Fungible

 

Health care is moving to assembly line medicine which means that physicians are completely interchangeable, or fungible, entities. This does not mean that people will get poor care, but it does mean that the role of the physician has changed from cultivating relationships to following algorithms. In the long run, those attracted to a medical career will be a different personality type than those in the past, as following algorithms is a different skill set than feeling the pleasure of healing relationships. I understand the value of fungibility, yet I am sad about this change.  Adapt or die, comes to mind, and so I will adapt.

 

 

 

 

Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, shares in a company, bonds, precious metals, or currencies.

It refers only to the equivalence of each unit of a commodity with other units of the same commodity. Fungibility does not describe or relate to any exchange of one commodity for some other, different commodity.

As an example: if Alice lends Bob a $10 bill, she does not care if she is repaid with the same $10 bill, two $5 bills, a $5 bill and five $1 bills or bunch of coins that total $10 as currency is fungible. However, if Bob borrows Alice’s car she will most likely be upset if Bob returns a different vehicle–even a vehicle that is the same make and model–as automobiles are not fungible with respect to ownership. However, gasoline is fungible and though Alice may have a preference for a particular brand and grade of gasoline, her primary concern may be that the level of fuel be the same (or more) as it was when she lent the vehicle to Bob.

 

http://en.wikipedia.org/wiki/Fungibility

 

 

CS Lewis: Known as “Jack”

 

According to Wikipedia, “at the age of four, shortly after his dog Jacksie was killed by a car, he (CS Lewis) announced that his name was now Jacksie. At first, he would answer to no other name, but later accepted Jack, the name by which he was known to friends and family for the rest of his life.” This vignette intrigues me, as I continue to prepare for my upcoming Talkback. My contention is that CS Lewis and Freud are each representing different aspects of their own belief systems. In essence, they agree with each other, they maintain conflicting opinions, but, for the purposes of a writing career, for the purpose of establishing a place in history,  they articulate only one side of the argument about G-d, sexuality and the meaning of life. Given that point of view, I take from CS Lewis, insisting on being called the name of his suddenly deceased dog, is a way in which he lives out  his belief that death is not permanent, so long as someone keeps your memory alive. So much of the discussion about the meaning of life, stems from one’s view of death. If death is final, then fear might ensue. If death is one step on a longer journey, then perhaps one can relax into life. If CS Lewis could think about his dog every day, as he is called by his dog’s name every day, then Jacksie is still alive, yet in a different way then before he was hit by a car. As February represents a month of memories for me, of a particular person that I was close to, who is no longer with us (or me), I, too, am aware of how important it is to keep the discussion, and hence the person, long away from our living world, alive in a way which still has meaning for me. I imagine telling others to now call me by the deceased person’s name. I can feel how special this would make me feel. I can feel that I was not just living my life, but theirs as well. The name would represent a “containment” as Winnicott  would say. In this “containment” there is peace. CS Lewis, Jack, was on to something psychoanalytic; a fact he may take issue with. May he rest in peace.

Unknowable

Trina, fifty-six, a physical therapist in private practice for twenty-two years does not understand how her business works. She has great referral sources, but the flow of her practice changes “wildly,” she says. “Sometimes I have no time to myself, whereas other times I think I am going out of business,” she says, with palpable anxiety and uncertainty about her future. “I have many colleagues and they have the same experience, except for them, they make these false attributions, like blaming the economy.” Trina says, explaining that her perspective is that her business plods along at a rate which is not simply explained by market forces. “There is no way to get a handle on the supply and demand aspect of what I do,” she says, with a sound of frustration that she cannot control her world. “Well, let’s assume it is unknowable, what does this mean to you?” I ask, wondering how she manages this anxiety. “It means to me that I have to understand that my business is vulnerable in a way that I may never fully comprehend.” Trina says with resignation. “When you hear your colleagues talking about how the economy is hitting their practice and you don’t see it that way, how do you cope with that?” I ask, wondering about how she deals with not finding colleagues who share her point of view. “First, I think they are saying that to make themselves feel better. Maybe their practice is down because someone is guiding them to someone who they feel is doing a better job. That is always a possibility. It is hard to go down that road. It is hard not to take it personally and feel that a low practice is secondary to poor work, so it is comforting to know that the force is external instead of internal. No one ever says that their practice is down because they are not good at what they do, but I am sure many people feel that. We, in private practice, get so vulnerable because training programs that offer additional certification can seduce us into believing that if we just could use one more machine then our practice would flourish. Of course, that may be true, but it may also be a way for these training programs to make more money. It is so hard to know. Other people feel the key to building a practice is marketing, so they spend a lot of time and energy trying to package their practice, but it is not possible to know if that is helpful, or the tides are turning on their own. You cannot do a randomized control trial to see what the key ingredients to building a practice. I think this is why a lot of physical therapy students are looking at a place like Kaiser, where there are no business worries. I could not do that because then I would have a boss, and you know me enough to know, that as much as I hate thinking about how vulnerable I am, I also do not like the idea of working for someone else.” Trina explains to me why she copes with this uncertainty. “So, living with the unknowable in private practice seems better than living with the knowable of having a boss while being employed.” I say, articulating her dilemma. “That is exactly right. Life is unknowable. This is just one more thing,” Trina says poetically.

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!

Women Doctors

Last night I had the privilege of speaking to a group of women physicians, mostly psychiatrists, leading to the inevitable topic of how quickly the field of medicine is changing in that it is unrecognizable from our field twenty years ago. We were middle-aged women who remember when it was a big deal for a woman to become a physician; gender atypical, one might say. Now, over half of most medical students are women. As a group, our daughters, not our sons, are entering medical training. “What does this mean?” one woman asked. “Women will earn the money and men will take care of the household,” one woman answered. “Or women will do both, like they have been doing for generations,” another woman said. “Women are twice as likely to get depressed as men,” I say, adding in a well-established psychiatric statistic. “Is this related?” I ask out loud. “Yes, but women are twice as likely to get depressed from menarche to menopause, so that makes it seem hormonal,” one knowledgeable woman answered. “Yes, but those are also the years where women have to juggle a lot of competing responsibilities,” another well-informed woman chimed in. “Men are more likely to be alcoholics,” another woman said, implying that maybe men deal with their psychological issues through substances and not through talking about their mental state. As usual, we had no answers, but many questions. Our worlds,  the world of knowing a “woman’s role” and the world of medical practice, is confusing to us. We want to help people, but how best to do this, is not completely clear. We want to be role models to our younger colleagues, but we do not understand their world and they do not understand ours. All in all, it was nice to be together to chat about common concerns. My job was to keep the conversation going. They did not need me for that. The passion for this topic generated the energy in the room.

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.

Professional Development

“How can I get a job at a University?” A fellow, about to launch, in nine months, that is, into the world, seemingly fearful of leaving a University life that he has known for over ten years. I remember that feeling, I think to myself. High school, college, medical school, residency, child fellowship, is a long journey before having a “real job”. It makes sense to want to find employment in the system that one has “grown up” in. I suppose it is similar to not wanting to leave home after high school. The familiar is hard to give up. New adventures are exciting and scary at the same time. Today is career day, where seasoned professionals, such as myself,  come to talk to UCLA Child Psychiatry Fellows about their journey. Each year is a bit different. I anticipate being asked abundant questions about private practice, but instead, this group of ten, wanted to know about employment opportunities. Once again, I was taken back to my years in training where the idea of working for oneself was the ideal. Autonomy was held in high regard. Now, at least with this crop, steady employment, with benefits like retirement and health insurance seem to be more attractive. Security seems to trump independence. I understand this and I do not understand this. I can certainly appreciate the value of knowing that your paycheck is flowing at a steady rate. I can also appreciate being taken care of, in terms of retirement and insurance needs. Yet, I also remember the excitement of thinking that after so many years of being told how to practice medicine, that finally, finally, I could make my own decisions. I could be my own boss. Yes, my adage continues to be that ‘I am self-employed and I hate my boss,’ but this is only a half-truth. I also love my boss. I love that I can practice in a way which makes sense to me on a very deep level. I can listen to my patients, without concerns for “productivity,” which is often measured in medical practices these days. I can take the time to appreciate the inner workings of people, in the context of family and school systems. No one is rushing me. That is worth so much. Maybe these students need to be tossed around in the world of employment to want to break out into an independent way of doing things. Or, maybe these students will continue to cherish the security of employment. I do not usually get follow-up, but I can hope.

The Embedded Psychiatrist

Oh, no. Psychiatry is heading towards another turn and once again, I am deeply concerned. As I understand the future of psychiatry, according to my highly respected colleagues, is that psychiatrists are now going to be ”embedded” in primary care offices where they may or may not see the patient, but they will consult on the diagnosis and psychopharmacological intervention for patients that are seen by nurse practitioners and primary care physicians. Now, understand, that I work in primary care, and I am a strong advocate that primary care physicians should have psychiatrists to consult with on their cases, but this does not mean that the psychiatrist should not have the ability and skill set associated with deep listening to patients and understanding the nuances of a good evaluation. My concern is that the psychiatrists of tomorrow will help primary care physicians prescribe psychotropics, without developing the tools of listening to patients and having continuity with patients. Psychiatrists will mostly be trained to consult, without having direct patient care responsibilities. Once again, this will change the field, both in terms of how it is practice, and in terms of who is attracted to this kind of work. In essence, the doctor/patient relationship, the most valued aspect of the treatment, will disappear from the field of psychiatry. I have previously posted about the development of a psychiatrist, strictly as a psychopharmacologist, has minimized the doctor/patient relationship, but this new development, where the psychiatrist is strictly a consultant, takes my issue into a deeper concern. I wonder if history taking and relationship building will be a lost art in medicine. I certainly hope not.

 

See also…http://shirahvollmermd.wordpress.com/2010/11/08/patient-centered-medical-home/

Going Global

Education is global, like all other industries these days. Medical schools are having training programs around the world. Exchanging information, exchanging students, a long-time practice of college education is now expanding to graduate schools and post-graduate education. UCLA Medical School are now setting up guidelines for their world-wide electives. Cornell Medical School has started a “branch” in Qatar. Two UCLA Child Psychiatry fellows are off to India to explore child mental health in a rural area. Some UCLA Family Medicine Residents ventured off to Haiti after the earthquake to help with the pressing medical needs of the distraught population. This, strikes me, as a new and exciting expansion of medical education. In my day, it was the rare soul who ventured out of the country to explore how medical care is administered in different health care systems. Sure, we were allowed, maybe even encouraged to do electives at other US medical schools, but we were never supported to go beyond our borders. I suspect that this relatively new development goes along with our increase in connectivity and thereby the increase in cross-fertilization. It is wonderful to think that our next generation of physicians will have a broader world view. It is also wonderful, selfishly speaking, to think that there might be opportunities for teaching around the world. Teaching and learning always go together. Global teaching and learning seems so rich and vibrant with new ways of thinking about how to help people. For example, European physicians write prescriptions for spa treatments as a way to help those in mental distress. I think that is brilliant. Trite but true-the world has so much to offer.

 

See also….http://shirahvollmermd.wordpress.com/2012/08/21/calling-my-266-german-friends/

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