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 (geumaphobia, patroiophobia).

Here's where you come in. These and many others have me stumped so far: Celtophobia, agraphobia, bibliophobia, computerphobia, heresyphobia, mottephobia, tomophobia. Please leave suggestions under comments. Enjoy.

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.

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 StoptheDrugWar.org.

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.

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.

Electronic Records, Subpoenas and the Hubris of Lawyers

The notice of subpoena did not surprise me; I already knew about the litigation. In my state attorneys must provide two weeks notice before serving a subpoena duces tecum to allow the affected parties time to seek protection, that is to quash the subpoena, in this case for medical records. Like most such subpoenas, this one, signed by attorney Nancy W. Anderson, representing Wells Fargo Bank, commands me to appear at the law office (Graham and Dunn) this coming Monday at 9 AM "to produce and permit inspection and copying of the following documents or tangible things." Typically one simply provides copies of the records by mail. Also typically, circa 2012, and for many years prior, such a subpoena might also likely mention electronic files. Since this one does not, I faxed attorney Anderson a letter asking for clarification and assistance. As of today she has chosen not to respond except that she did confirm that no one has succeeded in quashing the subpoena, so I must comply.


It turns out that the records in question exist not only in a manila folder in a file cabinet in my office, but also on the hard drive of an old computer, and in the cloud in three different locations. I can probably (I am no computer expert.) make digital copies of one or two of the files on a CD, but I know no way of copying some of the files that exist in the cloud. This means that anyone who wants to review the records will need to access them directly via the Internet. An attorney for my EMR (electronic medical record) service assured me that this can be done.

Attorney Anderson does not seem to appreciate the difference between paper medical records and the EMR, or maybe she just does not know what to do. This particular record includes at least two items that I am unable to "copy" to paper: a voice mail recording from Anderson herself and the digital signatures that I assume accompany each item. I can do no more than assume as I know of no way to view the signatures myself, much less render them to paper. I might liken the notion of copying an EMR to paper to that of copying water or the barking of a dog.

The confusion here certainly inconveniences me (although it does give me something to write about), but having myself reviewed as an expert witness pathetic paper counterfeits of electronic records, I have concluded that today an expert who has not accessed the EMR directly using a computer should be accorded no credibility in court. The credible expert witness therefor must not only demonstrate expertise in the area of medicine at issue, but must also know how to navigate the EMR, which in some cases requires considerable training and experience.

Still faced with an unresponsive -- if not rude -- attorney I sought help from Judge Dean Lum (pictured above), but officials at Superior Court advised me that I would have to file a motion to spur Judge Lum into action. Someday, maybe, but not now. Instead, they advised me to contact the opposing attorney. He simply told me not to worry too much but to keep after attorney Anderson.

All I need is for Anderson to tell me what she wants. Perhaps this post will move things along.

Firing All Patients With Medicare

When I announced on my favorite physician Web board that I had mailed discharge letters to five patients solely because they have Medicare my colleagues hailed me as their "hero."

I don't feel like a hero.

I opted out of Medicare years ago, but Medicare requires physicians who have opted out to write a letter reaffirming that status every two years. Last year I realized it might have been four years, so I dashed off a letter and waited. You can imagine my shock when, on February 10, 2012, I opened a letter from "Darla" (no signature or last name) dated August 4, 2011, but with no postmark on the envelope. Darla writes that my "affidavit does not meet CMS requirements." (What affidavit?) She goes on in her 6th grade English: "Opt Out Affidavit was unable to be processed. We did not receive the requested information in a timely manner. A request for information was sent June 13, 2011 to apply for a Type 1 NPI number." (If Darla intends to say Noridian, the Medicare administrator for my area, sent that information to me, I never received it, and I already have some type of NPI number.) Then she writes that I need to use my "Legal Name" when "filling out the information." (How does one "fill out information?")

I called Noridian provider enrollment to investigate. "April" reminded me that treating these Medicare beneficiaries without opting out subjects me to prosecution. I don't want to go to jail, although at least there I might have a right to free medical care.

I sent discharge letters to 5 patients and asked my office manager to call them to warn them in advance. Now I am completing a Medicare DISenrollment form. In the future I will require all new patients to demonstrate that they do NOT have Medicare.