What Goes On In My Waiting Room?

 

There is a little LEGO man standing on one of my pictures in my waiting room. Yes, I have LEGOS in my waiting room and so, I can imagine, that some person, child, adolescent or adult, thought it would be fun, funny, cute, or something to deposit Mr. Lego man on my picture frame. The gauntlet is laid. Who did that? Do I ask my patients? Do I take it down? Do I smile when I see it? Yep, that is an easy question. I am reminded that so many things happen in my waiting room that I am not privy to. Patients can sit there before or after appointments. There are magazines to read, toys to play with, and yet, when I open the door, most of my patients, regardless of age, are on their phones. I joked with one patient that I can stop my subscriptions, and she said “no, I like to see the magazines, even if I don’t read them any more.” I suppose if I ever get a new office then perhaps the waiting room is unnecessary. I can just text my patients to come in, and then they can tell me their ETA, just like Uber, I suppose. I can give them a little warning, like I will be ready in 5 minutes and then they will show up exactly at that time, as their phone will them to do that. Yet, in this imaginary scenario of a waiting room-less office, I would miss out on seeing my little Lego so cutely sitting atop a picture. I would miss that.

Psychiatry Business

 

Can Psychiatry scale up? Mildred, sixty-one, went to her insurance company because she thought she might need medication for her poor focus and “lousy” mood. She found a Dr. Lolli who had what she considered to be excellent credentials. Upon arriving at Dr. Lolli’s office, named ‘Lolli Psychiatry’ she was told that her appointment was with Dr. Edwards. Surprised that this information was not disclosed when she made the appointment, the office manager told her that ‘Lolli Psychiatry’ meant people who work for ‘Lolli Psychiatry’ and although this was not clear from the website, this is how the office worked. Mildred, not sure what to do, decided to see Dr. Edwards. She was content with the visit, but at the end, he told her to take Prozac, specifying a particular generic and to call him “whenever she felt like it.” There was no mandate for follow-up. Mildred thought this was a bit strange, but she took the prescription, did not fill it, and decided to forget the endeavor of pursuing medication. So, the trend, as I see it, continues. The personal part of psychiatry is dwindling away, while the interchangeable psychiatrist replaces it, for the vast majority of folks who use insurance to seek medical care. Those, like with hospitality, who are willing and wanting to pay for personalization, can get their physician to remember their name, but, for most patients, there will be a deep impersonal quality to medical care, at least medical care administered by a physician. Although I understand this trend, and I have blogged about it for years now, I still find myself quite sad and dismayed at this change. Mostly, I wonder what motivates the physician to set up such a practice. Does Dr. Lolli charge more to see ‘Dr. Lolli’? I wonder. Does Dr. Lolli, recruit young psychiatrists to be the Dr. Edwards of his practice, knowing that eventually Dr. Edwards will be a competitor? Is. Dr. Lolli going to franchise and create multiple locations? Will the name ‘Lolli Psychiatry’ have a brand meaning? Confusion sets in for me. Dr. Lolli needs to create a business, while at the same time, create a model of care which generates patient satisfaction and improved well-being. Compare that to my idea that the physician/patient dyad is unique, creating a sense of care, and love, and in that relationship, along with deep insights and understanding of human motivation, the healing journey begins. Perhaps, Dr. Lolli creates a bench of psychiatrists who can provide this personal care. More likely, though, Dr. Lolli sees his ‘bench’ as interchangeable widgets, giving patients availability, but also, anonymity. I am in the psychiatry business, but I struggle to understand the business of psychiatry.

What Do You Do?

In trying to explain what I do for a living, I am acutely aware how inarticulate I become. “Well, I try to help people sort out their psychological issues and the points in their lives that lead them to feeling confused and bewildered.” I say, not quite happy with this answer, but unable to say it in a better way. “Sure, I prescribe medications and I think that is very important, but that is incorporated into a bigger picture of trying to listen and understand how the person has made important decisions in his life.” I continue, still not satisfied with my answer. As a psychiatrist, some folks imagine my practice to be filled with the chronically mentally ill, and, of course, I do see these folks and I have the skill-set to help them. Yet, in addition, I work with many people who do not meet criteria for a mental illness, but still benefit from medication and psychological exploration. My listener often looks confused as I talk about this. I try again to encapsulate my work, but I feel that my response does not capture the variety in my work. I work with kids, families, couples,  and individuals of all ages.  I work with people who have spent time in psychiatric hospitals, as well as those who will likely never need those services. I prescribe medication to many, but  not all of my patients. My work is varied and customized to each client. How do I communicate that? I need to think more about this.

What Do Psychiatrists Do?

Private practice, county jobs, VA jobs, academic jobs, are all examples of how psychiatrists jump into a career. As I have ranted in this venue before, most psychiatrist jobs, these days, are what I call “psychopharm” jobs, meaning the institution hires the psychiatrist to be a “pill-mill”. “What’s wrong with this?” My imaginary readers ask, to help me launch into my current post. What’s wrong, is the psychiatrist should be the thought leader, the one who designs programs for the mentally ill or creates systems of care in which problems such as homelessness and substance abuse can be approached in a comprehensive, and compelling way. Checklists are not the answer, and yet, there is a large push, particularly in the public sector, for the practitioner to check off boxes, signaling that important issues are discussed. Yet, the issues of the mentally ill, be they anxiety or psychosis, is that the individual needs to feel deeply understood, and then there needs to be services which connect with their underlying pathology. Psychiatrists are in a unique position to both understand patients, as well as help other mental health professionals understand the deeply disturbing experience of mental illness. As such, psychiatrists understand the kind of social services that patients need. They also understand the kind of individual work a patient needs. Putting these two skill-sets together, creates a thought leader who should run agencies, direct programs, or design curriculum. Yet, in most institutions, those jobs are done by non-MDs. The psychiatrists fill the check-box of “psychopharmacology evaluation” and that is usually all they do. This is the big picture/small picture issue. We, as a field, have bought into the ‘small picture,’ without feeling the responsibility of the ‘big picture.’ For this, I think, my field needs to reflect and re-group.

Women And Opiates: My Rant

Pills of hydrocodone, also known as Vicodin, are shown. Drug overdose is one of the few causes of death in the United States that is worsening, eclipsing fatal traffic accidents in 2009. (Toby Talbot / Associated Press / February 19, 2013)

“About 15,300 women died from overdoses of all kinds in 2010, more than from car accidents or cervical cancer, according to the CDC.

Overdose deaths rose most rapidly among middle-aged women who, previous research has shown, are more likely to suffer from chronic pain and to be prescribed painkillers.

“Mothers, wives, sisters and daughters are dying at rates that we have never seen before,” Frieden said. ‘These are really troubling numbers.’ ”

http://www.latimes.com/news/local/la-me-rx-painkillers-20130703,0,916397.story

 

I highly suspect that many of these “middle-aged women” taking opiates, overdosing from opiates, complaining of chronic pain, are suffering from disappointments, psychic pain, and frustration with their lives, particularly their relationships. This “middle-age” for women, as we all know, is associated with launching children, coping with elderly and disabled parents, menopausal body changes, along with mid-life relationships which range from long-term marriages to being new to the dating scene to perpetuating a single life, which may or may not feel satisfying. Where do these women turn? The psychiatrist? Nope. For both social and financial reasons, these women, generally speaking,  turn to their trusted primary care physician. However,  complaining about their husbands, children or their parents, seems like a “waste of time,” so they focus on the very real pain of aging. Joints do not work as well. Injuries are more common. The fluidity of the body is slowly declining and so they complain. Exercise, of course, should be the first line of defense, but primary care physicians are usually coached to get rid of pain quickly, rather than telling patients to exercise, as primary care doctors often feel that the exercise  recommendation is unlikely to be understood as helpful, but rather the patient responds with  “yea, I know, but I won’t.” The culture of doctors wanting to please their patients, encourages physicians to give them opiates for pain that is not clearly understood, but complained about. “What is going on with your life, right now?” is the question that I wish happened in that eight minute office visit. Primary care doctors could venture an educated guess, that the pain of aging is exacerbated by disappointments in relationships. Middle-age is a hard time for women. The culture seems to understand the “mid-life crisis” of men, but women, too, examine their choices, sometimes with feelings of deep regret and despair. Maybe opiates numb that despair, and over time, as the feelings mount, so does the opiate use, leading to tragic and preventable death. My solution: Exercise and psychotherapy for these women who come complaining of body pain, while working them up to make sure that they do not have an underlying disease process which requires medical intervention. Opiates are wonderful drugs for those facing the end of their lives due to a debilitating disease. By contrast, opiates ruin the lives of those who could have a lot to look forward to, but who need to get over a major hurdle in their lives.  Physicians need to understand that. Women deserve it.

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.

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.