Shirah Vollmer MD

The Musings of Dr. Vollmer

Lab Rant

Posted by Dr. Vollmer on April 6, 2015

Ordering laboratory tests is an important part of my work as a physician. I prescribe drugs which require laboratory monitoring and as such, blood work is important for some of my patients. I write an order. The patient takes it to their lab of choice and results are sent to me. When it is urgent, I tell the lab, and results are given to me promptly. Sounds simple? Well, not so much. As the wheels of payment changes, as patients and physicians are being forced into specific ecosystems, the flexibility is lacking if a patient or a physician is not part of a larger group. Like a PC user who feels foreign in an IOS environment, so a patient that gets most of his healthcare at UCLA will have trouble integrating his medical record if he also goes to Cedars. Example. A patient needed a stat or urgent lab. I called the lab and they said that since I did not have a physician member number, they could do the lab, but they could not do it stat. “Isn’t that unethical?” I asked, wondering how the laboratory has the right to refuse a physician’s order. I got the repetitive answer that I had to sign up with that lab in order to get the blood result quickly. There are politics here, and payment streams and consumer manipulation, all of which I am not clear about, but a laboratory telling me that they refuse to do a stat lab because I am not a frequent flier, just seems wrong. Rant complete.

Posted in Psychiatry in Transition | 2 Comments »

Andreas Lubitz

Posted by Dr. Vollmer on April 3, 2015

27 years old. Premeditated murder/suicide. 149 innocent victims. h/o depression with suicidal ideation. What of it? How do we make sense of these facts? As a psychiatrist, what are my thoughts on the matter? For a week I have thought about my perspective, wondering how I reconstruct this story which has no answers and only questions. As this is also the eve of holidays in which many family and friends get together, Mr. Lubitz might make it into dinner table conversations. For the families of the victims, there are simply no words. For the world, there is fascination and quick answers, hoping that the next plane we step on, or the plane our loved ones step on, does not suffer this tragic fate. My first point is that I want to rid the world of the shock value of these tragedies. Like school shootings, or suicide bombers in the middle east, there is a  small group of people, who will take harmless victims with them to the next world. This will always happen, and there is no way for psychiatrists, or anyone else to fully prevent these tragedies. For a variety of reasons the perpetrator of these crimes believes that this murder-suicide is justified, and as the human brain can convince oneself of almost anything, once the brain is convinced, the behavior follows and terrible consequences ensue. To be shocked by this behavior is to be naive to human nature. Most humans want to help others, but a minority of humans do terrible destruction. This is our landscape. To pretend that is not true, is denial. The shock of Andreas Lubitz behavior is evidence of this denial. My second point is more difficult to articulate. Mr. Lubitz has a history of depression with suicidal ideation and he sought medical care immediately prior to this event. Does this mean he was mentally ill? Probably, but we will never know, unless the physicians who evaluated him can disclose their findings. Assuming he was depressed and a danger to others, then he should not have been allowed on that plane. However, it is rarely that clear. He may have been vague in his description of his mental state, and he may not have mentioned that in his suicidal ideation he was contemplating taking down innocent people. A psychiatric assessment includes asking about homicidal ideation, but his answer could range from “sometimes I hate people” to “I can understand the man who did Sandy Hook.” The privacy laws in Germany are not clear to me, and so I can only imagine if Mr. Lubitz walked into my office in California. If he specifically stated that he was going to take the plane down, then I would call Lufthansa immediately. However, the likelihood is that he hinted at his plan without being explicit, leaving, I imagine,  the five doctors he saw prior to the plane crash in terrible despair, desperately trying to remember exactly what he said. Unfortunately, the relationship of mental illness to violence is not clear. Our most clear understanding of behavior comes from the past and from family  history. The adage that past behavior predicts future behavior holds true. I do not know what is in Mr. Lubitz’s past, but I suspect he had no violent history, making this event even more difficult to predict. My final point is that as awful as this tragedy is, we need to acknowledge that we are terribly inadequate at predicting these events, and hence having two people in the cockpit at all times is a good intervention. Trusting passengers to one pilot will ensure that this tragedy will repeat.

Posted in current events, depression, Media Coverage | 1 Comment »

Where Have I Been?

Posted by Dr. Vollmer on April 1, 2015

 

I went dark there for a bit, compelling me to talk about my professional transitions. First, I am slowly working on making my office an electronic, moving into our digital world, with all the associated fears and excitement. My first goal is to e-prescribe, giving my patients the freedom to go directly to the pharmacy without the hassle of dropping off a prescription. My hesitation thus far has been that scheduled drugs, meaning stimulants and sleeping medications, require more sophisticated software to e-prescribe and so that limits me considerably. Still, I am going to take the baby step of e-prescribing to those who do not take regulated medications. This will give me mobile access to more information and it will make information management simpler. On the other hand, privacy concerns are huge, as is the dependence on connectivity. I can still write prescriptions, but with each baby step, I get more and more dependent on the internet.

Second, I am expanding my clinical practice to include an emphasis on “recovery” patients, meaning those people who find themselves wanting (and usually needing) to clean themselves from dangerous substances. This is an exciting expansion for me, as I am curious to drill down into the psychological underpinnings of self-harm. Self-harm, in big ways and small ways, has always been a major emphasis of my practice, but adding a focus of substance abuse expands my understanding of the human mind. My inquiry, my passion, for hearing a person’s narrative fits well with helping those who are seeking to start a new chapter. My understanding of psychotropic drugs both helps me understand some of the consequences of their addiction as well as helping me use prescription drugs to decrease their suffering while they transition from substance dependence to sober living.

These two areas of expansion have consumed the part of my brain which allows me to post often. As I settle into my new routines, while maintaining my previous focus on private practice and teaching, I hope to resume frequent postings. Thank you, readers, for your patience.

Posted in Musings, Psychiatry in Transition, Substance Abuse | 2 Comments »

NYer Cartoon

Posted by Dr. Vollmer on March 23, 2015

I knew I would be replaced by a robot, but I did not know I would be picking up a robot.

Posted in Cartoons | Leave a Comment »

Teaching Child Psychiatric Assessment

Posted by Dr. Vollmer on March 11, 2015

A child comes into the Emergency Room because the parents are worried about their behavior. The adult psychiatry resident, not schooled in child development, is called to make an assessment, to triage this patient. Send them home, admit them, call for help, these are the choices. My task today, in one hour, so nearly an impossible task, is to teach psychiatry residents how to begin to triage these children and adolescents. Given that I do a three-hour assessment, and the reality for these residents is that they have, at most, one hour to make this decision, I need to help them pare down my three hours, such that they distill the most important clinical issues. Clearly, this is an inverse situation, in that I, with more experience, could do one-hour assessments, and these residents, in order to learn, should be given three hours, but alas, that is not the current reality.

I will begin by helping them think about where the presenting problem lies?

Emotional?

Cognitive?

Physical?

Behavioral?

Behavioral disorders are the most acute, since those issues can lead to immediate self-destruction or harm to others. We all worry, I will tell them, about seeing the next school shooter, and somehow, tragically, missing the acuity of the situation. At the same time, we know that we will let children and adolescents out of the emergency room, only to find out later, that violence ensued. Our tools are flawed. Our ability to predict, hopelessly fallible.

Next, I will talk about how to get a history, by thinking about the child in four domains.

Family Situation

School Functioning

Community Functioning

Cultural Issues

Returning to the reason for landing in the Emergency Room, the major questions are “why now” and “says who?’ Pre-pubertal children can usually, but of course, not always, return to the care of their parents, but post-pubertal adolescents are much more challenging because they have the means to independently cause destruction. On the other hand, if the parents are part of the problem, or if there is any suspicion of abuse, then the Psychiatry Resident is charged with contacting the authorities, with the possible outcome that the child will land in an emergency foster care situation. The dance between being sympathetic and suspicious of the parents begins. Likewise, this same dance with the child begins as well. Is the child a victim of his circumstances or are the parents victimized by this child, or is it some combination? Eventually, after the data is obtained, both by direct interview and record review, the resident is charged with making a diagnostic formulation and treatment recommendations. Finally, these ideas need to be conveyed to the parents in a way which minimizes defensiveness, as talking to a parent about psychiatric issues in their child is a very delicate conversation. As complicated as all this is, the most challenging issue will be finding outpatient referrals. Child psychiatrists are in short supply, and as such, most families have tremendous difficulties finding good care. Further, the good care that is available is not always well-known to those that work in emergency rooms.

At the conclusion of my lecture, as most of my teaching goes, there is usually a heavy feeling associated with the uncertainties in our field, which is tied together with huge responsibilities, leading to an uncomfortable sense of fear and uneasiness in the provider. I will joke about how this uneasiness might be correlated with the shortage of child psychiatrists. Maybe though, this is no joke.

 

Posted in Child Psychiatry, Teaching | 2 Comments »

Sonia Nazario

Posted by Dr. Vollmer on March 9, 2015

soniaheadshot2

http://www.enriquesjourney.com/about-sonia/bio-2/

 

The best talk I have ever heard. She presented her investigative reporting about a boy named Enrique who fought incredible odds to find his mother in the United States. He traveled through five countries, as a twelve-year old, in search of his mother. As Ms. Nazario says, storytelling is the best way to help people understand, and indeed, she told an amazing story. What was gripping and sad about her tale was that she mirrored his journey, herself, so that she could convey the determination and the tenacity that these children, these young people, who cross multiple borders in search of a parent. Her emphasis on wanting to tell Enrique’s story, mirrors my daily attempt to understand my patient’s story. It is through understanding the narrative, the tale, that we connect as human beings, and we reach out to each other. If we do not take the time to understand the story, then we miss out on understanding the common humanity. I cried and cried as she illustrated the danger that Enrique faced, day after day, and yet he persevered, and yet she persevered in parallel. Sonia first told her own immigrant story, and then told Enrique’s story, and at the end she tied them together, as if they were one tale, as if there were more commonalities than differences. She was right. The deeper you dig, the more the differences drift apart. Rarely, am I that moved by one speaker. Sonia Nazario did that for me.

Posted in child abuse, Child Psychiatry, Child Psychotherapy, child safety | Leave a Comment »

NYer Cartoon Contest

Posted by Dr. Vollmer on March 9, 2015

People think we are doing things under the table, and although it appears that way, we are multitasking and doing yoga while we work.

Or….

We made smart-chairs for our meetings and now they have unionized and they are on strike. They are tired of being taken for granted.

That is the problem with a high-tech company. The old days were better, when a chair was just a chair.

Posted in Cartoons | 2 Comments »

Girls And Suicide: Oh No!

Posted by Dr. Vollmer on March 6, 2015

Depression, Generic

http://www.ctvnews.ca/health/suicide-rate-for-u-s-girls-and-young-women-continues-to-climb-1.2266974

 

“From 2007-2013, the rate for young females went from 2.2 to 3.4 per 100,000. That’s the highest since the 3.1 rate recorded in 1981, when such tracking began.”

These girls and young women, 10-24, are increasing their rate of suicide in the US. What to make of this pit in the stomach feeling of sadness and grief for these developing females and their families? No one knows, so we are left to speculation. They are choosing more lethal means, such that before they may have had an “unsuccessful” attempt, but now they are finishing the job, so to speak. I do not have any glib explanation, except to say that psychic pain is invisible until it is so visible that we squirm when we see it. Does this correspond to my chronic complaining about simplistic interventions for mental health care? Maybe, except that before there were simplistic interventions, there were more people getting no care, returning us to the question of whether bad care is better than no care? There is still a gender gap for suicide, but does this statistic represent a perverse desire for females to close that gap, to show that they can be as violent towards themselves as boys can be? I hope not. Is this a result of social media where there is a vulnerability for developing women to feel that are missing out, based on the images they see on their networking sites? What is the shock associated with these suicides? I wonder if there were any warning signs? As a child psychiatrist, I cannot help but feel that we are failing these girls and women. This data is a call to action. The question is what action? Screening tools?  Should we be empowering teachers to do mental health triage to identify children and adolescents at high risk? Are these foster children, such that more attention needs to be given to this population, a population we know is overmedicated, and is high risk for social ills? Psychiatrists should not stay silent, both to help these kids and to stay relevant. Suicide reminds us about why we do, what we do. We help people with psychic, and hence invisible pain. At the same time, we need to be visible to promote this work.

 

Posted in Suicide | 12 Comments »

Picking A Supervisor

Posted by Dr. Vollmer on March 5, 2015

Residents, psychiatric residents that is, pick supervisors to help them learn psychotherapy. From medical student to hard-working internship to inpatient psychiatry, these residents jump off a cliff into outpatient psychiatry land, which requires learning a completely new skill set. Acuity decreases, and the long journey of psychotherapy begins. The skills required to manage emergency situations, skills which are honed over many years, are no longer needed. Instead, the skills of patience, careful listening, thoughtful hypotheses, and a cerebral mode of being, rather than an action mode of being are required. For some, this transition is the reward of many years of training. For others, it is simply terrifying. And for a few, this is “old fashioned psychiatry” with skills that are “hardly useful.” As their second academic year comes to a close, they are faced with the uncertain task of finding a supervisor, a psychiatrist who can shepherd them through their development as a psychotherapist. They want to learn, but they do not want to feel the shame of not knowing. They are faced, as they hover thirty, with the humiliation of being a student, a pupil who knows little, but is expected to grow rapidly. The anxiety, for some, is large, whereas for others, it is yet another hurdle in their long road of professional development. So, how do they choose their teacher: by reputation, by their curriculum vitae, and/or by the chemistry they feel when they have seen these teachers in other settings such as journal clubs or lectures? Or, is the system broken? Maybe the supervisor should choose the student, based on the supervisor’s judgment of which student would have the most growth potential? Or, as I said in a previous post, maybe supervision is not the best way to teach psychotherapy. Maybe they need to have a psychotherapy boot camp, where, with the help of a facilitator they can rely on each other to struggle through the fog of psychotherapy. Or, maybe they need to learn some basic concepts of technique before launching into seeing outpatients? Maybe they need to read, and write papers, to demonstrate knowledge of psychotherapy before seeing outpatients? At the moment, that is not how the system works. The resident picks their teacher, making it so charismatic teachers, those who the residents perceive to be nonjudgmental, are highly sought after, leaving the less assertive residents with the quieter, less charming supervisors. Maybe the system works, despite its flaws. Maybe, though, this is a time for big data, a time to be more scientific about what works. It is a thought.

Posted in Supervision | 4 Comments »

Binge Eating Disorder

Posted by Dr. Vollmer on March 4, 2015

 

DSM 5 has expanded our notion of eating pathology to include a diagnosis of binge-eating, a behavior that almost all of us have experienced from time to time, but as with all of mental health, when the symptom is both intense and frequent, then a diagnosis is made. Along with a new diagnosis, there is now FDA approved treatment for Binge Eating Disorder, Vyvanse, a stimulant medication, typically used for ADHD.    http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm432543.htm

Truth be told, I, and many of my colleagues have been using stimulants to treat bingeing for over 20 years, but now we have support both from the DSM 5 and the FDA. In other words, our treatment went from “off-label” usage to “on label” usage and so for my existing patients this means more security, and for new patients, this means more awareness that there are treatments available. The closet eater can now come out of that closet. This is an exciting step forward, although the concept is simple. Drugs which suppress appetite will suppress the gratification from bingeing. Medical health improves as bodies return to a normal weight range and mental health improves as the patient feels less shame and guilt associated with binge eating.

Since I normally discuss working from the inside out, it might surprise some of my readers that here I am talking about working from the outside in. In essence, both are important. If I could not prescribe medication to help people help themselves, then I would be limited in my toolbox. Likewise, if I could not explore psychodynamic concepts with my patients, I would be even more limited. Binge Eating Disorder is an example of how if we begin to change the behavior first, then we can then proceed to work on the inner workings of the mind which led to this type of self-destructive behavior. Medications change behavior, sometimes, and when we have that tool available, with minimal side effects, then I am happy to prescribe. As with eating, it is the extremes which are a problem, not the middle ground.

Posted in DSM 5, Eating | 2 Comments »

 
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