What About Treatment?

To considerable fanfare (press release) last week the Obama administration announced an action plan for addressing the "prescription drug abuse epidemic." Along with ONDCP, FDA, HHS, and DEA will lead the effort. Notably absent from the alphabet soup of federal agencies are CSAT and SAMHSA, or indeed any mention of treatment. The plan just lays out more of the same old supply side war on drugs that will make it harder for physicians to manage pain with narcotic analgesics in the patients who really need it, and likely restrict supply which will lead to higher black market prices, more crime, and more cartels. And more job security for DEA agents.

You might think professional organizations like APA and ASAM would raise the issue of treatment, but no, that does not seem politically correct from their point of view. In a press release treatment barely achieves afterthought status. When I asked ASAM's government relations representative, Alexis Horan, she responded with this:

"ASAM has been working with the DEA since last March to have them issue a guidance to all prescribers re: what to expect from these audits, how to prepare, etc.  We’ve also suggested to the DEA that their agents be better trained on how to perform these audits, how to work with the providers and their staffs, etc.  In fact, we’ve facilitated some meeting between local DEA agents and ASAM chapters to have an open dialogue about audit experiences.  We are also working with SAMHSA and other HHS agencies to offer prescriber training and other ways of education people about these issues.  I promise you, ASAM cares! "

In other words, "comply, comply, comply."

I wrote back:

"ASAM seems to care more about compliance than the rights of members and their patients. What keeps ASAM from demanding that DEA schedule the audits to minimize disruption? What keeps ASAM from demanding and publishing an "Administrative Warrant?" How can ASAM educate if it cannot provide such a document to its members? Is it not politically correct? What repercussions does ASAM fear if it takes a stand?

"Many of my readers believe their professional associations have failed to advocate vigorously enough where they believe their rights have been violated. Is this not a legitimate role for such an organization?"

No response to date.

What are these organizations afraid of? Why are they shaking in their boots when they hold an excellent position from which to advocate not only for treatment, but also for freeing physicians to do their jobs without gratuitous interference from law enforcement disguised as auditors. While paying lip service to "caring," ASAM, with this cowardly approach, misses the opportunity to call DEA on the carpet for discouraging treatment, thus working at cross purposes with agencies charged with encouraging treatment.

The federal government must deal with its ambivalence toward treatment if it really wants to solve the prescription drug problem, and professional associations like ASAM must keep up the pressure rather than rubber stamping failed policies.

The Good Med Check IV: Getting Physical

(Continued from The Good Med Check III: Time Is Money)

Critics of the med check often equate the abandonment of psychotherapy by psychiatrists with tragic abandonment of the biopsychosocial model, viewing psychotherapy as a necessary ingredient of every patient encounter (if only for psychiatric patients). You might think they were invoking the bio-psychotherapy-social model. But in fact when psychotherapy in the form of psychoanalysis stuck it's foot in the psychiatric door a hundred years ago was it not the "bio" that was abandoned? Back then  few drugs competed with non-"biological" treatment modalities, but as the model of psychiatrist as psychotherapist (or just "therapist") evolved psychoanalysts pronounced the physical examination, so long an integral part of patient-physician encounters, incompatible with analysis, and eventually any psychotherapy, citing potential boundary violation: talk, but don't touch. (Thankfully, we do not hear protests that psychotherapy should accompany electro convulsive therapy.)

To be sure physicians of many specialties have abandoned the physical exam in favor of laboratory tests and imaging studies. If your non-psychiatrist physician lays hands on you at all, she will likely limit or direct the examination to only that which relates directly to your complaint or diagnosis. Admittedly, at least at first look, few aspects of the physical (other than the mental status exam) seem directly related to psychiatric complaints or disorders, unless the psychiatrist assumes the role, as some do, of primary care provider. But a psychiatrists probably could do a better job by attending to a few physical findings, whether part of a med check or a psychotherapy session. A few examples follow:

• Monitoring blood pressure in patients taking venlafaxine, and some other drugs
• Weighing eating disorder patients or patients taking drugs that affect weight
• Pupil diameter when you suspect unadmitted drug use
• Examination for cogwheel rigidity in patients taking dopamine antagonists
• Neurological examination to rule out neurological causes for psychosis or conversion

One could argue that the psychiatrist needs to "see" the patient more than the patient needs to see the psychiatrist. In some ways physical examination of a psychiatric patient stands at the opposite end of the spectrum of clinical tasks from psychotherapy, but it is at least as legitimate.

The Good Med Check III: Time Is Money

(Continued from The Good Med Check II: Getting to Know You)

Shorter visits to the psychiatrist translate into more than lower cost to the patient and higher income for the doctor.

Blogger Steven Balt commented on my first post in this series: "And be sure to get it all done in the 15 minutes you're allotted for each patient!!" Come to think of it, the usual pejorative label actually reads "15 minute med check." Steve refers to this as a "cookie-cutter treatment mentality" and tells us he works part-time in a community mental health center. I surmise that means sicker patients with fewer resources and less discretion on the part of the psychiatrist in determining the schedule. More likely than not many if not most patients could use more than 15 minutes even for a med check. In my practice, however, I have the luxury of determining how often I schedule patients. Maybe I'm spoiled. Even if I schedule a different patient every 15 minutes, many of the visits take less than five minutes, so I can spend more time with others. And we all pray for late cancellations and no-shows on busy days, so we can get some (administrative) work done.

The tradition of the 50 minute hour has raised expectations in psychiatry more than any other medical specialty that patient and doctor will have time to chat. It's not just about psychotherapy. Both patient and psychiatrist complain that loss of such relaxed visits resulted from a need to limit payment. As psychiatrists have moved away from the 50 minute hour because of financial considerations patients have questioned the now standard practice of charging almost as much for a medication management encounter as they might have to pay for full session psychotherapy, or the converse, from the psychiatrist pointed view, of getting paid little more for what really occupies an entire hour than they can charge four (or more) times in that same hour. But what does the psychiatrist really get paid for? Not just time.

Consider treatment of two patients for an entire year. One patient gets 50 minute sessions weekly while the other gets four 15 minute medication management encounters during the same year. The psychiatrist still likely spends equivalent amounts of time with administrative work like prescription refills, and each of the two cases represents similar risk of a professional liability lawsuit. Yet the annual revenue for the two patients differs dramatically. This should explain to some degree the apparent discrepancy in the two fees charged. And while some patients still want to spend lots of time talking to the doctor, or actually doing psychotherapy, others resent having to present themselves more than once a year just to get that prescription renewed. After all, if something goes wrong they know they can always schedule an earlier appointment.

Shorter visits make for more flexible scheduling too. Double booking full session psychotherapy means someone has to reschedule or sit it out for an hour in the waiting room. But when you double book medication management encounters accommodating both patients requires only that one wait for an extra 10 to 15 minutes. This makes it more feasible to schedule an encounter earlier to address a problem that cannot wait the usual interval. The same applies to phone calls. Some psychiatrists still seem to interrupt psychotherapy sessions for "emergency" phone calls (a bad idea in my book), but a fifteen minute med management encounter means postponing that call fifteen minutes at most, making interruption unnecessary.

(Continued in The Good Med Check IV: Getting Physical)

The Good Med Check II: Getting to Know You

(Continued from The Good Med Check I: Checking the Med)

Critics of the now nearly ubiquitous medication management encounter frequently recite the mantra that psychiatrists who use this procedure  do not "get to know" their patients. They would have us believe that spending 45'-50' for psychotherapy once or twice a week in an artificial setting subject to numerous restrictions on verbal and other interactions allows the physician to really know the patient. They would also have us believe that only psychiatrists need to know their patients. They rarely complain that endocrinologists don't know their diabetic patients or gastroenterologists the patients on whom they perform colonoscopy.

I believe the better any physician knows his patient the better care she can provide. But don't equate psychotherapy with getting to know the patient. Many psychotherapies probably interfere with really knowing the person in treatment. One of the first things a psychiatrist should do when embarking on a medication management practice: Dump all the psychoanalytic dogma about blank slates, boundaries (no, maybe not all of those), and self revelation, and relate to your patient like any other physician, like a human being.

You can get to know your patient even in a 10' med check. Here are some ideas:

• Ask the patient about new developments in his life since the last encounter.
• Talk about an interest or concern you share with the patient, something the two of you have in common.
• Establish an interest in a matter you know is a priority in the patient's life.
• Discuss sports, hobbies, entertainment.
• Follow up on the patient's evolving relationships with significant others.
• Ask the patient what has changed most in her life since the medication started to work.
• Inquire about the patient's pets. Even encourage them to bring one to a visit.
• Chat about current events, religion, politics
• Encourage dialog about health care reform.
• When (if) you conduct encounters via video-conference you may see the patient at home, at the office, or even in a vacation spot. You may see a family member, pet or other element of the patient's life you would never see in your office. Ask about what you see.
• Google your patient and tell them what you discovered.

Look for a subject that will evolve over time. Make a note in the patient's record to remind you to inquire about change in that subject during every encounter. Even one or two minutes devoted to such dialog will enhance the effectiveness of your services.

(Continued in The Good Med Check III: Time Is Money)

The Good Med Check I: Checking the Med

The much maligned "psychiatric medication management" visit, sans psychotherapy, pejoratively labeled the "med check," has become standard for many if not most psychiatrists. Contrary to the mantra, everyone does not need psychotherapy, but all med management encounters are not created equal. My concept of the elements of a good, even great, and comprehensive, med check follows. Don't expect to cover every one of these on every visit. Feel free to suggest additions to the list:

• Inventory of target symptoms and behaviors
• Assessment of success or failure of treatments
• Discussion of dose adjustments and adding or removing medications
• Monitoring of substance use emergence or relapse and use of recovery tools such as 12 step groups and sponsors
• Reassessment of working diagnosis and safety
• Review of status of psychotherapy or other treatments provided by other professionals
• Inventory and management of side effects
• Prior and emerging medical problems
• Review of medications for other conditions started since last visit and potential interactions
• Overall assessment of treatment status
• Review of long term goals and plans
• Education about the illness and its treatment
• Education about new related developments and treatment alternatives
• Referral to other services or professionals
• Laboratory and other tests: drug screen, medication levels, thyroid, liver function, renal function, imaging
• Administrative matters such as reimbursement, refills, appointments, changes in practice policies and procedures
• There's no law against throwing in one or two brief and carefully selected psychotherapy interventions, especially CBT or systemic
• Getting to know the patient (next post)

How many of these items might we apply to almost any patient-physician encounter, not just psychiatric, even perhaps including the psychotherapy interventions?

(Continued in The Good Med Check II: Getting to Know You)

"Self Abuse" Redefined

Consider "child abuse": Who gets hurt? The child.

Now consider "Drug abuse." Who gets hurt? The drug? Hardly.

One who "abuses drugs" hurts oneself.

"Self abuse."

I propose we abandon the old use of the term. Who uses it that way anymore anyway? The light bulb flashed on in my head as I became embroiled in yet another dispute over the notion of "self medication," once more misapplied to an individual using drugs and alcohol in the context of another separate (presumed) psychiatric disorder.

As in most such cases the drugs and alcohol more likely hurt rather than help the patient, as I argued in my earlier post: A Working Definition for Self Medication

So when you hear or see the term self medication in the future think self abuse and see if it doesn't lead to more accurate conceptualization of the case.

Sleeping for Fun and Profit

The recent New York Times article describing the psycho pharmacotherapy practice of Pennsylvania psychiatrist Donald Levin, M.D. garnered considerable negative attention from the psychiatric blogosphere, mostly from advocates of psychotherapy and detractors of psycho pharmacotherapy. Desperate to garner support for what I call sporkiatry, the practice of combining psychiatric medical treatment with psychotherapy (sporkology when performed by psychologists with prescribing privileges), they all seem to have ignored an article published in New York Times Magazine only a few days prior in which the author describes his multiple experiences of psychoanalysts falling asleep during his sessions.

Although I cannot recall ever having fallen asleep myself during a psychotherapy session I came close on a few occasions, and I know that the problem is not peculiar to psychoanalysts. However, regardless of how you feel about Dr. Levin's short patient encounters, I would be surprised to hear that he ever fell asleep during one of them, regardless of how "boring" (Danny Carlat's suggestion) or "unfulfilling" he may find medication management. (If you know of a psychiatrist who fell asleep while administering electroconvulsive therapy or transcranial magnetic stimulation, please report below.)

Blogger Carlat places more importance on the psychiatrist's job satisfaction than on what best serves the patient: "doing therapy is fun--it's involves getting paid for having interesting and intimate conversations with people." Or interesting dreams?

Blogger Steven Balt accuses Levin of "selfishness." [correction: Dr. Balt in his comment points out that the article, not Dr Balt himself, accuses Levin of selfishness.] Is Dr. Levin selfish to sacrifice the "fun" of psychotherapy? Balt still seems to think it's all about the session: feeling good about what goes on during the 50' hour rather than relief from symptoms outside the psychiatrist's office. Or maybe it's whether the psychiatrist reaches REM sleep.

According to blogger 1 Boring Old Man, "Days like Dr. Levin describes change you into a machine, and you become kind of brain dead." Might this result from sleep deprivation?

In contrast blogger Reidbord at least understands the proper purpose of psychotherapy:  "I’m a huge advocate of psychotherapy, yet I don’t recommend, much less provide, it for everyone.  It’s a treatment..."

It is not so much that these (we?) fallible professionals fell asleep in the course of their (our) work, but as the author points out, at least one psychoanalyst writing in a professional paper appeared to blame the patient. And it took the author's mother to raise the question of whether he might not have needed psychotherapy to begin with, underscoring the fact that almost no professional providing psychotherapy will likely tell the patient after the first interview, "Get outta here. You don't need treatment."

Everyone makes compromises and mistakes, and there is no perfect psychiatrist or psychotherapist, but I'll take a Dr. Levin, awake, alert and responsive, over a somnolent psychoanalyst any day.