Is The ‘Self’ Lost in Psychiatry?

http://www.nytimes.com/2013/04/28/magazine/the-problem-with-how-we-treat-bipolar-disorder.html?pagewanted=all

Linda Logan talks says ” for many psychiatrists, mental disorders are medical problems to be treated with medications, and a patient’s crisis of self is not very likely to come up in a 15 minute session with a psychopharmacologist.” She goes on to say that non-medical professionals are taking on the task of understanding the self, but “new therapies and treatment philosophies, founded mostly by clinical psychologists and other practitioners who are not medical doctors, recognize the role of the self in people with mental illness.” This is my rant and so I will continue to both understand that my professional world is changing and, at the same time, attempt to push back and bring the “self” back to psychiatry, in my own way, through my work and through this blog.

Many in my cohort went into psychiatry because we felt that the patient had the disease, as opposed to our medical colleagues who treated patients like they were the disease. This personal aspect of psychiatry was the draw. The “liver patient in room one,” was the inspiration for leaving a field in which people were defined by what organ system failed, and not their social histories, their occupational histories, or their contributions to society. As psychiatry becomes more “medical,” patients are now a “disease” and there seems to be little value in understanding how the person copes with their illness, but rather the value, is in getting rid of symptoms. Clearly both are important. Moreover, it is important, in my mind, that one clinician be able to look at both symptom relief and coping styles. When these two issues are bifurcated, the patient is left to feeling misunderstood and frustrated, as Linda Logan articulates clearly in this article.

Of course there are exceptions, but the trend in psychiatry is towards this medicalization, which means towards a depersonalization of care. This trend crushes my soul. If we, as psychiatrists, do not carry the banner of knowing our patients, for the human beings they have worked hard to become, then who is going to provide comprehensive care to those with crippling neuroses and/or psychoses? Who is going to see the big picture of medication management within the context of defense mechanisms and family dynamics? Who is going to understand that to lean too much towards nature or nurture is to rob the patient of the complexity of their condition? We, as psychiatrists, must embrace both complexity and uncertainty. If we do not do this, then patients will suffer, and as they are, by definition, compromised, and hence  mostly unable to advocate for themselves. This is my rant, one which bears repetition, and so I will continue to post on this topic. Thank you, Linda Logan for triggering my continuous outrage.

Brain Stimulation: Literally Speaking

 

Deep Brain Stimulation (DBS), Transcranial Magnetic Stimulation (TMS), Electroconvulsive Therapy (ECT), and Vagus Nerve Stimulation (VNS) are all FDA approved treatments for neuropsychiatric disorders, heralding the new modality of treatment for psychiatric diagnoses. Darin Dougherty MD from the Division of Neurotherapeutics at a Harvard-affiliated hospital, presented his studies, demonstrating that when subjects were given active treatment, versus sham treatments, there was a high placebo response. To date, he has not been able to show the effectiveness of Deep Brain Stimulation, but he believes, that is because he has not determined where to place the electrode in the brain. Nevertheless, whereas drug companies used to sponsor most of the psychiatric research, now there is a lot of research sponsored by those who make these machines, such as Medtronics. Procedure-based psychiatry is the frontier, with hope of targeting a more specific area of the brain, moving us forward from ECT in which the entire brain has to seize in order to achieve the desired results. If we could localize the emotional brain, we could tickle it, and make folks feel better, or so the hope goes, for our future. In this way, this is an exciting time to be a psychiatrist, with the hope that like our medical colleagues, we hope to be able to offer our patients both pharmaceuticals and medical procedures which “fix” the underlying problem. Do I think this will put psychotherapists out of business? On the one hand, I would welcome the immediate relief that these procedures promise. On the other hand, I cannot imagine a substitute for working through difficult life decisions in a way in which one approaches junctures with thought and deep appreciation for the gravity of the decision. As always, I imagine these procedures could enhance psychotherapy by giving folks who are paralyzed by life’s traumas a way to move forward in psychotherapy so that they can navigate their world in a deeply conscious way. My work dovetails the work of those like Dr. Dougherty and so I welcome his neurotherapeutic  innovations.

Crowd-Sourcing

 

You can evaluate your psychiatrist, as with any service provider, online. Drug addicts being told they can’t get refills can rant about their physician’s poor bedside manner and lack of empathy. Patient satisfaction evaluations are being used to determine physician salaries, as test scores are now tied to teacher’s pay in some school districts. Technology has made it such that the consumer has a voice, and although one does not know to trust the consumer’s opinion, in an uncertain world, internet evaluations through crowd-sourcing, give information which guides the client through the confusing maze of choosing a trusted professional. As Sandy Banks stated in the LA Times, yesterday, http://www.latimes.com/news/local/la-me–banks-yelp-backlash-20130423,0,7103175.column?page=2 , those with negative complaints tend to be more detailed and hence get put higher up in the algorithms, than those with flowery, complimentary feedback. Hence, negative reviews tend to float to the top, and in the case of businesses, if they advertise, then they can change the algorithm such that more positive feedback floats to the top. So, how much anxiety should a new psychiatrist feel when a patient calls and says “I was given your name by another doctor, but I googled you and found some negative reviews, so I am not sure if I should see you or not, but I thought I would give you a call  to see what you sound like on the telephone.” “The best way to see if I can help you, is to come in and meet me and form your own opinion” would be my advice to this young psychiatrist. The personal nature of this relationship makes it such that it is not “one-size fits all,” it is not “fungible”. As such, I would suggest this new psychiatrist say, “the question is not whether I am a good psychiatrist, but rather, the question is am I the right psychiatrist for you?” Crowd-sourcing has no way to address this “goodness of fit” approach to this very personalized service. On the one hand, this is terribly obvious, but on the other hand, it is hard not to flip out over a negative written evaluation, as the internet gives a certain permanence to words. Psychiatry is in transition. As such, psychiatrists need to cope with negativity on the internet. My suggestion-we all need to blog to remind folks out there that crowd-sourcing, when it comes to a psychiatrist, is out of  context. We need to promote this doctor/patient relationship without sounding defensive or paranoid. Once again, this is a new world for my profession. We are learning as we are going. The challenge of the internet continues. We, psychiatrists,  used to worry about protecting patient privacy, and of course, we still do, but now we also worry about protecting our privacy, as well. I think there is little hope for the latter. I can live with that.

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

 

 

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!

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.

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/

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

How Many Patients Should Residents See? The Confusion Of Medical Training

When I was in training, I had six or seven outpatients, three clinical supervisors, along with the responsibility of doing inpatient psychiatry work. In this pre-Prozac era, there were not very many “outpatient clinics” since there was very little that we could do for patients on an outpatient basis, other than psychotherapy. Today’s resident spends his time in a series of clinics in which he prescribes medication to patients in a medical model which resembles a primary care visit. In programs that I am familiar with, the requirement to do long-term psychotherapy work is usually one or two cases a year, during his last two years of training. Once again, I must ask myself if I am resistant to change or if this change is harmful to our future generation of psychiatrists. The training programs are focused on the brain and not the mind. Hence, the medical student drawn to psychiatry is a different student than in my day when the common thread in going into psychiatry was the passion to mine the mind. The sadness I feel about this cannot be overstated. I am not saying that every psychiatrist trained today does not appreciate the depth of meaning which is learned from deep listening. However, I am saying that the priorities have shifted such that a “clinic” model of psychiatry is overtaking the long-term psychotherapy model of psychiatry. This shift causes most psychiatry residents to feel most comfortable with a prescription pad and less comfortable with formulating psychodynamic understandings of how a patient’s mind has come to give that patient deep suffering. I am left to hope the pendulum will swing back to prioritizing intense listening. This skill is what so many patients need to heal. Have I said this loudly or too many times? I don’t think that is possible. This series of posts will continue until training programs turn back the clock, just a little, in order to bring back psychotherapy training. Change is good, sometimes. This change was too far.