Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Primary Care’ Category

Pri-Med West: Shameless Self Promotion

Posted by Dr. Vollmer on February 28, 2016

Pri-Med

West Annual Conference

Anaheim, CA | April 27-30, 2016

Anaheim Convention Center

 

Adult ADHD: How To’s for Diagnosis, Management and Remission

Shirah Vollmer MD

Description

This session will illustrate how ADHD manifests in adulthood. Assessment and management tools will be explored. The complicated interface between stimulant treatment and addiction will be discussed. Both old and new stimulants will be presented, along with behavioral interventions. Mindfulness as a tool for ADHD will also be discussed.

Learning Objectives

Discuss diagnosing ADHD in adulthood

Review treatment options for ADHD in adulthood

Discuss treating the adult ADHD patient who is also an addict

Learn non-pharmacological interventions for adult ADHD

Posted in ADHD, Primary Care | Leave a Comment »

Integrated Care: I Don’t Think So

Posted by Dr. Vollmer on November 19, 2015

Training primary care physicians to manage mental health problems is now termed “integrated care,” a phrase I have come to associate with those fingers on a chalk board. In my old, pre-Prozac life, integrated care was a wonderful way of encouraging collaboration between mental health providers and bodily health providers. Communication facilitated a deeper understanding of the patient and that excitement brought me to the field of  psychiatry. Psychiatrists could share with primary care (we did not call them that then, they were internists or family practitioners), the issues the patient was struggling with, in broad confidential terms, while at the same time, primary care physicians could shed light on how their physical problems might be impacting their activities of daily living. This was, dare I say, the “good ole’ days.” Now, however, integrated care means that the psychiatrist does “chart review” and based on the electronic medical record (which tends to have a minimal narrative) offers suggestion for treatment. Oh my, the history taking skills of a psychiatrist are once again, no longer valued, or needed. In fact, the psychiatrist is seen as the physician who offers the “magic potion” which will elevate the patient away from his suffering, all without ever making eye contact with the patient. The primary care physician makes the eye contact, but not really, since he/she is buried in making sure the electronic record is filed and hence his eyes are often on the computer, and maybe for a few minutes on the patient. Yes, the upside of this paradigm is that more people will have mental health services, but that brings us back to the question of whether bad care is better than no care? However, for the moment, I am not focused on the patient care aspect of this paradigm, but rather I am focused on the job satisfaction of the psychiatrist. How do you feel pleasure from suggesting a medication, when in fact, there are no “magic bullets,” but rather a journey, or as Yalom says, a “fellow traveler” aspect to healing. Psychopharmacological intervention needs to be woven into that journey, rather than extracted as a separate avenue. In my mind, integrated care means integrating medication into psychotherapy, rather than integrating medication into a seven minute primary care visit. So, I am all for a comprehensive approach to mental health care, one that integrates body and mind, but doing this with limited time, simply makes no sense.

Posted in Medical Education, Primary Care, Psychotherapy, Teaching | 4 Comments »

Greg Louganis

Posted by Dr. Vollmer on September 13, 2013

 Greg Louganis

 

http://www.latimes.com/sports/olympics/la-sp-plaschke-louganis-20130913,0,903841.column#axzz2emmEgRpF

 

The Greg Louganis story has returned to prime time, giving me the opportunity to remind my readers, and my students, that this is an example, of how not only do doctors care about their patients, but patients care about their doctor. In this case, the doctor was my beloved old boss, Dr. James Puffer. As the story goes, and some of you might remember, Greg Louganis hit his head during the Olympics of 1988, at which point, Dr. Puffer ran to stitch him up, enabling him to get back in the game and win a gold medal. Many years later he was quoted as saying that his biggest regret was that he did not tell Dr. Puffer that he was HIV positive. I tear up, as I think about this confession, as it speaks to the intensity of their relationship. Sure, the story has a happy ending. Dr. Puffer is HIV negative, and Greg Louganis is now 53 and seemingly enjoying his life. Yet, this story, even without it’s positive outcome, is a tale of connection, which I fear will be lost as medicine becomes more dependent on electronic devices. If a faceless doctor came to stitch him up, would Mr. Louganis have felt so bad? I do not think so. I think modern medicine has made it such that both physicians and patients believe that “buyer beware,” which in this case the buyer is the physician. This bond, where the patient cares about his physician, leading to the patient taking better care of himself, seems to me, is slipping away, as we, as a society, become more dependent on machines to evaluate our symptoms. The joke, on medical teams, is that the doctor will not believe the patient’s leg is amputated until he sees the X-ray. I am compelled to remind my readers that I love technology and I am excited about how modern science is rapidly changing how we track people and disease states. The complex area of following patients over time is much simpler with machines which contain the notes about  the last visit and the last time the medication was changed. However, if these tracking systems are valued over the personal connection between the doctor and the patient, then I fear that medicine will be less fun for doctors, and patients will lose incentive to take care of themselves. The human touch, remains in my mind, a vital force for promoting wellness. In the case of Greg Louganis, that human touch, could have had fatal consequences for Dr. Puffer, but luckily, instead, it brought to  light, the humanity between patient and doctor.

Posted in Doctor/Patient Relationship, Media Coverage, Primary Care | 2 Comments »

Medical Students: What Do They Want To Know?

Posted by Dr. Vollmer on July 10, 2013

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.

Posted in Medical Education, My Events, Primary Care, State of Psychiatry, Teaching, Teaching Psychoanalysis | 5 Comments »

Women And Opiates: My Rant

Posted by Dr. Vollmer on July 3, 2013

Doctors prescribe narcotics too often for pain, CDC chief says

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.

Posted in Gender, Office Practice, Primary Care, Professionalism, Substance Abuse | 9 Comments »

Changing Face of Medical Care

Posted by Dr. Vollmer on June 12, 2013

 

There is change mentioned at every lecture I attend, every lunch time discussion, every committee meeting. I hear these discussions in primary care and in psychiatry, but I think it is likely that every corner of health care is struck by the feeling that we have reached a pivot point. Today’s angle was delivered from an esteemed Duke primary care physician, director of the Family Medicine Residency, and a former student. Family Medicine, he says, will no longer focus on why patient A does not take his blood pressure medication, but the physician will look at a bigger picture of how can he/she implement a system which facilitates compliance. We changed the name from compliance to adherence and back to compliance, but that is another story. This system is going to involve using technology, nursing and administrative staffs, wellness groups and community outreach. It sounds like Kaiser to me. In fact, it is the Kaiser model. Have lesser trained folks work on the patient interface, while the physician does what he is trained to do; decide what the problem is and how to treat it. After that, the can gets kicked down the road, and the health care team deals with the details of implementation. Theoretically, this makes a lot of sense. Practically, Kaiser, as the model, does a good job, mostly. My issue, as my readers have heard before, is that the reward system for the physician has changed drastically. It used to be that the implementation of the details, understanding why patient A does not want to take his medication, his resistance, if you will, to making his life better, was where the deep relationship developed, and hence the career satisfaction. Now, unless a physician “goes concierge,’ as my colleagues like to say, that connection is lost, leading to a more technical job of diagnosis and treatment recommendations. More technical means that patients, on average, will get good care, but the physician will only be using his left brain. The integration of the right brain, the understanding of how human emotion interfaces with disease management, will no longer be in the physician’s scope. As a policy maker, this makes sense. As a physician, well, the world is changing.

Posted in Primary Care, Professional Development, Professionalism, Psychiatric Assessment, Psychiatry in Transition | 4 Comments »

Fungible

Posted by Dr. Vollmer on April 17, 2013

 

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

 

 

Posted in Health Care Delivery, Medical Education, Office Practice, Primary Care, Professional Development, Professionalism, Psychiatry in Transition | 4 Comments »

Automated Medicine Versus Personalized Medicine…Narcissism Versus Self-Care

Posted by Dr. Vollmer on April 15, 2013

 

Financing health care fascinates me. So many folks who have private physicians resist changing to a health maintenance organization because they will lose the “personal touch”. I, who have advocated for the value of the physician/patient relationship, am always shocked by this choice. Sally, fifty-one, for example, spends $1500.00/month for her and her husband to maintain their physicians. This number represents their premiums, not their co-pays, or deductibles. The could spend half if they switched to an HMO, and finances are really tight for them. Plus, she and her husband are healthy, and rely on their physicians only for yearly check-ups. Still, the notion that they can call Dr. Lee, and Dr. Lee knows them, means so much to Sally, that she steadfastly refuses to change carriers. “What if the quality of health care was the same at an HMO, perhaps even better, would you still consider switching?” I ask, Sally, curious by what might be a sense of narcissistic pleasing, which comes with more personalized medicine, as is the difference between levels of service at three star versus five star hotels. “I don’t know. It just feels bad for me to switch, so I cannot think of it.” Sally says in a dismissive way, although I am also aware that her initial reaction to my comment is one of negativity, she often gives it deep thought. We, as a society, get used to a certain level of service, making it very difficult, even in the face of financial hardship, to go down to a system which meets the goal of good health care, without the special treatment of someone knowing your name and your family circumstances.  Personalized care is often mistaken for better care. Automated care might not appeal to one’s narcissism, but it might get the job done. The rules of business prevail. Making people feel good sells. Outcome measures, or hard data, does not sell as well. Concierge medicine works on this principle. Business minded folks understand the rules. The public, unless mindful, are vulnerable to financial hardship as a result. The Affordable Care Act will bring these notions into the foreground. The change in level of service will be interesting to observe. The doctor/patient relationship will still be there, but it will be expensive. Service costs money.

Posted in Health Care Delivery, Narcissism, Primary Care | 2 Comments »

PMDD Walks Into DSM 5

Posted by Dr. Vollmer on March 12, 2013

 

PMDD, premenstrual dysphoric disorder is currently a diagnosis in the appendix of DSM IV, meaning that if a physician believes the patient has PMDD, then he/she must write Depression NOS (not otherwise specified). At the same time, there are currently drugs approved for PMDD, despite the fact that it has not achieved diagnostic status. Well, come May, 2013, after Bill Clinton speaks to the American Psychiatric Association in San Francisco, California, the DSM 5 will be announced and the criteria for mental illnesses, in the United States, at least, but probably around the world, will change, including more folks, causing a large stir about the wider scope of psychiatric disease.  DSM IV came out in 1994, making almost ten years of a classification system, which for the most part, has not matched the explosion in psychopharmacology. DSM 5 has taken a long time, mostly, as I can tell, because the debates over the diagnostic system were tense. So, it is very likely that PMDD will hit the light of day and now women who suffer from terrible irritability before their periods will merit a psychiatric diagnosis. The good news is that there will be more acceptance of the biology of mood swings, and then hopefully more acceptance of psychopharmacological interventions. The bad news is that some women, through no fault of their own, will be labeled, potentially increasing their premiums for health insurance, life insurance and disability insurance. The triad of emotional lability, irritability and anger, during the luteal, or last phase of the menstrual cycle, in about 2-5% of menstruating women, had been validated in the research over the past 20 years. This additional research, the DSM 5 committee argued, gave good reason for PMDD to be “promoted” to  a diagnosis and out of the appendix. PMDD now joins the ranks of a full blown mood disorder; it is in parallel with bipolar disorder, which also has prominent mood lability and irritability, but PMDD symptoms cease on the first or second day of menses. Plus, PMDD comes with physical symptoms of bloating and breast tenderness, making it easily distinguishable from bipolar disorder. What about heritability? You ask, knowing that most psychiatric diagnoses run in families. The heritability of PMDD ranges from 30-80% which is indeed, a wide range, but enough to merit a full diagnosis. What about treatment? PMDD is ameliorated with an SSRI (Prozac and his cousins), quickly, unlike when an SSRI is used to treat Major Depression. Also, intermittent or continuous treatment are both helpful, suggesting that a constant blood level is not necessary, but rather more serotonin in the premenstrual or late luteal phase, seems to do the trick. So, the world will change in May, 2013, the psychiatric world, that is, and hence all of us who work, love and/or experience others who suffer with negativity, irritability, and quickly shifting moods. Now, women who cycle in and out of these mind states will be legitimized on the one hand, and maybe, but hopefully not, stigmatized, on the other.

Posted in DSM 5, PMDD, Primary Care, Psychopharmacology, Teaching | 11 Comments »

The Embedded Psychiatrist

Posted by Dr. Vollmer on October 2, 2012

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…https://shirahvollmermd.wordpress.com/2010/11/08/patient-centered-medical-home/

Posted in PCMH, Primary Care, Professional Development, Professionalism, Psychiatric Assessment, Psychiatry in Transition | 4 Comments »

 
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