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

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

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

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

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

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

Are all medical jobs created equally?

Guest blogger: Elizabeth O’Malley

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

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

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

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

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

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

How do you rule out ADD?

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

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

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

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

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

What difference does it make?

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

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

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

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

How do you rule out ADD in adults?

or

How do you rule out ADD in adults?

Who ya gonna call?

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

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

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

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

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

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

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

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

Doctors: Push back!

Attracting Easy

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

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

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

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

Contingency Fee for Physicians

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

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

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

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

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

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

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

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

Voir Dire and HIPAA

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

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

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

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