Board Certification Patient Feedback May Be Unethical

According to 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.”

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...”

And yet the American Board of Psychiatry and Neurology (ABPN) has apparently implemented plans to require psychiatrists who want to maintain board certification status to not only solicit evaluation by other health care providers, but also from their own patients. According to ABPN policy the patient would complete a feedback questionnaire and give it to the psychiatrist who would keep it on file. As I understand it, based on feedback from both other providers and patients, the psychiatrist would look for opportunities for improvement, plan and carry out steps to improve their practice, then measure improvement over time with follow up questionnaires. ABPN would conduct audits of selected psychiatrists to confirm compliance.

One can easily imagine problems with such an approach. Psychiatrists might agree to provide glowing reports to other psychiatrist who agreed to reciprocate. Patients might suggest that an increase in dose of Xanax or a few prescriptions of OxyContin might lead to a more favorable evaluation. At best such data would seem unreliable.

Even the patient who would never think of submitting a dishonest assessment of the psychiatrist might fear the consequences of submitting a critical report. As stated in the ethics excerpts above a physician should never put the patient in the position of having to make such a choice which could hardly be made freely.

Unless I am missing something here I would suggest that patients consider refusing to complete such assessments and even consider filing ethics complaints against physicians who asked them to do so. Let us see to what extent organized psychiatry will sacrifice ethical principles to create an illusion of superior ability has represented by a framed piece of paper hung on the wall.

Better yet I hope psychiatrists will refuse to participate.

eRx Bogged Down

I started using electronic prescribing several years ago, and, despite flaws, which have diminished over time, I believe it to carry less risk of error and much greater efficiency. For a while it seemed that most pharmacies were moving toward adoption, but if anything it seems that some have reversed course. Almost all pharmacies accept electronic orders, but fewer seem to send requests for refill authorization electronically. In the past few weeks I have received electronic requests from Top Food Pharmacies and Rite-Aid. I have also received requests from Safeway, but they seem to have stopped. A pharmacist at one store in a chain may tell me the chain has not yet implemented eRx even though I have received such requests from other stores in the same chain. Can a chain really have implemented eRx on a store by store basis? More likely they have simply failed to educate their pharmacists.

The failure of most vendors to implement eRx of controlled substances continues to limit the overall efficiency of the technology despite approval by DEA as long ago as two years. I know of only one vendor having adopted this late last year, but mine, Practice Fusion, has not. This means I still need two separate systems to track and record prescriptions and refills. It also means I still must use paper prescriptions or telephone, both of which I believe to be more vulnerable to fraud and error.

My vendor has only recently implemented (apparently) formulary status check when using eRx. This could help avoid the shock of high copay or required prior authorization, but I have yet to try it.

Speaking of prior authorization, eRx could dramatically increase efficiency. Recently I pursued prior authorization from Medco involving numerous faxes. Ultimately it seems that reimbursement hinged only on whether I prescribed the drug for smoking cessation. Instead of all the faxes and finally a phone call, I should have been able to simply check a box during the initial order.

eRx is not perfect, but with so much potential we should aim for complete conversion in months, not years. Maybe if a large enough number of physicians simply blocked fax requests...

The Genericebo Effect

Google:

 No results found for "genericebo effect".

Does that mean I can claim to have coined the term?

genericebo effect

It seems like patients switching to generic preparations of drugs newly off patent increasingly report intolerable adverse effects or loss of efficacy. I intend the new term to capture the possibility that these apparent changes may originate from an expectation on the part of the patient, and possibly initiated by the prescriber, that generics, particularly those manufactured by certain pharmaceutical companies, must fall short of their branded predecessors.

Of course generics and even branded drugs can suffer from real manufacturing problems, so we must not assume these phenomena occur only in our patients' heads.

Much Ado About Nothing

As I reviewed the Administrative Actions section of Washington state's Medical Quality Assurance Commission Update! bulletin I recognized the name of a physician who often shares the physicians' lunch table at the hospital with me, Alan Bunin, M.D. According to the bulletin Dr. Bunin "allegedly failed to maintain medical records for patient." Now I know that Dr. Bunin is old-school (But not exactly right wing: he claims to have been a freedom rider in the 60s.), so for a moment I wondered whether perhaps he just does not keep medical records at all.

I easily found the Statement of Allegations here. According to the statement Dr. Bunin "failed to maintain a medical record of the treatment he provided" and when the patient's "subsequent treatment provider requested the patient records, Respondant only produced a one-page document." Furthermore, when the MQAC (pronounced imquack) investigator asked him to provide records Dr. Bunin "was unable to provide" them.

Mystery:

Did Dr. Bunin ever create a record? What became of the missing records?

Mystery Solved:

According to the Statement, "he had given the entire original medical chart" to the patient "without keeping any copy."

Oh for shame Dr. Bunin!

MQAC To the Rescue:

Fortunately we have this august body of distinguished professionals and lay people to intervene. (What would we do without them?) In its infinite wisdom the Commission, showing considerable restraint, proposed an Informal Disposition, also accessible from the link above. I will not bore you with the details, except to mention that Dr. Bunin agreed to complete "a minimum of four (4) credit hours of preapproved Continuing Medical Education (CME) on the topic of medical record-keeping" and to submit to chart audits. (That should teach him.)

Only by reading further do we discover that any damage to the patient that might have resulted from this egregious error was "moderated" by the fact that the patient "was able to provide them to subsequent treatment providers."

Maybe my imagination is running wild here, but I find myself wondering why MQAC, having discovered that the patient had the records all along could not have simply suggested that he or she simply return them to Dr. Bunin. If things were that simple I guess we would not need government.

Keep up the good work MQAC.

Duh.

PS: Dr. Bunin is still waiting for MQAC to approve that four hour (minimum) course he hopes will teach him to keep a copy next time he provides an original record to a patient.

Next critique of MQAC: A New Kind of Abandonment

What makes some of us believe in an unconscious?

The idea has been around for over a hundred years, but nobody has seen one.
You will not see the unconscious mind on a CT, MR, PET or SPECT scan.
It will not pop into view when a neurosurgeon opens the skull.
Like gods and Ptolemeic epicyles it seems to explain anything and everything you want it to.
Like most such myths there is no way to prove it does not exist, but unlike the myth that the world is round, it has not advanced knowledge, even our ability to treat mental illness.
What would believers accept as failure to demonstrate its existence?

Suicide risk? I don't want you.

Why do psychiatrists and other mental health professionals continue to accept into their practices patients who contemplate suicide? Do they want to be heroes? Do they feel too guilty about rejecting someone who "needs" their help?

Know that if a patient kills herself on your watch any survivors and their attorneys will very likely come after the money in your malpractice policy.

Know too that a colleague will gladly testify that if only you had done or not done something you should or should not have done the patient would still be alive today. Licensure boards will do the same. Never mind whether the patient's choice to die had anything at all to do with that for which you were treating them.

Because of these potential devestating consequences, including the emotional impact on yourself, once you know that the patient entertains thoughts of dying you will likely focus the preponderance of your efforts, not on providing the best treatment for the problem, but on preventing a suicide. Consider carefully whether you can keep someone from killing himself. In my community years ago a patient shot himself while in the office with the psychiatrist. Could you have stopped him? Patients kill themselves in psychiatric hospitals. If we cannot prevent those suicides, how can you imagine you have any control over someone between encounters?

Mental health professionals need not accept these risks. We can still ethically decide whom to accept and whom to reject as patients. If judges and juries continue to hold us responsible for the intentional acts of others we can choose not to accept the risk. Consider the consequences if we turned away potential patients whom we judged to carry an unacceptable risk of suicide. Patients would likely soon learn they must lie in order to obtain treatment. Might we add statements to our treatment agreements like, "I have never contemplated or attempted suicide." Would you demand to review prior records for evidence of past attempts or impulses to suicide? If you published on your Web site your policy of rejecting patients with unacceptable risk would they look elsewhere or simply be better prepared to lie.

Might such a change impact people contemplating suicide? Might knowing that mental health professionals might reject them as patients afterward (if the attempt failed) make them less -- or more -- likely to kill themselves? How might a patient react if after the initial evaluation you tell them you will not accept them as a patient? Who will accept them? Will they overwhelm those who do?

Consider making at least a small adjustment in deciding whom to accept as a patient. Maybe if more of us reject them, higher risk patients might not find anyone to treat them, and the courts or legislatures might do the right thing and stop blaming the treaters for the choices of their patients.

Suicide Risk Monitoring, Inc.

In an earlier post I criticized my state's Medical Quality Assurance Commission for faulting a physician for not requiring more frequent visits with a patient who appeared to need monitoring of suicide risk.

The official CPT code for Psychiatric Medication Management (the infamous med check) is 90862. As far as I know a code for Suicide Risk Monitoring does not exist. Yet responsibility falls on the shoulders of mental health professionals simply to "see" patients who might be at risk of suicide often enough that somehow sufficient frequency will prevent a suicide attempt. This means presumed suicide risk dictates frequency of visits not otherwise needed for treatment.

Regardless of whether increased frequency of patient encounters can actually prevent suicide, I argue that, particularly in light of shortages of psychiatrists in many areas of the country, a nonphysician could more cost-effectively carry out this function which amounts to little more than behavior control. Here's how it would work: a given clinic or professional or even a family member could require any patient deemed at risk of suicide to purchase suicide risk monitoring services separately. Such a company would regularly contact the client to assess risk of self harm, independent of treatment of any mental disorder, using a tally of risk factors and standardized rating scales. This would free treating professionals to focus on treatment, possibly increasing its cost effectiveness and leaving behavior control to SRM, Inc. In fact, since suicide frequently occurs in the absence of any mental disorder, such individuals might not need mental health treatment at all.

Increased risk would lead to increased monitoring or even incarceration. SRM, Inc. behavior control teams (BHT) could follow clients into hospitals.

Who would pay for suicide risk monitoring? Should medical insurance pay even in the absence of a diagnosed mental disorder? Should society bear this cost? the individual? a family member? Would the cost be offset by reduced number of suicide attempts and associated needs for treatment? Could such a service reduce the need for expensive psychiatric hospitalization?

I am actively seeking investors.