breaking some law if we continue to bill cash patients the old fashioned way while claiming new codes for those insured? Possibly.

How to prepare: I plan to look for online courses, ask my internist friends, and borrow a copy of one of the coding manuals published by AMA from a library. Good luck. Stay out of jail: only code for what you actually did.

Not Your Doctor's Medical Record?

As I prepare to shred box after box of patient files, all those more than ten years old, I contemplate the implications of now using an electronic medical record (EMR) "in the cloud." I wrote here about the impact of EMR on my deposition as a fact witness, but the more I think about it, the more additional potential I see for change.

Consider, for example, medical record law, both statutes like HIPAA and case law. Almost all of that body of law seems to evolve from the fact that until now the professional actually possessed the physical embodiment of the record. So it made sense to ask the professional to produce the record, to keep it secure, perhaps to copy it or allow the patient or a third party to copy it. And now it makes sense for me to destroy the older paper records in my possession.

I no longer possess those records that reside in the cloud as a jumble of bits and bytes on hard drives connected to servers located in one or more locations quite distant from my office. Now I have only the ability to access those records.

If I die or become disabled someone will have to provide for storage of, and control access to, my remaining paper records, but the bulk of active clinical information can remain in the cloud indefinitely. Third parties like my malpractice insurer and the patients themselves will retain an interest in preserving their access to the records. They have no need of me or my agents to control access. Nor should I or my estate have to pay for retention or copying (which with EMR means digital copying).

I believe patients should have full access to their medical records from the beginning, along with the ability to record change requests and disagreements. This access should persist after I have closed shop. The EMR vendor can easily allow read only access to my records while allowing the patient to add to the record as they see fit. But along with rights goes responsibility. The physician should assume no responsibility for any consequence of the patient accessing the record. Furthermore, the malpractice insurer and the courts should have unfettered read only access as well (with the usual safegards), as well as power to veto the patient's request to destroy it.

Cloud based records also promise to remove the physician from the often uncomfortable position of gatekeeper for third parties while the case remains active. With permission from the subscriber payers should  access the record directly to determine whether to authorize reimbursement for drugs, other treatments, and diagnostic procedures, rather than wasting the physician's time with telephone calls and forms. A patient applying for life insurance could likewise authorize access for review by the company. Patients involved in litigation like marital dissolution (divorce), contested custody, personal injury, criminal prosecution and other kinds of cases could authorize direct access by their attorneys and expert witnesses.

Direct access to cloud based records can ease administration of worker's compensation claims. Instead of wading through stacks of paper, independent examiners can access the electronic record directly.

Cloud based EMR as currently implemented offers access from almost anywhere, but the real potential may lie in the ability to offer -- or not -- access to almost any one, indefinitely.

Biased Medical Board Members

The first phase of a lawsuit by physician organization AAPS against the Texas Medical Board ended earlier this month, proving that state medical boards can no longer operate with impunity, not just in my state (Doctor Bites Medical Board), but perhaps nation wide. Conflict of interest and other ethical transgressions among board members may be among the issues raised in the Texas litigation, so I read with interest the description in a recent email about Robert Small, MD, a "Pro-Tem (ad hoc)" psychiatrist member of the Washington Medical Quality Assurance Commission (MQAC) who also reportedly acts as "Behavioral Health Medical Director for health plans administered by Premera Blue Cross and LifeWise Health Plans... [and] Behavioral Health Medical Director for the CHAMPUS/TRICARE program for Washington, Oregon, Northern Idaho and Alaska."

First, even though Dr. Small, as an ad hoc member, may only fill in as needed, I wonder how a physician member of MQAC can represent the viewpoint of and knowledgeably judge the conduct of other physicians without practicing full time. It might reassure me that I do find Dr. Small listed in the usual rating Web sites, but I wonder how much time his insurance company duties leave him for clinical work.

If Dr. Small were acting as an expert witness in, say, a malpractice trial, opposing counsel could easily cross examine him to establish possible bias. But as a voting member of the board I am not sure a defending physician can raise such questions. Besides, given that all physicians either contract with companies like those for which Dr. Small works (or their competitors), or not, I argue that these other relationships always imply potential bias or prejudice, or at least the appearance thereof. Such a board member might, for example, want to minimize evidence against a physician who contracts with one of his companies, or exaggerate that against one who contracts with a competing company, or one, like myself, who contracts with no one other than my patients.

And how would Dr. Small maintain freedom from bias and prejudice in a case involving a subscriber to one of these plans he represents?

I question the ethics of a physician contracting with health plans in general (at least depending on the contract terms), so I believe physician members of MQAC should have no such relationships to skew their decisions. Dr. Small and any other physicians similarly encumbered should resign from medical boards now to be replaced with physicians in full time private practice with no conflicting relationships to payers, perhaps even to their employers. (I may address the question of whether employed physicians are really professionals who should be licensed and sanctioned by medical boards in a later post.)

PECing Order

Would you know what "PEC Questionnaire" means? I did not. Only in the second (of three) reminder letter did I see the words "pre-existing condition" and realize what this insurance company wanted: an excuse to deny or restrict benefits for an illness their subscriber might already have. Understandably, no insurer wants to take new subscribers who waited until they got sick to purchase insurance. Obamacare seems to promise to solve this problem by making everyone pay. We will see.

Let us look at the questions posed. The first seems reasonable enough, except that the insurer could find all that information in the medical record. (Although I do not provide coding services. Let them look up ICD-9 codes on their own dime.)

I have a problem with question 2. How can I know what prescription medications the patient "was using?" I know what I prescribed, but the insurance company (insco) could ask their subscriber what they used. Ah, but perhaps the insco does not trust the subscriber!

Question 3 crosses the line. Now the insco really seems to want to use me as a detective, and not only do they expect me to name names (which they could also obtain from their subscriber), but they want me to save them the trouble of looking up addresses of the physicians I list.

I appreciate the need to keep premiums low, especially for Regence which is my insco! (Is there a conflict of interest here?) But trust your subscribers and do not try to use me the physician as a snitch. Do you wonder what physicians do with their time? Inscos should work toward accessing this kind of information electronically via the electronic health record (EHR) and leave us docs out of this loop so we can spend time with patients.

Incidentally, Regence never pays me a penny on any claim, so providing this information would not have led to any reimbursement for my patient.

Prescription Monitoring Programs: Improvements Needed

When I woke up this morning mulling over a complicated case a significant fact occurred to me: When I had first used my state's online prescription monitoring program (PMP) I discovered that two other prescribers had ordered benzodiazepines for this patient with addiction problems without contacting me. I confronted the patient and the prescribers, all of whom agreed to shape up, but now I realize that I have not checked this particular patient's record in a few months, and with the patient facing increasing medical challenges I plan to access the database today.

But I should not have to.

I have written about this program's limitations before here and here, but the problem I have encountered in the case above begs for another technologically easy solution. To state the problem in general terms, busy physicians will never check the PMP often enough to catch everyone's transgressions. It takes too much time. How often must we do this? Monthly? Weekly? Daily?

Two solutions occur to me. First, instead of requiring me to check patients one by one, entering name and birth date each time, the program should allow me to build a list of patients of interest. Every time I access the PMP it would generate a list of all such patients and any prescriptions filled since I last accessed the records. Better yet I could opt for email or text notification for each new prescription, or my electronic health record might alert me. The program could also allow me to opt out of notifications for prescriptions I deem appropriate.

Come to think of it I need to check the PMP for a new patient I examined yesterday. While I'm at it I will check the patient above:

New patient: Negative! I did not use the exclamation point just because the report showed no controlled substance prescriptions, but because this is the first time ever that the PMP actually confirmed finding that patient even though no prescriptions showed up. Maybe they fixed one of those problems I wrote about before! (Or maybe in all prior cases I entered the wrong name or birth date, but let me think positively.)

Complicated patient: No inappropriate prescriptions.

Total time: about 8 minutes, almost enough time to do one of those 15 minute med checks. ;) Imagine how much time it would take to check every patient in a busy practice.

Physician Heal Thyself

Ask ten health care professionals to describe the statutory threshold for reporting professional impairment or misconduct in their state, and you will get ten different answers. In some states you must report across professional lines, that is, a psychologist, for example, must report an impaired physician.

Until a few weeks ago I assumed I must only report a professional I suspected might pose a danger to patients, but when I called the state physician health program on an unrelated matter I inquired, and the medical director disabused me of that notion. I made a quick call to my professional liability carrier for advice about a physician I had examined a few years ago who did not return and I did not report. The risk management consultant advised me not to report.

A few days ago someone left a message on my voice mail identifying themselves as Dr. ________. Not wanting to put myself or the "doctor" in a bind it occurred to me that I should warn that I might have a duty to report to the health program or the licensing board if I heard evidence of impairment. After all I try to warn all patients of other limitations of confidentiality. The doctor indicated willingness to take chance it, but I had to refer elsewhere when the doctor admitted to having Medicare. You might ask whether I should still report, but all I have at this point is a phone number, and for all I know he could be a "doctor" of divinity rather than a physician. I will not play detective.

What were the legislators thinking when they passed such laws? Did it never occur to them that the law of unintended consequences might intervene? How many physicians, knowing the duty of a treater to report them, eschew getting help and with what consequences?

Workarounds occur to me. One might seek help from a professional licensed in another state, paying cash to avoid a data trail. One might purchase medication out of state as well. Telephones and the Internet could facilitate both.

A physician who fears the consequences might indeed try to "heal thyself" rather than seeking help. Is that what we want?

EMR and Deposition

 The day before yesterday attorneys deposed me for the first time since I started using an EMR (electronic medical record). I appeared as a fact (not expert) witness in a case involving litigation by a patient against another party. I had already provided extensive records to both plaintiff and defense attorneys, including faxes of my old paper records, copies of computer files on CD, and two different attempts at providing the patient's record from the EMR, at least one of which was almost certainly incomplete.

Because the EMR exists in the cloud I can access it from anywhere I have a browser and Internet connection. But since I do not "possess" the record I cannot comply with the usual subpoena that requires the witness to bring such an item to the deposition. Instead I faxed the attorney who apparently most wanted to depose me a letter informing him that I would need a browser and Internet connection in order to access the record during the deposition.

The attorney had me access the patient's electronic medical record prior to swearing me in. While all the attorneys looked over my shoulder I clicked through much of the record, attempting to print as much as possible of what appeared relevant. Satisfied and with multiple stacks of records in hand the attorneys proceeded to interrogate me.

Only one real problem surfaced: Attorneys can now automate printing of what used to be called Bates numbers on printed records, making it much easier to get everyone -- literally -- on the same page. Achieving this with a browser might require a different approach, such as sending the same image to a screen in front of each person.

Although everyone seemed happy with this solution I maintain that only through use of a browser can we access the complete record. Paper copies do not accurately represent the electronic medical record, if only because no electronic signature appears with each progress note. Also, I frequently save .mp3 files of voice mail messages to the record, and of course these cannot be printed on paper. Finally, relationships among different data sets cannot be represented accurately in a stack of paper copies.

I predict that someday the judicial system will have to adapt depositions and trials to allow for viewing such "exhibits" in real-time on a computer screen. Likewise, expert witnesses will require access to medical records via the Internet instead of attempting to understand the case by reading paper copies. For this to happen vendors of electronic medical software, especially cloud-based services, must provide temporary read-only access to a single patient's record. Currently my vendor does not have such capability.

Doctor Bites Medical Board

Not exactly, but if a man biting a dog qualifies as news, so must a physician successfully suing a medical licensing board, in this case the one I criticize best, the Washington State Medical Quality Assurance Commission or MQAC (That's right, M Quack.)

According to this news report in settlement of the case of Werschler et al v. State of Washington et al the State of Washington paid damages of $600,000 to a Spokane dermatologist for publicizing unsubstantiated charges against him while investigating an anonymous complaint which his now ex wife filed in the setting of a contentious divorce. The state also formally apologized.

Dr. Werschler's license credential page still displays documents related to a minor charge of failure to maintain a log of controlled substances in his office, but no indication of the bogus investigation -- or the apology:

https://fortress.wa.gov/doh/providercredentialsearch/ProviderDetail_1.aspx?CredentialIdnt=386799#

In my opinion Dr. Werschler demonstrated considerable restraint in settling for such a small amount given the impact on his practice. The revelation of such poorly executed, and presumably poorly supervised, investigation raises such serious doubts about the competence of MQAC that resignation of one or all board members might be needed to restore public faith in the organization.

At a minimum the state should add a document outlining the errors made and including an apology to Dr. Werschler's credentials page.

"Medical" Marijuana Users Need Not Apply

Only recently has "medical" marijuana begun to directly impact my psychiatric practice. When the drug was simply illegal I could deal with patients who admitted to using it just as I would if they admitted to using heroin or ecstasy. I could refer them for addiction treatment or maybe help them recognize how the drug might harm them, maybe even cause their psychiatric symptoms.

With the advent of physicians legally authorizing use of the drug as a treatment, however, I have struggled with how to approach new patients who believe that because a doctor recommended it they must need it. Were it any ordinary prescription drug I might consider whether to take over prescribing myself, or I might telephone the prescribing physician to coordinate treatment plans. But I suspect that physicians who authorize marijuana almost always do so indiscriminately with little regard for adverse effects, essentially circumventing the law in order to give these "patients" access to the drug for getting high, and I am not convinced the drug has any role in treating psychitric illness. In fact I suspect it would interfere with other treatments, or even worsen most psychiatric conditions. (Someday, just for kicks, I must try to call a marijuana doc and discuss the pros and cons of the drug for a particular patient.)

My choices of how to proceed:

• Pretend that the patient does not use the drug.
• Demand the patient stop using.
• Discharge the patient.
• Continue treating the patient, but regularly encourage them to give up the pot.

Recently another choice occurred to me: I can simply refuse to accept these patients into my practice even for an evaluation. This same approach has worked well for prospective patients who admit to wanting to continue benzodiazepines. Some time ago I made a decision to stop accepting these patients into my practice. Not only did I find the process of weaning them off to find out whether they still needed treatment of an anxiety disorder unsatisfying and troublesome, but it might discourage physicians from prescribing the drugs in the first place. I figure if physicians cannot assume that if something happens to them another physician will just pick up the ball, maybe they will try harder to find a different treatment.

Maybe if more of us refuse to accept "medical" marijuana patients we will discourage its use. Or patients will just lie about it. 

I hope this just represents another stop on the road to legalizing marijuana so doctors can get out of that loop altogether.

"Medical" Marijuana and Prescription Monitoring

Having run state prescription monitoring program reports on a few patients who report use of "medical" (Yes, I'm skeptical.) marijuana I wonder what should prevent the drug's inclusion. If the law requires pharmacies to report dispensing drugs from Schedules II-V, how hard could it be to require marijuana dispensaries to report this Schedule I drug? The same justification holds.

Physicians need to know what other physicians have prescribed, including marijuana. I certainly want that information about what my patients take, just as I want to know who prescribes what other controlled substances for them.

Marijuana should have a legal status similar to that of alcohol and tobacco, neither of which is scheduled despite the obvious danger and harm associated with them. Nobody talks about "medical tobacco." Leave us doctors out of it. But as long as doctors can authorize its use we should see it in monitoring reports along with oxycodone and alprazolam.

The more things change...

"Such was the view taken by the famous psychologist, Dr. William Erb, of the University of Heidelberg. He said "Nervousness (meaning nervous excitement, nervous weakness) the growing malady of the day, the physiological feature of the age. Hysteria, hypochondria and neurasthenia are increasing with fearful rapidity among both sexes. They begin in childhood, if not indeed inherited. Minds are overburdened in school, with too much teaching or misdirected teaching. The pleasures of social life follow, overexciting the already enfeebled nervous system. Business life is made up of hurry and worry and shocks and excitements. Society, science, business, art, literature, are all pervaded by a spirit of unrest, and by a competitive zeal which urges its victims on remorselessly. No man knows repose. The result is, wreckage. The pharmacopceia is overcrowded with nerve tonics, nerve stimulants, nerve sedatives. The medical profession devotes its best energies to the treatment of neuropaths. And as a people we are, or are becoming, excitable, irritable, morbid, prone to sudden collapse through snapping of the overtense chord of the nervous vitality." Nowhere are the rush and hurry and overstrain of life more marked than in this much-achieving Nation. The comparative youth and freshness and vigor of the American people enable them to do and to endure what would be beyond the power of an older and more worn-out community. Yet there is no disguising the fact that the pace tells even here, and often tells to kill. True, all the tendencies of the age are in that direction. Inventions, discoveries, achievements of science, all add to the sum of that which is to be learned, and widen the field in which there is work to be done. What we need to learn is, however, that all these things are for man, not man for them. If knowledge has increased, we should take more time for acquiring it, knowing that, with the consequent increase of power, we shall be able to achieve as much afterward in the shorter time as our Predecessors did in the longer time their briefer study afforded."

The People's Common Sense Medical Adviser 

1935

- R V Pierce, MD

Prior Authorization: Optumrx

My colleagues tell me more and more prescriptions require prior authorization (PA) from the pharmacy benefit manager (PBM). My experience obtaining authorization for buprenorphine for a patient who has been using the drug for close to ten years may help illustrate the problems and opportunities. I last addressed the subject in 2009: Prescription Preauthorization: The New Medical Emergency.

Since we expected the last PA to expire in 90 days it took neither myself nor the patient by surprise when the pharmacy faxed me indicating I would have to call the PBM, Optumrx. As usual I asked the patient to sign my agreement indicating whether I should forward a copy of the medical record at no charge or make the call for my nominal prior authorization fee of $50. The patient chose the latter, and after confirming online payment I made the call.

I navigated the usual menus until the robot told me to enter the number "we have on file." This stumped me. Not only do I not know whether Optum wants my number or the patient's, but surely Optum knows better than I what numbers they keep in their files. Time to start hitting "0" on the keypad. This roused a human, and we got started.

We quickly established the identity of myself and the patient and the details of the prescription, all of which information I had already transmitted to the pharmacy. Then the representative asked for my fax number. Having no desire to receive information from this company via fax or any other medium, I refused. After placing me on hold to confirm that Optum can continue to function without my fax number (What if I do not have a fax number?) we proceeded. Next she asked me for a diagnosis and code. I provided the diagnosis but explained that I do not know the code.

Ultimately Optum approved reimbursement for another 90 days after about ten minutes during which I provided no information that I had not already provided to the pharmacy.

The question of whether PA saves health care dollars is beyond the scope of this post. The patient's contract with the payer determines the conditions of reimbursement. Unless the physician has contracted with the payer this remains between the patient and the payer.

• The physician has no responsibility to obtain reimbursement for drugs.
• The physician must provide a copy of the medical record at the patient's request.
• The pharmacy benefit manager should determine whether to authorize reimbursement based on the record without talking to the physician or requiring the physician to complete a form.
• PAs never constitute emergencies. They are only about money.
• PBMs do not need the physician's fax number or tax ID number.

Some physicians attempt to obtain PA during patient encounters. While this allows the patient to know what transpires, in my opinion a physician who claims such an encounter as psychotherapy or medication management risks accusation of fraud. Better that the patient pay for the service directly, regardless of whether they attend.

With eRx and cloud-based electronic medical records (EMR) we have an opportunity to greatly increase the efficiency of PAs. Ideally, patient and physician should grant the PBM read-only access to the record, allowing such determinations without demanding further involvement of the physician. Until EMRs implement such capabilities eRx should alert the physician to the need for PA immediately on placing the order, allowing the physician to proceed immediately to an online form requesting necessary information.

Physicians afraid to say "no" to yet another intrusion on their time by companies happy to exploit us have enabled this monster. Only when the people who purchase insurance must shoulder the cost will the payers realize they must respect physicians' time.

A New Kind of Abandonment

This third in my series of critiques of the Washington State Department of Health Medical Quality Assurance Commission (MQAC) focuses on the February 9, 2012 Stipulated Findings of Fact, Conclusions of Law and Agreed Order concerning physician Ronald Schubert, M.D. (Respondent).

I extracted the following from the complete Order:

"Over an extended time frame between January 2001 and September 2008... Respondent engaged Patient A in personal e-mails, kissing, dating, phone sex, watching X-rated media, and repeated sexual contacts and intercourse. These activities occurred at Respondent's clinical office, at their respective residences, and at other locations."

The Respondent agrees to take an ethics course in addition to other stipulations, including:

"Respondent's practice is restricted to the treatment of adult male patients."

"(a) Respondent will not have social contact with patients... (b) Respondent will see patients only during normal business hours. (c) Respondent will not treat individuals with whom he has had a social relationship... (d) Respondent will not accept gifts from patients. (e) Respondent will not engage in talk of a sexual nature with patients, except as necessary in the treatment of that patient. (f) Respond will not disclose personal information about himself to patientsg... (g) Respondent will I make house calls... (h) Respondent will not communicate with patients via text messaging, instant messaging or e-mail."

In item (h) the board would seem to see a technological solution to the boundary problem here. This naïve tendency to blame text messaging, instant messaging and e-mail raises questions about the extent to which MQAC members may be out of touch themselves with the realities of communication in 2012. Why for example do they implicitly allow the Respondent to continue use telephone to communicate with patients? Do they not realize that text messaging, instant messaging, and e-mail may create permanent records that might allow for tracking of continued boundary violations? According to the Order the respondent and his patient engaged in "phone sex." Does MQAC not appreciate that telephone contact usually does not create a permanent record and arguably allows for considerably more intimacy than do the prohibited textbased modalities? The Board seems blissfully ignorant of videoconferencing (eg, Skype).

I would argue that the Board should promote rather than prohibit use of textbased modalities to communicate with patients, and even consider adding a requirement that the Respondent maintain permanent copies of all such communications.

"Respondent will enter into psychotherapy with a Certified Sex Offender Treatment Provider therapist approved by the Commission or its designee.... Respondent will see the therapist at least once every two weeks for a period of one year. After this one-year period, the therapist shall determine the frequency of Respondent's therapy... therapist shall inform the Commission of Respondents progress... to protect the public... Respondent may terminate therapy only with prior written approval..."

This stipulation raises questions about the Board's understanding of psychotherapy, about the treatment, and about the ethics of providing that treatment. I will not attempt here to exhaustively analyze the entire subject of "treating" sex offenders. I believe this topic has been and probably continues to be discussed exhaustively elsewhere. The language used in this Order betrays a few of the inherent problems however. The Order speaks of "entering into" psychotherapy without specifying the target of treatment. Will the "patient" be deemed cured when he stops sexual involvement with his patients? Treatment usually implies illness, but no diagnosis appears in the order.

I suspect that no treatment will take place, but rather a "certified" professional will accept remuneration for meeting with (or "seeing" as the Order indicates) the Respondent and monitoring his attitudes for the period required while regularly trumping up reports to the Board in the hope of generating more referrals in the future. I believe this charade will accomplish nothing other than to line the pockets of a psychotherapist whose own participation in this endeavor may be unethical on its face by virtue of the inherent role conflict, while the "patient" learns how to present himself to the "therapist.' The duty of the psychotherapist here would appear to be not to the "patient" but to the Board. I believe this so-called psychotherapy differs little from that which would pretend to change one's sexual orientation, a practice which has been prohibited in some jurisdictions. That a medical board would dignify such a practice by requiring it reflects negatively on the Board as well as the therapist.

"Respondent's abandonment of Patient A without referral to another provider after conclusion of their affair..."

Does this unfortunate language suggest that physicians licensed in the state of Washington have an obligation to refer their patients to another provider at the end, rather than the beginning, of a romantic involvement? Maybe Dr. Schubert should have sent a letter giving 30 day notice: "I will only be available for sexual emergencies." This gaffe strikes me as almost tantamount to Sen. Akin's recent illusion to "legitimate rape." Surely we have a right to expect more from this august body.

Psychiatrists, Light Bulbs, and Bad Medicine

Had it not inspired me to compose a new light-bulb/psychiatrist joke this apparent accusation from David M. Reiss, M.D. on a recent listserv posting that implies I practice "bad medicine" might have offended me: 

"Another (less obvious reason) why the "15 minute med check" that is now the U.S. "standard of practice" is bad medicine. No therapeutic relationship by which to know your patient and communicate effectively on an emotional basis as well as simply providing a few "facts" = increased risks."

Here's the joke:
How many psychiatrists does it take to change a light-bulb? (punchline below)

So a medication management visit that lasts 15 minutes or less is bad medicine? Does that only apply to psychiatrists? What about internists and orthopedic surgeons? There must be a lot of bad medicine out there.

Maybe Dr. Reiss really just wants psychiatrists to provide psychotherapy to every patient on every visit. But what about those non-psychiatrists again? Must the gynecologist do psychotherapy? What about the dermatologist? More bad medicine?

Maybe Dr. Reiss just thinks patients with psychiatric disorders need this extra time. But psychiatric patients need gastroenterologists and ophthalmologists too. Still more bad medicine.

What about knowing your patient? Would Dr. Reiss have us believe that every encounter in which a physician does not "know" the patient constitutes bad medicine? That would probably cover almost every emergency room and urgent care encounter. What's more, I suspect most psychoanalysts would tell us that it takes years to know a patient. Until then, bad medicine? Besides, I would argue that even in intensive long-term psychotherapy the psychotherapist only knows the patient in the context of that artificial setting in the office with no one else around.

Apparently reading my mind, Dr. Reiss jumped the gun, sending me a comment even before I could post this, taking some of the wind out of my sails. He says:

"My argument is not that 15 minute med checks are always "bad medicine", not at all, I believe that it should be a clinical decision how long and how often a pt should come in, not an administrative decision. I would go heavy on 15 minutes being inadequate in the situation that I see advertised all the time - come in as a new doc/locum, take over a case load, but for existing cases, you don't get time to do your own eval or really meet the pt, it's all pre-scheduled at 15 minutes."

Perhaps we agree after all. Even a 30 minute med check may not suffice for a complicated patient, but for a stable patient taking only one medication for a long period of time five minutes may be more than adequate. This is no more true for psychiatric patients than for non-psychiatric patients. Good -- and efficient -- medical practice requires that the physician know which questions to ask in a minimal amount of time. We cannot afford the luxury of truly knowing our patients. Forcing every patient to undergo a 50 minute psychotherapy session whether they need it or want it or not would also constitute bad medicine in my book.

In his "comment" Dr. Reiss addresses two other important problems. He mentions the practice of a new physician jumping in with short follow up visits having not performed a full evaluation. I share his concern. However, one might not be able to accommodate such a thorough evaluation in situations like locums or when covering for another physician at home. As for the prescheduled 15 minutes slot, one can only hope that a no-show or other shorter than scheduled encounter might compensate for a patient who requires extra time. I might add that the old practice of scheduling one patient per hour usually results in less such flexibility of scheduling.

Punchline:
Only one, but the psychiatrist has to know the lightbulb.

Safely send your patients to the Big Easy!

I have it officially from the Louisiana medical board that physicians can talk to established patients traveling in LA by phone or Skype, and even charge them for it without the State of LA charging you with practicing without a license, provided you have a current relationship with the patient in the state in which you are licensed and the patient resides.

Every state should adopt this or similar policy. Enjoy those beignets.

Mississippi: Docs contacting their patients traveling there take a risk

I inquired of the MS medical board as to policy regarding tele contact with patients traveling there from their physician in their home state who is not licensed in MS:

Email from Frances Carrillo at the Mississippi medical Board, responding to my inquiry: “I will forward to the Board attorney on Monday. You have not received a response by the end of next week send me an email.” No attorney contacted me, and Ms. Carrillo did not respond to a follow up email. When I called the board the receptionist would only send me to Ms. Carrillo’s voice mail. It appears that out of state physicians contacting their patients traveling in Mississippi do so at their own risk.

QR Codes for Patient Education Material

There's something archaic about paper "handouts" for educating patients about disorders, drugs and other treatments. Emailing a Web URL is too much trouble, but so many patients have smart phones now I plan to try QR codes. I'll display this page on my tablet PC and ask patients to scan the appropriate codes. I can add more as needed. Other candidates: The Big Book online, doctors and psychotherapists to whom I frequently refer, advocacy and support organizations, etc.

I generated codes at http://www.qrstuff.com/ and created the document in Google docs. Printed to .pdf with CutePDF. (All free.)

Prozac Never Sleeps

Despite all the bad rap heaped on psychopharmacotherapy (psych meds) lately, neither does any other drug. If it's in your brain, it's doin' it's thain. Not so psychotherapists. They (alright, we) do occasionally fall asleep on the job.

Patients: What do you do when your psychotherapist nods off in the middle of a session? How do you feel about that, and do you ever feel safe telling the psychotherapist how you feel about it? Does she ask? Do you start talking louder in the hope it will wake her up? Give her a little nudge? Walk out of the session? Do you blame yourself: "I must be boring her." Does she blame you: "You must be angry." Does she apologize? Do you ever see the eyelids start to droop and do something to try to increase sleep latency? How would you want your psychotherapist to handle the situation when she awakens?

Psychotherapists: Be honest. How often have you nodded off mid-session? What do you do when you feel it coming on? What would you want your patient to do or say? What have your patients done or said? Do you blame the patient or yourself? Do you apologize? Do you educate the patient in advance or wait for it to happen? Sleep latency supposedly reaches a minimum in early afternoon. Do you have any strategies for staying awake then? Ever pinched yourself? Ever refund the patient's fee? How much of a session can you sleep through and still claim reimbursement from a payer?

One of my favorite supervisors for group psychotherapy, a rather brilliant psychologist, used a novel approach. When he sensed the group avoiding significant material he would gradually slouch in his chair. If he did eventually fall asleep, and awaken before the end of the session, he would, he claimed, share his dreams therapeutically with the group.

Hug a Narcissist

What happened to empathy? Narcissists are people too. But narcissism seems to have become the new universal pejorative label with which to criticize, externalize or marginalize someone you dislike. It's the new borderline. Narcissism has become the whipping boy for anything you want to see as a problem in society, especially if you can associate it with bad parenting.

Don't bother to examine the individual or obtain information about their personality functioning over much of their life. Watch them on TV or observe them at a party for a few moments, and you can make the diagnosis. Even rank amateurs can do it.

Want to improve your appearance? Narcissism. Watch movies about superheroes? Narcissism. Use Facebook? Narcissism. Send tweets to your followers about what you are doing? Narcissism. Use a smart phone? Narcissism. Feel good about yourself? Narcissism.

Mother Teresa got a kick out of helping others? Narcissism. Big time.

Blame it on the Me Generation and the Self Esteem Movement. Ayn Rand and Nathaniel Branden.

Can these narcissists, human beings like you and me, really be the root of all that evil?

Birth of a Terminology: Unified Psychotherapy

Watch BehaveNet's newest psychotherapy glossary grow in real time. Psychiatrist David Allen's Family Dysfunction and Mental Health Blog has long occupied a space on the blog list you see here. Dr. Allen has created a new psychotherapy method he calls Unified Psychotherapy and a glossary of related terminology. He has permitted BehaveNet to publish the definitions on BehaveNet. With minor edits by yours truly we plan to add more definitions during the next few weeks.

Thank you, Dr. Allen. We are excited to be part of this project.

If you would like to comment on the terms or definitions, please do so below. We also need suggestions of YouTube videos to illustrate or complement the definitions.

Blind Leading the Blind

I cringe every time I see this: A patient's counselor or psychotherapist, rather than referring him to a psychiatrist for whatever reason, instead recommends a drug they think has helped some of their clients, and the patient's physician prescribes it, often with no other justification than the fact that the (unqualified) psychotherapist recommended it. From a purely clinical perspective most psychiatric drugs cause little harm, even to those who should take a different drug -- or no drug at all. But in participating both professionals do the patient a disservice. Psychiatrists can make mistakes too, but we bring much more knowledge and experience to the table, and when those not adequately trained play psychiatrist they risk malpractice, and their license to practice.

Occasionally as well, the patient's record will come under scrutiny by a forensic psychiatrist, insurance reviewer or other third party, perhaps related to a claim, a problem at work, divorce, or a disability application. Indications for the drug, as well as adverse effects and therapeutic response can carry substantial implications in such cases, but the reviewing psychiatrist may be forced to discount what might otherwise have been useful in arriving at a determination, often to the detriment of the subject.

Many primary care physicians have sufficient experience to competently prescribe psychiatric drugs, but many non-psychiatric specialists do not. Inexperienced physicians will serve their patients -- and themselves -- better by declining to prescribe psychiatric drugs, and non-physician psychotherapists should let qualified prescribers decide which drugs to recommend to their patients.

Psychotherapy: Informed Consent

There are more kinds of psychotherapy than I can count. I trained most in family systems, but my residency exposed me to Jungian analysis, Freudian analysis, psychodynamic psychotherapy, cognitive behavior therapy and biofeedback. I stopped offering psychotherapy myself a couple years ago, so when I recommend that modality to a new patient at the end of an initial evaluation I find it difficult to omit a brief lecture on the differences among psychotherapies, especially the ones I recommend for that particular patient.

If you do psychotherapy yourself how far should you go to educate the patient, especially about alternatives you do not offer? If all your patients get whichever version you provide, whether or not it is the one most likely to succeed for that patient, how much should you tell about alternatives and advantages and disadvantages? Do you know enough about different kinds of psychotherapy to adequately describe the prime candidates? If you have reason to believe the patient will do better with a kind of psychotherapy that you cannot offer, will you admit as much and refer them out? Some items for consideration:

• How it works
• What determines duration of treatment
• Likely frequency of sessions
• Who will attend: individual, group, family
• Cost
• Availability
• Risks
• Benefits

What do you do if you know (or find out the hard way) that the kind of treatment you believe would best serve that patient cannot be found in your community?

Like so much of what we do a good starting point might involve considering what you would want a professional to tell you or your loved one if the roles were reversed. So you are the patient? Take these questions with you to that evaluation and ask a million questions.

Not Your Father's Travel Coverage

Only a few years ago covering for a colleague's practice while she traveled consisted almost entirely of taking the occasional crisis call, often to authorize a refill. Rarely you might meet with a patient in the office. Things have changed. I just returned from a ten day vacation. Thanks to the cloud I did not need anyone to cover for me, but a sampling of what came at me will give you some sense of some potential coverage duties.

Prior authorization has become an emergency, at least for patient and pharmacy, thanks to payers. Imagine trying to get authorization for a patient you have never met, especially without access to the medical record.

Record requests. Three of them came in by snail mail in the days before I left town. These can wait. But why should they? My records reside on a server somewhere in the cloud. I have no problem with my patients granting electronic view-only access to whomever they wish, whenever they wish. Alas my vendor does not seem to offer that capability. Yet.

Letter for a judge. A patient has run afoul of the law, and the attorney wants me to write a letter. This time it can wait, but I can envision a situation where delay could jeopardize the patient's defense. Regardless, I refuse to write letters if an opinion is requested, so we fall back on providing access to the medical record.

Nursing order. A patient taking clozapine needs regular blood draws, and the nursing service claims to urgently require my signature on the order form. Would you want to sign this if you were covering for me? Since I received it by electronic fax you probably would not know it had come in, but I suspect the nursing service would start frantic phone calls as the deadline approached. Seems like faxing the order form a few weeks early might help. Hint, hint.

Refills, other than controlled substances, rarely pose a problem. 

The one that really challenged me involved a recovering alcoholic who relapsed, no longer trusted oral naltrexone and desperately wanted a Vivitrol injection before leaving on an extended trip abroad. I met with the patient via video conference and agreed this plan made sense. I downloaded, signed, and faxed back the order, something a covering colleague could probably have handled (assuming room in the schedule). But then I received, while out of town, a confirmation letter, which indicated that Alkermes had shipped the drug to my office. But a representative assured me that the drug had been shipped to another office for injection and that the company just sends the same letter regardless. Any unemployed writers out there? This may seem like a minor discrepancy, but suppose the patient failed to get the injection after the physician relied on an erroneous form letter and drank again with some kind of terrible consequence. Please get that language right Alkermes.

The Positive in a Negative Online Review

Physicians, including psychiatrists, trying to cope with negative online reviews take heart. You can turn these lemons into lemonade. How many readers really trust them anyway? I often suspect that positive reviews may have been fabricated, and I have long believed that many negative reviews from real patients result when good doctors refuse, to the benefit of the patient, to prescribe bad drugs.

A recent negative review of my practice included accurate information about the way I run my practice. In many ways I do not like any more than does the patient that I must practice this way, but the broken system in which we work today requires me, for example, to collect payment at the time of service. I am glad the readers can learn about these problems from such reviews.

If the physician can identify the patient she may discover information that the patient has not shared directly but which may help in getting the best care for the patient. For example, if the patient clearly dislikes the physician the patient may benefit from discharge so he can find a physician he likes.

Some Web sites provide the physician an opportunity to respond as I did to the review mentioned above. I took advantage of the opportunity to describe my practice policies in a neutral tone. Avoid defensive responses and criticism, even implied, of the reviewer. You will just invite a counter attack. If the reviewer levels valid criticism use the opportunity to own up to your mistakes and lay out a plan to rectify them.

Even negative communication can better no communication.

Adderall Is For "A"

This New York Times article has already generated enormous controversy and not a little resentment from psychiatrists who seem to believe the Times is out to get them. The article would have us believe that the number of students using psychostimulant drugs like amphetamine and methylphenidate (Ritalin) has increased dramatically and that younger students than ever use the drugs to improve their performance on tests. I immediately connected the story to a recent listserv conversation among child psychiatrists touting the advantages of prescribing ever higher doses for presumed ADHD. How many of their patients actually take the higher doses rather than diverting to their friends, which of course could land them in jail? But perhaps more significantly, and more surprisingly to me, the article has generated numerous comments from physicians suggesting that anyone and everyone should have access to drugs that improve performance regardless of whether they suffer from a diagnosable condition.

Where will this take us? Some possible consequences:

• Patients and their parents will lose credibility with some physicians.
• Patients will drop reluctant physicians and seek out those more willing to write a prescription.
• Payers will demand more proof that subscribers really have the claimed condition.
• Schools and testing organizations will require pre-examination drug testing.
• Test takers will require proof of need from students who test positive for drugs.
• Increase in ADA complaints of discrimination if those who test positive for drugs are excluded from examinations.
• Independent psychiatric examinations costing thousands to prove appropriateness of prescriptions. (Never mind that no objective test for ADHD exists.)
• More will abuse or become dependent on the drugs.
• More will suffer adverse effects and overdoses.

How far should we go in allowing access to these drugs for performance enhancement? Why even involve physicians in deciding who gets them if a diagnosis is not required? How can we assure fairness in high stakes testing of students?

Silver Lining in Illinois

If you thought the process to revise the Diagnostic and Statistical Manual to produce  DSM-5 might short change science (what little exists) in favor of politics, imagine a gaggle of real politicians legislating diagnosis in the Illinois Senate. IL Senate Bill 679 appears to do just that to the apparent joy of Autism Action Network. As I read it the bill provides that anyone diagnosed with Autistic Disorder under DSM-4 TR will keep benefits they might have lost with adoption of more restrictive DSM-5 criteria.

You can call this a slap in the face to the American Psychiatric Association and DSM-5.

However, in effectively disconnecting benefits from DSM the IL Senate may have freed the authors of the diagnostic manual from external political pressures, allowing them more discretion to give priority to evidence and science rather than financial impact in crafting criteria and categories.

Now if only we could get out from under the AMA's CPT codes so physicians could charge by the hour or by whatever other paradigm we choose, and let the payers and their subscribers fight over reimbursement without trying to put physicians in the middle.

Zombie Drugs Defeat Policy

The sellers of Zombie Matter, perhaps the latest legal (so far) version of "synthetic" marijuana chose the right brand name. Every time DEA kills a cannabinoid by placing it in Schedule 1 a new version seems to spring to life. This new version may be more addictive and dangerous than good old fashioned "natural" pot, and undetected with drug screens currently in use. If you do not believe the negative test results on the product Web site it is probably only a matter of time before a patient reports using the drug and testing negative at home with a retail drug test.

I predict that DEA will soon identify the psychoactive compound or compounds in Zombie Matter and classify them as Schedule 1 too. Will another zombie drug then rise from the dead? Will its use lead to even more problems for those who use it than its predecessors?

Like the song asks, "When will they ever learn?" But for drug policy that seems to demonstrate its failure more every day would anyone have had an incentive to market these drugs? Let's demand drug policy that avoids giving new life to the very business it pretends to kill.

When Independent Treatment Goes Dysfunctional

What does a psychiatrist, or even a primary care physician, do when she harbors doubts about the patient's psychotherapy? As I have opined previously I believe the advantages of independent psychotherapy and medication management (or other biological treatment, such as TMS) outweigh the disadvantages. But when the physician does not know the psychotherapist well because the patient chooses his psychotherapist or the physician does not know the psychotherapist well, problems can arise, for example when there is:

• No sign of improvement after extended treatment.
• Evidence of boundary violations or other impropriety in the relationship.
• Failure of the psychotherapist to respond to phone calls or other attempts to establish or maintain contact for coordination of treatment.
• Lack of evidence of effectiveness of the treatment approach for the patient's disorder.

or when:

• The physician has a vague negative sense about the psychotherapist from past encounters.
• The physician dislikes the psychotherapist.
• The physician knows that the psychotherapist dislikes her.

One might expect to resolve some of these problems with a phone call, email, or other communication, but a persistently dysfunctional treatment team can ultimately harm the treatment. Which relationship should take precedence over the other, the medication management relationship in which the patient spends ten minutes with the psychiatrist every three months, or the psychotherapy relationship consisting of fifty minute meetings weekly? Medication may work the same regardless of how you feel about the person who prescribes it. This may not hold true for psychotherapy. At what point should the physician impose an ultimatum: Find a new psychotherapist, or find a new psychiatrist?

Board Certification Patient Feedback May Be Unethical

According to the APA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry Section 1.1:

 “A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor-patient relationship, and thus upon the well-being of the patient.”

From an APA Ethics Opinion: Section 2-RR:

“Their consent, while ‘freely’ given, is likely to be heavily influenced by their transference feelings, the need to please you… suggests an exploitation of your patients for your personal gain that outweighs the potential benefit...”

And yet the American Board of Psychiatry and Neurology (ABPN) has apparently implemented plans to require psychiatrists who want to maintain board certification status to not only solicit evaluation by other health care providers, but also from their own patients. According to ABPN policy the patient would complete a feedback questionnaire and give it to the psychiatrist who would keep it on file. As I understand it, based on feedback from both other providers and patients, the psychiatrist would look for opportunities for improvement, plan and carry out steps to improve their practice, then measure improvement over time with follow up questionnaires. ABPN would conduct audits of selected psychiatrists to confirm compliance.

One can easily imagine problems with such an approach. Psychiatrists might agree to provide glowing reports to other psychiatrist who agreed to reciprocate. Patients might suggest that an increase in dose of Xanax or a few prescriptions of OxyContin might lead to a more favorable evaluation. At best such data would seem unreliable.

Even the patient who would never think of submitting a dishonest assessment of the psychiatrist might fear the consequences of submitting a critical report. As stated in the ethics excerpts above a physician should never put the patient in the position of having to make such a choice which could hardly be made freely.

Unless I am missing something here I would suggest that patients consider refusing to complete such assessments and even consider filing ethics complaints against physicians who asked them to do so. Let us see to what extent organized psychiatry will sacrifice ethical principles to create an illusion of superior ability has represented by a framed piece of paper hung on the wall.

Better yet I hope psychiatrists will refuse to participate.

eRx Bogged Down

I started using electronic prescribing several years ago, and, despite flaws, which have diminished over time, I believe it to carry less risk of error and much greater efficiency. For a while it seemed that most pharmacies were moving toward adoption, but if anything it seems that some have reversed course. Almost all pharmacies accept electronic orders, but fewer seem to send requests for refill authorization electronically. In the past few weeks I have received electronic requests from Top Food Pharmacies and Rite-Aid. I have also received requests from Safeway, but they seem to have stopped. A pharmacist at one store in a chain may tell me the chain has not yet implemented eRx even though I have received such requests from other stores in the same chain. Can a chain really have implemented eRx on a store by store basis? More likely they have simply failed to educate their pharmacists.

The failure of most vendors to implement eRx of controlled substances continues to limit the overall efficiency of the technology despite approval by DEA as long ago as two years. I know of only one vendor having adopted this late last year, but mine, Practice Fusion, has not. This means I still need two separate systems to track and record prescriptions and refills. It also means I still must use paper prescriptions or telephone, both of which I believe to be more vulnerable to fraud and error.

My vendor has only recently implemented (apparently) formulary status check when using eRx. This could help avoid the shock of high copay or required prior authorization, but I have yet to try it.

Speaking of prior authorization, eRx could dramatically increase efficiency. Recently I pursued prior authorization from Medco involving numerous faxes. Ultimately it seems that reimbursement hinged only on whether I prescribed the drug for smoking cessation. Instead of all the faxes and finally a phone call, I should have been able to simply check a box during the initial order.

eRx is not perfect, but with so much potential we should aim for complete conversion in months, not years. Maybe if a large enough number of physicians simply blocked fax requests...

The Genericebo Effect

Google:

 No results found for "genericebo effect".

Does that mean I can claim to have coined the term?

genericebo effect

It seems like patients switching to generic preparations of drugs newly off patent increasingly report intolerable adverse effects or loss of efficacy. I intend the new term to capture the possibility that these apparent changes may originate from an expectation on the part of the patient, and possibly initiated by the prescriber, that generics, particularly those manufactured by certain pharmaceutical companies, must fall short of their branded predecessors.

Of course generics and even branded drugs can suffer from real manufacturing problems, so we must not assume these phenomena occur only in our patients' heads.

Much Ado About Nothing

As I reviewed the Administrative Actions section of Washington state's Medical Quality Assurance Commission Update! bulletin I recognized the name of a physician who often shares the physicians' lunch table at the hospital with me, Alan Bunin, M.D. According to the bulletin Dr. Bunin "allegedly failed to maintain medical records for patient." Now I know that Dr. Bunin is old-school (But not exactly right wing: he claims to have been a freedom rider in the 60s.), so for a moment I wondered whether perhaps he just does not keep medical records at all.

I easily found the Statement of Allegations here. According to the statement Dr. Bunin "failed to maintain a medical record of the treatment he provided" and when the patient's "subsequent treatment provider requested the patient records, Respondant only produced a one-page document." Furthermore, when the MQAC (pronounced imquack) investigator asked him to provide records Dr. Bunin "was unable to provide" them.

Mystery:

Did Dr. Bunin ever create a record? What became of the missing records?

Mystery Solved:

According to the Statement, "he had given the entire original medical chart" to the patient "without keeping any copy."

Oh for shame Dr. Bunin!

MQAC To the Rescue:

Fortunately we have this august body of distinguished professionals and lay people to intervene. (What would we do without them?) In its infinite wisdom the Commission, showing considerable restraint, proposed an Informal Disposition, also accessible from the link above. I will not bore you with the details, except to mention that Dr. Bunin agreed to complete "a minimum of four (4) credit hours of preapproved Continuing Medical Education (CME) on the topic of medical record-keeping" and to submit to chart audits. (That should teach him.)

Only by reading further do we discover that any damage to the patient that might have resulted from this egregious error was "moderated" by the fact that the patient "was able to provide them to subsequent treatment providers."

Maybe my imagination is running wild here, but I find myself wondering why MQAC, having discovered that the patient had the records all along could not have simply suggested that he or she simply return them to Dr. Bunin. If things were that simple I guess we would not need government.

Keep up the good work MQAC.

Duh.

PS: Dr. Bunin is still waiting for MQAC to approve that four hour (minimum) course he hopes will teach him to keep a copy next time he provides an original record to a patient.

Next critique of MQAC: A New Kind of Abandonment

What makes some of us believe in an unconscious?

The idea has been around for over a hundred years, but nobody has seen one.
You will not see the unconscious mind on a CT, MR, PET or SPECT scan.
It will not pop into view when a neurosurgeon opens the skull.
Like gods and Ptolemeic epicyles it seems to explain anything and everything you want it to.
Like most such myths there is no way to prove it does not exist, but unlike the myth that the world is round, it has not advanced knowledge, even our ability to treat mental illness.
What would believers accept as failure to demonstrate its existence?

Suicide risk? I don't want you.

Why do psychiatrists and other mental health professionals continue to accept into their practices patients who contemplate suicide? Do they want to be heroes? Do they feel too guilty about rejecting someone who "needs" their help?

Know that if a patient kills herself on your watch any survivors and their attorneys will very likely come after the money in your malpractice policy.

Know too that a colleague will gladly testify that if only you had done or not done something you should or should not have done the patient would still be alive today. Licensure boards will do the same. Never mind whether the patient's choice to die had anything at all to do with that for which you were treating them.

Because of these potential devestating consequences, including the emotional impact on yourself, once you know that the patient entertains thoughts of dying you will likely focus the preponderance of your efforts, not on providing the best treatment for the problem, but on preventing a suicide. Consider carefully whether you can keep someone from killing himself. In my community years ago a patient shot himself while in the office with the psychiatrist. Could you have stopped him? Patients kill themselves in psychiatric hospitals. If we cannot prevent those suicides, how can you imagine you have any control over someone between encounters?

Mental health professionals need not accept these risks. We can still ethically decide whom to accept and whom to reject as patients. If judges and juries continue to hold us responsible for the intentional acts of others we can choose not to accept the risk. Consider the consequences if we turned away potential patients whom we judged to carry an unacceptable risk of suicide. Patients would likely soon learn they must lie in order to obtain treatment. Might we add statements to our treatment agreements like, "I have never contemplated or attempted suicide." Would you demand to review prior records for evidence of past attempts or impulses to suicide? If you published on your Web site your policy of rejecting patients with unacceptable risk would they look elsewhere or simply be better prepared to lie.

Might such a change impact people contemplating suicide? Might knowing that mental health professionals might reject them as patients afterward (if the attempt failed) make them less -- or more -- likely to kill themselves? How might a patient react if after the initial evaluation you tell them you will not accept them as a patient? Who will accept them? Will they overwhelm those who do?

Consider making at least a small adjustment in deciding whom to accept as a patient. Maybe if more of us reject them, higher risk patients might not find anyone to treat them, and the courts or legislatures might do the right thing and stop blaming the treaters for the choices of their patients.

Suicide Risk Monitoring, Inc.

In an earlier post I criticized my state's Medical Quality Assurance Commission for faulting a physician for not requiring more frequent visits with a patient who appeared to need monitoring of suicide risk.

The official CPT code for Psychiatric Medication Management (the infamous med check) is 90862. As far as I know a code for Suicide Risk Monitoring does not exist. Yet responsibility falls on the shoulders of mental health professionals simply to "see" patients who might be at risk of suicide often enough that somehow sufficient frequency will prevent a suicide attempt. This means presumed suicide risk dictates frequency of visits not otherwise needed for treatment.

Regardless of whether increased frequency of patient encounters can actually prevent suicide, I argue that, particularly in light of shortages of psychiatrists in many areas of the country, a nonphysician could more cost-effectively carry out this function which amounts to little more than behavior control. Here's how it would work: a given clinic or professional or even a family member could require any patient deemed at risk of suicide to purchase suicide risk monitoring services separately. Such a company would regularly contact the client to assess risk of self harm, independent of treatment of any mental disorder, using a tally of risk factors and standardized rating scales. This would free treating professionals to focus on treatment, possibly increasing its cost effectiveness and leaving behavior control to SRM, Inc. In fact, since suicide frequently occurs in the absence of any mental disorder, such individuals might not need mental health treatment at all.

Increased risk would lead to increased monitoring or even incarceration. SRM, Inc. behavior control teams (BHT) could follow clients into hospitals.

Who would pay for suicide risk monitoring? Should medical insurance pay even in the absence of a diagnosed mental disorder? Should society bear this cost? the individual? a family member? Would the cost be offset by reduced number of suicide attempts and associated needs for treatment? Could such a service reduce the need for expensive psychiatric hospitalization?

I am actively seeking investors.

Phun with Phobias

Although I have created several videos for YouTube myself, I had not spent much time surfing those created by others until I finished adding a huge list of phobias to BehaveNet. I have tended to focus on songs, especially rock videos from the golden age of MTV (See ablutophobia.), but I have also discovered numerous movie clips and trailers (selachophobia), amateur videos (pyrophobia) and educational videos (emetophobia). Some qualify as works of art in themselves (gynephobia).

(This is fun.)

For the phobias it has been easiest to find a video illustrating the feared object (atomosophobia), but sometimes I can illustrate avoidance otherwise motivated (chorophobia). A few raise delicate issues (virginitiphobia), and I worry about offending with others (homophobia). Some are right on the mark (pentheraphobia) while others are a bit of stretch (geumaphobia, patroiophobia).

Here's where you come in. These and many others have me stumped so far: Celtophobia, agraphobia, bibliophobia, computerphobia, heresyphobia, mottephobia, tomophobia. Please leave suggestions under comments. Enjoy.

Prescription Monitoring & Standard of Care

I wrote about my early experience with the state of Washington's new program that allows prescribers to monitor patients' prescriptions from other prescribers here. Questions about use of the program continue to emerge:

• How often should prescribers perform searches?
• What should we do when we discover undisclosed prescribing by other prescribers?
• Can we contact other prescribers without the patient's authorization?
• When should we discharge patients who have withheld information from us?
• Can we rely upon a negative search?
• Can we charge a fee for performing a search?
• How will we redefine standard of care in light of this new capability?

If we define standard of care as that which is "reasonable and prudent," as an expert witness I believe I would consider that a prescriber must conduct at least one search in order to meet standard of care. There can be little question whether a prudent provider would want to inquire as to what controlled substances a patient might have been prescribed. Such information can aid in diagnosis and may help prevent dangerous drug interactions. We know patients sometimes lie about drug use. The patient who does so should retain some responsibility for misleading a physician, but with this new tool the prescriber assumes more responsibility.

Whether standard of care requires repeated searches may depend on other factors, perhaps most import among them the results of the first search. If a search produces no positive result a prescriber may not need to  repeat the process for a year or more in some patients. After a positive search, however, the prescriber must take action. She should confront the patient and establish contact with any other prescribing providers to coordinate which provider will assume responsibility for addressing which problems and prescribing which classes of drugs. Too many chefs spoil the broth. Prescribers should consider discharging patients who do not cooperate.

Prescribers should repeat searches more frequently after a positive result, not only to determine whether other prescribers adhere to mutual plans, but also to determine whether the patient has sought prescriptions from other providers, each time taking appropriate action on positive results.

The increase in transparency afforded by prescription monitoring enables us to provide better care, but only if we access the information and act on it.

Close to Home

Monday evening I attended the memorial service for the 17 year old grandson of my office manager of 25 years. As I understand it his father, returning from a trip, had found his lifeless body on a couch at home after he apparently used heroin.

I never met him myself, but I heard about his birth and milestones in his life, especially when his mother died of complications of alcoholism. Even with that tragedy he enjoyed love and excellent parenting, much of it provided by his grandmother with whom he lived for many years. The adults in his family apparently knew nothing of his drug use. Indeed it seems possible that he may not have used the drug before this. He did well in school until the end.

When you see the outpouring of love and respect from friends and family you cannot write such a loss off as the expected consequence of drug abuse. But you do naturally start thinking of who to blame, and it neither brings him back nor prevents the same from happening again and again.

We can seek changes that might minimize harm to innocent victims like this young man. I do not pretend to know the answers, but tragedies like this prove that the current prohibition only increases harm to those who least deserve it. We must abandon the "war on drugs" which has become a war on drug users. This war assures only that unregulated suppliers will provide drugs like heroin with unpredictable impurity and dose, needlessly endangering those who use them.

Demand an end to irrational drug laws, and support organizations like SAMA and StoptheDrugWar.org.

Tried to kill yourself? You're fired!

The mythical psychiatrist or psychotherapist accepts and understands everything. Or does she? Years ago a respected colleague told me of his policy. If a patient in his practice attempted suicide he would discharge them. The more I think about this the more I like it. Assume that either the patient's care has been transferred, likely to a hospital, and that the psychiatry has given the requisite thirty day notice in writing, not only to the patient but to the hospital. Ethics might obligate the original psychiatrist to continue providing care for the remainder of the thirty days, but the hospital should probably take the opportunity to refer the patient to a new provider for a fresh start.

One would likely invoke such a policy on a case by case basis with exceptions as indicated. Would ethics require the provider to notify all patients of the policy before starting treatment?

Many will balk at this idea, perhaps in part related to the professional's feelings of failure, anger, and perhaps fear of recurrence. But does a suicide attempt not represent the ultimate breach of treatment contract as well as a clear statement that the treatment has failed? Does rejection of the patient after the attempt not offer the possibility of more effective treatment?

From the psychiatrist's perspective such a policy also sets a limit, expressing the position that she will not accept society's misguided attempts to hold her responsible for the acts of another.

If all psychiatrists and psychotherapists refuse to work under such circumstances, who will take care of the patients. Perhaps society needs to answer that question.

Why Just Homicide and Suicide?

In the film Sybil psychiatrist Wilbur actually travels to her patient's home and rescues her from imminent suicide. The case of Tatiana Tarasoff led to a "duty to protect" on the part of treating professionals. These expectations play a key role in malpractice cases with plaintiffs invoking a theory base on the legal concepts of proximate cause and duty.

But why limit such expectations to suicide and homicide. Why not hold treaters responsible when sex offenders re-offend or when alcoholics relapse? What about a manic's spending sprees or sexual indiscretion? How far should we go in holding one person responsible for the conduct of another? Is there any doubt that a plaintiff can find an expert witness who will testify that if only the professional had provided better treatment or "admitted the patient to the hospital" she would not have spent all that money on the shopping channel.

You may argue that the courts hold treaters responsible only for providing treatment that fails to meet standard of care, usually defined as "reasonable and prudent," but in the end most professionals will focus their efforts on preventing the bad outcome.

No one should ever be held responsible for the acts of another. Such policy may feel good for the presumed victims, but it gives treaters a strong incentive to avoid accepting risky cases, thus depriving many of needed treatment, or at least raising the cost of that treatment.