Announcement! New Email…..svollmer@vollmers.us

Connectivity is vital to my work. So, an abrupt change in email means a lot to me. Let me begin with the punch line. My new email address is as follows…

svollmer@vollmers.us

Everything else stays the same: my office location (941 Westwood Blvd #204), my office phone number (310-824-4912) and my practice style.

Yet, what would have been a trivial change, just a few years ago, is now a major transition, as I have come to see that email is a vital portal for communication. As such, transitioning email, makes me hope that no messages will be “dropped.” After a few grey hairs, all portals are open and I am open for business. Some of you may wonder why is this change happening? To my devoted readers, curious about such things, I am becoming more independent from UCLA and so I need to establish an independent email address. Am I still going to teach? Yes, yes and yes. I am still active on the faculty at UCLA, in both adult and child psychiatry. I am excited to kick off this 2013-2014 academic year with teaching opportunities with psychiatric residents and child psychiatry fellows, interested in learning about listening, thinking, and taking time to understand complex mental states.

Next question-what about this email address with my name in the domain? First, I am sure you devoted readers have noticed that my domain name is “vollmers” and not “vollmer”. You have likely guessed, that “vollmer” was already taken and so I became myself in the plural. This is narcissism at its best. Vollmer appears twice in my email, with the idea that I am part of the larger “vollmers”. Will I miss “UCLA” in my email address? Was this a badge of honor? This was a major question that I asked myself. I had the option of using svollmer@ucla.edu, but I declined. I am taking this transition as an opportunity to re-define myself as an independent operator, teaching at UCLA, but doing my private practice as an independent practitioner. I have been at UCLA, in various capacities, since 1979. 34 years later, I am ready for a change. I am excited. Who knew that my email address would have both such practical and emotional significance? I learned the hard way.

Subtle Child Abuse

Kids raised, with the almost universal assumption, that parents want to promote the mental health of their child, are left to feeling alone as they struggle with the inability to please their parents. Kids, some more than others, need to feel that they are making their parents proud, often suffer, when this goal is simply unobtainable. This “little t” trauma, as some call it, cause these kids to suffer from depression and anxiety, giving them a psychiatric diagnosis, which often, further disappoints their parents, thereby promoting the disappointment that they already feel. This downward spiral requires these children to develop the self-confidence, where their well-being is no longer tied to the pleasure in their parent’s eye. This separation is often the work of long-term psychotherapy, leaving many therapists with the upward battle of promoting boundaries, while at the same time, understanding how attachment to a disappointed parent can feel safer than no attachments at all. Psychopharmacology can be helpful, but the majority of the work, lies in creating a bridge for the patient to mentally leave their plea for parental acceptance, so that they can learn to please themselves and people they choose to care about. Some families can be cherry picked, and some people need to understand that those ‘families’ will stimulate positive growth and fulfillment. Elisa, twenty, comes to mind. She is the product of a single parent. Her mother, Jasmine,  had a “quickie” and wanted to keep her. Jasmine, frustrated with her life, always made Elisa feel like she wished she was not born, or so Elisa relates to me. Elisa, trying to make Jasmine happy, has been frustrated at her inability to do that. Elisa is doing well in college, has a nice boyfriend, but she still feels that Jasmine is disappointed. Their relationship is strained and so Elisa avoids interacting with Jasmine. Jasmine does not initiate contact with Elisa. Elisa gets depressed and engages in self-injurious behaviors. She feels like she will never be happy with herself. This dynamic where her struggle with her relationship with Jasmine, appears now, to be the central theme of her depressed mood, is the core of our work. Elisa needs to develop the self-esteem, where her mood is not a reflection of Jasmine’s mood. This involves a movement away from the centrality of this relationship, while at the same time, understanding that Elisa and Jasmine’s connection has been intensely important to both of them for two solid decades. This is the work of therapy. This takes time and patience. There is simply no quick fix. Once again, the theme of my rants continue. Time and sophistication are essential to helping Elisa.

Joke For The Day

From today’s WSJ.

Moses was coming down from Sinai with good news and bad news about G-d’s commandments: “The good news: I kept him down to ten. The bad news: adultery stays.”

The Doctor/Patient Relationship: Why Care?

“It’s more important to know what sort of person has a disease than to know what sort of disease a person has.”-Hippocrates

 

I am not so sure. As I think about Hippocrates famous quote, I want to argue with him, as being too simplistic. When it comes to hypertension, diabetes or depression, I completely agree that understanding the person with the disease is more critical than understanding the disease, by itself. However, if this same person had a rare blood cancer, then the first order of business is to understand the disease, treat the disease and then, or at the same time, try to understand how this rare disease impacts this particular person. As a patient, my first priority is to become disease-free, and then my second priority is to have a doctor who understands what my disease put me through. Ideally, the treating physician is the same person as the understanding physician, but with the change in health care, this is likely to be two different people, and the latter is not likely to be a physician. Hence the main therapeutic relationship is likely to be with a non-MD, and on the face of things, I think that is fine for most situations. What I moan about is the rare event where it is critical to have a doctor who is both diagnostically sophisticated and deeply compassionate. For prolonged illnesses, such as those dealing with heart transplants, it is helpful if the physician is both sophisticated with the nuances of anti-rejection drugs, while at the same time, understanding of how this transplant has significantly altered this patient’s daily life. Most of us, though, do not have rare illnesses (redundant, I know), and hence most of us need someone to remind us of how to take care of ourselves, while another caring soul can help us integrate our medical problems into a new understanding of ourselves. So, my response to Hippocrates-“it depends”.

No Need To Attend to the Changes: ADHD and DSM 5

From WSJ June 16, 2013 “A Nation of Kids on Speed” by

By PIETER COHEN AND NICOLAS RASMUSSEN

 

“Last month, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders—the bible of mental health—and this latest version, known as DSM-5, outlines a new diagnostic paradigm for attention-deficit hyperactivity disorder. Symptoms of ADHD remain the same in the new edition: “overlooks details,” “has difficulty remaining focused during lengthy reading,” “often fidgets with or taps hands” and so on. The difference is that in the previous version of the manual, the first symptoms of ADHD needed to be evident by age 7 for a diagnosis to be made. In DSM-5, if the symptoms turn up anytime before age 12, the ADHD diagnosis can be made.

It’s also easier to diagnose adult ADHD. Before, adults needed to exhibit six symptoms. Now, five will do. These changes will undoubtedly fuel increased prescriptions of the drugs that doctors use to treat ADHD: stimulants such as Ritalin and Adderall.”

 

ADHD stabilizes in DSM 5, but the debate about it does not. This quote above, from  the opinion section of the Wall Street Journal, expresses deep concern about the over-diagnosis and hence the over-treatment of kids and adults with stimulant medication. The arguments are tired and true, but also exaggerated. This is a clinical diagnosis. There are no objective findings. Physicians make a lot of money making this diagnosis and drug companies, in kind, profit from the illness. Kids are given stimulants with the potential message that they are not responsible for their own behavior. “Boys will be boys” and so why are we trying to push square pegs into round holes. In the comments, one writer expressed the notion that savvy parents help their kids get an ADHD diagnosis so the child can qualify for extended time on tests, as if extended time will necessarily help the child have a higher score. The issue of whether any child should have a timed test is yet another question in education, but that puts us on a tangent. The issue here is first, DSM 5 is not moving us forward in the ADHD world. Without an objective test, diagnosis abuse will continue. Financial incentives are there, and so abuse will happen. At the same time, for some kids, going on stimulants is like getting a pair of eye glasses. The world is simply clearer to them, so that they, and their families appreciate the monumental change in their interface with the world.  My solution is simple. The better the history taking, the more likely the physician will hit the mark and the less likely there is financial incentive to over-prescribe. Quickies, or short appointments, lead to “ADHD mills” where over-diagnosis and over treatment is rampant. Physicians who take considerable time exploring the possibility of ADHD are much less likely to be vulnerable to the pressure to prescribe. A prescription can be a quick tool to rapidly get someone to leave your office. These hasty interactions is what has got to change: not the diagnosis or the treatment.

A Pediatrician’s Fantasy: My New Yorker Entry

“I am going to write you a prescription for a new owner.”

Guest Cartoon Entry….

“You need to stop wearing the dog costume before we can begin to address your problems.”

Practice Visibility

The issue of practice visibility intrigues me because I trained in an era when marketing was a dirty word for physicians. Advertising was not allowed. Word of mouth was the key, which meant that networks developed (often on the golf course) which created referral bubbles. People referred to their friends which often meant that male physicians referred to male physicians and women, in smaller numbers at the time, responded, in kind. Then, drug companies began direct to consumer marketing, the internet appeared, and suddenly, or so it seemed, marketing was not only allowed, but expected. Of course, professionals still refer to their friends, for the good and bad of that, but now, the consumer is more sophisticated and does his own research into his providers. I am excited and pleased with this turn of events, even though, as per my previous post on crowd-sourcing, consumers can write critical comments, often unfounded, and this can tarnish a reputation. On balance, though, the internet has allowed the physician to present herself in a way in which she can beckon those who sense, from their website, blog, tweets, a possible “good fit”. This ‘good fit’ works well for both the physician and the patient. The physician sets expectations before the first contact. The patient has a greater sense of whose office they are walking into. So, yes, Jon, more visibility seems good to me. The more people understand where I am coming from, both in terms of my education and my attitude towards mental health, the better the chances that the person who reaches out to me will benefit from my services. Thanks, Jon, for stimulating this post.

Westwood Wellness Center?

 

To continue the theme of marketing my practice, I know imagine a name change to “Westwood Wellness Center”. I like the alliteration, but beyond that, the word center, seems so grandiose. The word “wellness” is also troubling. On the one hand, I do promote wellness, and I do appreciate the shift away from psychopathology towards improving the quality of life. A person does not have to be “sick” to seek wellness. I appreciate that concept and have felt, since medical school, that helping patients improve the quality of their life, is an essential part of medical education.  Most people are not ‘sick” but they suffer in their inability to enjoy life in the deepest possible way. In the DSM II days, they called this neurosis. In light of the ways in which we all mess up our own lives, promoting wellness is a way to promote living with less neurotic tendencies. The cheap guy who bemoans the fact that he cannot buy things for himself could come to learn to understand his withholding nature which leads to a perpetual sense of deprivation-self-induced! . This fictional “cheap guy” does not have a DSM 5 illness, but he does suffer from chronic feelings of coldness and rigidity. Would this fictional ‘cheap guy” be drawn to a “wellness center” or a “psychiatric practice” or does it not matter since the “cheap guy” is not going to pay to help himself? On the other hand, a “wellness center” implies a fad-like approach to the latest ill. The trendiness of the name concerns me, as it promotes a superficial sounding approach to some very deep-seated issues. On balance, given the pros and cons, I do like the word, wellness. Perhaps I can change my practice from ‘Shirah Vollmer MD’ to ‘Westwood Wellness,” leaving out the word “center” and creating a staff of one, me. I could be “Westwood Wellness” and have this be the evidence of my practice’s mid-life crisis. I transition from the old-fashioned solo psychiatric practitioner to the more modern psychiatrist who wants people to deeply care about their minds and their bodies. The method does not change, but the packaging does. I am liking it.

Naming My Practice: ‘Westwood Psychiatry’

Should I re-name my practice? There is Beverly Hills Psychiatry which is a one-man shop. Old School, Dr. Vollmer over here, started practice when the standard was to use your name as the name of the practice, particularly since almost all psychiatrists were solo practitioners. Now, it seems there is a movement to have “wellness centers” or “behavioral health” centers where the name represents what  or where people are seeking and not the particular person doing the work. Once again, I feel stunned by this, perhaps subtle, change. Google might have something to do with this new “branding”. Someone seeking psychiatric care on the internet would  not know my name, but they would know the location they want to see someone and they know the issue that they want to explore further. As such, to optimize a google search, one could name the practice to get more electronic traffic. This, I understand. My concern, however, is that the naming of a practice means that the person, the professional, is less important than the location or the skill set. If I change my practice name from ‘Shirah Vollmer MD’ to “Westwood Psychiatry” I would worry that I am creating a distance between myself and my patients which is larger than I want. On the other hand, maybe if I become “Westwood Psychiatry” I would have an ego boost, of sorts. Maybe the name gives my work a certain grandiosity. Oh, so much to think about. Change is tough.

Oh, Westwood….90024!

http://www.latimes.com/news/local/la-me-westwood-village-20130618,0,6690518.story

 

Westwood Village, where I practice, is in a slump, making parking easy, and my patients, happy, I think. Today’s LA Times notes that the powers that be want to bring traffic back to Westwood. I return to parking. Having practiced in the same office for 23 years, I have seen the ups and downs of parking problems. When I began, the first ten minutes of almost every session seemed to focus on how hard it was to park. Now, those ten minutes, are spent on traffic nightmares encountered while getting to my office. Now, with the ghost town of the village, parking is easy, and relatively inexpensive. I love the location, close to UCLA, central in WLA and now, close to Target and Trader Joe’s. With the hope of returning the Village to its popularity, comes my concern that access to my office will cause frustration and irritation. Luckily, for me, at least, every attempt to bring “back” Westwood has failed. The 1998 shooting, changed Westwood boom into a bust. The competition from Santa Monica and West Hollywood has pulled away the throngs of folks coming to Westwood for a good time, allowing me to enjoy the relative quiet and peace of being close to a University without the chaos of parking or waiting to sit at a restaurant. Adapt or die, as I often say in these posts, yet that does not mean I have to welcome the tides turning, yet again.