Hands Free Mic for VR

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

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

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

Controlled Substance eRx: Is it live?

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

Is your eRx live with EPCS yet?

If so, please reveal their identity.

Forms R Us

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

Physician

Will Fill Out Forms

For Free

Any Forms

All forms

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

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

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

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

"I think he's a doctor."

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

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

Approval Form

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

Supplier Classification Form

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

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

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

I think I'll pass.

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

Waking Up Is Hard to Do

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

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

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

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

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

What's making more Greeks kill themselves?

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

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

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

The Birth of Managed Care

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

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

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

Managed Care Bloopers

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

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

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

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

Substance abuse program the patient is attending? ________________________

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

Current dose of Suboxone for PA approval?

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

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

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

TITLE: Columbia United Providers Suboxone Therapy Policy

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

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

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

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

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

I'm starting to feel like Andy Rooney here.

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

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

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

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

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

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

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