Should Doctors Dispense Medications?

http://www.latimes.com/business/la-fi-lazarus-20130412,0,1884241.column

 

http://shirahvollmermd.wordpress.com/2012/10/24/doctor-patient-and-pharmacies-an-oedipal-triangle/

 

Should doctors dispense their own medications? Why do we need pharmacies? Many optometrists also sell glasses, so why should a doctor not give out the medication that he/she prescribes? This question has baffled me for years. As a psychiatrist, I fantasize about the possibility of giving medication on the spot, avoiding the second step of what many of my patients call the “shame” of having to go to a pharmacy, with the often-felt look of dismay on the dispenser’s face, as my patient picks up his third psychotropic medication because the first two did not work. As the LA Times series, mentioned above, illustrates, pharmacies, as the middle-men, are subject to miscommunication and possibly fraudulent behavior. If doctors dispensed medication, the patient paid the physician, then the physician gave the patient a receipt, allowing the patient to get reimbursement. This reimbursement would be done at the same time the patient is reimbursed for the office visit. Simplicity and efficiency would prevail. Fewer mistakes, as it would be unlikely for me as a physician to dispense the wrong medication to my patient. Costs are less because I would bear the overhead expense of storing and tracking the medication. The intimacy of my relationship with my patients would benefit, as adding a third player into our relationship often feels intrusive and unnecessary. Rarely, pharmacists answer important questions for my patients, but for those situations, I would hope that there are pharmacists, on call, for a fee, that are available to explore medication inquiries, including drug interactions. There-health care in the next century-maybe if the folks in Washington consulted me-real progress could be made. Whose ear do I need?

Arrogance or Confidence?

Arrogance or confidence-what’s the difference? “All the other doctors released the medical records,” the trustee of a patient’s estate told me. “Yes, but that does not mean that all the other doctors did the right thing,” I respond. “Releasing medical records after someone passes away requires a court order,” I point out the law. I have confidence in knowing this fact, but to an untrained ear, I might sound arrogant and stubborn. As a psychiatrist, I have more medical training than non-medical therapists. This is true, but to some, this would also sound arrogant. As a psychoanalyst, I have more psychotherapy training than my non-analytic colleagues. Again, true, but potentially misconstrued, if spoken aloud. As a teacher of psychoanalysis, I convey psychoanalytic ideas, in a way which I hope enlightens my students, but I travel a fine line of sounding over-confident, as opposed to relative certainty. Is it that my confident colleagues can view alternative points of view with curiosity, whereas insecure folks view differences of opinion with contempt? The issue here is that the arrogant person, rarely, sees him/herself as arrogant. He/she sees him/herself as confident. Arrogance is a judgment laid on others, sometimes out of envy, and sometimes out of a certain tone, and sometimes out of experiencing a feeling of inferiority. At the same time, arrogance can be attractive when it is viewed as confidence. So many folks lack certainty, that when they are in the presence of one with certainty they are drawn into their presence. This may, in part, explain charisma, another challenging quality to articulate. Relationships often flip over, when it begins by admiring confidence, but over time, becomes a hatred for arrogance. I struggle with these ideas. Help!

Doctor, Patient and Pharmacies: An Oedipal Triangle

 

For years, pharmacies call me “demanding” a refill for a patient. Sometimes I have never heard of the patient. Other times, I just saw the patient and handed them a prescription. Still, other times, I have not seen the patient in quite some time. Without knowing the circumstances, pharmacists leave messages like “this is our third call,” as if, I have been a “bad girl” and not responded, as if I need to respond to a message that does not make sense. Today’s LA Times, exposes a practice that I have long suspected. Pharmacies call for refills, even when the patient does not ask for a refill, so that they can bill the insurance company. “That is why I don’t call back pharmacies unless the patient tells me ahead of time that I will get a call,” I want to scream to all who will hear. As I see it, the pharmacy represents an intrusion into my relationship with my patient. I work to help my patients, not the pharmacy. The pharmacy enters into my relationship with “demands” which I find out of place. One of the many advantages I have, by not having a staff, is that I am on the front lines with all of the administrative details of practice. My ship is small, but it sails. No intrusions allowed.

 

http://www.latimes.com/business/la-fi-cvs-caremark-20121024,0,6138463.story

Tele-Psychiatry for Kids?

At the risk of sounding like an old fart, I am not prepared to accept the changing nature of psychiatry, yet again! For many years, I have appreciated the advancement in technology leading to Tele-Psychiatry, where people who cannot leave their homes, or who live far away, can connect remotely to a psychiatrist, allowing for access which would otherwise be impossible.  For adult patients, I am excited by expansion of our services. Now, let’s move into Child Psychiatry. Can a Child Psychiatrist do an assessment through a computer screen? It seems to me that evaluating children, working with families, mandates a three-dimensional exposure which would be severely limited by Tele-Psychiatry. As so much interaction is non-verbal, and as so much of an assessment includes “playing” with the child, I do not see how remote communication can simulate this encounter. Two-way communication devices are wonderful advances in medical settings where doctors do not need to touch their patients, but as a Child Psychiatrist, the “touching,” or more specifically, the shared use of space is critical to understanding how a child navigates their world. Some kids come and sit quietly, whereas other kids have a hard time staying still. Sometimes my words help kids focus, whereas other times, a child needs to be active in my office. These nuances will be lost with a remote access device. Once again, I am left thinking that change can be good, but then again, not always. I understand the dilemma between improving access and quality assessments. I also understand that as a field Psychiatry, particularly, Child Psychiatry, has to hold on to the key tenets of the profession. For me, this includes being in the physical presence of a family is an important component to the understanding of powerful relationships and their sequelae. I am not sure I would be willing to compromise on that issue. Technology should aid us in our goals, not detract us from them. Tele-Psychiatry for kids seems to move my field in the wrong direction.

SIG-E-CAPS

This is the mnemonic for diagnosing depression, according to our current manual, DSM-IV. Five symptoms, two weeks, seriously? Let’s review. Suicidal thoughts, are these active or passive? Perhaps they are related to a traumatic event. What if they go away in three weeks, then does the person still get a diagnosis of “Major Depression”. Interest in activities, is this losing interest or diminished interest? What if the person is fatigued, as a result of anemia, and this explains the lack of interest in activities? Guilt, my favorite criteria, since so much of guilt is unconscious, are we talking about conscious guilt? If so, very few people admit to this, particularly not int he first interview. Energy, see my comment on interest. Concentration, again, see my comment on interest. Appetite, decreased I can understand is a sign of mental dis-ease, but increased appetite is often a result of increased energy expenditure. Psychomotor changes, maybe a result of fatigue, or boredom, not necessarily depression. Sleep, same as appetite, in that it is often dependent on activity level.

So, am I dismissing our current diagnostic system? Yes and no. Symptoms must be taken in context. Context is understood through building a relationship where the patient increases trust, and therefore feels more free to display the context of his/her symptoms. A rush to judgment leads to a rush to medicate, leads to a patient not understanding his/her own mind. A delay in judgment could lead to needless suffering, but I would argue that the relationship building helps the suffering, so while I obtain a thorough history, I am also helping the patient symptomatically by providing a space for thought and reflection.

I want the patient’s history to become relevant again in psychiatry. This is a major reason I have this blog. I will repeat this point until my field changes its emphasis, or until I retire. I hope for the former.

A Concierge Psychiatrist?

Are psychiatrists going concierge? Wait, I am confused. I understand that certain primary care physicians charge patients an annual fee to be on their patient panel. In exchange for this annual fee, the patient is given more personalized service including easy access to their physician, house calls and sometimes the physician goes with the patient to their specialist. This means that the primary care physician goes from a panel of patients in the thousands to a number which is less than one hundred. The ethical dilemma is who is going to take care of the patients who are no longer seen by primary care doctors who change their practice. There is a primary care physician shortage, but whose job is it to fill in that gap? Is that the doctor’s responsibility? I recognize the dilemma both for patients and for physicians over this trend to pay for more personalized service. Now, let’s add-on. Are psychiatrists now charging patients a retainer to be on their panel? Does this make sense? Maybe. Maybe not. Fees are interesting therapeutic issues. When people pay do they value the service more? Sometimes. On the other hand, paying for service could make them value it less, as some people see financial exchange for immediate service as a right, without an appreciation for the  effort that goes in to accommodating other people. There are a limited number of hours in a day, so one has to limit the time or limit the patients somehow. What is the fairest way to do this? Maybe fair is not relevant here. Maybe this is a personal choice, where physicians choose how they practice and patients choose what makes sense for them. On the other hand, maybe there should be public service requirements of physicians, where they have to spend some time serving a low income population in order to maintain their license? Maybe The Medical Board should require physicians to teach in medical schools as a way to spread their knowledge and experience. I have no answers-just questions.

See also…http://www.latimes.com/news/local/la-me-concierge-medicine-20120729,0,269142.story

http://www.youtube.com/watch?feature=player_embedded&v=8IX-zdZdOco

‘Nonessential Medications:” Another Rant

Teaching Primary Care Residents, I learn so much. I also get frustrated, angry, and fantasize about going on the rooftops to let others know of my unhappiness. “Sometimes, when a patient comes in the hospital, and we are not sure what is going on, we stop the SSRIs and all the nonessential medications to see what is going on with the patient,” an excellent, smart, hard-working resident says to me. “Who says the SSRI is nonessential?” I ask, thinking that no one is checking in with the patient to see if he feels their SSRI is “nonessential”. “Well, you know, it is not life and death,” he says, understanding my discontent. “No, it is usually not life or death, but it is quality of life, and this can determine if the patient is motivated to help himself get better,” I say, knowing that the resident does not need an education about the importance of SSRIs, but that he is reflecting back to me the feelings of the team-the medicine team, composed of interns, residents and attendings. “I am sorry,” I say, “but I think that behavior suggests a dismissiveness to mental health. I think that the team is believing that SSRIs are relatively trivial medications and so they can be stopped, similar to vitamins.” He agrees, but looks at me with some sense of regret for bringing this to my attention because he can see my upset. I wonder how to push through this arrogance, sometimes seen in primary care, where they believe that physical health trumps mental health, every time, as if they are not closely linked. Medicine, as a field, has a lot of room for growth. Openness, as with all growth, has to be the first step. For now, I am stuck.

‘Too Sick For Therapy’

Meital, twenty-year old female, long-standing issue with drug and alcohol abuse, with long-standing history of psychotherapy, along with a history of intermittent psychosis, which could be drug-induced or it could be a primary psychotic process.  She goes out of state for an upscale rehabilitation center at which time she is forced to develop a new relationship with a psychiatrist because her new facility insists that she use their staff psychiatrist as her treating physician. Dr. Luigi, her new psychiatrist, reviews the records of her psychiatric hospitalizations, but he does not talk to her previous treating psychiatrist, me. Meital, anxious to be in a new setting, is guarded and reluctant to engage in a new relationship with Dr. Luigi. Dr. Luigi, basing his opinion on hospital records and not outpatient treatment experiences, views Meital as “psychotically withdrawn” and therefore not amenable to psychotherapy. “Maybe she is frightened and therefore she needs the time and patience of a good and attentive listener before she will express herself,” I say to the staff at her treatment center. As I say that, I am once again feeling like I hearken back to an age where listening was so valued. Instead, Dr. Luigi maintains Meital on high doses of antipsychotic medication because it is his professional opinion that she is “very ill.” I, in contradiction, think that the medication is hindering her recovery because she is overly sedated and more withdrawn on the medication, making her appear more ill than she is when she is unmedicated. Dr. Luigi and I discuss this, but no meeting of the mind happens. We agree to disagree. There are no objective tests to settle the score. I worry for Meital, but I also worry for my field, where medications not only mask underlying issues, they also cause people to misunderstand what is going on in their internal world. Maybe Meital will never have the opportunity for personal exploration. Maybe Meital will come to see herself as mentally impaired, and as a result, she will not strive to build a life for herself. The downstream of these decisions could be grave. There are people who are “too sick for therapy.” I just think Meital is not one of them. The weight of this decision point is huge. I can only hope the tides will turn.

Psychiatry Residents: Thinking About Psychoanalytic Training

This is not the group I spoke to today, but the picture gives you an idea of psychiatry residents, physicians who decided sometime in their medical career to specialize in psychiatry. These folks, graduates of medical school,  have decided to spend four years doing adult psychiatry training and they can then decide to add-on another one to two years to do child psychiatry training. At a noon-time talk, we discussed why I did psychoanalytic training and whether it makes sense for them. “I felt when I finished my adult residency and my child psychiatry fellowship that I needed more psychotherapy training.” I said to astonished faces. “After all this training you did not feel competent?” One resident asked me. “First, you have to remember that I trained in the eighties where we had a lot of psychotherapy training in residency and we did not have as many psychopharmacological tools, which means that we did not have psychopharmacology clinics like you have now.” I say, emphasizing that doing psychotherapy in residency made me appreciate the depth of knowledge necessary to do deeper work, such that more training seemed mandatory to me.

On the one hand, I understood that from their perspective, they are about to graduate from ten years of education, many of them saddled with substantial debt. The idea of further education must seem both financially and academically absurd. On the other hand, the work of a psychiatrist/psychotherapist can be so deep that training is never finished. This is a field of ongoing in-depth analysis of the human mind, which requires expert consultants, ongoing study, along with group training experiences to fully appreciate the nuances of motivation. “The end of residency is not the end of learning,” I say to a group that continues to look stunned.

I am left to reflect on my own classmates in residency. We knew that psychoanalytic training was in our future. We accepted that as part of our professional development. Psychopharmacology was a nice addition to our tool box, but it was no substitute for studying how the mind navigates a complicated world. I fear that my cohort is a dying breed. “The one thing I am sure about is that I cannot be replaced by a computer.” I say with confidence. “Oh yes, you can” the residency director  says. “One day a computer will study your every move and then be able to do exactly what you do, except that you keep learning and the computer cannot do that,” he corrects himself with a good point, supporting my point. Psychoanalytic training, as a lifelong process, makes my work deepen with time. Each patient adds to my experience and my wisdom, along with consultation with colleagues and study groups, such that replication of my work is nearly impossible. “I work in a personalized way and I am grateful for that opportunity,” I tell the residents. “No one else thinks like I do, and so I bring something unique to each session,” I say, without modesty, emphasizing the privilege of being a psychiatrist. I am not sure these residents will be able to say the same thing, but I sure hope they will.

The OBGyn Finds High Cholesterol: Now What?

Continuing on our discussion about referrals, http://shirahvollmermd.wordpress.com/2010/07/07/the-referral/ and http://shirahvollmermd.wordpress.com/2012/02/27/why-dont-pediatricians-refer-to-child-psychiatrists/, Olivia, seventy-two, presents to me for issues of depression and anxiety. In the course of thorough history taking, we review her medical problems. She is remarkably healthy, absent major medical issues and she is trim and fit and active with a good energy level. We review her treating physicians. Dr. Lesley Lee, a prominent female OBGyn in the community has followed her for years for routine gynecological examinations. Twenty years ago, Dr. Lee noticed on the laboratory tests that her fasting cholesterol was high so Dr. Lee referred her to Dr. Jay, a prominent female cardiologist. “Why did Dr. Lee send you to a cardiologist?” I asked, shocked that Dr. Lee did not send Olivia to a primary care physician. “Well, I don’t know, that is just who she sent me to,” Olivia replies, indicating that she never considered this question before. “Do you have a primary care physician?” I ask, trying to mute my concern for this referral pattern. “No, I did not think I needed one,” Olivia replies, again, seemingly disturbed that I am intruding on her medical issues. Over time, we discuss the importance of primary care and over time, Olivia agrees to go to a primary care doctor that her friend raves about.

I am left to imagine why Dr. Lee sent Olivia to the cardiologist, Dr. Jay. Both physicians are female. Maybe they are friends. Maybe they go to female networking breakfasts. Beyond that, I cannot imagine why a healthy woman, with the only abnormality being an elevated cholesterol should not be referred to a primary care physician, so that diet, exercise, and maybe statins can be discussed in the treatment plan. Clearly a primary care physician can screen for heart disease, diabetes and other metabolic issues. The public health aspect of this referral also concerns me. Dr. Jay as a cardiologist needs to spend her precious time on those who need specialty care, not on those who can be handled by Internists of Family Medicine physicians. Are we, as physicians, not obligated to be concerned about how we use our resources in the best possible way, not just for the patient, but for the population as well? Sometimes, I feel so old-fashioned. Still, old ideas are not necessarily bad ones, as I have said many times.

What can I do? I ask myself. I can try to persuade Olivia to develop a relationship with a primary care doctor. Yep, I did that. Should I call Dr. Lee and discuss my issue with her? I don’t think so. I don’t have a relationship with Dr. Lee and I am not sure I know how to make that call without making her defensive. Should I call Dr. Jay and discuss my issue with her? Again, without a personal relationship, I only stand to make her angry and upset. So, this post serves as my outlet for my discontent. Thanks readers for allowing me to vent.