BehaveNet® Opinion

Second Guessing the Medical Board II

2012-01-26T10:04:00.000-08:00

(Continued from Part I)

Diagnosis and Medication

MQAC provides minimal information about diagnosis and treatment:

After his initial evaluation in March Dr. Roys diagnosed Major Depression, rule out Bipolar Disorder.
Dr. Roys stopped venlafaxine because it no longer worked and prescribed lamotrigine.
In June he prescribed ziprasidone.
The documents state that in August Dr. Roys "was aware" that the patient "was taking clonazepam" and advised her to taper and discontinue the drug while prescribing mirtazapine.
During an encounter on August 16 the patient complained of increased anxiety and depressed mood and "was increasingly suicidal." Dr. Roys recommended reduction in lamotrigine dose by half, and prescribed diazepam 10 mg four times daily as needed, a quantity of 120 (a standard one month supply if taken regularly).
On September 3 the patient took an overdose of "primarily" "all of her" diazepam. Since the document fails to specify whether this meant 120 or 2 capsules/tablets the actual number requires imagination.
After less than one week in the hospital the patient was discharged back to Dr. Roys' care with a diagnosis of "major depression" on lamatorigine, mirtazapine and trazodone.
Dr. Roys continued the lamotrigine "along with various other medications."

MQAC criticizes Dr. Roys as follows:

Inadequate documentation of his rationale for his treatment of her depression.
"prescribing her Lamictal and stopping her antidepressant."
Prescribing a large amount of diazepam.
Failure to document the rationale for treating the patient as "having bipolar depression instead of uipolar depression."

Analysis

Believing as I do that most psychiatric disorders can be adequately treated without benzodiazepines, I applaud Dr. Roys for recommending Patient A stop her clonazepam. But the statement that he was "aware" of her using the drug suggests that she obtained it from another physician or from the street rather than by his prescription. MQAC neglects to address this key question suggestive of noncompliance, mismanagement by another provider, or even an undiagnosed substance use disorder.

I might say that I agree with MQAC's criticism of his decision to then treat Patient A with diazepam. However, the Board appears to regard such prescribing as quite legitimate, provided the amount prescribed remains below some unspecified number of dose units. If the Board agreed with me it would sanction half the physicians in the state. Indeed, MQAC would have us believe that the number prescribed increases the risk of an overdose. Insofar as 2 dose units taken at once represent an overdose how can one argue with that logic? In fact this is a cheap shot, a pejorative ploy to prejudice the reader. Only the patient determines how many pills she actually takes and when. Can MQAC really be so naive as to think that patients always take their medications as prescribed? Even this case gives the lie to that notion.

The Board would deceive the reader into confusing the risk of overdose with the risk of suicide attempt. In fact he number of pills prescribed does nothing to affect the risk of sucide attempt. How cynical of MQAC to insinuate that the number of doses prescribed caused the suicide attempt while neglecting to propose a "safe" number of doses. Could this be because there is no safe number? Any patient can accumulate a dangerous quantity of any prescription drug unbeknownst to the physician. In fact, one could applaud Dr. Roys for providing the patient with a relatively safe means with which to attempt suicide. But MQAC has covered that base. The documents suggest that combining the diazepam with alcohol or other CNS depressant would increase the lethality of the drug. This is true but entirely irrelevant since there is no evidence the patient did so. Such pejorative, gratuitous statements do not belong in such a document. (Combining diazepam with rat poison would also increase its lethality. So what?) It is perhaps surprising that the Board failed to fault Dr. Roys for not telling the patient that adding alcohol would make for a more lethal cocktail. After all, was it not his duty to provide informed consent thus educating her as to how to kill herself?

In fact, this patient like all of us had at her disposal numerous and sundry methods for attempting suicide.

Why did Dr. Roys' start diazepam instead of clonazepam during that August encounter. Did he think the latter would be more helpful for the severe anxiety described. Or did the patient imply that she would surely kill herself if he did not provide the requested drug? The Board does not seem to consider that question relevant.

I also wonder about the Board's interest in whether Dr. Roys diagnosed unipolar or bipolar depression. Some authorities believe recurrent depressive episodes represent a variant of bipolar disorder and should be treated as bipolar disorder. Psychopharmacotherapy is a process of auditioning drug after drug, combination after combination, until something works or the patient begins to see the process as futile. There is nothing in the information provided by the board to suggest that Dr. Roys neglected an effective drug or combination or that any of the drugs he prescribed might have adversely affected the patient (provided the patient chose to comply with the ordered regime). Overlake Hospital's psychiatrist seem to have continued more or less the same regimine, only adding trazodone and presumably stopping the diazepam. Kudos to Overlake for bucking the fashion and dropping the bipolar diagnosis, but Patient A needed effective treatment more than she needed the correct diagnosis.

In the documents MQAC claims Geodon (ziprasidone) is "indicated in bipolar disorder" "to help reduce anxiety" Not exactly: Geodon's FDA label approves the drug for treating

"acute manic or mixed episodes associated with Bipolar Disorder, with or without psychotic features"

MQAC cites no evidence for a mixed or manic episode, in fact describing chronic depressed mood and anxiety rather than mood episodes. The document also criticizes Dr. Roys for "prescribing her Lamictal and stopping her antidepressant" but fails to specify the "antidepressant" to which it refers while also apparently failing to appreciate that psychiatrists often prescribe lamotrigine as an antidepressant. Does MQAC criticize Dr. Roys for discontinuing venlafaxine which stopped working? Does MQAC believe mirtazapine is not an antidepressant?

The documents criticize Dr. Roys for failures in documentation. Medical documentation as an end in itself should only be criticized for failure to serve a purpose in advancing the patient's care. Dr. Roys' putative failure to document rationale for his diagnosis or treatment may damage his ability to defend his choices, but does nothing to adversely affect the patient's care, either by Dr. Roys or any future provider.

In future installments I will address:

Scheduling of appointments
Coordination of treatment
Suicide attempt
Reimbursement
Possible unintended consequences of MQAC's expressed and implied positions

Second Guessing the Medical Board

2012-01-19T12:51:00.000-08:00

When state medical licensing boards started posting on the Web the documents associated with discipline of physician misconduct physicians worried about the negative impact on their reputations and practices. But these documents also make public the work of the boards, leaving that work open to scrutiny, analysis, and criticism.

It only occurred to me to embark on such a critique after the name of a physician in my community appeared in the regular Washington Medical Quality Assurance Commission (MQAC -- pronounced M Quack) publication. I wondered whether readers might appreciate my analysis. Whether that includes Dr. Roys or MQAC is yet to be determined.

Links to documents related to Case M2009-897 appear in order from last to first on the linked Web page.

Disclosures

I met David Roys, MD 15-20 years ago, but never knew him well or worked closely with him. I have worked as a consultant for MQAC in the remote past, reviewing patient records for the most part, although I may have examined a physician or two for them. I practice in the same community as Dr. Roys, so you might rightly consider us competitors. Robert Small, MD may have been pro tem psychiatric member of MQAC at the time of this case. If I recall correctly Dr. Small trained in child psychiatry. I knew him when we both belonged to the medical staff of a local psychiatric hospital (presumably Overlake), and I believe we both worked as consultants for a managed care operation. I believe Dr. Small continued his career on the payer side by working for a health insurance company, perhaps as medical director. He seems to have managed to keep a very low profile on the Web. I have been a member of the Overlake Hospital medical staff for approximately 25 years.

Disclaimers

Understand that my sole source of information about this case is the five documents alluded to above. I have not reviewed medical records or discussed the case with Dr. Roys, his attorney, or anyone from the Board. Board attorney James Mclaughlin provided limited information as to who may have written the documents and Dr. Small's possible involvement. I can draw conclusions only about MQAC documents, not about Dr. Roys' handling of the case or MQAC's decisions. It is not my intention to help or hurt Dr. Roys or anyone associated with the case. It is my intention to shed light on the disciplinary process to the extent that the reports accurately reflect that process. It does occur to me that MQAC might find my analysis useful in future cases and that either side might find my analysis useful if litigation follows the complaint, as it often does. So be it. If such litigation should involve a jury trial, any prospective juror who has read this might use the fact to disqualify herself from duty.

Case Summary

According to MQAC documents, a psychotherapist refers a patient to the Respondent psychiatrist (Dr. David Roys) after failed treatment for an apparent depressive disorder with another physician. Dr. Roys makes some changes in the regime, including stopping the clonazepam, wondering whether the patient might suffer from Bipolar Disorder. After nearly 6 months the patient reports continued depressed mood with thoughts of suicide. Dr. Roys prescribes diazepam, but patient and doctor do not schedule a follow up appointment, possibly for financial reasons. Soon thereafter the patient attempts suicide (presumably) with overdose of "her medications, primarily the diazepam," is admitted to hospital, discharged back to Dr. Roys, then finds a new psychiatrist and files a complaint with MQAC (not necessarily in that order).

Sanctions

MQAC charged Dr. Roys under RCW 18.130.180 Unprofessional Conduct: "Incompetence, negligence or malpractice which results in injury to a patient or creates an unreasonable risk that a patient may be harmed." MQAC criticizes Dr. Roys' management of the case as follows:

Prescribing too much diazepam given the purported level of suicide risk.
Prescribing that was ineffective for treating the "noted depression."
Stopping antidepressant medication even absent sufficient evidence for Bipolar Disorder.
Treating the patient's anxiety without "fully addressing" (whatever that means) her depression.
Failure to provide a "well structured care and monitoring plan."
Asking the patient to return "only when she felt the need."
Prescribing a drug (diazepam) that had "propensity for abuse."
Failure to document coordination with the psychologist "to better tailor the medication plan with the mental health issues of Patient A that the psychologist was dealing with."

Points for Analysis

I will address the following issues from the official documents in this and future installments:

Writing style and grammar
Benzodiazepines
Diagnosis and medication regime
Documentation
Scheduling of appointments
Coordination of treatment
Suicide attempt
Reimbursement
Possible unintended consequences of MQAC's expressed and implied positions

Style

In a word I find the documents, particularly the Statement of Charges and Amended Statement of Charges, sloppy, particularly given their importance. It may seem petty to criticize the authors, for example, for capitalizing generic drug names like diazepam which are not proper nouns, but the ambiguity in many statements leaves me wondering whether the statement reflects MQAC's views or whether MQAC actually knows what it wants to say or indeed understands the issues.

The Amended Statement of Charges includes several "amendments" to the original Statement. The original refers to the referring professional as a psychologist, but this individual becomes a "therapist" in the Amended Statement. Was this a physical therapist, massage therapist, or a psychotherapist? If, as I suspect, he or she was a psychotherapist I hardly think it would break the MQAC budget to add those extra six letters.

Both Statements allude to whether the patient "was bi-polar." Not only is there no hyphen in the term, but Patient A may have had bipolar disorder; it is incorrect to say that she was bipolar. The patient may have taken antidepressant medications, not "anti-depression" medications. According to the Statement paragraph 1.7 the patient "manifested serious depression and anxiety." Apparently we are not to confuse this with comical depression or anxiety.

In paragraph 1.8 the report indicates that Dr. Roys told the patient to return "as needed." We see this term recorded later as "prn," an abbreviation of the Latin pro re nada which physicians usually reserve for prescriptions. Since we learn later that the patient's budget may have affected the frequency with which she wanted to visit Dr. Roys, and that MQAC criticized Dr. Roys handling of this matter, one wonders whether this pejorative language accurately reflected the event.

Paragraph 1.11 uses the legal term "grounds" to describe the patient's motivation for transferring care to a new psychiatrist. The author should have chosen a more appropriate word; legal jargon is gratuitous. This paragraph also refers to Dr. Roys as "not resolving" the patients symptoms. Doctors do not resolve symptoms; they treat them. Symptoms and illnesses might, however, resolve with treatment, or indeed without treatment.

With paragraph 1.12 the author takes us abruptly from laying out the facts to criticizing Dr. Roys' handling of the case leaving me with the impression that MQAC has failed to discriminate between facts and charges. I believe this shift justifies a separate, appropriately labeled, section in the report. The original Statement criticizes Dr. Roys' treatment as "not effective," seeming to insinuate that ineffective treatment is negligent treatment. Since psychiatric illness frequently fails to respond to standard treatments the author acted correctly in dropping this statement from the amended version. Also correctly omitted from the amended report is the ambiguous criticism of Dr. Roys' in paragraph 1.13 for not "fully addressing her depression." Psychiatrists do not "address" depression. We treat it.

The ambiguity continues in 1.14 of both statements which refer to a "well structured care and monitoring plan." In this paragraph in the original statement the author states Dr. Roys "was asking her to return only when she felt the need." This language leaves me wondering when and how often he "was asking," and more importantly, given the pejorative tone, whether MQAC criticizes Dr. Roys for what he did (was asking) or for what he should have done. Paragraph 1.14 in the amended statement provides little more clarity in stating that Dr. Roys "on several occasions did not schedule appropriate follow-up visits." Does MQAC want us to understand that he did schedule inappropriate visits? How does MQAC differentiate between appropriate visits and inappropriate visits? Perhaps we should focus instead on the fact that he did not schedule (the visits). If so, all physicians should indeed fear board sanction. In fact I myself have spent this entire morning not scheduling visits of any kind, appropriate or inappropriate.

The original statement criticizes Dr. Roys for prescribing a "large amount of Diazepam (Valium) which had the propensity for abuse." Was it the amount that had the propensity for abuse, or was it the diazepam? If the latter, does MQAC expect us to believe that some diazepam has a propensity for abuse and other diazepam does not? Does not all diazepam have a propensity for abuse? Is that not why it is a controlled substance? The author correctly omitted this language from the amended statement.

Paragraph 1.15 in the original statement is a near total disaster. In it the author criticizes Dr. Roys' records for failing to "reflect the kind of coordination with Patient A's psychologist that would be required in monitoring the patient, to better tailor the medication plan with the mental health issues of Patient A that the psychologist was dealing with." Fortunately for us readers the author clarifies this mess, at least partly, in the amended report.

One can only hope that MQAC was less sloppy in adjudicating this case than these documents reflect.

In my next installment I will address questions surrounding medication, especially the benzodiazepines clonazepam and diazepam.

BehaveNet needs help with terms and definitions

2012-01-18T12:42:00.000-08:00

Psychostimulant, analeptic, stimulant, CNS stimulant, wakefulness promoting: Are they all synonyms? If not, what might distinguish one from another? Would you classify the same group of drugs in all of them?

Anorectic, anorexiant, anorexigenic: same questions

Hypnotic, soporific: any difference?

The EMR and Litigation

2012-01-07T09:46:00.000-08:00

Years ago in my work as expert witness I realized that the paper versions of EMRs documenting care at early adopters like HMOs and the VA seemed awkward and poor representations of the actual computer record. A few days ago a prominent hospitalist friend observed at a grand rounds on EMR that these systems have become so complex and unique that each may require training and even certification for the physicians who use them, a significant problem for docs who cover hospitals with different EMRs.

Will these facts affect future litigation? Will an expert need certification to be a credible witness in a case where records are electronic? Will it suffice to provide the expert a stack of printed records, or must access be granted to the EMR itself, perhaps even in the courtroom, to achieve a valid picture of the record? If so, how will we provide the expert an accurate picture of the record at the relevant point in time?

WA Rx Monitoring Program Flawed

2012-01-05T09:42:00.000-08:00

First thing yesterday morning two messages appear in my inbox. A few minutes later I am searching the controlled substance records for the patients on my schedule for the next few days. Health Information Designs provides the service via a Web interface that looks like a throwback to the 1990's and features data entry windows that do not line up with their labels. The "practitioner/pharmacist query" page features a check box for "Prescriber Search by DEA." Does HID intend that DEA agents should be able to use this to search for providers like me? Or did they mean "Prescriber Search by DEA Number?"

Undaunted by the amateurish interface I conduct my first queries. Bingo. I discover more than one non-physician has prescribed controlled substances I consider contraindicated for a patient I treat for addiction without contacting me to coordinate care. I strike more pay dirt:

One buprenorphine maintenance patient had already told me his dentist had prescribed a -codone for a dental procedure.
I discovered another physician had prescribed zolpidem to a buprenorphine patient without consulting me.
I discovered another physician had prescribed eszopiclone unbeknownst to me.

Now what? Should I test each patient by asking if there's anything they want to tell me? Should I discharge the filthy liars? And how often should I check the database?

I am inclined to avoid the drama, but let each patient know that I can now discover what other docs (and non-docs) prescribe. Since these other providers also have access to the records there will exist no illusion that the patient can keep them in the dark.

Out of a total of 18 patients I was unable to find any record of 7 patients. In one case I had entered the wrong birth date, but in several cases I myself have prescribed controlled substances regularly for months. This means that a negative query can result from entering the name or birth date incorrectly, but it could also result when no controlled substances were prescribed. So a positive result tells you something, and a negative tells you nothing. This flaw merits urgent attention.

I inquired about the problem via email to HID. The response:

Your search may be too narrow and will only pull specified information. I am able to help you with a search if you are available. Also your search should be used as a tool in addition, to the information you know is true and it allows the prescriber/pharmacist to make a better decision about health care. When used this will prove a very useful tool when used in conjunction with good sense and caring health providers like you.
Thanks,
Ayana Lewis
Technical Support Specialist
Prescription Drug Monitoring Program
Health Information Designs, Inc.

If anyone out there can interpret that for me, please comment.

When I called HID for that promised help I predictably encountered Ayana's voice mail, so I called back to navigate the menus. The states are divided alphabetically with menu choices, but I waited in vain for Washington. I guess I could have extrapolated from Vermont (8), but I chose to call once more and try my luck with an operator. With minimal hold time I spoke with a representative who ultimately did not seem to grasp the gravity of the problem or offer any hope for correction. I have since contacted the State of WA and am expecting a return call.

On the positive side for the interface: security. Not only must I use a username and password to access my account, but I must register the devices (computers) I intend to use.

An unexpected positive consequence: Patients in the past have refused to allow me to coordinate care with other providers for fear I will reveal their addiction history. Since this strategy will no longer keep the secret I can expect more cooperation in the future.

The patient I "caught" above (or I could more accurately say I caught the providers of the prescriptions) admitted to the problem, allowing us to develop a new plan, including giving me permission to contact those providers and read them the riot act. Overall this program will likely help a lot of people and save more than a few lives.

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

2011-12-29T09:59:00.000-08:00

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?

2011-12-15T10:52:00.000-08:00

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 default 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

2011-12-08T07:46:00.000-08:00

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?

2011-11-28T07:44:00.000-08:00

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

2011-11-17T08:11:00.000-08:00

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

2011-11-10T09:02:00.000-08:00

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?

2011-11-03T08:35:00.000-07:00

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

2011-10-20T07:43:00.000-07:00

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

2011-10-13T08:35:00.000-07:00

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.

2011-10-06T09:33:00.000-07:00

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?

2011-09-29T08:50:00.000-07:00

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?

2011-09-22T11:16:00.000-07:00

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?

Who ya gonna call?

2011-09-15T10:03:00.000-07:00

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

2011-09-08T09:19:00.000-07:00

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

2011-08-25T08:28:00.000-07:00

"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

2011-08-18T09:33:00.000-07:00

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

2011-08-07T14:59:00.000-07:00

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

2011-08-04T09:07:00.000-07:00

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?

2011-07-28T08:06:00.000-07:00

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.

2011-07-21T09:49:00.000-07:00

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

2011-06-29T06:50:00.000-07:00

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

2011-06-26T15:22:00.000-07:00

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!

2011-06-19T08:23:00.000-07:00

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

2011-06-18T13:05:00.000-07:00

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?

2011-06-18T08:39:00.002-07:00

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?

2011-06-16T08:48:00.000-07:00

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

2011-06-09T09:51:00.000-07:00

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

2011-05-30T17:53:00.000-07:00

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

2011-05-26T08:15:00.000-07:00

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.

2011-05-19T09:41:00.000-07:00

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?

2011-04-28T09:22:00.000-07:00

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

2011-04-21T08:22:00.000-07:00

(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

2011-04-07T09:07:00.000-07:00

(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

2011-04-07T09:06:00.000-07:00

(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

2011-03-31T08:56:00.000-07:00

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

2011-03-24T08:21:00.000-07:00

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

2011-03-17T09:49:00.000-07:00

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?

2011-03-07T16:35:00.000-08:00

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

2011-03-06T14:06:00.000-08:00

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:

Next to Normal: Is Bipolar a Dysphemism for Life?

2011-02-27T11:33:00.000-08:00

If you thought this Broadway musical was just about Bipolar Disorder, I won't spoil the surprise. It is a tribute to the strength and resilience of patients and families who must cope as best they can with serious mental illness on top of everything else life can throw at us. And with less help from psychiatry than we would like to offer.

I found the view of modern psychiatry balanced and accurate. Broadway has finally moved past it's obsession with psychoanalysis, but still seems stuck on individual psychotherapy. How might this story have unfolded with a family psychotherapist? There was one glaring omission: How might this story have unfolded under managed care?

Take heart psychiatrists. As Diana tells her Dr. Madden, "You're not a scary rock star anymore."

Next to Normal

Another Doc's Buprenorphine Audit

2011-02-21T16:28:00.000-08:00

Another physician's experience of DEA audit of his buprenorphine practice turned into considerably more and suggests the agents involved were ignorant, inadequately supervised, out of control, and unable to conduct themselves properly in a physician's office. Our tax dollars pay for this:

"On April 5th, 2010, two female agents presented their paper ID, but when I asked if they had badges, they said no. They arrived at 5pm and stayed until nearly 8pm. They interrogated me about my Suboxone patients. I have 2 on compassionate care. The patients receive their Suboxone at no charge, and I also do not charge them for their appointments. They wanted to see my bookkeeping and where I kept the Suboxone locked up. I showed them the lockbox, inside a locked cabinet; showed them the two bottles of 30 tablets each, with the patient's name on each bottle. They wanted to see my documentation, including the receiving documents that come with the bottles. They informed me that I should not keep these receiving documents in the patient's charts, but in a separate file of their own. That was an irregularity. They also said I need to segregate all my Suboxone patient files into a separate file away from my other patient files. That too, was an irregularity.

"I have listed all my Suboxone patients including my 2 compassionate care patients in a bound notebook that is locked in the cabinet next to lockbox of Suboxone. They said I should have put "0" on the first line, as that is what I started with, and that was an irregularity. They also said I should put "Suboxone" "8mg" "tablets" and my "X - DEA number" on the top of each page, and since I didn't, that was an irregularity. They had me Xerox copies of all my entries, as they stood. They had me sign an accounting record indicating that I had dispensed a total of 600 tablets to the 2 compassionate care patients, and that I had 60 tablets remaining in the lockbox.

"Then after about 2 hours, they began asking me about the medications I ordered and dispensed when I had worked at a pain clinic years ago. They informed me that since it was past the 2 years required to keep records for the DEA, re: dispensing controlled medications, they were not interested in who received them. But they asked many questions about the now defunct clinic; some questions that were very uncomfortable such as, "Why was this clinic given that name?" Although I attempted to explain to them who the person was it was named for, they would jump on my answers before I was finished saying,"So it was the doctor who owned this clinic?" Again, I tried to explain who he was, how he was one of the fathers of modern medicine who invented a new treatment back in the 15th & 16th centuries. They didn't know what the new treatment was and wanted to know if I was dispensing it at this pain clinic. I told them it was a medicine from a long time ago. They asked where this clinic was located, and as I attempted to give them the directions, they again, would jump on my answers with more questions before I could finish, also making remarks, such as "Do you turn North or South when you leave the freeway." I tried to tell them that for anyone who knows me, I have no idea about North and South directions, but that people turn right at the off-ramp and then take the first left. They asked again, "is turning left going South ?" I said I didn't know. I am not good with compass directions. They continued with this line of questions, wanting to know more about the types of treatments were offered at this clinic, who the owner was, where he was now, what my interests were there, how often I was there, how long did I stay there, etc. (I continued to wonder why they asked all these questions, if this was years ago, the clinic is now defunct, the owner is deceased, and in their own words, the documentation for the dispensing of these medications, was no longer needed since it was beyond the DEA requirement of keeping records 2 years). They wanted to know why I ordered these medications for the pain clinic. I informed them that I was there to learn from an expert, and I was asked to order them, as they were for my patients. They then informed me that I should have not used my DEA number at one of my offices, and that this was also an irregularity. I informed them that I had a DEA number at the other clinic, but there was some confusion with the ordering of medications, as they would be delivered to my other address. As I had a separate DEA number for each location, I never gave it a second thought, and attempted a number of times to correct this, but there was confusion at the ordering company with different customer numbers, and there still is as there remains on my file two customer numbers. So I kept accepting the medications at the other address. If the DEA bothered to look at some of these invoices, they could see that the medications were being ordered for other clinic, which the distributor put on the top of some invoices, or they just would put PA, but would have my Seattle address. In addition, because of this confusion, I received charges for medications and other supplies that I didn't order or receive.

"When the older agent went to the restroom, she insisted upon me staying in the hallway and not returning to my office where the other agent was left by herself. In addition, they asked me to copy my bound ledger book of all my Suboxone patients, both agents stayed in my office alone without my supervision, as the copy machine was in another room.

"When they left, they handed me copies of Web pages. They informed me that there were several irregularities and that they would have to turn everything over to their supervisor who would be in touch with me. This really started freaking me out.

'A colleague told me that much of the information the agents told me was untrue, ie, I didn't have to segregate my Suboxone patient files from my other patient files; that I didn't have to keep a separate bound journal for my regular Suboxone patients, as I wasn't dispensing anything to them but a written prescription. That there was a lot of the nit-picking with putting "Suboxone" "8mg" "tablets" and "X-DEA" at the top of two pages and putting "0" on the very first entry line, was more for harassment than anything else.

"On Thursday, April 9th, I called Supervisory Agent Ruth Carter, and left a message informing her of my distress, that since this 3 hour interrogation on last Monday night, (with the agents basically telling me I was in trouble for these irregularities but wouldn't say what kind of trouble), that I have not been sleeping or eating this past week. That I am having constant ruminating thoughts: Have I done something wrong ? Am I going to jail ? Will I lose my license and livelihood ?

"This distress is all true as I have discussed how I have been feeling with several colleagues. It was indeed an ordeal, I was very nervous having DEA in my office. My mouth was dry and I kept drinking lots of water, and I kept thinking to myself, "They're going to see this as an indication of some sort of guilt."

"Other questions and answers and comments that came to mind later:

"They asked if I ever heard from any of my patients, of any place that sells drugs. I informed them that I heard in back of a Jack-in-the-Box downtown. They asked where it was, how many Jack's there were, and I told them I only heard, "in back of a Jack-in-the-Box." They asked where on Broadway. Again, I said all I heard about is in back of a Jack-in-the-Box on Broadway. (I learned later from a colleague that this Jack-in-the-Box on Broadway was razed several years ago).

"In addition to the information on the other clinic I mentioned above, they asked a lot of other questions. How many doctors worked there (several) ; what did those doctors treat (I don't know) what kinds of treatments were provided at this clinic (pain, cancer; alternative, brief anesthesia, use pain medications, trigger point injections, prolo therapy, chelation, hormones, heart disease treatments, arthritis, fibromyalgia, thyroid, any and every kind of muscle and joint therapy); were other doctors providing pain management (I don't know); they asked if the clinic or the owner were ever under investigation (I don't know); what other kinds of medications were being used (I said I knew about liquid cocaine, but never used it, or saw it used). The older agent said it is used in eye surgery or treatment. I told them the doctor who owned the clinic died last year and it was a great loss to me personally and to the community as he was a world famous physician, author, had been on radio, TV. They asked me if I knew why he died. I said I didn't, but I speculated. I told them that he was to retire soon, had arranged for his clinic to be sold soon, but I was never formally informed of a specific reason.

"I kept thinking how odd it was to continue asking me questions about a defunct clinic, with books that have been closed years ago. And how the older agent said she was not concerned about how the medications were distributed as the times those medications were ordered and distributed were more than 2 years ago. Obviously, I had not continued to order medications since. So I didn't understand why all the harassing questions, but I was becoming more uncomfortable, and visibly shaken, feeling I had done something really wrong and I was going to be arrested or lose my license on the spot for something that happened years ago, and was never investigated then for any improprieties. In addition, they can easily pull my Schedule II records, and they can see that I am rarely writing for pain medications, as I don't want people to get the wrong idea, and have a line at the front door with people drug seeking.

"As I have said to several other colleagues, if I had known that there was so much involved in paperwork, DEA investigation ,etc with dispensing Suboxone to 2 patients under compassionate care, and it was going to be any different than giving other compassionate care medications, like Seroquel XR, Effexor XR, Pristiq, etc, I would never have done it. I still don't understand why the doctors who prescribe Suboxone are under such scrutiny for a Schedule III, which is relatively not abusable, requiring a separate DEA, and yet, the prescribers of Oxycontin, a schedule II narcotic, which appears to be the drug responsible for causing most of this opiate addiction, don't need a separate DEA number, like those of us who prescribe Suboxone. I further understand that Suboxone was originally a Schedule V med (as buprenorphine), but was moved to Schedule III for FDA approval (as buprenorphine + naloxone). It appears that the DEA is targeting those of us who are trying to provide treatment and even a cure for opiate addiction. It also appears that the DEA is trying to harass and intimidate those us from providing this treatment and that there may be some collaboration with Purdue Pharmaceuticals, to keep patients away from a cure or treatment for the addiction they have caused as it is cutting into their bottom line.

"They asked me how I induced patients on Suboxone. I told them I don't induce anyone. My patients came to me already on Suboxone from hospitals, detox clinics and other doctors who induced the patients, but already had too many Suboxone patients on their books. They asked how these patients heard of me. I told them the Internet. The older agent, said in an attacking manner, (which scared the hell out of me). "Do you advertise? Do you have a Web site that advertises you prescribe Suboxone?" She kept it up even after I stood and showed her a paper indicating it was from the Suboxone company, and that is where many of the patients come from. She asked how many patients total I have. (I said we would have to count, but they are all here, including the ones who are no longer coming to this office). They asked if I had ever prescribed Subutex. (I said I did, as one pregnant woman informed me her OB/GYN said it would be less harmful to the fetus, but that she is no longer coming here).

"I also talked about how I hope Vivitrol takes over much of the opiate addiction treatment. Neither agent heard of this medication. I informed them it was injectable naltrexone which lasts for a month. They asked what naltrexone was (and at that point I knew they had no understanding of Suboxone being a combination or buprenorphine and naloxone). I told them about the history of naltrexone (the oral medication) and injectable naltrexone (Vivitrol) and how if it is injected once a month, the patient could not sell medication, like some sell or trade Suboxone, that it works all the time, and there is no problem with forgetting a daily dose, since it is given monthly. I also gave them brochures on this medication. They asked if I have prescribed Suboxone for chronic pain. (I have). And if I wrote Chronic Pain on the prescription (I do).

"The also said that the primary point of their visit is to provide education (even tho they kept harassing me with questions about the other clinic with the younger agent writing down lots of notes). But it wasn't for education, but to discover as many violations as they could. If it was for education, they would have instructed me and had me put on top of the two pages "Suboxone" "8mg" "Tablets" "X-DEA" then and there, and not use those ploys to say I violated the CSA. The cover page on my ledger has all that, and I didn't understand why it had to be on the top of these two pages.

"They asked if I did urine tox screens (I do not because these have to be witnessed) but I have saliva tests I can use. That substance abuse treatment is not my primary activity, but I am providing a service to about 35 people, who cannot afford treatment unless covered by insurance or compassionate care. They asked if I required people to attend 12-step groups (I do not as how would I know for sure they do). That as a physician - psychiatrist, I need to be able to trust my patients to some degree, as many have lost their trust in others, and vice-versa. But my patients must come in every 30 days to get their prescription. And I have discharged patients from my practice if I discover they are misusing their medications, not keeping timely appointments, etc.

"They also said if methadone is prescribed, it can only be prescribed for pain in low doses, and not for opiate addiction. If prescribed for opiate addiction it must be in an approved clinic.

"They said that if I had an office in 3 different states I would have to have a separate DEA for each state (as well as a state license). They said that my prescriptions can be honored in any state even without being licensed in that state where the prescription is filled. If I were to work at another clinic which dispensed medications, I would need to obtain a separate DEA for that clinic. If I were to dispense Suboxone from another clinic, I would need to obtain a separate X-DEA as well.

"They asked if I had purchased my new prescription pads yet (I have not.) and then informed me that they have already investigated fraud with the use of these new prescription pads.

"They also remarked that although (in their opinion) doctors no longer make house calls (which we still do, and some of my colleagues know I do this), I would be allowed to carry all schedules of medications with me, and then when I return, I should lock up my medical bag. Apparently not taking into account that many doctors who do house calls keep their bag with them at home, as they often will make the house call from their home.

"On Monday, April 13th, Supervisor Ruth Carter, returned my phone call and said I should not be concerned with the investigation. She said these "irregularities" are actually violations, but these are easily taken care of. I told her that they asked me about a pain clinic I worked at years ago where I dispensed medications, and was told it was an "irregularity " by the agents, as I was sent medications by the pharmaceutical company to my one clinic address that were used at another clinic address where I also had a separate DEA. She said it was a violation, as I am only suppose to dispense medications from the location where they are received. (I never knew this was a problem as I had two separate DEA's and was dispensing them to my patients under the guidance of a mentor, and that's the only reason that I ordered them). I told her that there was quite a bit of confusion during the ordering of medications, as the company would send the medications to me under the name of one clinic but to my the other address. I attempted to correct this clerical error several times, but it was apparently too confusing.

"I also said that the agents told me I had to keep my Suboxone patient files separate from my other patient files. Ms Carter said this is not true. All I would have to do is to show the DEA the number of patients who are on Suboxone (which they should know as Suboxone patients are easily identifiable by our special X-DEA number). I said I was told there was another irregularity as the receipts for the Suboxone were in each of the two patient's charts, and it was supposed to be in a separate file. Ms Carter said this was not a violation. She said I would be receiving a letter about these violations, and that I would need to send a return letter stating that I had done what was asked. She also stated that if there was anything serious, her agents would have spoken to her right away but they haven't contacted her about any serious violations and her agents haven't met with her for over a week. I told her I was disturbed when the older agent asked me to wait outside the bathroom door and not return to my office, where the younger agent remained by herself. Ms Carter said I should never have left her agents in my private office unattended and I should always conduct any questioning in a conference room or some other neutral ground. (This disturbed me even more, and I began thinking that these agents are not trustworthy if they cannot be left unattended in my private office. What were they doing, downloading my personal files? Bugging my phone? Or what?). I told her that they were left alone in my office on a couple of occasions as they requested record copying, as the copier is in the other room. Since her agents were out asking me all these questions, I asked Ms Carter why her agents knew nothing about Vivitrol, the injectable naltrexone for opiate abuse. Ms Carter stated they should know about the drug they were questioning me about and any alternatives that they may want to question, (like they did with methadone). I told Ms Carter about my anxiety, how stressed I was as after 3 hours I was getting worried that I did something really wrong and was going to have my door kicked in, be arrested, lose my license, my patients who depend upon me, my livelihood, my home and everything I worked so hard to achieve. She reassured me that this was not going to happen. They have no intention of taking my license from me and no one would be kicking in any doors. Ms Carter apologized for any anxiety this investigation has caused as it was meant to only be educational and not vindictive. I asked Ms Carter why her agents continued to ask me questions about a pain clinic I worked in years ago, when the agents don't require any records that are more than 2 years old. She didn't know why her agents were asking me all these questions about events that happened more than two years ago, as they are only supposed to be discussing Suboxone prescribing, dispensing and record keeping. (I kept thinking to myself: these agents are not supposed to remain alone in my office; that several of the statements these agents made to me are false, ie, what is a violation; they are not supposed to question me about anything but Suboxone, ....are these rogue agents? Agents who do not follow directives of their supervisor? Does this violate any DEA rules, that agents are not supposed to question doctors outside the scope of their investigation? Are they trying to score extra points? Are we responsible for what we say under duress, but the DEA does not require proof of what we did greater than 2 years ago? Again, I kept wondering if these agents were real DEA, as they had no badges. And if they weren't agents, do they use contractors to do this questioning as that way they don't violate rules of conduct if they don't follow DEA rules but do as they please to get the information they want to pursue? Like a rendition?)

"I also asked Ms Carter why the DEA was going after Suboxone prescribers and not the prescribers who are causing the opiate addiction ? Why don't Oxycontin prescribers need an X-DEA? Wouldn't it be more judicious to go after those who are causing a lot of the problem and not those of us who are prescribing a treatment and cure? I told her there is rumor that the DEA is being funded by the opium industry as Suboxone interferes with their profits; ie, if people use Suboxone, they won't use and abuse opiates; that we are in Afghanistan protecting opium fields like we did in Viet Nam, Laos and the entire Golden Triangle. There is no oil in Afghanistan and pharmaceutical giants like Mallinckrodt buy 80% of the world's opium from Afghanistan (20% from Turkey). It is Afghanistan that most of the worlds heroin (93%) comes from. She said she didn't know anything about it, but she is following directives from D.C. Again, she apologized for any undue anxiety and reassured me that it is not their intention to do anything but to educate doctors on proper record keeping, and that I they have no intention of taking away my license to prescribe or practice.

"The last thought why the DEA was doing this, is to rack up as many "irregularities" (aka violations) as they can. No matter that they are clerical errors such as not putting the word "Tablet" on the top of each page. It is a violation of the DEA code. But the DEA can present these many violations to Congress and point out they have discovered all these crooked doctors who blatantly violate DEA regulations, and if they only had more money from Congress they could do a much better job.

"At the bottom of it all is money."

Wisconsin Docs Provide Sick Notes

2011-02-20T21:22:00.000-08:00

Is this OK? Wisconsin doctors (or say this man claims) provide notes on request so workers can get paid leave. The man interviewed implies that stress or almost any other reason justifies a sick day. Are "mental health" days OK? Is it ethical for a physician to support this?

Should Employers Ban Smokers?

2011-02-15T15:00:00.000-08:00

This recent New York Times article raises some interesting questions about the extent to which the law should dictate whether employers can discriminate on the basis of behavior outside the workplace. The article focuses on health care facilities that have banned smokers, but opponents argue that smoking differs little from other legal off site behaviors like engaging in risky sports, eating unhealthy food, drinking, and (by implication) unsafe sex. According to the article even one anti-smoking organization opposes this form of discrimination citing apparent socioeconomic differences between smokers and nonsmokers.

Employers apparently want to reduce absenteeism and health costs. Health care institutions also want to present an image of their employees as healthy, perhaps to enhance their image and set an example. The ban would also present an incentive for smokers to quit.

Employers could go further by banning fast food eaters, sky divers, drinkers, and people who don't use condoms. But eliminate enough categories of risk takers and you will not find sufficient qualified workers. Furthermore, employers will have to decide whether the costs of discovering such behaviors and firing high risk workers only to have to find low risk workers and train them makes business sense.

As for secondary discrimination by association, remember you're providing an incentive to better health, and continuing to smoke is a free choice.

I say let the employers decide. What do you think?

Are Drug Reps Going to the Dogs?

2011-02-13T10:18:00.000-08:00

Is it unethical for my dog to accept treats from a pharmaceutical representative?

Reps can't influence my prescribing with free pens and sticky notes, or by taking me out to lunch, but where there's a will there's a way. Last week a drug rep brought treats for my dog who always comes to the office with me. (Even if they were FDA approved, I'm sure this is an off-label use.) At least the drug name doesn't appear on the treats.

Now every time I write a prescription for the rep's drug my dog rolls over, and when I write for a competing drug he growls!

Letting Your Giftedness Out of the Closet

2011-02-10T17:18:00.000-08:00

I recently became acquainted with Lisa Erickson, a local (you know, the old fashioned geographic way) counselor who has specialized in helping people who designate themselves or have been designated by others as "gifted." She told me about the publication of her article, Coming Out Gifted. I suspect I, as a psychiatrist, have lots of company in struggling with the idea that what might be wrong with someone is that there is too much right with them. How can one have trouble with superiority to the rest of us schmucks?

Lisa admits that her analogy falls short of perfection and lists a few ways in which "coming out" as gay differs from coming out or facing the ugly fact that one's intelligence or other capacities exceed those of others. I'll add a few, while admitting that I consider myself straight as an arrow, so what do I know? Gay doesn't come by degree. Giftedness probably does. You either have a sexual attraction to the same sex or you do not. Even bisexuality seems pretty black and white. (Speaking of black and white, perhaps race might serve up a better analogy in the sense that one can be of or from any of a number of races to a differing degrees depending on ancestry.)

But not only does giftedness occur on a continuum, but where it starts is arbitrary, a judgment call. Even if you can substantiate your claim with results of an intelligence test or star status, there will always be the question of where to draw the line. However, by the very act of "coming out" as gifted, one would seem to be drawing a bright line, saying, "I am different from you." which others may hear as, "I am better than you." And unlike gay, there exists no moral or religious condemnation of smart or talented, no matter the degree.

Of most interest to me as a psychiatrist is the notion that we might mistake attributes of giftedness as evidence of a mental disorder like attention deficit disorder or bipolar disorder. While I accept the notion that individuals with extraordinary talent or intelligence may benefit from help in adjusting to their differences, we should arguably never view their superior abilities as illness. This is where the concept of "over-excitability" starts to excite me. I'm still looking for a rigorous definition, but what I've seen makes me think psychiatrists might easily confuse gifted individuals with those who have ADD or bipolar disorder. Not that we should think giftedness renders immunity to any mental illness. But most of the attributes associated with giftedness, even over-excitability(?), can occur in individuals who are not gifted.

Help!

My DEA Buprenorphine Audit: My "Violations"

2011-02-08T11:12:00.000-08:00

I fully expected retaliation from DEA for my open criticism of their disruptive practices and policies in auditing buprenorphine addiction treatment practices. Here's how they nailed me. You can judge for yourself whether DEA should penalize me.

To recap briefly, last fall two DEA agents appeared in my office without an appointment, despite my written requests to schedule their "routine" obligatory audit of my buprenorphine opiate addiction treatment practice. When I told them they would need to obtain a warrant they left. The following week five DEA agents invaded my office, copied some files from one of my computers, asked some questions, and left with a copy of my prescribing record. Days later two agents appeared in the office with no appointment or warning to discuss their determination. After I made it clear that I was not interested in chatting with them they left my waiting room, and I wrote a letter demanding a written enumeration of their findings.

Inexplicably it took DEA approximately 2 1/2 months, but finally, a couple weeks ago, I received a letter (return receipt requested) citing me for two "recordkeeping [sic] violations." (In fact both related to transmission of prescription orders rather than record keeping.)

"Failure to include your "X" DEA Registration number on prescriptions for Schedule III narcotic drugs approved for detoxification and/or maintenance treatment.
"Failure to use an application that meets the requirements to electronically sign and transmit controlled substance prescriptions.

"The purpose of this letter is to afford you the opportunity to come into compliance with the requirements of the Controlled Substances Act. Please ensure that these are corrected. This is a serious matter which, if continued, can lead to sanctions, finds, or the possibility of the suspension of your DEA registration."

You might consider item number one to be technically correct but for the fact that the statutes permit me to order such prescriptions by telephone with no written communication whatever. In order to minimize the risk that my DEA number might fall into the wrong hands I always communicated it to the pharmacy by telephone.

Item number two reveals the ineptness of those who draft and interpret these statutes. Literally it cites me for failure to use an "application" that does not exist. But we apparently cannot expect DEA to compose a sentence that reads as intended (even with 2.5 months to prepare!). I believe they meant to cite me for, "use of an application that fails to meet the requirements..." referring to statutes regulating eprescribing. As of yet no eprescribing "application" (service) meets DEA requirements. In fact I used a service that allows me to fax a prescription that exists as a word processing document file to the pharmacy. I did not use a digital or "electronic" signature. I used a stylus to produce a manual signature with digital "ink" on a tablet computer. Like any other fax device now in use this sends a copy of the signed document to the pharmacy. When the pharmacy views or prints this transmitted document the pharmacist cannot distinguish it from a paper document signed with a pen or pencil except that the signatures on successive transmission do not differ.

Our federal government must find this kind of efficiency threatening. Perhaps I am naive, but it seems to me that DEA should concern itself with preventing diversion and fraudulent prescribing. I contend that my procedures minimize the risk of both. Furthermore, the statutes failed to anticipate the technology I use, and DEA, rather than assessing the risk it poses, chose to trump up a charge based on technicalities. In other words, they didn't think. Today I believe all faxes are electronic, if not digital, and in all case in which the image of a manual signature arrives via fax the pharmacist sees only a copy of that signature. I also wonder why DEA has not cited the pharmacies for dispensing based on inadequate prescriptions since none of these was a "paper" prescription. After all no harm is done in transmitting the prescription. The harm occurs only when the pharmacist dispenses the drug to the wrong person. Of course the pharmacist cannot differentiate between a facsimile transmission of a computer file and of a scanned paper document except perhaps by the inferior quality of the latter.

Here is an applicable federal statute:

"Sec. 1306.21 Requirement of prescription.
(a) A pharmacist may dispense directly a controlled substance listed
in Schedule III, IV, or V that is a prescription drug as determined
under section 503(b) of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 353(b)) only pursuant to either a paper prescription signed by a
practitioner, a facsimile of a signed paper prescription transmitted by
the practitioner or the practitioner's agent to the pharmacy, an
electronic prescription that meets the requirements of this part and
part 1311 of this chapter, or an oral prescription made by an individual
practitioner and promptly reduced to writing by the pharmacist..."

My plan, which I have already communicated to DEA and which I implemented on receiving the letter, consists of providing signed paper prescriptions displaying my DEA numbers when the patient appears in the office or, when the patient does not appear, authorizing refills or ordering new prescriptions by telephone. Incidentally -- and not surprisingly -- only one pharmacist has asked me to provide my DEA number.

So what is your verdict, reader? Should DEA revoke my registration? fine me? send me to Club Fed (where I will be entitled to free health care)?

Pain Practice Invaded by Agents

2011-02-02T10:00:00.000-08:00

According to stories in Washington's Peninsula Daily News and Port Townsend Leader on December 21, agents from a variety of federal, state and local law enforcement agencies invaded the home and office of physician James Kimber Rotchford, MD, disrupting his practice, which subsequently reopened. Rotchford is immediate past president of Washington Society of Addiction Medicine and supported my own campaign against unscheduled buprenorphine practice audits by DEA. He appears below in a brief interview about his pain treatment practice.

This appears to be yet another example of disregard for patients and physicians when inept and ham-fisted law enforcement authorities invade medical practices. In their defense of course we must acknowledge that real fraud happens and must be stopped. Is the only way out of this mess for all medical providers to work as employees for a single entity (not the patient)?

I susepct Dr. Rotchford is guilty of nothing more than a minor technical error in attempting to recover a small portion of the cost of practicing from Medicaid. His experience bolsters my own conviction that I have done the smart thing by opting out of Medicare and refusing to accept Medicaid at all. More here.

I have read neither of these books, but both would appear to address the problem of "criminalization of almost everything."

Why Psychiatrists Should Enter the Blogosphere

2011-01-27T08:52:00.000-08:00

A few weeks ago Shrinkrap Dinah posted Why Shrinks Don't Blog, quoting my earlier comment:

"The fact is, though you claim your blog is for psychiatrists, my impression is that few of us participate in any blog. What stops them? Snobbery? Hubris? Ignorance? Apathy? Fear?"

Despite a lively conversation I'm not sure we ever answered the question, but it occurs to me, now that I've been doing this since August 2009, to put the hard sell on my colleagues who have not yet jumped in.

Doctor, you are in control. You do not have to start your own blog and post to it every day. Just read someone else's when you get the urge. Read a few comments, too. Most of us isolate ourselves pretty completely. We put together a pretty narrow view of psychiatry. Reading blogs will not provide a complete psychiatry world view, but it will expand your horizons.

You will discover how some of your colleagues think and practice. Once in a while you may incorporate some of these ideas in your own approach. Better yet you will discover what some of our patients think about us, especially what they may not feel free to discuss during a visit. You will become more sensitive to their concerns.

Enter the fray by posting a comment. Most blogs allow you to post anonymously, so you need not worry that your patients or colleagues will discover your innermost secrets and opinions. Your opinion matters to the rest of us, and we want to learn from your experience. You can influence psychiatric thinking. Test your own ideas by provoking disagreement from others. It is not so terrible to discover that you were wrong. I know from experience.

Starting you own blog may be easier than you thought. Decide whether you want to remain anonymous or use your blog as a vehicle to increase exposure for your professional identity, even to market your practice. You can make a commitment or not. Write as little or as much as you want. You will not spend every waking moment screening comments.

To paraphrase, "Doctor, blog thyself." You will make psychiatry better.

Psychiatric Ethics of Publishing Cases

2011-01-20T06:57:00.000-08:00

Publication of psychiatric cases in the media can benefit the public, patients, and psychiatry in general. It can also benefit the author and the publisher, but such publication raises the question of whether, and how, we can ethically make patient treatment information public.

Do we as psychiatrists want prospective patients to wonder whether they might end up in the same positions as Dr. Spork and his patient Barbara?:

In the past week or so two psychiatrists appear to have described real cases in national media. In neither was there any indication that the author had made up the case; in neither was there indication that the psychiatrist obtained permission from the patient; and in neither was there any indication of the extent, if any, to which the author might have disguised the case. In both the level of detail seemed sufficient that the patient might be identified:

Depression On The Rise In College Students
In fairness to the Dayton, Ohio psychiatrist, Jerald Kay, MD, who did not author the story, I can find only one sentence in which he seems to have supplied the information. Perhaps the author obtained the story elsewhere and Kay just added to it.

When Self-Knowledge Is Only the Beginning
New York psychiatrist Richard A. Friedman, MD authored this story.

In each of these articles:

Does potential benefit to the public outweigh risk of damage to the patient?
What constitutes adequate disguise?
Can a psychiatrist ethically ask a patient to allow publication without damaging the treatment relationship?

An author can attempt to disguise patient information, but what constitutes adequate disguise? In a private communication a chair of the American Psychiatric Association ethics committee pointed me to the standard used by a professional journal. The sole criterion was whether the patient herself could recognize her case. But, in my opinion the most critical piece of information in determining whether a case describes oneself is the name of the treating psychiatrist who will generally be the author. Regardless of the criteria used, the author should make note of the fact that a case has been fictionalized or disguised.

When it seems likely that any reader can identify the patient from published information, and even perhaps when there seems to be little such danger, one might consider obtaining the patient's consent to publish their case. However, this raises the additional question of whether a patient can freely consent. In most situations where it is desirable to release patient information the patient benefits directly, and often the patient initiates the request. In this case however the author, publication, and perhaps the public -- not the patient -- stand to benefit. The physician asking for consent risks placing the patient in a difficult position where he might feel pressured to consent against his will, damaging the treatment relationship. If the patient did consent to publication, the author should state this fact in the article.

Relevant sections of 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.”

Section 4.11 “It is ethical to present a patient or former patient to … the news media only if the patient is fully informed of enduring loss of confidentiality, is competent, and consents in writing without coercion.”

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 of public education.”

Dr. E. Fuller Torrey Unethical?

2011-01-12T13:13:00.002-08:00

The January 10 New York Times quoted psychiatrist Torrey with regard to accused Arizona mass murderer Loughner: “I’d say the chances are 99 percent that he has schizophrenia.” (Red Flags at a College, but Tied Hands)

According to Section 7.3 of the Ethics Code of The American Psychiatric Association, "On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."

Are we to believe that Dr. Torrey conducted an examination and obtained authorization? Was he acting ethically when he made the statement (assuming that's what he actually said)?

The Sporkiatrist Tries to Do Psychotherapy

2011-01-11T17:04:00.000-08:00

More New Ways to Communicate

2011-01-06T06:55:00.000-08:00

A few weeks ago I asked, Is It Time to Give up on the Phone?, bemoaning the challenges our increasingly complicated and varied modes of communication present. Here I add alternatives that arguably increase the complexity and opportunities for dysfunction, but at the same time allow workarounds when other modalities fail.

Fax
How did I forget? I use a fax service that, for a reasonable monthly fee, assigns my own private fax number and allows me to send and receive via Internet. Received faxes appear in my email inbox as .pdf files. I can even receive a document in .pdf format, print it to a .jnt (Windows Journal) file, sign it with the stylus on my tablet pc, print back to .pdf format with CutePDF Writer (a free download), and fax it back, all without paper. One patient who had lost his phone actually did cancel his appointment via fax.

Videoconfernce
Of course videoconferencing via Skype, Google Video Chat, or other such service makes for a nice alternative to the voice only phone, but users can also send text messages. The chief limitation for me comes from the fact that I usually do not leave Skype running unless I have scheduled a patient contact. The notifications whenever someone signs distract me. Phone-based videoconferencing services like Tango depend on an operating telephone, so they do not add much.

Google Voice
This free and flexible service offers the capability of customizing an outgoing message to an identified caller. I almost tested this a couple weeks ago with the patient I mentioned in the earlier post who apparently was unable to access voicemails I had recorded. I could have recorded a message specifically for him containing more or less the same information I had left on his voicemail. The same capability used to "block" unwanted callers. Once you have identified a caller you want blocked simply so indicate through your Google Voice contacts list. The caller then encounters a message that says something to the effect that the number is no longer in service. An accommodating DEA agent actually confirmed for me that this works very nicely. (I recorded a custom outgoing message for a patient yesterday after several failed attempts to contact him by phone.)

Another more mundane feature probably available in one guise or another to many cell phone users actually allowed me to communicate with the patient mentioned above. Between Google Voice, my software-as-a-service contact management vendor, and my Android phone I am able to send unidentified callers as well as selected identify callers (usually all of my patients) directly to voicemail without ringing the phone. However, in the case of this particular patient I had not yet set his contact for immediate forwarding, so shortly before I intended to record a special outgoing message for him the phone rang identifying him, and, of all things, I actually picked up the phone and answered the old-fashioned way.

Google Wave
Google has indicated it plans to abandon the service in the near future. However, just yesterday it occurred to me that it might offer a solution to a different problem. I like to be able to hand my patients information at the end of a visit. Most commonly this would relate to a new medication I have just prescribed. However, I also like to be able to provide a business card when I refer someone to a psychotherapist or primary care physician. (I could write down the name and phone number, but the patient could never read it, and I always seem to run out of cards.) Since these kinds of information, as well as information about specific mental disorders, reside on Web pages, I would like to be able to efficiently provide the patient with a link. Google Wave appears to offer the capability of establishing a private forum for myself and the patient where I might post URL's for future reference by the patient. Since one can also leave messages or use a Wave for real-time text and even video chat, it could also serve in place of the telephone in a pinch. Furthermore, I can envision, with the patient's permission of course, inviting the patient's psychotherapist and primary care provider into the Wave.

Each of these modalities carries risks and benefits. In particular I wonder about the privacy and security of Wave. However, like with other modalities, we can always manage the content of the conversation in such a way as to maximize privacy. And as with other modalities such as e-mail, a written agreement can go a long way toward assuring that patient and physician understand rules and expectations.

After all, as far as I know it's still okay, even under HIPAA, to smile at the patient when you see him in public.

Placebo Rocks

2010-12-27T10:38:00.001-08:00

Apparently, results of a recently published study* suggest that placebo works (sometimes) even when the patient knows he's getting (only) placebo.

So...

How did they measure compliance? serum placebo levels?
Maybe patients just have to THINK you're a doctor. This could end the physician shortage.
Can we compare placebo to psychotherapy?
Does it work with kids? at what age? by proxy via parents?
Works for what? If you give a patient placebo for one illness will it cure a concurrent illness a well?
Placebo effect apparently varies, eg I recall ~60% for Germans ~30% for Brazilians. Will these distinctions hold?
Have we discovered a "psychological marker?" Response to placebo means it was "all in your head?"
Will Medco require prior authorization for placebo prescriptions?
Will we have to wait seven years for generic placebos?
Will manufacturers of placebo pay leading physicians to use their names on ghost-written publications that exaggerate benefits and play down risks?
Will physicians consider it ethical to accept pens and free meals from placebo reps?
Will placebo sold on the street be cut with other materials to increase profits for dealers?
Will Teva generic placebos work as well as or better than other generics?
Will over-the-counter placebos work as well as prescription placebos?
Will emergency rooms be flooded with placebo overdoses?
Will placebos effectively treat drug addiction? Internet addiction? Addiction addiction?
Will placebos effectively treat drug withdrawal?
Will people become addicted to placebos? (Placebo Anonymous?)
Will placebo work if you don't know you're taking it? if someone puts it in your food without your knowledge? Will placebo become the new date-rape drug?
Will there be a new spate of DUI (driving under the influence of placebo) offenses?
Will spies carry suicide placebos to use if they get caught?
Will insurgent groups use money from illicit sales of placebo to finance overthrow of regimes?
Will we need a PEA (Placebo Enforcement Administration)?
Will natural placebo be safer than synthetic placebo?
Will we be able to treat allergic reactions to placebo with another placebo?
Will placebo work better if you smoke it instead of eating it in brownies?

*Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, Kokkotou E, et al. (2010) Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome. PLoS ONE 5(12): e15591. doi:10.1371/journal.pone.0015591

Is It Time to Give up on the Phone?

2010-12-22T16:46:00.000-08:00

I wrote before that mental health professionals must not rely upon cell phones for handling emergencies. Now I wonder whether we can rely upon them even for routine communication with patients, and I have an idea that other technologies may provide a solution. In just one day, yesterday,

after I thought I left a message for a patient who wants to schedule an appointment he called again to say he knew I called but did not get a message,
after a patient failed to appear for an appointment I tried to leave a message but an automated voice told me the mailbox was full,
when I tried to call a pharmacy to order a prescription for a patient who had just left the office I got a fax handshake: beeeeeeeeeep. I left a message on the patient's relative's voice mail asking for another phone number or some other way to identify the pharmacy, but 12 hours later there was no return call.

Then there's,

Aliens abducted my cell phone.
I dropped my phone in the toilet.
My voice mail got wiped out.
They turned off my phone service because I didn't pay the bill.

I have resisted using email to communicate with patients so far, but I believe the time has come for me to stop bucking the trend. Snail mail is too slow. We can't rely on telephones, cell and otherwise. I believe the solution lies in diversity. Sure, there are problems with email. There are also problems with videoconferencing and texting. But if I fall back on one when the other fails, I dramatically increase the likelihood of success.

Here's an example. Often when attempting a video-conference contact with a patient we have audio problems. First we can use the texting capability of Skype to discuss the problem and arrive at a solution. Then we generally just pick up the phone while using Skype for the video only.

Technological complexity can cause problems, but it can also lead to solutions. Now for the hard part: getting it all set up and rewriting my patient treatment agreement to lay out all the rules. I'll need a new email address that uses the domain of my practice Web, which is on Google sites, which means I'll need a new POP account... Oy.

Who Wants to Be a Sporkiatrist?

2010-12-16T07:36:00.000-08:00

As I joined in yet another debate over the extent of the tragedy of psychiatrists who have relegated psychotherapy to non-physician professionals and restricted their practices to the now infamous "med check," an analogy occurred to me. The spork represents the combination of two perfectly good eating implements, the spoon and the fork. Each of these does its job quite well, but by combining them you can achieve one-stop-shopping, at least a small advantage.

The spork compromise, however, leaves you with an inferior spoon and an inferior fork, not to mention that you can't take along a 3-tine vs. a 4-tine fork, or a smaller or larger spoon. You are stuck with the design of the implement. If you lose the spork, you've lost both implements, while if you had brought separate tools, you might still have one. You are not likely to ever need to use a spoon and fork simultaneously, but those tines make for a leaky spoon, and their stubbiness makes for a decidedly inferior fork.

And so it goes with psychiatry. Some patients and their psychiatrists will find the combined approach suits them best. For the rest, independent professionals offer decided advantages.

More ad nauseum:

The Sporkiatrist Tries to Do Psychotherapy

The Real Reasons Psychiatrists Want to Provide Psychotherapy

Unhinging Dr. Carlat

Personality Disorders Aren't

2010-12-08T15:00:00.000-08:00

Before I comment on his article published in the New York Times, a word about psychologist Charles Zanor and how he is treated by the Times. His byline gives his name with no prefix or degree. In contrast, when he refers to John Gunderson, whom I believe has an M.D. degree, if not a few others, he writes "Dr. Gunderson." I had to Google Charles Zanor to confirm that he too has a doctorate degree, a PhD. Not only do I believe it is disrespectful of the New York Times to omit any reference to this, but I believe readers, myself included, also may want to know whether he has a doctorate degree or a lesser degree, perhaps even whether he has a PhD vs. an EdD or a PsyD.

Having said that, I disagree with much of what Dr. Zanor says in his article. He comments on another article reporting on the apparent direction of the committee addressing personality disorders for the upcoming DSM-V. He describes abandonment of the current 10 defined personality disorders in favor of a "dimensional" approach. He also describes Dr. Gunderson's opposition to this direction.

Dr. Zanor makes some good points, but he fails to adequately address two aspects of this problem. Personalities exist on a continuum of traits, and whether one's personality is labeled as disordered or not depends on where we decide to draw an arbitrary line. Under the current system a clinician makes a judgment call about the degree to which an individual's personality traits interfere with his functioning. Compare this to judging "how pregnant" a woman is. Unlike in "diagnosing" pregnancy there is no bright line.

Having decided to classify the patient as personality disordered one may then attempt to pigeonhole them in one category or another. All individuals with narcissistic (or other) personality disorder do not necessarily display the same pattern of personality traits. One individual may also display some dependent traits while another may display some obsessive compulsive traits. However, generally the narcissistic traits dominate the clinical picture. It's comparable to skin color. Nobody is really just black or white.

Dr. Zanor also errs in referring to "syndromes" of traits. Syndromes are collections of symptoms. Ill people complain of symptoms. Most people with personality traits (We all have them.), even the self-defeating ones, don't complain about them: "Help me doc. I've been feeling really generous for the last few days." or "Gee doc, I've noticed my speech is 'impressionistic and lacking in detail.' Do I need surgery?" Syndrome implies Axis I in the DSMs, at least from III on.

So despite what Dr. Gunderson says, a dimensional approach is more intellectually honest. And what difference does it make anyway? Nobody really believes any medication effectively treats a personality disorder. Imagine the FDA approving moxapoxatoxatine for the treatment of Avoidant Personality Disorder. Most don't believe psychotherapy works very well either. I suspect only the psychoanalysts care, and they probably approach every case the same way regardless.

Some addiction psychiatrist once said AA was the best treatment for personality disorder, and I tend to believe it, but you can bet that AA doesn't care how you classify them either.

Suicide by Any Other Name

2010-12-02T08:32:00.000-08:00

The thought of suicide makes mental health professionals even more uncomfortable than it does lay people, probably because we associate the act with personal failure, having bought into the myth that we can and should somehow control this tragic behavior in others, that we are responsible. When you hear the word today you will most likely think of Muslim extremists on the other side of the world or mental illness in your hometown, yet if you consider the films listed on this suicide page you will be hard pressed to find more than a few that depict either context. And unlike the self-immolation practiced by the Vietnames Buddhist monk as filmed in Mondo Cane 2, Muslim extremists generally murder others in the bargain.

Suicide: Abstract, technical and clinical, the term suicide, like the term homicide, is a euphemism which distances us from the stark gravity and emotional impact of the act.

Committed Suicide: When we say "committed suicide" we imply killing oneself constitutes a sin or crime, stigmatizing the act, the person who acts, and mental illness, if it seems likely to have played a role. We should avoid this term.

Died by Suicide: If I play linguist it seems to me that the preposition "by" here requires an object that implies some kind of method or action. For example, died by drowning or died by gunshot. Similarly one cannot say "died of suicide." Use of the word "of" requires a disease as in "died of cancer" or "died of malaria." Use of the word "from" might work for either as in "died from heat stroke" or "died from a fall." An actor might also follow the word by, as in suicide by cop. But is that really suicide?

Ultimately, however, I believe redundancy prevents "died by suicide" from working: the word suicide already includes and implies death.

Suicided: Technically the word may be used as a verb, but I find this awkward. Imagine saying, "She homicided the man accidentally." Perhaps the fact that homicide requires a specified object while suicide implies the object explains the difference. One cannot suicide anyone else, but homicide requires a victim. Which brings us to:

Victim of Suicide: Somehow "victim of homicide" is more comfortable, but constructions starting with "victim of his own" occur commonly, in keeping with our all too frequent self-defeating behaviors. Still, we think of victims as passive, and the idea of killing oneself implies intent.

Completed Suicide: This term belongs only in discussions contrasting it with "attempted" suicide. Otherwise the word "completed" is redundant. Imagine a "partial" suicide. Similarly:

Successful Suicide: Is this not a contradiction in terms? We generally view suicide as a failure, perhaps the ultimate failure, but of course the word "success" refers only to the act itself.

End His (Own) Life: Another euphemism, like:

End Her Life by Suicide: This construction suffers from the same problems as died by suicide, although perhaps somewhat less redundant. However, it does imply active intent.

End It All: Even more of a euphemism.

Kill Himself: My favorite, this phrase is stark and direct. It pulls no punches.

Take Your (Own) Life: Introduces the idea of taking something away, but too often the life is taken away from friends and family. Although one can certainly take someone else's life, even omitting the word "own," in the absence of another specified actor we generally understand this to imply suicide.

Die By Your Own Hand: Quaint.

Suicide by any other name is still suicide.

DEA Buprenorphine Audit Animated

2010-11-23T09:40:00.000-08:00

Digital Diagnosis Duo for DSM

2010-11-18T09:12:00.000-08:00

I have found that turning ideas upside down often leads to truth. An example from my personal experience follows while another pokes fun at those who thrive (and even profit from) labeling any activity they deem excessive an addiction, then claim to offer treatment for it. (Nothing here should be interpreted as making fun of anyone who suffers from any psychiatric or substance use disorder or any professional or program intending to help such individuals.)

Digital Gaming Aversion Disorder (DGAD)

About two years ago, while sitting at my desk, I realized that there was really nothing I wanted to do. A friend had been playing solitaire on her computer, and that was all it took to get me going. Within a few days I was hooked. Almost every time I got done with whatever computer task I had been engaged in, I started playing solitaire. After a couple weeks I realized my skills were improving gradually. I began to develop winning strategies. Maybe I wasn't addicted yet, but I certainly might have been headed in that direction.

Then one day I noticed that some of the pleasure had gone. I almost had to force myself to finish a game. Next time I thought about starting another game I simply could not do it. I have not played solitaire since. When I see my friends playing, the screen looks totally two dimensional, unlike previously when it was as though I could see into the game. I cannot even imagine myself starting a game. The thought of how it works, the different suits, the different colors, the different numbers, all are blocked from my mind.

To be honest I cannot say this has interfered substantially with my social or occupational functioning. I cannot say that I am particularly distressed about this aversion to solitaire. However, should I want treatment, I have two approaches to propose, both probably requiring double blind studies to prove their effectiveness.

Psychotherapy of Digital Gaming Aversion Disorder

Cognitive behavior therapy will be the first line psychotherapy for this disorder. I believe a sufficient and appropriate reward will quickly overcome the aversion. I suggest rewarding the patient with $1000 for each game played to conclusion will rapidly reverse the aversion. I of course expect this to be covered by medical insurance.

Pharmacotherapy Of Digital Gaming Aversion Disorder

I believe a similar approach to that proposed for psychotherapy will lead to rapid resolution of this disorder using cocaine as the first line agent. A small dose after completing each solitaire game should lead to rapid resolution.

Digital Media Avoidance Disorder (DMAD)

For years now people have admonished those who, in their minds, use computers and/or the Internet "too much," calling these behaviors, like almost any other behavior they can label excessive, "addiction." It occurs to me, however, that those who engage in this "addiction addiction" simply want to deflect attention from their own dysfunction. This clever but pathological strategy, based on severe denial, has enabled them to avoid needed treatment, often for many years, for the condition I address below.

Today we must all face the fact that we can only experience true reality through digital media, using devices like computers, smart phones, and other devices, regularly, if not continually, connected to the Internet. Avoidance of this reality can be compared to intoxication with drugs or alcohol, which we all know provides an escape for the user who wants to avoid the realities of day-to-day life.

To address this problem first we must confront the denial, rejecting the notion that we can experience reality without digital media. This dangerous idea will certainly lead to impairment of social and occupational functioning and probably distress as well. In particular, avoidance of social media can lead to digital social isolation. A disturbing percentage of the population may have never communicated with another person via email or texting with resulting alienation from digitally connected friends and family!

Treatment of Digital Media Avoidance Disorder

Due to its similarity to chemical dependence, treatment requires admission to inpatient rehabilitation where a holistic approach involving staff of numerous disciplines will immerse the patient in (digital) reality with gradual elimination of escape into non-digital media euphoria. Cell phones with non-removable ear buds will start the detoxification process. Only in the first hours will staff allow patients gradually diminishing access to analogue devices such as harmonicas, nose whistles, and, for more severe cases, ukuleles to ease the transition. At first specially trained staff even engage in face to face conversations with them. Motivated patients will work the (binary) 1100 step program. They will gradually learn that ordinary feelings associated with life in the real digital world are normal and they they can tolerate them or even to appreciate them, that feeling them affirms life. They will learn to turn them over to Google (as they know it, their higher power). Patients who can tolerate tweeting and blogging while simultaneously listening to streamed audio, playing computer games and shopping on ebay will participate in a ritual upload to YouTube of a digital video showing their dysfunctional pre-digital escapest functioning followed by scenes showing them leading a fully sober digital life one virtual day at a time. They are ready for discharge. Most will continue working the binary 1100 steps in video-conference meetings for years after discharge, starting with 1001010 meetings in 1001010 days. After working the program for a year or more, some individuals can play World of Warcraft non-stop for 11000 hours without face-to-face contact with another human. Rarely do such individuals relapse.

Short Psychotherapy

2010-11-11T06:53:00.000-08:00

No, not "short term," short, as in short sessions.

Who says psychotherapy requires 45-50 minute sessions and a formal commitment? Although I cannot claim to know the history I suspect the almost-an-hour session originated with psychoanalysis, and the 45' session allowed psychotherapists to pack more patients into a day, and make more money. Modern psychiatric visits started out as psychotherapy sessions. The medication management piece snuck in slowly and now threatens to take over entirely. Despite the numerous advantages of independent provision of medication management and formal psychotherapy a compromise model offers a few advantages that might quiet some of its critics.

Since I ostensibly stopped offering psychotherapy I have noticed that the patient and myself often wander off the subjects of symptoms, medications and side effects, and almost as often I yield to the temptation to offer a systemic intervention, even when I know the patient is "in" psychotherapy in the more formal sense with a non-physician professional.

When I reflect, I realize this is nothing new. My family systems perspective lends itself to this less rigid approach to psychotherapy. I have done this all along. There is no real contract. Patients appreciate it, possibly partly because it's one-stop shopping and I charge no more for the added time.

There's always that dilemma over whether to charge a flat fee whether the visit lasts only five minutes or requires twenty five. The payer, whether a third party or the patient herself, likes to know in advance how much any visit will cost. I don't like to have to worry about whether the patient can afford an extra ten minutes with me. Besides, my fee always covers much more than actual time with the patient: office rent, staff, billing services, postage, telephone calls, malpractice insurance, contacts with other treating professionals, writing medical records, copying medical records, reading some other provider's medical records, ordering prescriptions, etc, ad infinitum.

CBT, which can be directed at specific symptoms and disorders also may lend itself to this model. Read High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide or the article in the October, 2010 issue of Psychiatric Times.

Pitfalls do exist:

The psychiatrist risks working at cross purposes to the independent psychotherapist treating the patient formally.
Without a contract patient expectations may exceed reality.
It's a lot easier to say "time's up" when you both see the minute hand on ten. In this model you decide when to stop based on when you want to go home or how many patients are in the waiting room. There's no entitlement to the full 50'.
Some patients may not feel permission to bring up a matter they want help with.
That matter the patient wants your help with might require referral for formal psychotherapy. But you can figure that out with the patient and steer them in the right direction.
Some interventions benefit from follow-up within a few weeks, but for medically stable patients the next regularly scheduled appointment may be months away.

The notion that psychotherapy must be an all or nothing proposition may prevent you from providing the best treatment to your patient. If you the psychiatrist include a psychotherapy intervention now and then, you may increase efficiency, cost-effectiveness, and your chances of success.

More Harassment from DEA

2010-11-03T14:49:00.000-07:00

A few days after the audit I started getting voice mails (2) from a DEA auditor asking when I would like to meet to go over the "findings" growing out of The Audit. I ignored them and set Google Voice to block all numbers associated with the local DEA office. The auditor emailed me (He told me my number had been disconnected. Thanks for confirming the call blocking feature works!), this time asking if we could meet the next day (10.29). I faxed a terse letter to his boss that morning (last Friday) telling him he could send any comments or questions in writing.

That same Friday morning, as I waited for a new patient to finish her paperwork, my office manager informed me the auditor above and another male from DEA had just appeared in the waiting room.(They did not present a warrant.) Furious at this presumptuous invasion of my office I called the Seattle field office. Apparently they got the message that he was wasting his time (and our tax money). After they received a phone call they left.

I filed a formal complaint with the US Attorney. I attempted to have them charged with criminal trespass by local police, but the police refused to interfere with an ongoing "investigation." I have contacted the ACLU. I figure at a minimum DEA has violated my right to freedom from unreasonable search and seizure and the privacy rights of both myself and my patients, not to mention the patients of my office mates.

I don't recall that it was a requirement of DEA registration that I allow these thugs unrestricted access to my office, which I regard as my castle. If that's the case they can so inform me, and I will decide whether I might prefer to continue my practice without DEA registration. (Other than buprenorphine I only prescribe controlled substances to 4 patients, one with schizophrenia who takes clonazepam to prevent seizures related to clozapine, a couple of patients with ADD who take methylphenidate, and one buprenorphine patient who takes pregabalin (Has anyone heard of addiction/abuse associated with that drug?). Partly because most of my patients are usually recovering addicts/alcoholics I have convinced myself that I can handle almost any case without controlled substances. Hey, it could even help me market my practice.

I'm fed up with the harassment I apparently must endure to prescribe buprenorphine, and have allowed my buprenorphine practice to shrink since early this year anyway. I could retire. I would have time to picket in front of the local DEA office. At least one other physician I no of has said he will stop prescribing the drug because of DEA harassment.

My plan if another auditor shows up in my office without a warrant: Depending on whether patients are present I will call 911 or ignore them and maybe leave. I don't know whether my office mates have enough nerve to demand they leave if they present when I am not there.

When I spoke to the auditor at the field office while the two auditors were in my office I made her aware that I expect DEA to communicate with me in writing. She told me that's not the way they do things. Fine. If DEA wants to have a meeting, "their way," they can meet without me.

Five days have passed since I faxed my request for the findings from my audit in writing. So far I have received nothing, but this makes the third time DEA has ignored my letters. These are public servants?

Who's the Doctor?

2010-10-28T06:59:00.000-07:00

In my post Independent Treatment: The Whole Truth I believe I made it clear that I like the idea of independent providers for treatment of psychiatric disorders, a psychiatrist to prescribe medication, rTMS, ECT or whatever, and a non-physician psychotherapist to provide psychotherapy. I believe we can overcome the challenges posed, one of which arises when the psychotherapist advises the patient about medication.

I admit to irritation when my patient tells me her psychotherapist told her she should ask me about lamotrigine, or her chemical dependency counselor told her the acamprosate I prescribed for alcoholism really misses the mark for her particular drinking pattern. But I also must admit to considerably greater irritation when I have never worked with the psychotherapist before. If I know the psychotherapist and am familiar with his work, it just doesn't bother me as much.

Several key facts impact these situations. Psychotherapists may not be qualified to recommend or prescribe medications, but every now and then one of them has an idea that works, and I cannot claim to be perfect in my knowledge of psycho-pharmacology. Bottom line, if the patient gets better I'm glad for the help. Psychotherapists often express surprise that I, a physician, bother to contact them to coordinate treatment. This model does not require weekly or even monthly email or phone contact between psychiatrist and psychotherapist, but, especially when the two professionals do not know each other, either should initiate contact with the other on learning of the other's involvement in the case, and each should always respond promptly to attempts to contact the other. Without such open communication you cannot provide the best care to your patient.

Still, I wonder how a patient feels when his psychotherapist suggest, "Ask Moviedoc about clonazepam." I imagine my patient must wonder what's wrong with me if I didn't think of that, or what's wrong with the psychotherapist when I tell the patient what a horrible choice that would be and why. I believe we would all do better if the psychotherapist contacted me directly with the suggestion or question. I would also like to think I might not be too proud to give the psychotherapist credit for the idea if I endorse it and bring it up with the patient.

Usually such discussions between myself and the psychotherapist extend beyond a simple suggestion of a drug and thus likely lead to better treatment overall. Sometimes what's behind the suggestion of a drug is a symptom of which I was not aware, either because the patient didn't tell me, or because I didn't ask.

The independent practitioner model works, but we must do it right by working as a team. If you're a psychiatrist, always respond promptly when the psychotherapist tries to reach you about a patient. If you're a non-physician psychotherapist, consider contacting the physician directly about your idea of that medication you think might help the patient before you mention it to the patient. And if you don't get a response, consider suggesting the patient find another psychiatrist.

The Audit

2010-10-20T19:01:00.000-07:00

The big audit. At last.

In my last post I told you I expected DEA agents to return, "Administrative Warrant" in hand, to conduct the obligatory audit of my buprenorphine practice. The entourage did arrive on October 14, conducted the audit, and I'm still a free man. Nobody got hurt.

Let me recap: When I applied for the special DEA number that allows me to treat opiate addiction with buprenorphine it was clear that I might have to submit to audit of my prescribing records. However, only about a year ago I discovered DEA had embarked on a project of auditing all such physicians. I only objected to a few aspects of the plan. DEA law enforcement agents, the sort that might carry badges and guns, would conduct the audits. This I could accept, but what really galled me was DEA's refusal to schedule the audits. I guess they thought they might catch me red-handed doing something illegal. I expected this to disrupt my practice unnecessarily, and I began to protest. Professional associations such as the American Psychiatric Association, the American Association of Addiction Psychiatry, and the American Society of Addiction Medicine, to my disappointment, focused their efforts on assisting physicians in complying rather than assisting us in assuring that our rights and those of our patients would not be violated. We all learned early on to expect agents to present physicians with Form 82 on arrival. This form permits agents to enter the office and conduct the audit. We were warned that if we refused to sign Form 82 agents would return with an "Administrative Warrant." (Yikes!)

Warrants, even the administrative kind, sound pretty bad, like something to be avoided at all costs, something that will brand you a criminal for the rest of your life. But it seemed possible there might exist some advantage in going this route, and that has turned out to be true. I asked DEA to provide me with a copy of such a warrant and detailed description of how they conduct such an audit. The description proved vacuous and useless, and DEA refused to send me a copy. I figured I would have to get it the hard way.

After agents Sanchez and Carter left my office on October 8 I wondered how long I would have to wait for them to return with the dreaded administrative warrant I had the audacity to demand from them, but I decided to use the time to prepare. I would not have wanted to do the audit on the 8th anyway. Although my office manager was there to help, it had been a busy morning, and I was running behind. The buprenorphine prescription logs I wanted to show the auditors still needed hours of work to remove patient names, so that night I copied all buprenorphine prescription records of patients I deemed active going back the requisite 90 days to a single spread sheet on Google docs. Then it was just a matter of keeping it up-to-date.

When I walked back into my waiting room October 14 after lunch and a haircut, a casually dressed man introduced himself, handed me my warrant (the moment I had been waiting for -- I wonder how long he had been waiting.), and told me to read it over and get settled while he summoned the rest of the troops. He staked out the waiting room for the rest of the audit. Agent Carter took charge. A big guy with a couple suitcases turned out to be their computer "expert" (his description). There was an African-American woman who didn't do much. And remember the attractive woman I mentioned from my own unannounced visit to the DEA field office? She's their secret weapon. I call her Ms. Waterboard. She can interrogate me any day. Anytime she wants to. I'll confess to anything. Making obvious assumptions about everyone's sexual orientation and marital status, if you're 10-20 years younger than me, and have not already found the woman of your dreams (like I have), and practice in the area covered by the Seattle field office, do whatever it takes to get interrogated by Ms. Waterboard. And she loves dogs, so arrange to have one in your office for the audit.

Just to speculate on DEA strategy: Have enough agents to keep the doc so busy that he won't really notice when they do something they probably shouldn't or that he might say something he might have preferred to avoid saying. I let down my guard with the interrogation. I can only blame Ms. Waterboard so far. I did confront the agents with the fact that there was no mention on the warrant of any interrogation. However, it seems fair to me that they should be able to ask me questions directly related to my buprenorphine records.

I do believe DEA exceeded the appropriate boundaries in interrogating me. Agent Carter asked me my observations about the relative numbers of heroin addicts versus pharmaceutical opiate addicts presenting for treatment. I had no idea. I was also asked how many active patients I was currently treating. When I asked for a definition of "active" none was forthcoming. When I made a wise crack about my experience testifying in court where a definition would be damanded, the African-American woman reminded me that she knew all about my background. So I hedged and estimated between 30 and 40 patients without a real definition. Ms. Waterboard asked me about my office hours. Rather than getting into a discussion of the fact that I don't really have set office hours, I evaded the question by reporting the days and times when my office manager is usually present. No one seemed to notice that I didn't really answer the question. (This often works in court, too, by the way.)

The auditors presented me with a single page printout of prescriptions from a local pharmacy, citing it as evidence that I stocked buprenorphine in my office, which I never have. When I explained that these were simply prescriptions picked up by patients before coming to the office to have their induction the auditors made a few phone calls and dropped the issue.

The real fun was with my log. The DEA computer "expert" seemed befuddled by the notion that my log resided on a server somewhere in cyberspace. The warrant simply did not contain any language to allow for seizure of such an abstract entity. I offered to print a copy, but I think he really wanted to snoop around in my hard drive. It appeared as though he had never seen a tablet PC before. He opened a case containing an impressive array of hard drives, and connected one to a USB port, but ultimately was unable to figure out how to download the elusive file. I offered to help. He accepted, and thus began the most time-consuming part of the audit. We are dealing with computers here after all. Unfortunately, I had not yet installed Adobe Acrobat Reader on my tablet since installing Windows 7. After 15 or 20 minutes I was able to download a copy of the file to the hard drive so he could make a copy, and I was also able to print a copy on paper.

Of course the whole notion of "seizing" evidence, whether on a computer or elsewhere, implies that the evidence will be incriminating. In this situation, however, the only evidence would likely exonerate me.

Early in the audit one of the agents confronted me that this all could have been so much easier had I just cooperated by signing Form 82 the week before. Although I will never be sure, I suspect they meant to imply that they subjected me to a more intimidating or disruptive audit to punish me for forcing them to get a warrant. In fact, though, because I had time to prepare, I believe things went more smoothly, and the timing disrupted my practice much less. Only one patient appeared in the waiting room while they were doing their dirty work, and he complimented me on my handling of the situation. (One of the agents seemed to be holding the door to the waiting room open during most of the audit.)

How would I handle the audit differently if I could do it again? First, I would not have volunteered access to my computer. As far as I can tell the warrant does not require me to allow DEA to commandeer my computer for its own purposes. Instead, I would have printed out a fresh copy of the log every day so I could simply present it to the auditors. I might also refuse to answer questions unrelated to my buprenorphine practice. I would really like to know whether DEA would revoke my license just because I refuse to confabulate office hours that do not exist.

What else did the auditors do wrong? When I did resist answering questions, citing absence of reference to interrogation in the warrant, I seem to recall at least a veiled threat of admonishment or revocation of my DEA number. When I sarcastically suggested that that might not be such a bad thing, agent Carter, a little too eagerly, offered to relieve me of the burden of the audit if I would surrender my special number. This same interaction has played out before around these audits elsewhere in the US, and I have seen at least one letter from a DEA field office claiming to deny any effort to discourage physicians from treating addicts with buprenorphine. Agent Carter's offer would seem to betray DEA's real position: By treating opiate addicts we threaten DEA job security. I believe the agancy would be very happy to have us abandon our efforts.

DEA also needs to get up to speed with computers and the Internet. I had provided agent Carter with access to my log at Google docs months ago. Let's compare the costs of two or more agents showing up only to be told they need to return with the warrant and five agents showing up the next week unnecessarily versus the cost of going online and peeking at my log at your leisure while sitting in your office downtown. Think about this next time you pay federal income tax. Maybe the auditors thought they would find a meth lab in my office. If so, they did not conduct a very thorough search. The whole exercise was a waste.

If you prescribe buprenorphine to treat drug addiction, I strongly suggest you place your prescribing log online. If DEA has not yet audited your practice, plan to refuse to sign Form 82 when agents arrive unless you are completely prepared, and they have arrived at a convenient time for your office. If we all force them to obtain warrants, maybe they will back down and start scheduling.

I cannot speak from experience since I have never wanted to stock any controlled substance in my office. When the opportunity presented itself for me to stock buprenorphine, I declined. I suspect those of you who do stock that drug or others will find the audit considerably more difficult regardless of whether you sign Form 82.

I initiated a moratorium on accepting new buprenorphine patients almost a year ago with the idea that I would end the moratorium after my audit was completed. I do plan to accept a few new patients for buprenorphine induction and maintenance, but before I will want to accept significant numbers of new patients (like anywhere near my limit of 100) I would like the United States government to deal with its ambivalence. All the agencies need to get together and decide whether they want us to treat addicts or not. If not, I certainly have better things to do with my time than subject myself to this kind of harassment.

DEA can chalk up another victory in the war on drug treatment.

The saga continues.

DEA Suboxone Audit: The Wait is Finally Over. Or Is It?

2010-10-09T10:53:00.000-07:00

This story started for me almost a year ago: DEA On-Site Investigation of Suboxone Prescribing Physicians

Sometime late last year I wrote a letter to the Seattle field office asking to schedule my audit as soon as possible. I asked DEA to provide a detailed description of how they carry out the audit after serving an "administrative warrant" on a physician who refuses to sign Form 82, giving permission for the audit. After several months without a response it occurred to me to give the DEA a taste of their (it's?) own medicine. I had to be in the city early for an orchestra rehearsal anyway, so I made my own unannounced visit to the Seattle field office last spring.

When I entered the office I explained to the polite guard that I wanted to hand deliver a letter and that I wanted to dispose of some unused samples of modafinil I brought with me. He asked me whether I was carrying any explosive devices. Fortunately that day I had left my C-4, dynamite, and IED's at home. He asked whether I had an appointment. The answer of course was no. He asked whether the agents might know who I was. The answer of course was yes. Sitting in the waiting room I was struck by a wall covered by portraits of DEA agents who lost their lives in the line of duty. I trust none of the deaths occurred while auditing physicians trying to treat patients suffering from addictive diseases.

After a short wait a very attractive young woman entered the waiting room and asked me whether I might wait for agent Carter since chief agent Thomas was on vacation. When I asked agent Carter to please proceed with my audit, she explained this would not be possible and told me how to dispose of my drug samples.

Once more there was no response to my letter.

I was pleasantly surprised when, on September 29, agent Sanchez left a message on my voicemail asking me to call him back on his cell phone. I in turn left a message on his voicemail suggesting when he might reach a person by dialing my office number, but I did not hear from him until Friday, October 8. I was standing at the reception window talking to my office manager and agents Sanchez and Carter entered the waiting room, introduced themselves, and told us they were ready to perform my audit. I asked them whether they had a warrant. They said no. (If only I could have obtained a photograph of the look on their faces.) I explained to them that I wanted to know what would happen during an audit performed under administrative warrant. They asked me if I had not received a letter from the diversion office in Springfield. I explained that the letter I had received was woefully inadequate. I asked if they wanted to schedule an audit later, but they repeated the mantra that that doesn't fit with their policy. I pointed out that I had shared my buprenorphine prescribing log, which resides in Google Docs, with Agent Carter. They told me they are not allowed to access the Internet. They left. I completely forgot to ask whether they were carrying explosives.

So I'm back to waiting and wondering what will happen next. It would have been so much easier for everyone concerned if they had only honored my request for a detailed explanation of how an audit is conducted under administrative warrant. But I hope without too much further delay to be able to provide a first-hand description.

As a taxpayer I'm really OK with DEA agents having access to the Internet. Maybe we could arrange for the FBI to monitor their use. Or maybe we could establish another agency. We could subject them to unannounced visits to audit their browser histories.

Next: The Audit

APA vs. APA

2010-10-06T22:05:00.000-07:00

Psychology vs. Psychiatry: What's the Difference, and Which Is Better?

Starts out, "Psychologists and psychiatrists tend to hate each other."

Metaphor or joke? Did this guy talk to even one representative of either profession? Is this just a wild extrapolation from his gross misinterpretation of the new APsychiatricA Guideline? Regardless, it's an opportunity for me and others to set the record straight.

Psychologists and psychiatrists not only should not, but do not, hate each other. In fact as fewer psychiatrists do psychotherapy we tend to refer our patients to psychologists for psychotherapy more than ever. Which reminds me of the biggest insult in this article, namely that the author seems to completely ignore the most numerous categories of psychotherapists and counselors, those who are neither psychologist nor psychiatrist, and who are, in my experience, often equally respected for their skills.

There is no "idea of psychiatry." Psychiatry is a profession, a medical subspecialty. Psychology is a science. Clinical psychology is another profession. The first "chemical" treatment used on psychiatric patients was probably a group of drugs called mercurials which effectively treated neurosyphilis, leaving mostly patients with bipolar disorder and schizophrenia in the asylums. Morphine and barbiturates may have been the only chemicals available to help them at that time, and those drugs simply sedated them.

Contrary to what the author would have us believe, after Sigmund Freud (a neurologist) developed his very psychological theory of neurosis, psychiatry began to embrace talk therapy in the form of psychoanalysis, and circa the 1970's I believe psychologists had to sue to gain acceptance to psychoanalytic institutes that only admitted physicians. (I wonder whether the author realizes that the picture that accompanies the article portrays a "psychiatrist" -- not a psychologist -- psychoanalyzing a patient on a couch.)

So he thinks the Guideline "denigrates" CBT. Perhaps this best illustrates that such guidelines are just that, and are intended for trained professionals, not amateurs hoping to conjure up conflict where none exists. The real problem is that too many psychiatrists cling to psychoanalytic/psycho-dynamic methods. Those of us who restrict our practices to prescribing chemicals, however, regularly refer to psychologists, usually the real CBT experts.

The author accuses our leaders of acting like children for not relinquishing the acronyms APA, one organization to the other. Surely this must lead to confusion from time to time, but I have been blissfully unaware that anyone on either side ever wanted the other to change it's name. I wonder if the author would think the same of two SCCA's, the Seattle Cancer Care Alliance and the Sports Car Club of America.

I do agree with one statement: Combining medication with the right type of psychotherapy often works better than either alone. But "national guidelines that will shape the treatment of millions?" Most psychiatrists will not even read them, and those who do will probably keep practicing as they always have.

Which is better? Neither. Apples and oranges. They are just different.

I only have one (more) comment. Almost any psychologist or other psychotherapist could probably help John Cloud get in touch with reality and let go of his hatred for psychiatry.

Therapists on a Plane

2010-09-28T07:59:00.000-07:00

A triple coincidence: I am replying to the email of a family psychotherapist friend with whom I used to share an office. She told me she sat next to John Gottman on the way home from attending the recent AAMFT meeting in Atlanta. I told her of my similar experience seated next to UW psychiatry professor David Avery, MD who was flying home to Seattle after this spring's APA meeting. And my partner shows me the article "Cornered: Therapists on Planes" in this morning's New York Times.

First, I would like to point out that the author, Liz Galst, undoubtedly used that term I dislike so much, "therapist," as shorthand for psychotherapist. Amazing how some seem to forget the existence of all the other kinds of therapists. But, too, this betrays the misguided popular perception of all mental health professionals as givers of "advice," professionals with whom you just talk to feel better, rather than people who treat mental illness or family dysfunction.

Kudos to Galst for sharing with readers the very legitimate concern of Rhode Island psychiatrist Scott Haltzman, MD, that seemingly casual interactions with a fellow traveler might lead to a lawsuit. She found an opponent to this notion in Gregg Bloche, MD who labels this an "urban myth." I hope he's right, but judges and juries -- not authors -- decide such matters. The notion that the patient's perception of the doctor-patient relationship rules still holds sway in court to the best of my knowledge.

Guest Blog: Dr. Douglas Landy on the Crisis in Inpatient Psychiatry

2010-09-22T13:15:00.000-07:00

Psychiatrist Douglas Landy, MD, generously permitted me to publish his thoughts about the current crisis in inpatient psychiatry, which I suspect are not unique to New York State [links courtesy of BehaveNet]:

It seems to me that over the years the face of inpatient psychiatry has been changing. It looks like we are seeing progressively sicker patients, and violence is more common than used to be the case. These factoids are supported by statistics throughout New York State (length of stay, violence, disability secondary to violence, etc). It seems to me that a number of factors have brought this about:

1. More severe psychopathology is tolerated in outpatients. Many of the people we see on an outpatient basis, at least in mental health clinics, would have been hospitalized when I was a resident, but are now more frequently treated on an outpatient basis rather than on an inpatient basis.
2. Many of the people who (with the above taken into consideration) are treated on an inpatient basis are harder to place owing to their penchant for inappropriate if not frightening behavior, making them personae non gratae for most placements.
3. Many of the people that society asks us to care for are more emotional misfits (who have been acculturated to using violence as a means of expressing dominance, social pecking order, and so forth) rather than having a mental illness such as bipolar disorder, etc. An associated problem is our societal tendency to “pathologize” behaviors that the majority culture of the location dislikes or fears. Another associated problem is our profession’s wholesale trade of contextual diagnosis for single symptom diagnosis (i.e., racing thoughts = bipolar disorder, end of discussion). As a result, we are in part contributing to this problem by agreeing that someone who behaves in a way that is not acceptable to the majority culture is mentally ill; and that implies we can treat that mental illness; and so forth. This is, of course, an entirely separate controversy, but you get the idea.
4. Because our inpatient models are based on context-based diagnosis driving treatment – as opposed to mere symptom-suppression treatment along with (generally fruitless) attempts to use a model for a problem that is generally not amenable to the inpatient model of treatment (ie, many of the people referred to in paragraph 3) – we fail spectacularly at accomplishing any kind of effective inpatient treatment in this population.
5. As a result, the inability to place this group, along with error-driven treatment, results in many people being more dissatisfied, and that does not mean the patients alone. Staff gets overwhelmed by this as well.
6. Staff dissatisfaction and hopelessness (as well as fear) leads to petty tyranny or abandonment of responsibility, either of which leave the situation rife with the potential for violence and loss of the therapeutic milieu owing to patient “take-over.” This is exacerbated by continually decreasing money for mental health resulting in lowering staffing to unsafe levels, while bloating administration to ensure that the paperwork is all in order for our “friends” at the regulatory agencies.

My own conclusion is that we need to do a couple of things, some of which are clearly easier than others.
1. We need to have adequate staffing.
PROBLEM: Costs money
2. We need to help society understand that:
  a. Not all annoying behaviors, even those that are violent, are driven by mental illness. Even the presence of mental illness does not ipso facto make it the cause of the unwanted behavior.
  b. With mental illness in general (such as the major mood and thought disorders) and the “softer” diagnoses of personality disorders, impulse control disorders, etc, treatment is not always successful. In such a case the questions for society are:
   i. Do we block up the hospital system with people who don’t need to be/shouldn’t be hospitalized?
   ii. In the case of a criminal act, should such a person be restored to health and then sent back to prison for the remainder of their sentence (ie, guilty but mentally ill)?
   iii. What should we do with dangerous people who don’t, won’t or can’t respond to treatment and victimize peers and staff in the hospital system where their current lack of criminal behavior precludes incarceration? Why should the mental health system be responsible for this group (I suppose that you can correctly infer that I object vehemently to the idea that sex offenders who have finished their criminal sentence can be sent to a psychiatric hospital for an indefinite period of time afterwards).
  c. PROBLEM: It’s like changing the course of a river. It can be done but it takes considerable time, energy, and a lot of money.
3. We need as a profession to be clearer about diagnosis, remembering that symptoms are contextual and not independent phenomena. The current craze (and I use that word pointedly) for single-symptom diagnosis is merely a rationalization to use medications that perhaps needn’t or shouldn’t be used, considering the ramifications of so doing. Additionally, the current diagnostic patterns make us all look like fools. I’m sure that many of have heard (or even said) about a colleague something like, “It’s curious how all his/her patients are Bipolar.”

PROBLEM: It is not clear if the pharmaceutical companies promote this kind of diagnosis/treatment strategy because it’s good for the bottom line, or if their speakers promote this (I can’t say more for fear of libel) to boost their own earnings from the companies (doubtless in which they have already invested as well). Additionally, we tend as a profession to use medications more than non-pharmacological treatment options, and as a result think more in that way. I would love to see psychiatric training spend an additional year or so on how effectively to do combination treatment – psychotherapy and psychopharmacology together, which is something you don’t see any more.

Douglas A. Landy, MD
Chief of Psychiatry
Rochester Psychiatric Center

The opinions expressed above are those of Dr. Landy, and do not necessarily reflect the mission or opinions of BehaveNet, Rochester Psychiatric Center or the New York State Office of Mental Health.

Washington's Narcotic Analgesic Prescribing Rules

2010-09-16T07:09:00.000-07:00

The State of Washington, plagued by record opiate overdose deaths, drew national attention recently with the announcement of an initiative to address the problem by formulating guidelines for physicians treating pain. I offer my comments on the August 26, 2010 draft proposed rules submitted to the Pain Management Workgroup by the Medical Quality Assurance Commission's subcommittee on pain management as an outsider with no direct stake since I do not treat pain.

In fairness this is only a draft, so perhaps we can excuse the duplications, typos, and misplaced items. But better writing will not make for better policy, nor will more documentation by doctors, which seems to be the goal. Overall the effort is misguided and constitutes a waste of state funds during a budget crisis.

Risk Factors
One rule requires the provider to "screen for risk" by looking for history of addiction, "aberrant behavior and underlying psychiatric conditions." Aberrant behavior could cover a lot of territory. Without a definition this requirement fails to advance the cause. I find the term "underlying" psychiatric condition offensive and stigmatizing. Absent evidence that any psychiatric condition causes chronic pain or addiction the committee should substitute co-morbid or coexisting.

Informed Consent
Another rule addresses informed consent. This rule states that the provider should discuss with the patient the "risks and benefits of the use of controlled substances." Providers should probably discuss the risks and benefits of any treatment, certainly any drug, even if it is not a controlled substance.

One Provider, One Pharmacy
This rule goes on to suggest the patient should "receive prescriptions from one provider and one pharmacy" if possible, a nice idea but hardly within the control of the prescriber. I am not sure I see the connection to informed consent. Another loosely related rule suggests that the provider should document indication for opioid usage on the prescription. Perhaps this is so the pharmacist will know that the patient wants that OxyContin for pain rather than to get high. It will not prevent overdose deaths.

Patient Responsibility
Also included under this section is the suggestion of use of a written agreement "outlining patient responsibilities." I welcome this wording as in medicine in general I believe there is far too little focus on the responsibilities of the patient and too much on the responsibilities of the physician. Ultimately overdose death results when a patient takes too much drug on a single occasion. The physician cannot prevent such an occurrence. However, the committee could do us all a great service by providing at least a prototype agreement. Such agreements often fail to live up to their promise and frequently add to confusion. For example, the committee suggests requiring the patient to agree to "medication levels screening when requested." This may work well if the sample is collected when the patient is already in the office, but if the patient must provide a sample when ordered to do so at a random time between office visits, the physician must assume the role of arbiter when the patient delays appearance at the lab or office, forced to make judgments about the validity of the excuse. This is not an appropriate role for a physician.

The committee suggests a requirement that the patient provide consent to allow coordination of treatment between the prescribing physician and local emergency departments and pharmacies. Such authorizations, however, expire in 90 days in the state of Washington, so when such communication is required the physician must have access to the date of the authorization in order to confirm its continued validity in order for this provision to work. This problem also makes for difficulty and adherence to another provision of the proposed rules. In this provision is suggested that the patient must consent to reporting by the physician of "concern" that there may have been "illegal activity." Again, vague language limits usefulness.

Of course such an agreement or contract must specify consequences, most likely discontinuation of the drug, when the patient fails to adhere to its terms. The proposed rules also alludes to "tapering" before discontinuation, but this implies control over what the patient takes when the physician can only control what she prescribes, and, other than the unenforceable "one prescriber" notion nothing prevents the patient from seeking another physician.

Safekeeping of Drugs
The suggestion that responsibility for safekeeping of the drugs rests with the patient admonishes the patient to use "discretion" and keep medications in an "inaccessible" place. The only feasible way of addressing the issue of potential theft is to make it clear to the patient that replacement prescriptions will not be issued when the patient claims to not have enough to last until the next planned refill, regardless of the reason given, except perhaps if the drug has been confiscated by law enforcement and the patient can provide a receipt proving this to the physician.

Consultation
One proposal suggests that the provider should be "willing" to refer to the patient. I can imagine a prescriber documenting his "willingness" in a progress note. Willingness alone will not help. Not only must the consultation actually take place, but patient and prescriber must alter the treatment in response to the consultants recommendations.

Episodic Care
The draft discourages provision of narcotic prescriptions for chronic noncancer pain without objective evidence of acute injury. I applaud this principle as well as inclusion of the statement, "The treatment of patients with chronic pain is not considered an acute health service." I believe emergency physicians far too readily prescribe controlled substances.

Photo Identification
The suggestion that providers should write prescriptions for controlled substances "to require photo identification in order to fill" should apply to all controlled substance prescriptions, not just those for pain. But the best way to effect such a change should start with pharmacies, not physicians.

Reportable Acts
The committee suggests that physicians may have "an obligation" to report illegal acts by patients to law enforcement. The committee should also however admonish providers to do this only consistent with applicable statutes and ethics guidelines relating to confidentiality.

Opiate deaths result from too much drug not from too little documentation. These new rules will likely discourage many doctors from prescribing for pain, and will make it easier to discipline doctors who ignore them.

Overall these guidelines will likely fall short. There is little real substance here but much to make the prescribers who care want to avoid treating this population with narcotics. Perhaps most unfortunate is the fact that we have in buprenorphine a much safer drug which the committee does not even mention, perhaps only because the FDA has approved no oral formulation for treating pain. (Treat Physical Pain Safely with Buprenorphine) The committee, rather than demanding more documentation, should encourage prescribing of safer drugs like buprenorphine.

Taking Insurance

2010-09-09T07:26:00.000-07:00

Surely one of the most ubiquitous euphemisms in medicine today.

Another professional (William Shryer at Diablo Behavioral Healthcare) subscribing to a listserv I read inspired me to write this with his comment on a frequent type of post: "Need psychiatrist in Omaha who takes Aetna [or some other brand of payer]." He advances this quaint idea that, rather than basing a referral on who "takes" which insurance, one should base referral on the qualifications of the provider and the clinical needs of the patient.

I imagine myself ordering two hamburgers, fries and a soda, and asking, "Do you take insurance?" like I might ask whether they accept checks or credit cards.

I imagine myself answering, when a prospective patient in our first telephone contact poses the same question, "I take money."

Insurance is definitely not money.

Taking insurance is a gamble. When the insurance company pays the provider, it is entitled under federal law, and some state laws, to say, "Gosh we didn't mean to send you that money after all. Please send it back now." And you have to send it back. I call it funny money. That applies even if the provider has not signed a contract with the payer. It's even stickier if the provider has agreed to the terms of the contract. Like the professional I mentioned above I contract with no payers, including Medicare. So I have not read one of those many paged contracts in some time. My objection arises from the fact that most of them appear to lead to the provider working, not for the patient, but for the payer, what I see as a conflict of interest.

But here's the catch: most patients cannot afford to pay our fees out-of-pocket, and many of those who can feel entitled to get something back for all those dollars they spend on premiums. I have to sympathize.

And which provider is most qualified? The provider who "takes insurance" from whomever offers it may have a very busy practice indeed. This may translate into lots of experience. Are quality and quantity necessarily at opposite ends of the spectrum? Would you rather have your appendix removed by a surgeon who does the procedure once a year or one who does it four times a week? Experience is not the only consideration though. The provider with the less busy practice may take more time and provide a more individualized approach. She may also have more time to return phone calls or schedule early appointments. Insurers usually verify credentials, attempting to guarantee at least a minimal level of competence, but providers who do not contract with insurers may stay busy enough to avoid contracting by virtue of referrals from other providers and patients who respect them.

That referral should take qualification and the clinical needs of the patient into consideration, and reimbursement may be necessary, but more patients might benefit from reading the provider's contract with the payer rather than pretending the provider answers only to the patient. Providers who complain about insurers but sign those contracts have no business complaining. They are enabling them.

Guns and Psychiatry

2010-09-01T16:23:00.000-07:00

What comes to mind when you think of guns and psychiatry? Probably the Army psychiatrist at Fort Hood, or maybe the Virginia Tech student with psychiatric problems who went on a shooting rampage. Next you may think of the obligatory removal of access to firearms when you send home a patient at risk for self harm. Then there are the myths about violence and mentally illness.

But millions of Americans own firearms, so it should not surprise you that other considerations abound. How do you, the psychiatric provider, feel about the fact that a patient or family member might bring a concealed weapon into your office? Do you have a policy? signs on the waiting room wall? How many psychiatric providers themselves might keep firearms in the office? Would you ask a patient to leave if you discovered she had a revolver in her purse?

What about your patient with PTSD who has himself been a victim of violence and may want a weapon for protection? Would you argue against such a practice on principal? Maybe he's physically disabled as well, making him even more vulnerable.

Have you, the mental health practitioner, ever conducted a background check on a patient to determine whether there might be a history of criminal conviction? Possession of a permit to carry a concealed firearm can provide you with strong evidence that the individual has never been convicted of domestic violence or a felony in many states?

How important are leisure activities to a patient struggling with anxiety or depression? If your patient's favorite pastime relates to gun-smithing, collecting or hunting, do you want her to abandon an activity that contributes to self-esteem and possibly social connection during a time of crisis?

Most of us in the helping professions, especially medicine, are all too aware of the devastation wrought by violent death or serious injury, but do you want a patient who likes, owns, or even carries guns to feel judged by the very person to whom he has come for help?

Even if, like me, you do not believe in "transference," know where you stand with your feelings about people and firearms, and take care not to let them interfere with your work.

The Myth of the 30 Day Notice

2010-08-25T21:24:00.000-07:00

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

But what happens during those 30 days?

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

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

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

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

How Many Psychiatrists Does It Take?

2010-08-18T17:18:00.000-07:00

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

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

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

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

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

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

Plog My Medical Records

2010-08-11T14:51:00.000-07:00

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

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

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

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

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

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

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

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

Pharmacists Gone Wild

2010-08-04T17:29:00.000-07:00

(Facts altered to disguise cases.)

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

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

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

Is Grief Ever a Mental Disorder?

2010-08-02T17:11:00.000-07:00

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

Is Emotional Pain Necessary?

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

Doctors Who Lie!

2010-07-28T16:40:00.000-07:00

First I read about it at shrink rap: Is It Malpractice To Lie?

Then they accused Dr. Carlat of admitting to it on the air: Carlat on NPR's "Fresh Air"

Reminds me of a retired surgeon who was still practicing when surgeons started using laser tools for various procedures. He said patients started asking him whether he would use laser tools for their procedure. He said he would look them in the eye and say, "Of course."

Whether he intended to use laser or not.

Google Ga Ga

2010-07-21T09:32:00.000-07:00

In my earlier post EHR's and APA I outlined more than you would ever want to know about my tech resume. What follows is a brief overview of my recent moves into the cloud with free Google offerings. I do not expect that you will want to copy my implementations, but I hope this will help you generate your own ideas for managing and presenting information for your practice, and maybe your personal life. (I have found that combining personal and practice makes for much increased efficiency.)

Blogger

I am not sure why I chose this particular platform, my first real foray into things Google, but I like that when I comment on other Blogger blogs I do not have to enter my name, email address, etc.

Gmail

I started forwarding almost all my email to Gmail to take advantage of the spam filter, but after a long period with no messages I feared that Google might have identified my domain as spam and started filtering everything. Soon I expect to move the whole domain to a new server at which point I will probably move the email account with my domain to Google. Meanwhile I found a compromise: I set Gmail to bring over all the messages at random intervals. The downside: I have to delete spam from two accounts.

Google Voice

By invitation only as of now. It took a couple months, but I set up this account just before I purchased an HTC Evo with Android. I selected a new phone number (yes, for free) and connected the account to my office and mobile phones. Ironically I see to use the Evo less than before. I record my voice mail out going message at Voice from the browser. Voice transcribes messages to text. Although the errors are numerous I can glean the main points of most messages without listening to them. I could forward them via email or archive them. I can easily listen to a selected message from phone or computer without listening to all older messages. To make a call now while at the computer I copy and paste the number, tell Voice which phone I want to use and click connect. The phone rings. I pick it up and hear the ring tone until the person (or robot) I am calling picks up. Regardless of which phone I use, the recipient sees only the caller ID of my new Voice number. Since I do not block this number my patients do not have to turn off blocking of unidentified calls for me to return their call from my mobile or home numbers. I have not used the feature which makes all my designated phones ring when a caller dials my Voice number (which is a local number by my choice).

Android

I chose the Evo for many reasons, but particularly because of the integration of Android with the other Google offerings, something iPhone cannot offer. Almost everything I see from my browser now appears on my phone as well. I use GoldMine to manage all my personal, business, and professional contacts. Although outdated I expect it will continue to do the job until I find a comparable application in the cloud. Google still does not do all I need, such as keep a history of prescriptions ordered for patients, appointments and phone calls. But with Companionlink I can sync a select group of my GM contacts (phone numbers, addresses, etc.) to the Evo. Android allows me to direct all calls from selected contacts, mostly patients, to voice mail. Voice alerts me by text message that a caller has left a new voice mail message, and the phone notifies me with a distinctive ring tone.

I have not yet been able to configure the Evo to only take calls from numbers in my contacts. I tried an Android app called Gblocker, but it seemed that every few days my phone would go into silent mode with no action on my part. I deactivated Gblocker almost a week ago, and the problem has not recurred. Since then I downloaded an upgrade to Gblocker. I will likely try it again soon.

Tasks

My favorite! Integrated with gmail this to do list allows me to keep items in order and it appears in all my browsers as well as on my phone. I use it for shopping lists, too. For example, I keep on an item entitled "Home Store" a list of all the items I need to buy next time a shop at one.

Calendar

I could sync a Google calendar with GoldMine, but I am not yet comfortable having all my patients names in the cloud. But I can sync with the Evo anyway, so I have a calendar there that is as up to date as the last time I synchronized using CompanionLink. I maintain one personal calendar accessible to selected family members, some of whom have permission to make edits themselves.

Chrome

It works fine as a browser but also allows me to add widgets (?). The Voice widget displays the number of unplayed voice mails. It also allows me to easily initiate calls (or texting, which I rarely use) as described above without searching for the Voice tab. Also, phone numbers displayed on Web pages appear as links. To call the number I simply click on it, select the phone I want to use, etc. Since I started using it I have also been hearing sporadic bells ringing. Unless I am hallucinating I believe one or more of my devices may be alerting me to the arrival of a new message.

The Gmail widget turns a flip when a new message arrives and tells me how many unread messages reside in my inbox. Clicking on it takes me to the inbox. I installed another Gmail widget that should allow me to send the current URL in the browser to a selected email address. I have not used that one yet.

Docs

Not all that sexy, but I have started moving documents that I might want to access from different computers to the cloud. I wish it would allow me to incorporate the name and address from my Google contact list, which I do not really use, into a letter template. For that I still rely on GoldMine and Word.

Sites

I have recreated my practice Web site and am in the process of redirecting my domain. Again, the price is right: free. And it offers some functionality that was not available in my now obsolete MS FrontPage.

Next

One of my other reasons for selecting the Evo: It has a front facing camera that should in theory allow for videoconferencing. In fact, soon before I purchased mine I found an Android app called Fring that allowed use of a Skype account with the phone. The only time I tried it the quality was unacceptable, but I was only using 3G, instead of 4G. Since then Skype pulled the plug on Fring. I hope to try Google's own video conferencing when I get a chance.

I would like to keep patient records in the cloud, but I need to determine how private and secure they will be first. Fortunately I am not a covered entity, so I do not have to worry about HIPAA.

As for moving contacts out of GoldMine and into the cloud I understand that comparable cloud based apps exist, some of which may actually use Google apps.

With all these capabilities available for free, and with all their integration, I see little need to venture into a costly EMR.

Tarasoff Duties and Independent Examination

2010-07-14T16:53:00.000-07:00

Gutheil and Brodsky have contributed an excellent introduction to the question of whether Tarasoff duties to warn or protect should apply to forensic examiners. (J Am Acad Psychiatry Law 38:57–60, 2010) I will add my thoughts and opinions.

Tarasoff duties and law evolved out of, and were originally intended to apply in, cases in which a patient or client obtaining treatment or other help revealed a the threat to harm a third party. More recently the AMA proclaimed (wrongly in my opinion) that forensic examinations constitute practice of medicine. Thus the question posed here arises.

The distinction between treater and examiner is not trivial. In the context of treatment the patient may view the professional as a trusted helper. By contrast the examinee in a forensic evaluation may view the examiner as the agent of an adversary bent on harming her. Any analysis of this question must keep that fact in close view. It impacts not only the examiner's analysis of the threat, but perceptions of confidentiality. The article refers to the examiner's "alliance" with the examinee, but there may be no such alliance in this setting. The examinee may be angry, hostile, fearful and distrustful, or the threat may be a manipulation in ways quite different from what might be expected in a treatment relationship. The threat might even be a way of "faking sick."

Another dimension absent from the article: The degree to which the reason for the examination relates to the threat. For example, an examinee may threaten to harm the individual(s), perhaps an employer, who referred them for evaluation, or the examinee's employer may have requested the evaluation after a less explicit threat or a display of hostility in the context of work. At the other end of the spectrum a mother undergoing parenting evaluation in the context of divorce might reveal a plan to kill a woman she believes may have stolen her new lover.

Adding a specific warning of non-confidentiality might help avoid the whole issue. The examinee might simply refrain from revealing such a threat for fear that it will be used against her. If the examiner remains ignorant of the examinees evil intent, he will be spared this dilemma. In the case where, as described above, the third party requested the examination specifically to assess risk of violence the examiner will not get off so easily, but must actively seek evidence of such intent. In my opinion such a warning should not be needed. Arguably the examinee's attorney should warn their client prior to any such examination, but of course there may not be an attorney. Regardless, preserving the safety of the intended victim should always be the priority, easily trumping any confidentiality concerns: This is not medical care. In fact such examinations are usually about money.

Hints at a threat by the examinee may demand further questioning by the examiner. How should an independent examiner pursue such questioning? It may require departure from the matter at issue in the examination. The facts that no prior relationship between examiner and examinee exists and that no subsequent relationship will evolve further discriminates such an investigation from what might occur in the context of treatment. And embarking upon such an investigations may alter the basis of the examination, perhaps irretrievably. At a minimum the examiner will need to ascertain the identity of the intended victim with sufficient specificity to enable protective actions. But the examinee might refuse. Then what must the examiner do? If the examinee threatens to kill his cousin, for example, can the examiner assume that other authorities can and will determine this individual's identity and extend protection, and can the examiner rest assured that he has discharged all duty, or more importantly, that the individual will not come to harm? The title of the article implies accurately that such a predicament could arise in independent examinations other than psychiatric. We should keep in mind too that most non-psychiatric physicians have little training and less skill in assessment of risk of violence.

The safety of an independent examiner might be at risk more so than that of a treater. The examiner must first protect herself. The examiner must make decisions based on different kinds of knowledge. Although the examiner may have reviewed extensive records not typically accessed by a treater, the examinee might be more open and honest with someone perceived as a potentially helpful advocate rather than adversary.

There should be no duty to inform the attorney of the examiner's potential duty to warn or protect. Attorneys should be cognizant of any such duty of the examer. An attorney restricted by privilege could still advise the physician as to how to proceed.

The physician's job is to evaluate (forensic) or to diagnose and treat (clinical) not to protect others from potential violence. That is a job for law enforcement, so informing the examinee's treating professional(s) as the authors suggest might be tantamount to the blind leading the blind. And this assumes that such a treating professional exists, which may not be the case.

If you find yourself in such a predicament apply the Golden Rule. Ask yourself what you would want another examiner to do if the intended victim were yourself or a loved one. And judges, juries and lawmakers should also ask themselves whether they would want that professional to hesitate to warn or protect themselves or a loved one out of fear of professional or legal consequences arising out of such protective action. Attempting to protect an intended victim should arise, not from statutory duty or professional ethics but from "a normal sense of personal and professional responsibility."

Send Your Patients to Michigan

2010-07-08T07:25:00.000-07:00

Summer vacations will leave doctors and patients in different states. The idea that medical care occurs in the state where the patient is located prevails, so if the patient's physician does not hold a license in that state the licensing board there could accuse the physician of practicing without a license, even because of a simple telephone contact to discuss a symptom or side effect. I have been contacting licensing boards where my patients may travel this summer to learn about their policies.

As I mentioned in my last post on this topic when I called the Michigan Bureau of Health Professions a gentleman there asked me to write a letter. I may have misunderstood the purpose of the letter at the time, but I believe the same gentleman clarified in a recent follow up call. He suggested the letter should indicate the approximate dates when my patient would be in the state of Michigan. He said the letter would be kept on file and that I would not be required to hold a Michigan license to contact the patient by telephone or video conference, regardless of whether I charge a fee for the service provided the patient remained in the state of Michigan for 30 days or less.

This strikes me as a reasonable and fair approach. One might argue with the 30 day limit, but in fairness I did not get the impression that this was a rigidly enforced time limit.

Internet Addiction Isn't

2010-06-30T14:15:00.000-07:00

Allen Francis, MD recently wrote an article published by Psychiatric Times challenging the proposed adoption of Internet addiction in DSM-V. In his commentary Ronald Pies, MD referred to his article published last year in Psychiatry 2009 which also highlights problems with introduction of the concept of Internet addiction as a mental disorder.

The Internet is not a behavior. It is a complex network of people, devices, and a variety of technologies connecting them, including radio waves, fiber-optic cables, and electrical cables. It is a tool and a conduit analogous to the needle and syringe of a heroin addict or the bottle of an alcoholic. It makes no more sense to suggest that someone might be addicted to the Internet than to suggest that an alcoholic is addicted to bottles or a heroin addict to syringes.

At a minimum we must substitute the term "Internet use" when discussing its merit as a kind of behavioral addiction. We might then consider whether Internet use might represent a class or category of behavioral addictions such as Block's (Block JJ. Issues for DSM-V: internet addiction. Am J Psychiatry. 2008;165:306–307.) so-called "subtypes" of Internet addiction: gaming, sexual, and communication. None of these, however, requires use of the Internet, which begs several questions:

Is gaming somehow more addictive when using the Internet rather than an isolated computer or no computer?
Is text messaging more addictive when conducted via the Internet rather than directly from one device to another?
Is solitaire more addictive over the Internet than using a computer? Is it more addictive using a computer than using paper cards?

More questions arise in discussing use of the Internet for sexual gratification. Use of the telephone for sexual contact predated use of the Internet. With today's cell phones it may not always be clear whether or not the communication from one telephone to another uses the Internet. Does that make a difference? References to use of the Internet to access "pornography" are confused by the difficulty in defining that term. I propose that we substitute the less pejorative "erotic media." Once more we must decide whether transmission of such media via the Internet plays a critical role in what ever addiction might be identified. The term "pathological use of electronic media" is equally problematic. If we are to identify behavioral addiction we must focus on the behavior, not the tools used to deliver the necessities of that behavior.
Perhaps there is an analogy here in the field of chemical addiction. Evidence suggests that use of pure cocaine and crack cocaine carries greater risk of addiction then chewing coca leaves. Do we have evidence to suggest that erotic media are more addictive when accessed via the Internet? And is Oxycontin any more addictive when obtained via the Internet than from a physician? What if the physician orders the drug by faxing the prescription via the Internet?

As for invoking psychoanalytic/psycho dynamic theory in this discussion, let me remind Dr. Pies that the DSM is a psychiatric, not psychoanalytic, nomenclature. I would also remind him of the dismal track record of psychoanalytic and psychodynamic treatments in patients suffering from substance use disorders.

Dr. Pies and others also focus too much on the purported "excessive" behavior as a problem existing in the individual patient. We must also learn about the purpose such behaviors serve in the larger family and social system.

It used to be that too much of anything was bad. Now too much of anything is addiction. But I do believe we have abundant evidence for one new diagnosis prevalent among some mental health professionals:

Addiction Addiction.

Testing the Unconscious

2010-06-23T10:21:00.000-07:00

Freud called dreams the "royal road to the unconscious," but the authors of the Implicit Association Test seem to claim an ability to measure "implicit cognition" (Is that a euphemism for unconscious?) by using a computer administered psychological instrument.

This approach was previously reported to uncover racial bias in the practice of medicine: http://www.ama-assn.org/amednews/2009/09/28/prsa0928.htm, but according to an article in a recent issue of Psychiatric News a variation of the test appeared to predict suicide risk more accurately than by traditional means such as psychiatric interview. I took one of the tests myself. The result was not what I would have expected. Did the test err, or do I simply not know or acknowledge my true attitudes? I suppose the authors might claim the result proves that my attitude is unconscious, but as far as I know no method of tapping the unconscious exists that might provide researchers with a way to validate the results of such a test, except perhaps by looking at my subsequent behavior.

The notion of a test of unconscious intent (Isn't that a contradiction in terms?) sends me on flights of fantasy. I imagine requiring psychiatric patients to undergo testing on a mobile device every 24 hours with results transmitted to a central clearinghouse. If the patient starts to lean toward suicide, the men in white coats home in on their GPS signal, pick them up, and hospitalize them until their attitudes right themselves, with or without treatment. Of course one would have to pass the test before purchasing a firearm, or razor blades, or matches. Or before being allowed to pilot an airplane or drive a car, or cross a street, or climb higher than the first floor of a building. Could we detect future suicide bombers?

Why limit the use of this technology to prediction of suicide, or to psychiatric patients? If such a test could detect intent to rob, rape or kill, to engage in insider trading, run a red light or shoplift, we could require everyone to take it and virtually eliminate crime. Maybe, rather than requiring formal testing, analysis of patterns of Internet use such as Web sites searched or visited could allow, for example, determination of how one might intend to vote in an election. Could such information be used to subtly influence attitude, intent or even religious belief by channeling selected stories through news sites and other media, or even what happens to you when you play World of Warcraft? And since it's all unconscious, how would you know? The possibilities for abuse approach infinity.

Somebody please make a movie!

You can take the tests yourself at: https://implicit.harvard.edu/implicit/, provided you can reign in your paranoia.

How Psychiatry Works

2010-06-16T13:23:00.000-07:00

An admittedly oversimplified illustration of how psychiatry works:

Scenario One

You have been suffering from loss of energy and motivation for a month or so, so you visit your primary care physician. She orders a blood test and finds that your thyroid stimulating hormone (TSH) is high. She diagnoses hypothyroidism as the most likely cause of your symptoms, rules out more serious disorders with more tests, and prescribes thyroid replacement drugs. After you start taking them you get better. She recommends that you continue taking them indefinitely.

Scenario two

What doctors call the history of present illness is the same as in Scenario One, but this time when the doctor finds that all your blood tests were normal, she tells you she cannot find a physical illness that might explain your symptoms, diagnoses some kind of depression (i.e. it's all in your head) and refers you to me, the psychiatrist.

You have become a medical leftover. Specifically treatable physical illnesses do not explain your symptoms, so in many cases the only physician who will take care you is a psychiatrist. But not to worry: Psychiatrists generally like talking to people, are fascinated by mental and emotional problems, and like helping people like you solve them. In the past you might have been locked up in an asylum or referred for psychoanalysis, but today, fortunately, we have specific forms of psychotherapy that can treat mental disorders, and we have a host of drugs that for most people are relatively safe and effective, somtimes miraculously so.

Diagnosis

After collecting lots of information about your history and your symptoms I will probably have some vague idea of your diagnosis. Given all the recent controversy about DSM V you might think this is a critical step. In fact it is somewhat important. I don't want to treat someone with schizophrenia for panic disorder or someone with social phobia for bipolar disorder, but I usually make a mental jump to the most important phase which is to choose a treatment that is most likely to help you with minimal adverse effects and minimal delay. Another nice thing about many of the drugs we have today is that, for example, antidepressants, at least most of them, often work very well for anxiety as well. That makes it less critical to determine whether you suffer from, for example, dysthymic disorder, or generalized anxiety disorder. If I prescribe paroxetine and you come back two weeks later to tell me that you feel all better, who cares how we categorize your problem? (It may be important to rule out bipolar disorder since evidence suggests many drugs with antidepressant effects can exacerbate the condition.)

Over-diagnosis

Many people that get diagnosed with bipolar disorder or attention deficit disorder may have never had either. A researcher or two publish data suggesting that we have missed a few cases, and everybody jumps on the bandwagon trying to make sure they never miss the disorder. Often we overshoot the mark and apply the diagnosis inappropriately. What's wrong with that? Delay in getting the right treatment for the right problem and exposure to adverse effects of the wrong treatment. There can be other fallout from simply having the wrong label as well. For example, if a psychiatrist evaluates your child, and you tell her that Uncle Harry has bipolar disorder, this may influence how the psychiatrist diagnoses your child. So if Uncle Harry really did not have bipolar disorder, your child may get the wrong treatment.

Under-diagnosis

Missing diagnosis can cause problems too. Once more we can have delay in appropriate treatment. But when I tell a patient I don't believe they really suffer from a mental disorder, I can add that we can monitor the symptoms over time with a plan to reassess if they worsen.

Getting It Just Right

We would like to be able to do this all the time, but it just is not possible. When I hear psychiatrists talk about patients as suffering from this or that disorder as though they are absolutely certain of the diagnosis it always makes me wonder. To me, especially if the patient has not responded very well to treatment, and even sometimes when they have, I tend to think of the diagnosis as what we call a working diagnosis. This is a provisional diagnosis we assume to be correct until proven otherwise, often by treatment failure. If I get too confident or locked in to a particular diagnosis there is a risk of barking too far up the wrong tree, usually trying treatment after treatment, all doomed to failure. Better to keep an open mind.

Drugs

You may feel like a guinea pig, but really you're the director auditioning drugs instead of actors. If we get it right with the first one that's terrific, but often patients have to try several medications before finding one that works and has acceptable side effects. Everyone seems to respond differently. Be warned though: You could keep trying different psychiatric drugs and combinations for years and never find one that makes the grade. At some point you may want to figure the solution is not in the (pill) bottle. If you haven't tried it already, consider psychotherapy. For more serious problems ECT and other biological treatments can work wonders.

Once you find a drug that works you have to decide how long to continue it. Some psychiatric drugs can prevent recurrence of your illness. You wouldn't stop oral contraceptives just because you didn't get pregnant. Many patients benefit from lifelong preventive or maintenance treatment, like for the hypothyroidism in Scenario One.

Ask your psychiatrist what to expect in the way of risk of dependence on medications and risk of adverse effects and whether there are ways to manage those risks. Sometimes additional drugs help control side effects of the primary drug. Be sure to keep the psychiatrist apprised of all other medications, conditions, symptoms, and side effects. And make sure the psychiatrist knows if you are disappointed in the effectiveness of the treatment.

Psychotherapy

It works, but not necessarily for your illness. For example, there seems to be no method of psychotherapy that treats schizophrenia, bipolar disorder, or ADHD, and certainly not Alzheimer's. But psychotherapy can help you and your family cope with any of them. Some kinds of psychotherapy actually effectively treat disorders like generalized anxiety disorder and panic disorder. Your psychiatrist may or may not provide psychotherapy. If she does, make sure it's the kind of psychotherapy that best treats your condition. If she doesn't insist that the two professionals communicate about your treatment.

Ask your psychotherapist what to expect, particularly how long the treatment lasts, how it works, and whether family members can be involved. Some kinds of psychotherapy can go on so long you can't tell whether the treatment or tincture of time got you better. Be sure to make the psychotherapist aware of any disappointment in the treatment. And if you don't like your psychotherapist, tell them so. A good one won't hold it against you, and will want to address it as just another interesting problem to work toward solving together.

Disappointment and Failure

If none of the above has produced acceptable results, ask for a consultation or second opinion, or just look for a different psychiatrist or psychotherapist. Most of us want you to get better, even if someone else gets to take some credit. And if you do get better, give yourself most of the credit.

Buprenorphine: First Aid for Overdose?

2010-06-10T10:35:00.000-07:00

A couple days ago I read about a new statute in Washington state that protects overdose victims and witnesses from prosecution if they call 911 for help. I assume addicts have died of overdose of illicit drugs either because they feared that calling 911, while possibly summoning help, might also lead to conviction for some kind of narcotic offense.

Whenever I think about illicit drug overdose I recall the scene from Pulp Fiction in which (as I remember it) John Travolta's character jams a needle about three feet long into Uma Thurmond's chest, hoping to save her from death by overdose. He has the angle and approach all wrong for what should be intracardiac injection of epinephrine (I did this myself once with a surgeon at my elbow directing me.), but if only from the pain of her sternum stopping a large needle, she regains consciousness and survives, maybe even until the end of the film. What this got me wondering was whether even an intoxicated addict faced with an overdose situation might have sufficient cognitive capacity to administer potentially life-saving first aid to self or other with minimal -- or at least acceptable -- risk.

We have known for years that naltrexone and naloxone reverse the effects of opiate agonists like heroin and oxycodone. Show up unconscious in an emergency department, and you'll probably get an injection of naloxone (Narcan) just in case you OD'd on an opiate. But I dare say few opiate addicts keep a supply of naloxone on hand for overdose emergencies. They might, however, have another drug that can block the effects of opiate agonists and can be procured on the street: buprenorphine. And what's more, you can administer the drug by dissolving it under the tongue like nitroglycerin, which is probably safer than swallowing for an unconscious victim. No need for an injection. I even wonder whether it might be adequately absorbed rectally to save a life. Buprenorphine, if it works at all, might also offer the advantage of working longer. Naloxone works rapidly, but has been known to wear off after the patient leaves the ED. Then the drug with which they overdosed, still on board, takes over again, and death ensues.

What would be the downside? Perhaps the worst might be delay in calling for help while attempting this measure, especially if something other than an opiate overdose caused the loss of consciousness. The new WA law might help. And perhaps 911 operators could walk callers through the procedure while help is enroute. Of course if the individual was addicted to opiates and regains consciousness they will likely be in withdrawal. I would be surprised if a number of addicts out there didn't think of this and try it years ago. Should we educate all addicts about it?

What we need now is for experts on management of opiate overdose to collect some evidence and offer their opinions as to whether the idea really works and is safe and feasible, and if so to get the word out. Maybe docs who prescribe opiate analgesics for chronic pain will want to order a few buprenorphine (off label of course) for patients to keep on hand for such emergencies.

Unhinging Dr. Carlat

2010-06-02T17:25:00.000-07:00

No, this is not a review. I have not read the book, and I don't entirely disagree with Dr. Carlat's ideas. I did, however, read a review, which I cannot now locate, but which included a short case said to have come from the book. A brief look may demonstrate the extent to which a different perspective can influence a psychiatrist's approach and challenge the notion that psychiatrists prescribing medication should also provide psychotherapy to most patients. (Let's not blame Dr. Carlat for any of this. The reviewer may have misread Carlat, and I may have misread the reviewer. If I didn't get it right, apologies to Dr. Carlat.)

As I recall the case involved a patient prescribed zolpidem for insomnia. Because of oversedation he nearly or actually wrecked his car. The patient had not been able to muster the courage to contact the doctor about the sedation because of his reluctance to confront authority figures, such as physicians. According to the reviewer Dr. Carlat argued that had he been treating the patient with psychotherapy the patient might have overcome his reluctance, telephoned the physician, and avoided the accident.

Here's how I would approach the case: First, I never prescribe zolpidem. Even if I prescribe a drug for insomnia I prefer melatonin, gabapentin, or a very sedating antidepressant like mirtazapine or trazodone. But before prescribing I want to know the source of the insomnia, and in some cases will recommend a sleep medicine consultation. I also like to address sleep hygiene (behavior) before resorting to a drug. Why would I want to prescribe a drug like zolpidem that can lead to dependence and has been associated with patients eating a buttered cigarette or driving while asleep?

But suppose, against my best professional judgment, I do prescribe zolpidem. I would do so only after warning the patient about the risks involved. And in fact the pharmacist would probably offer the same warnings orally and in writing when dispensing the drug.

But let's say it still boils down to that problem of psychological reluctance to call the authority figure. Successfully addressing such a problem in psychotherapy could take months or years, and there's no reason to believe it would happen any faster if the psychiatrist were providing the psychotherapy rather than a non-physician. Furthermore, we should not assume that psychotherapy would address said reluctance. Many kinds of psychotherapy don't address such problems at all, at least not directly. What would make a difference, however, is how often the patient visits the physician, even for a short visit to talk about medication effects, wanted and unwanted, and even with no psychotherapy.

This case also begs the question of whether psychiatrists should provide psychotherapy so patients can muster the courage to call between appointments about a side effect. I argue that psychotherapy should address a diagnosable mental disorder (however we choose to define it).

And wait. Suppose a sleep medicine physician, or heaven forbid an orthopedic surgeon, prescribed the zolpidem. Would we want all physicians to provide psychotherapy? Orthopods don't even do physical therapy.

This case provides little or no support for the position that psychiatrists should provide psychotherapy. It does underscore the importance of careful selection of medication, avoidance of medication when possible, and adequate patient education. In some cases there may be advantages to one-stop psychiatric shopping, but in this case the frequency of contact, rather than overcoming a psychological problem with psychotherapy might have made the difference.

Medical Practice at a Distance May Be Illegal IV: ME, AK

2010-05-28T18:12:00.000-07:00

Continued from: Medical Practice at a Distance May Be Illegal III

Maine:

When I called the Medical Board for the State of Maine I explained that a patient planning to travel during the summer might be in the state at the time of the next appointment, and I asked whether the Board might deem that I would be practicing without a license if I were to a) have a telephone conversation or b) conduct a medication management session via Internet teleconference with the patient. Both of the representatives with whom I spoke referred me to the applicable statutes which of course indicate that one must be licensed by the state in order to legally practice medicine there. However, I detected at least some suggestion that the Board might tend to adopt a lenient view of such practices. I was also told that Maine has not entered into reciprocity agreements with any other state, including New Hampshire and Canada.

Alaska:

(No Sarah Palin jokes, please.) I started with a phone call, but the representative asked me to switch to email. I indicated that a patient might work on a fishing boat harbored in Alaska during the time of the next expected monthly contact. I asked whether the Board might deem that I would be practicing without a license if I were to a) have a telephone conversation or b) conduct a medication management session via Internet teleconference with the patient.

Perhaps the most interesting aspect of the response was the suggestion that if the contact occurred while the boat was in waters beyond the 3 mile limit, Alaska would have no jurisdiction. This might solve the problem with (I count) 21 states. Of course the physician has no way of knowing exactly where the patient is, much less exactly how far from the coast of a given state, and neither the patient nor I have any idea whether the boat will have a broadband connection.

I wonder too about jurisdiction at anchor or a dock. Would the state of VA, for example, claim medical jurisdiction over a German physician attending to a French patient on an Italian cruise ship anchored in Hampton Roads? And is the 3 mile rule universal, or does it vary from state to state?

In the end the Board's representative told me, "if the patient is only here temporarily..., you’re fine." Alaska takes first place for most rational, informative, helpful and reasonable response thus far. So if you plan to boycott AZ this summer because of the immigration law, switch your itinerary to AK and need to talk to your physician, remember that he may not have to say, "Sorry, but I'm not licensed there. You'll have to find a physician who holds an AK license."

A good bet: Send Your Patients to Michigan

DEA Cracks Down On Safe and Efficient Prescribing

2010-05-26T16:24:00.000-07:00

A couple weeks ago, after I faxed a prescription refill to a Fred Meyer pharmacy near my office, a pharmacist there telephoned me. She explained that an inspector from the Washington State Board of Pharmacy had instructed the pharmacy to stop accepting prescriptions for controlled substances with "electronic" signatures, citing DEA regulations.

I had heard this reference to electronic signatures before and inquired at the Board of Pharmacy where a representative assured me that since I had written the signature on my prescriptions by hand, using a stylus, the Board would not consider it to be electronic. However, when I contacted the inspector, she indicated that since I had not used chemical ink from a pen applied to paper, but instead used a stylus and digital ink on a tablet computer, my signature would now be considered electronic. Never mind that the prescription was sent via fax to the pharmacy, so the pharmacist could not see the original paper or feel for the indentation made by the pen. Presumably the fact that the signature was identical to prior signatures gave it away. (Funny. I would have thought a signature that looked different from a former signature might raise suspicion.)

So at a time when the President encourages eprescribing (where there is no signature at all), at a time when we hear that regulators may permit physicians to order even controlled substances via eprescribing, and at a time when Washington statutes will soon require physicians to use special paper forms for prescriptions (but not when the prescription is faxed), authorities are cracking down on arguably safer and more efficient methods. Now to order a prescription I must print it on paper (wasting trees), sign it with a pen (not one obtained from a pharmaceutical representative of course) with chemical ink, and only then might I scan it with a fax machine to send it electronically to the pharmacy.

But I push back. So I have instituted a policy that I will no longer fax prescriptions to the Fred Meyer pharmacy in question. Rather, after printing and signing the prescription, I will hand it to the patient. Which means the patient must be in the office. If the patient needs to renew between visits they must use a different pharmacy that still accepts "electronic" signatures.

Unfortunately it gets worse: For years I have intentionally omitted my DEA number from prescriptions to prevent patients from using it to forge prescriptions. Instead I provided it by telephone directly to the pharmacist. Now, however, I understand from pharmacists that authorities are cracking down on this practice as well, and have admonished pharmacies not to accept prescriptions for controlled substances unless the DEA number appears thereon.

We can expect to have the DEA to thank for a spike in drug-related crimes and deaths, at least until we can eliminate written or printed prescriptions altogether.

Get This Doc Out of the Pharmacy Loop

2010-05-18T16:22:00.000-07:00

Patient leaves request for refill with pharmacy.
Pharmacy faxes me request for refill authorization.
Patient goes to pharmacy expecting to pick refill which is not there.
Patient leaves message on my voice mail: "Where's my refill!?"
I retrieve voice mail.
I call pharmacy: a) I did not receive refill request or b) Pharmacy did not send refill request
Pharmacy faxes refill request.
I fax refill or order via eprescribing service.

I suggested a solution to tech support at the eprescribing service I have been using, allscripts.com: Give the patient limited access to and control over the refill process. Instead of calling the pharmacy the patient would access her account at the eprescribing Web site. She would click on the prescription she wanted to refill and indicate the name of the pharmacy she wanted to use. My eprescibing service alerts me to the request. I access the Web site, check the patient's name, the drug, last date filled, etc. With a click I authorize the refill, and the pharmacy receives the order. The system alerts the patient who can check the status of the whole process at any time, and may opt for email notification from the pharmacy when the prescription has been prepared for pick up. The system could even alert the patient if there is a problem, like the medication is not in stock. The patient can then select a different pharmacy.

What do you think?

Medical Practice at a Distance May Be Illegal III

2010-05-12T13:44:00.000-07:00

Only a couple of developments since I posted Medical Practice at a Distance May Be Illegal II:

State of MI

When a patient told me he planned to travel in Michigan this summer (I don't hold a medical license in that state.) I called the MI medical licensing board. When I asked whether the State of Michigan might consider me to be practicing without a license if I talked to the patient on the telephone or used video conferencing, I asked me to write a letter of inquiry. I am still procrastinating, but will post when I receive a response.

Federation of State Medical Boards

If any organization exists that might advocate for sanity in state laws regulating physician contact with patients in states where the physician does not hold a license, it must be this one. After receiving no response to several emails I was directed to their PR person, Drew Carlson. In a telephone conversation I posed the question to him of whether the FSMB has taken a position on this matter. Three weeks have past with no further response despite at least one reminder. Perhaps FSMB does not consider this an important matter.

Continued in: Medical Practice at a Distance May Be Illegal IV: AK, ME

Who Can Be a Psychologist?

2010-05-05T16:59:00.000-07:00

In their article, “An Empirical Survey of Psychological Testing and the Use of the Term Psychological: Turf Battles or Clinical Necessity?” (Dattilio, Frank M.; Tresco, Katy E.; Siegel, Alex Professional Psychology: Research and Practice. 2007 Dec Vol 38(6) 682-689) the authors provide ample evidence to support their argument that state laws attempting to restrict use of the terms “psychology, ” “psychologist,” and “psychological” confuse more than clarify and have proved to be of little benefit to professionals or consumers. The legislatures were correct in attempting to protect the public from individuals claiming to have qualifications they lack. However, laws aimed at preventing fraudulent use of these terms by unqualified professionals have not prevented confusion in the minds of consumers, who regularly confuse psychologist with psychiatrist, and psychologist with psychotherapist of any type.

Many consumers do not appreciate the differences among so-called “mental health professionals” such as psychiatrists, counselors, psychotherapists, psychoanalysts, and psychologists. Statutes restricting use of terms related to psychology accomplish little or nothing to address this problem. The fact that some of these designations overlap increases the confusion: A psychoanalyst might also be a psychologist, a psychiatrist, or a social worker. Even professionals may wrongly assume that a PhD following the name of a professional implies that professional must be a psychologist.

Each of the terms protected under the statutes poses a different problem and calls for its own solution.

Psychology:

Comparison of the terms “psychology” and “psychiatry” helps clarify the problem. Psychiatry is a profession, a medical specialty encompassing the diagnosis and treatment of mental disorders in humans. In contrast, psychology is a science within the broader field of biology; in fact it is one of several sciences that inform the practice of psychiatry. Psychology encompasses the study of normal, as well as pathological, behavior, and it encompasses the study of behavior and functioning of non-human, as well as human, animals. Psychology per se is not a profession at all. Consider common uses of the term: Psychology Today, popular psychology, developmental psychology, The Online Journal of Sport Psychology, psychology 101, psychology department, evolutionary psychology, social psychology, political psychology, and others. Legislation probably cannot eliminate other uses of the term.

Psychologist:

The problem with efforts to restrict use of this term to licensed professionals are implicit from the discussion above and from the legitimate use of the term by non-licensed professionals to identify their professions. Not only do school psychologists and industrial psychologists identify themselves as such legitimately, but also scientists who study animal behavior and academics who teach but do not diagnose or treat and thus have no need or qualification for a license. The definition of psychologist should be “one who studies psychology” not “one who practices psychology.”

Psychological (test):

The authors’ focus on psychological testing legitimately arises from the fact that such formal assessment is a major role of psychologists. Psychological treatment (psychotherapy), however, is probably at least as central to the practice of psychology. Most of the same arguments could be made in an illegitimate attempt to prevent professionals who do not hold licenses as psychologists from claiming to provide psychotherapy services. As with “psychology” other common uses of the term “psychological” further blur the boundaries of acceptable use: psychological thriller, psychological aspects, psychological operation, psychological theory, psychological warfare, ad infinitum. The title of a catalog on my desk reads, “The Psychological Corporation.”

The problems with restriction of use of this term in the context of formal assessment arise partly from the lack of a universally accepted operational definition of “psychological testing,” and perhaps of psychological evaluation. The MMPI and the Millon, among others, would seem to be correctly classified as psychological tests regardless of the credentials of the individual who administers the test or interprets the data, but the Draw a Clock test, and the Mini Mental Status Exam would not. The authors also refer to “psychodiagnostic testing,” but do not indicate whether they believe the term should be considered synonymous with “psychological testing.” If any and all measures, instruments, tests, profiles, surveys, symptom inventories, and scales are included, there is no basis for restriction. If only a few, narrowly defined instruments are covered, the validity of the restriction increases, but its usefulness decreases.

The determination of which professional is qualified to administer a given test should depend on training and experience, not on their professional identity. Statutory restriction of the use of the term “psychological testing,” to be feasible, requires an adequate definition. I face a dilemma in completing an application asking whether I perform “psychological testing” as part of a psychiatric forensic examination. I routinely administer the MMPI, but the scoring is performed via computer program by Dr. Butcher. To me the MMPI is clearly a psychological test, but if I answer yes, I risk prosecution for violating Washington law. Conspicuously absent from the discussion, particularly with regard to testing, is any reference to the profession of psychiatry. Attempts to protect the consumer from fraud are legitimate regardless of any assumptions about pecking order. If a social worker cannot legally claim to provide psychological testing a psychiatrist should not be able to either. Efforts to protect the consumer should be limited to restriction of availability of test materials to those qualified to administer them.

The solution is to protect only the term “clinical psychology,” a term that clearly refers to a profession that addresses only humans, their evaluation, and sometimes, if present, treatment of pathological conditions.

•    Laws should not limit use of the term “psychology” at all.
•    Restriction of the term psychologist should be limited to the term “clinical psychologist” and then only when the term is used in an attempt to falsely hold oneself out as a clinical psychologist.
•    Until or unless we can arrive at general agreement on the scope of the term “psychological testing” no statute should limit its use.

Individuals who should be allowed to identify themselves as psychologists include school and industrial psychologists, professors of psychology and those who study animal behavior.

What Is Polypharmacy?

2010-04-29T09:59:00.000-07:00

How should polypharmacy be defined? In a list-serve in which I participate psychiatrists commented thus in relation to a case under consideration:

Dr. P: "My definition of "Polypharmacy" would apply to any inappropriate use of any medication."

Dr. R says the term is pejorative.

Dr. M says, "I don't mean to use the term "polypharmacy" in a pejorative way, simply that there are several meds
And it makes it difficult for me to know what is or is not helping..."

Here's my definition, written years ago.

Other thoughts? I think there is also a question of what should be the threshold. I can't see that as some arbitrary number of drugs, though.