How Important Is A Diagnosis?

Who can/should diagnose a psychiatric illness and after all, why is this necessary? The latter is easy to understand. Without a proper diagnosis, there cannot be the appropriate intervention. Yet, is psychiatry that simple? Of course  not. Many therapists do not think in terms of diagnosis, but rather in terms of psychic pain, and as such, they try to alleviate suffering, without too much concern for the category of illness. Sure, a diagnosis has to be written on an insurance claim form, but “depression” seems to serve that purpose for almost all. Yet, what if they miss something? What if they think someone is schizophrenic, when, in fact, they are looking at a drug-induced psychosis? What if they miss that someone’s enthusiasm, is really mania, requiring immediate intervention? What if the person needs to be treated against their will, and yet the therapist is mostly comfortable dealing with patients who consent? What about primary care physicians, who are becoming more and more responsible for managing mental illness? How much training do they get? Who trains them? Do they know when they have hit their limits, or does tragedy ensue? What about psychiatrists who attempt to train primary care physicians, or non-MD mental health professionals how to recognize serious mental illness? Are they adding to the problem of mis-diagnosis or are they part of the solution to help more of the mentally ill have access to care? If a middle-aged female is suffering because her husband left her for a younger woman, does she need to be seen by a psychiatrist, when the cause of her suffering appears to be straight-forward? Should she be triaged before being sent off to a therapist, or should she self-refer to a clinician she heard was good from her neighbor? That psychiatrists, through refined listening skills, and thorough history taking, can come to a diagnosis, is yet another skill set which seems to be trivialized and devalued. Systems of care look to psychiatrists to prescribe, but not to diagnose. “This person needs meds,” is often the reason for referral, as opposed to “this person needs an assessment.” Looking for an assessment is looking for a deeper understanding of the patient, whereas looking for “meds” is looking for the patient to be contained so the psychotherapy can proceed. Once again, it is clear to me, that with the excitement of our psychopharmacology boom of the early 1990’s, we lost sight of how valuable our diagnostic skills are. We neglected to trumpet that clinicians need to refer to us to help them understand what is going on, and not necessarily to prescribe medication. This nuanced issue is how we lost our way. We offer the mentally ill understanding, in ways that other clinicians, because of their limited training, cannot. We have been through medical school, learning pharmacology, physiology, anatomy and the pathophysiology of disease. We have been through residencies where we spent years in mental hospitals, working with the chronically mentally ill, day in and day out. We have worked in emergency rooms with violent and non-consenting patients, who are both frightened and frightening. We have worked in medical hospitals with patients who have recently tried to harm themselves in drastic and terrifying ways. We have seen the suffering in families trying to deal with a mentally ill relative, with all of the frustrations and despair that go along with this illness. This training, unlike other clinicians, has given us a way to say to people with psychic troubles, that we have seen this before and we understand, even if we do not have the best tools to help them cope. Understanding, even under these dire circumstances goes a long, long way. I never tire of saying that. I taught medical students that yesterday, and in a way, they seemed to understand their training deficits, if they did not undertake a psychiatric residency. Group by group, post by post, I hope to continue on with this message.

Changing Face of Medical Care

 

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.

Tele-Psychiatry for Kids?

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.

The Embedded Psychiatrist

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/

Shock in Child Psychiatry

   Stacy, a child psychologist of a mutual patient, says “I have never seen a child psychiatrist be so thorough. The mom tells me you are going to do a school visit. I think that’s great.” Although I am flattered by the compliment, I am also dismayed that a thorough assessment is no longer the standard of care in child psychiatry. School visits, as with meeting both parents, as with playing on the floor, as with talking with current and past treating clinicians, used to be the standard of care for child psychiatric assessment. These steps were the basic building blocks of understanding what was going on with the child. Now, it seems, that child psychiatrists are trained to look at symptoms which are amenable to psychopharmacological intervention. This means that the context, such as the school setting, or the family environment, is less important to understanding the nature of the presenting problem.

      James, our mutual patient, six-years old, is by all reports suffering from “terrible anxiety.” This might trigger the need for a medication such as Prozac, yet, upon further history taking, it seems that his parents are under a lot of stress, and as such, it might make more sense to help the parents be less anxious and that might calm down James. Further, James is having trouble at school, especially on the playground. I am going to do a school visit to see how James navigates his social milieu. Maybe if James could find a way to have friends at school then maybe he will not need medication to calm him down. Friends tend to relieve a lot of anxiety, both for kids and adults. On the other hand, maybe James needs medication to calm down so that he can make friends. This is a judgment call, but a judgment that will be better made after a school visit.

   Understanding, explaining and treating children is the job of a child psychiatrist. Understanding comes from deep history taking and sharply honed assessment skills. Seeing a child in multiple environments is key to thinking about a child in a comprehensive manner. The consultation room narrows the field, as children can behave so differently with one authority figure, as opposed to the challenge of peer relationships. These are basic concepts, yet lost in the present day of rushed assessments and low-thresholds for medicating kids. Consequently, psychologists like Stacy are appreciative of my 1980s, pre-Prozac, training. Again, it is nice to be appreciated for my assessment skills; it is sad that those skills, at least among child psychiatrists,  seem to be going the way of the typewriter.