Thursday, March 29, 2012

Phun with Phobias

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

(This is fun.)

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

Here's where you come in. These and many others have me stumped so far: Celtophobiaagraphobiabibliophobiacomputerphobiaheresyphobiamottephobiatomophobia. Please leave suggestions under comments. Enjoy.

Thursday, March 22, 2012

Prescription Monitoring & Standard of Care

I wrote about my early experience with the state of Washington's new program that allows prescribers to monitor patients' prescriptions from other prescribers here. Questions about use of the program continue to emerge:
  • How often should prescribers perform searches?
  • What should we do when we discover undisclosed prescribing by other prescribers?
  • Can we contact other prescribers without the patient's authorization?
  • When should we discharge patients who have withheld information from us?
  • Can we rely upon a negative search?
  • Can we charge a fee for performing a search?
  • How will we redefine standard of care in light of this new capability?
If we define standard of care as that which is "reasonable and prudent," as an expert witness I believe I would consider that a prescriber must conduct at least one search in order to meet standard of care. There can be little question whether a prudent provider would want to inquire as to what controlled substances a patient might have been prescribed. Such information can aid in diagnosis and may help prevent dangerous drug interactions. We know patients sometimes lie about drug use. The patient who does so should retain some responsibility for misleading a physician, but with this new tool the prescriber assumes more responsibility.

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

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

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

Thursday, March 15, 2012

Close to Home

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

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

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

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

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

Thursday, March 8, 2012

Tried to kill yourself? You're fired!

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

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

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

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

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

Thursday, March 1, 2012

Why Just Homicide and Suicide?

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

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

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

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