Pharmacists Gone Wild

(Facts altered to disguise cases.)

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

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

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

Is Grief Ever a Mental Disorder?

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

Is Emotional Pain Necessary?

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

Doctors Who Lie!

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

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

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

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

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.