Pill Mills

 

Most employed psychiatrists are hired to prescribe medication to the many folks who are thought to suffer from mental illness, while another practitioner provides psychotherapy and/or case management. At first glance, this seems appropriate. The psychiatrist is the only one in the mental health food chain who can prescribe, and hence, maximizing psychiatrist time, means having them do the most prescriptions possible. On the other hand, this narrows and denies the scope of psychiatric training, and in particular, it denies the value of the psychiatrist-patient relationship. For example, Sally, a fictional psychiatrist patient of mine, works for a social service agency, where she spends thirty minutes with each patient, ten hours per week, prescribing medication, but she feels, and I agree, that those thirty minutes are cherished moments in these severely ill patients’ lives. In this time, there is a frank discussion of their psychosis, their internal struggles, and their present worries, along with a prescription refill. This time is valued by both the psychiatrist and the patient as the healing relationship. The prescription is, in some secret way, almost an excuse for the psychiatrist and the patient to get together. In point of fact, the prescription could be written by a nurse practitioner, or more refills could be given, but the need for the prescriptions allows for quality time together. Sally reminds me that because our health care system is devaluing the doctor-patient relationship, the ‘work-around’ is to say the visit is for medication, but in fact, to use the time to build rapport. In my wishful life, I would like psychiatrists, like Sally, to come out of the closet and say that we need time with patients because our relationship with them matters, whether we prescribe medication or not. We represent a professional who can listen, understand and care about their internal and external struggles. We can also supplement our listening skills with psychopharmacology. Both are important. It is time to go public with our healing relationship with patients. We offer this to those who have hit tough times in their lives. We, as psychiatrists, should be proud, and not ashamed, of our bonds with those who seek us out. We are not, and should not be, pill-mills!

Medical Students: What Do They Want To Know?

Below is my post from 2010 about my presentation to UCLA Medical Students in the Primary Care College. Today, I repeated my lecture on ‘Psychiatric Emergencies’ , with the addition of a narrative about the wonders, and not such wonders, in DSM 5. I changed my presentation style, but not my content. I moved my body in front of the podium. I walked up and down the aisles, making me feel like a rock star, moving into  my audience. I made eye contact with each student. Only one person fell asleep. This, being 2013, most of these students were female, young, and enthusiastic. I arrived an hour early, so I could hear the lecture before mine. I learned that the Affordable Care Act is going to focus on patient satisfaction, public health and cost-efficiency. As such, pediatricians will, in all likelihood, not do ‘well-child checks’ as this can be done by nurses. Pediatricians, like in many countries around the world, will be specialists, referred to after the Family Medicine doctor gets stuck. Most doctors will not be self-employed. They will work for large systems of care, like Kaiser. Specialists will have trouble finding jobs in areas they want, as they will need to be “deployed” to where the need is. Primary care will be in demand. Loan repayment was the largest area of discussion. Most students are saddled with large debt. The rate they pay it off, and the type of job they get are influenced by their tolerance to handle such demands. Once again, I found myself in a field that is rapidly changing, feeling like, although I sat in those same chairs, thirty years ago, I cannot connect with the experience of the current students. They are entering in a world which is evolving so quickly, that they do not know what their world will look like when they finish their training, five or seven or nine years from now.

There was then a ten minute break which, quite cleverly, I thought, the physician-coordinator, told us that it was time to do our exercises. All fifty of us got up to do a series of dance steps, swinging our arms and legs, while this physician reminded us that physical exercise will help us concentrate. She transformed from Professor to exercise guru. It was cool.

I began by asking how many students were interested in psychiatry. Three hands went up, but the coördinator reminded me, that primary care has a lot of psychiatry. Yep, I knew that. These are new fourth-year medical students, about to apply for the “match,” meaning they had to rank order their list of residency programs that they were interested in. This is a major crossroads in their lives, and although I don’t know these students intimately, most of them, seemed quite relaxed about their education and their future. I proceeded to talk about the management of a psychiatric emergency, reminding them that there are no objective tests, and so, all of psychiatry relies on informed intuition, based on a thorough history and good mental status examination. I talked about the importance of learning to listen to the patient’s narrative, as listening provides information for a diagnosis, but it is also therapeutic. I reminded them that psychoanalysis helps train people to listen, and so they could consider psychoanalytic training, regardless of what field of medicine they chose. One student after the class, told me they were indeed interested in psychoanalysis. I felt relieved. Listening is not dead in medicine, at least not completely dead.

 

 

From a Post Done on Wednesday, July 14, 2010

What is the Primary Care College?

UCLA School of Medicine: Fourth-year Colleges

Faculty members and students interested in common career activities are grouped into academic colleges during year four. The colleges are designed to

• strengthen career advising,
• improve the quality and selection of electives,
• provide a means of honing clinical skills,
• stimulate discussion of new findings in the basic, social, and clinical sciences relevant to the future practice of medicine.

College activities include an introductory course focused on advanced clinical skills and decision making, a monthly series of evening seminars, a longitudinal academic activity that can be either teaching or scholarship, and regular advisory meetings.

Academic Medicine — Careers that will include research or subspecialty training programs that require research. The theme is the development of skills in basic and clinical research.

Acute Care — Careers in emergency medicine, anesthesia, and critical care specialties. Themes include time-based decision making, physiologic correlations, and crisis management.

Applied Anatomy — Careers in the various surgical specialties, obstetrics & gynecology, radiology, radiation oncology, ophthalmology, and pathology. The unifying theme is anatomical implications in medical practice.

Primary Care — Careers in internal medicine, pediatrics, family medicine, obstetrics & gynecology, and psychiatry. Themes include prevention, mental health, international health, geriatrics, and women’s health.

Drew Urban Underserved — Members of this college are students in the combined UCLA/Drew University program, which is recognized for its placement of graduates in underserved communities.

Judy Garland

 

Thinking about Judy Garland, having  just seen “End of the Rainbow” http://articles.latimes.com/2013/mar/16/entertainment/la-et-cm-tracie-bennett-end-rainbow-20130317, with fellow psychiatrists, we engaged in a heated debate about the nature of her suffering. ?Bipolar, ?ADHD, was the launching pad for the discussion, and yet my thoughts turned to her horribly sad childhood in which, she made money for the studios, and in the process, she was fed prescription drugs to keep the “machine” going. “Trauma,” I said firmly, in trying to understand this icon. She seemed robbed of a time in her life to “play” even though some might say that acting is a form of playing, Judy Garland had to play like she was told and so, by definition, this was not the kind of play in which she could make up her own rules, and have a time in her life in which her activities were inconsequential. This left an inner emptiness, a “zombie state,” as a colleague of mine says, in which she could never experience the sensation of being alive, but rather she enlisted her superego to do what she “was supposed to,” thereby leaving her feeling without satisfaction or fulfillment. She never had a chance to experience her ego, as her superego was running her life, from such an early age. Her many husbands, it seems to me, provided this superego, until one of them tired of the emptiness. She never seemed to know herself, to know her ego, and as such, she could never find a path towards happiness. As Ray Bolger, her co-star in the Wizard of Oz, succinctly stated, “”she just plain wore out.” Like a machine, the gears could no longer turn. Sad, sad, and sad. There is no diagnosis, as far as I can see, but only an incredibly talented woman who never developed a sense of herself. What do we call that? I call that child abuse.

Health Care Apps

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In the “adapt or die” mode, part of moving into the next wave of health care changes is using applications to help patients understand and treat their ailments. Knowing which application to recommend to patients will be an important tool in the ever-expanding toolbox of treatment modalities. This application, pictured above, helps patients learn diaphragmatic breathing by showing a man lying on the ground with a book on his stomach, demonstrating that the book rises and falls with each deep breath, but not with shallow breathing. Deep breathing soothes anxiety, and is a relatively simple means of coping with stress in very powerful moments, such as learning about the Boston Marathon. Teaching people to breathe is that simple, elegant, intervention in which there are no negative effects. The smart phone allows people to teach themselves deep breathing in the privacy of their own space, along with the value of repetition, if need be. There is no doubt, that the smart phone will serve as both a health care passport, in which patients travel with vital medical information, along with serving as a  treatment tool, particularly for stress-related disorders such as anxiety or insomnia. This advanced technology thrills me beyond words. Only in my wildest dreams did I imagine such useful patient information to be so incredibly handy and useful. In this way, medicine is in an exciting era.

Paranoid-Yes: Dementia-No!

Diagnosis, particularly psychiatric diagnoses, are history based. We have no objective tests. We have no imaging studies. We need to listen, pay attention, gather a history, and pursue collateral information. Yes, you have known me to say this for a very long time. Now, I will tell a fictional story which illustrates my point, since the fire in me pushes me to say it again. Diedre is a 70 year-old longstanding patient who has a long family history of mental illness. Her mother was bipolar. Her father had issues with alcohol. Her mother’s mother also had bipolar illness. Both her mother and her maternal grandmother had a history of long stays in psychiatric hospitals. Diedre, although high-functioning, has, what seems to be a more mild version of her mother’s illness. She does have a history of psychiatric hospitalization, but her mental illness manifests more in paranoia than in mood swings. She has long periods of time where she is quite agitated that institutions, such as the police department, want to hurt her. As a result, I have her on an antipsychotic medication, which, as she reports, makes her “much calmer”. Diedre also has a severe alcohol and prescription drug abuse problem, which she denied for many years, but she knew that I knew that this was an issue. Over a long holiday weekend, her drinking caused a change in mental status, leading to her boyfriend calling 911, and then a subsequent psychiatric hospitalization for delirium. The psychiatric team took her off her medications and she detoxed in the hospital. Although the patient told the team to talk to me, that communication never happened, so even as her mental state cleared, where she returned to her baseline paranoid ideation, the team did not re-start her antipsychotic. Instead, they interpreted her mental state as the beginnings of dementia. They administered one test of functioning, which, by her report, she was too paranoid to cooperate with the questions, so she “failed” the test and was diagnosed with dementia. This resulted in a report to the DMV stating that she was unsafe to drive. This also resulted in them insisting that she transition to a skilled nursing facility, at the cost of many thousands of dollars out of pocket, since the team did not feel she was safe to go home. When she was discharged she returned to me. I told her to re-start her antipsychotic, to return to her previous living situation, and to get private cognitive testing in order to have documentation for the DMV. As expected, she has no evidence of dementia, and although the hospitalization was very helpful in starting her on a sober life, the increase in paranoia was tragic to observe. Histories take a long time to understand. Quick diagnoses are not only wrong, they are harmful. There is a fire in my belly.

Is Everyone Bipolar?

This blog is part of my series entitled The Couch in Crisis: The State of Psychiatry

Last night at dinner I was having a conversation with a mental health professional. She told me that she was seeing so many patients diagnosed with bipolar disorder and then getting better on the medication. In typical fashion, I wanted to scream. The diagnosis of bipolar disorder should NOT be made based on a response to a medication. Our mood stabilizing medications make a lot of people feel good. They feel calmer and more in control of themselves. This positive response to medication does not imply that they suffer with a major psychiatric illness called Bipolar Disorder.

Bipolar Disorder occurs in 1% of the population. This is a psychiatric diagnosis is defined by the presence of an abnormally elevated mood, referred to as mania. The onset of full symptoms generally occurs between 15 and 25. Bipolar disorder used to be called manic-depressive illness. This term was coined by the German psychiatrist Emil Kraeplin in the late nineteenth century.

There is no blood test to confirm the diagnosis. This means that any doctor can say a person has it. A clinical diagnosis depends on the clinician. Herein lies the dilemma. In my mind, doctors are overdiagnosing this condition because physicians want to label a condition as opposed to seeming uncertain. It is this need for certainty which I feel we need to change. Many people will respond to mood stabilizers and not have bipolar disorder, so we need to tell them that we do not know their diagnosis, but we do know how to treat it. Although this may be unsettling, often times this is the truth. As a profession, we need to see how labels can hurt people and as such, it is sometimes better to remain uncertain in the diagnosis instead of prematurely labeling someone. To put it another way, if we do not embrace uncertainty, who will?