Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Professionalism’ Category

Tele-Psychiatry for Kids?

Posted by Dr. Vollmer on October 17, 2012

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.

Posted in Doctor/Patient Relationship, Play, Professional Development, Professionalism, Psychiatric Assessment, Psychiatry in Transition | 2 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 »

Going Global

Posted by Dr. Vollmer on September 19, 2012

Education is global, like all other industries these days. Medical schools are having training programs around the world. Exchanging information, exchanging students, a long-time practice of college education is now expanding to graduate schools and post-graduate education. UCLA Medical School are now setting up guidelines for their world-wide electives. Cornell Medical School has started a “branch” in Qatar. Two UCLA Child Psychiatry fellows are off to India to explore child mental health in a rural area. Some UCLA Family Medicine Residents ventured off to Haiti after the earthquake to help with the pressing medical needs of the distraught population. This, strikes me, as a new and exciting expansion of medical education. In my day, it was the rare soul who ventured out of the country to explore how medical care is administered in different health care systems. Sure, we were allowed, maybe even encouraged to do electives at other US medical schools, but we were never supported to go beyond our borders. I suspect that this relatively new development goes along with our increase in connectivity and thereby the increase in cross-fertilization. It is wonderful to think that our next generation of physicians will have a broader world view. It is also wonderful, selfishly speaking, to think that there might be opportunities for teaching around the world. Teaching and learning always go together. Global teaching and learning seems so rich and vibrant with new ways of thinking about how to help people. For example, European physicians write prescriptions for spa treatments as a way to help those in mental distress. I think that is brilliant. Trite but true-the world has so much to offer.

 

See also….https://shirahvollmermd.wordpress.com/2012/08/21/calling-my-266-german-friends/

Posted in Medical Education, Professional Development, Professionalism | 4 Comments »

A Concierge Psychiatrist?

Posted by Dr. Vollmer on August 1, 2012

http://http://youtu.be/8IX-zdZdOco

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

 

Posted in Doctor/Patient Relationship, Professional Development, Professionalism, Psychiatry in Transition, Psychotherapy, Relationships | 5 Comments »

“What’s Your Name?” I Ask My Students

Posted by Dr. Vollmer on July 26, 2012

The Clinical Practicum, the name for my class on child psychotherapy for UCLA Child Psychiatry Fellows, is, as the name implies, a “practical” class about how to begin treatment with children. My seven students are licensed physicians, able to practice as an adult psychiatrist, but wanting, for various reasons, to pursue further training in child psychiatry. The group hovers around thirty, which, of course, is the new twenty, or so people say. “So, what should your seven-year old patient call you?” I ask, somewhat to the shock of my students. “Dr. Sarah” (not her real name, of course), said, making sure that the child knows she is a doctor, but that he/she should use her first name. Another student got passionate. “Oh no, I am Doctor Green. I think it is essential that the child use my last name so that they understand that we are not just playing together.” She says with conviction. “What do they call you?” Another student asks me. “Shirah,” I said. “Over the years, I have become the most comfortable with that,” I say, trying to encourage the students to do what feels right for them, rather than look for the ‘right answer’. “My goal is to make you guys more conscious of your choices. The idea is that whatever they call you is going to set up a frame on the relationship which may or may not add meaning to the treatment. Deciding how you want to be addressed is a very serious matter.” I say, highlighting the idea that every decision, every interaction with the child and his/her parents, is, to use an overused expression, grist for that therapeutic mill.  The end of the class was very similar to how it began. There were questions. No conclusions were drawn. I like that.

See also….https://shirahvollmermd.wordpress.com/2011/03/08/whats-my-name/

Posted in Child Psychiatry, Professional Development, Professionalism | 4 Comments »

Closing Ranks

Posted by Dr. Vollmer on May 2, 2012

Lesley,fifteen  is “anorexic” according to three physicians she has seen at a well-respected institution. They have documented their clinical judgment and her diagnosis follows her. She then sees a fourth physician, Dr. Lee,  who determines that her lack of appetite is secondary to her family issues, and she does not have a body image distortion. She wants to gain weight, but she has lost her appetite due to the stress she experiences from her family. Lesley’s family, her parents in particular, do not understand the family stressors at home, so they agree with the three physicians that Lesley has anorexia nervosa. Dr. Lee is insistent that the critical intervention is family therapy, in order to help Lesley understand that although she is the identified patient, the issues she faces come from how her family members treat each other. Lesley’s parents disagree with Dr. Lee, so they take Lesley to a fourth physician at this well-respected institution. The fourth physician has no interest in gathering a history from Dr. Lee, but he reviews the records from his three colleagues and concludes, as they did, that Lesley has a severe eating disorder, requiring inpatient treatment. Dr. Lee says to Lesley’s parents, “they are closing ranks. They have to agree with each other in order to work together. The problem is that this is at Lesley’s personal expense.” The parents are not convinced. They agree with an inpatient program and they communicate to Lesley that she has a major psychiatric disorder. They do not acknowledge or believe that their behavior has contributed to Lesley’s issues. They believe, as they have been told, that Lesley is suffering from a disorder which is hard to understand, but requires individualized behavior therapy to treat. Family intervention has no role, according to these physicians. The parents fire Dr. Lee, and proceed with Lesley’s treatment. Psychiatry is a messy field. There are no objective findings. Lesley might get better, or she might have a persistent problem, given her family dynamics are not changing. The answers are not clear.

Posted in Professionalism, Psychotherapy | 4 Comments »

Keeping Up With The New Generation: Psychiatry in Transition

Posted by Dr. Vollmer on April 5, 2012

The Psychiatric Clinical Faculty Association (PCFA) is a group of voluntary psychiatrists who give their time to support UCLA Psychiatry Residency Education. Mostly, this is a group, including myself, of private practice psychiatrists who are interested in nurturing the next generation of psychiatrists. “The problem is that we do not understand this cohort,” I say in a recent meeting. “Until we know how they think of their work and their field, we will not know where we fit in,” I repeat, trying to say, that as with all interventions, one must understand the baseline before attempting to make a change. My idea was well-received, with a group notion, that we need to first see how the group of trainees are relating to this field that we call psychiatry. This is a group that grew up with electronics, but they seem as fearful and weary of electronic medical records as we do. Yet, unlike most of the clinical faculty, they seem comfortable with a “medication model” where their only role with a patient is one who prescribes psychotropic medication. By contrast, most of my committee feel the importance of medication within a larger scope of understanding the context in which the medication can then contribute to a better quality of life. As one colleague said “we have a tool chest with many different tools, but the residents seem to think that one tool is inherently better than another, rather than understanding that we keep trying our tools until we see what fits best for the patient.” As Paul Wachtel PhD wrote in his new book “Inside The Session” integrating different kinds of therapies seems to be taboo, and yet, most of us do this in our offices, even though we tend not to share this with multimodal approach with  younger colleagues, thereby leaving young people to believe that they must “choose” one way of treating patients.

UCLA, as an academic institution, has tenured faculty who are experts in their field. We, as the Clinical Faculty, do not claim to be “experts,” but we do claim to have the experience of seasoned professionals. Most residents do not stay in academic medical centers. Most will benefit from the expertise of people, like myself, who have been “in the trenches.” Yet, some of them do not understand that until well into their professional career and maybe that is how it should be. Then again, maybe if we understood what they were thinking, we could advise them to better utilize our services earlier in their training. Sure, some of us know a couple of trainees, but “none of us have the pulse of the entire group,” I say, highlighting the need for a representative sample. “Journal club,” one colleague suggested. We can review an article in an informal setting and get to know them that way. “That’s a good beginning,” another colleague says. It was a good meeting.

Posted in Professional Development, Professionalism, Psychiatry in Transition | 4 Comments »

What’s My Name?

Posted by Dr. Vollmer on March 8, 2011

  Erin, a new patient, age fifty, says “hi Shirah” as she walks in my consultation room. “I can call you Shirah,” she says sweetly. “Sure” I said, thinking to myself, why not? “OK, well you can call me Erin,” she says, even though I would never think to call her anything else. Sure, back in the dark ages of my medical training in the 1980s, we were trained to address every patient by their last name, but times have changed, and life, at least in Los Angeles, seems more casual. Plus, I have gotten older so the age difference between me and my patients has decreased. So, with a more relaxed culture, and my increasing age, I have become comfortable addressing all my patients by their first name. It would seem uneven if I insisted that they address me by saying “Dr. Vollmer”. On the other hand, the relationship is uneven, so maybe I should insist on “Dr. Vollmer” as a way of reminding myself and the patient that we are engaged in some serious business, in the same way that professional clothes, whatever that means, is supposed to remind both the professional and the client that serious work is at hand. Yet, the entertainment business, and many primary and secondary schools, insist that every staff member, including the principle be addressed by their first name. When Summerhill started this trend in education back in the 1960s it was radical. Today, students addressing teachers and coaches by their first name is comfortable and friendly, without any sense that their authority is somehow diminished. My name is Shirah. I feel clear about that. Call me “Dr. Vollmer” and I will answer to that too. You decide.

Posted in Professionalism | 4 Comments »

Cronyism

Posted by Dr. Vollmer on November 30, 2010

Roger, a psychoanalyst, sixty-two, was deeply involved in his psychoanalytic institute for his entire thirty year career as a psychiatrist/psychoanalyst. He served on committees, he taught candidates at the institute, he gave parties, he went to conferences, symposiums, presentations by local and out-of-town speakers. He enjoyed the camaraderie, the intellectual stimulation, the feeling of belonging, similar to the high school experience of “fitting in”. https://shirahvollmermd.wordpress.com/2010/03/10/belonging/. Regimes change, the leadership of the institute began to shift, such that his buddies were no longer in positions of power. As such, the new leaders tapped the shoulders of their friends, their cronies, to do the “work” of the institute. Roger began to feel marginalized and demoralized. His years of voluntary service began to fade away in his colleagues’ mind. He no longer felt he belonged. Understanding the issue is clear to Roger. The adage “it is not what you know, it is who you know” rings loudly for him these days. The emotional overlay of disappointment and abandonment also rings loudly for him. Roger wants to feel appreciated. He is searching for validation. His world has changed; Roger has to adapt. Grief, followed by rebuilding a professional community is his path. Good luck Roger.

Posted in Belonging, Professionalism | 2 Comments »

 
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