Monday, June 29, 2020

Should You Trust Your Physician?

As far as I can tell there are two basic considerations in whether or not you trust your physician. The first is combination of personality and cultural factors and the resulting expectations you have when you see a physician. That may have something to do with your actual experience, but also may have more to do with observations from the care of other people. As an example, you saw your father was cared for and thought it was excellent care and expect the same care for yourself. That can also backfire in the case where you believe the observed care was substandard and led you to be more skeptical of medical care administered by physicians. From a cultural standpoint, you may be from a culture that does not trust authority figures or even physicians.  These are all very complicated issues, that I will illustrate with personal examples of treatment I have received over the years.

The second approach to whether or not you trust your physician, is to adopt a very performance-based approach. That approach is the answer to the question: “What has this doctor done for me and do I like those results?” Medicine is a complex field made more complicated by subjective assessment of the patient in their experience of care and treatment. As a psychiatrist, I see people who are very satisfied with their care from physicians and surgeons and many who are dissatisfied. I see people who have had the exact same procedure – let’s say a hip replacement with identical functional results.  One of these patients will tell me, that they are doing very well and the other will describe disappointment.  The disappointed patient will often tell me they are only slightly improved than when their joint was “bone on bone”.

My own experience with physicians is mixed at best. When I was a teenager, was in a doctor’s office and developed acute facial swelling, wheezing, and my eyelids were swollen to the point I could barely see. The explanation was given to my parents at the time was it was “psychosomatic” I was not treated with anything. The next several years, the only treatment I got was to get up at night go out into the cool night air and drink caffeinated soda. Needless to say that was suboptimal. When I finally saw an allergist about six years later I was “allergic to everything” and finally started taking antihistamines. But eight years later when I was intern, I saw an allergy specialist who spent the entire interview demanding to know what I wanted to try immunotherapy. I guess it was his form of motivational interviewing.  I never went back.

In medical school, I started to get gout attacks. With the first attack I went the emergency department and spent six hours there.  I was discharged with acetaminophen and codeine – a medication that is essentially worthless for gout pain. During a follow-up appointment in the orthopedic clinic, I was told that I probably sprained my ankle in bed and they put a cast on it. Gout pain gradually resolves after about two weeks and that is what happened. But the gout saga does not end there. During residency I started to get acute wrist pain. I went to a primary care clinic where the physician learned my history and then tried to aspirate my wrist joint with a large needle. That was a skill set that he did not have, but he did end up aspirating some tissue into the syringe that was eventually identified as synovium from the joint.  At some point, I also had a left inguinal lymph node biopsy that went awry. I went back to work and started gushing blood all over my khakis. The surgeon advised me to come to his office right away and by then my shoes were full of blood. I left bloody footprints all over his carpeting.  He cut open the incision and tied off the artery in the office while two nurses held me down.

That is a sampling of my negative experience. There is actually a lot more, but despite these fiascoes I have been able to find physicians that I trust and routinely go back to see. I have been seeing the same primary care physician for the past 30 years - recommended by psychiatric colleague who worked with him.

From a cultural standpoint, I was taught to be skeptical of everyone. My father was a blue-collar worker who routinely talked about the abuses of the administrative class and how working people were taken advantage of. He was in a union and would routinely show me the house that the president of the union lived in compared to our house.  That perspective is still ingrained at some level, but it does not prove very useful when it comes to medical care. The reason is that at some point almost everybody needs medical care and that typically includes care that involves doing something that you would rather not do. That might be surgical procedure or taking medication for a long time or even getting an immunization. But the choices are often fairly dire and that is continue to be miserable or die or accept the recommended treatment. Despite my medical misadventures, I continue to accept doctor’s recommendations even when they have significant risk.

I also come at this from the perspective of interacting with thousands of patients, many of whom don’t trust doctors at all. In most extreme circumstances, I had to interact productively with people who not only did not trust doctors but were simultaneously being coerced into treatment by the probate court system. In other words they were on involuntary holds, probate court holds, or civil commitment. That was the best possible experience to conceptualize the physician trust issue. A typical exchange follows:

MD:  “Hi – I’m George Dawson and I’m the psychiatrist here. It looks like I am seeing you because you were admitted to this unit on a 72-hour hold.”

Pt: “I don’t trust psychiatrists. I just want to be discharged.”

MD: “In order to do that, I have to make an assessment of the situation and determine if you can be released or not.”

Pt: “Why should I trust you?”

MD: “I can’t think of a reason why you should. You just met me. I would suggest that we proceed with the evaluation and see how that goes. At the end of the evaluation I will let you know what my impression and recommendations are. You can decide whether or not you trust me based on what happens. If you decide to follow my recommendations you can also base your decision on whether or not those recommendations work for you. Does that seem reasonable?”

That is the basic framework that I tried to outline for people are focused on trust. The focus is on actual performance as well as subjectivity. The subjective elements are a number of factors on the patient’s side.  They include all of the conscious and unconscious factors involved in interpersonal assessments as well as any overriding psychopathology. The most important element of the patient’s conscious state is whether or not they can incorporate the information that they are receiving from the physician into their responses and adapt a different framework for the interaction. Not everybody is able to do that, but the great majority of people are to some degree.

The above example is from what is probably the most contentious situation.  I think the approach works even better in outpatient settings where people have had adverse experiences in psychiatric care like my experiences with medical care.  In some of those situations a description of the therapeutic alliance is useful. That might go something like this:

“It might be useful to discuss how these interviews work.  You and I are both focused on the problems that you identify.  We discuss them and at some point, my job is to give you the best possible medical advice on how to address them.  Your job at that point is to think about that advice and whether or not you find it useful and want to use it.  It is also possible that your problems are not medical or psychiatric in nature. I will let you know if I think so.”

That clarifies a few points.  The interview is not a unilateral “analysis”.  Many people have the psychiatric stereotype that a psychiatrist can just look at you and figure out the problem. To this day, many people that I casually meet still ask me if I am “analyzing them.”  It also points out that I am interested in what they identify as problems – not somebody else’s idea of the problem. Unless that is explicit, many people go out of their way to tell me that it was their idea to see me or go to treatment.  Most importantly – it emphasizes that this is a cooperative effort.  I have no preconceived idea about their problem or diagnosis.  My ideas develop from the discussion and there has to be agreement that I am on track.

That is my basic approach to the trust issue in interactions with patients.  There are many variations on that theme.  Although what I have written here is from the physician perspective – I can add that from the patient perspective the performance dimension is very important.  My personal internist always takes enough time to assess my problems and do an adequate evaluation.  He has made some remarkable diagnoses based on those evaluations.  That performance over time builds trust as well.  It also highlights another important aspect from the patient perspective and that is empathy towards the physician.  Is there an understanding of how the physician’s cognitive ability and emotional capacity can be affected by outside factors? Is there any allowance for even minor physician errors or lapses in etiquette – like being very late for an appointment?  People vary greatly in that capacity and often it is necessary to keep a productive relationship going.

Most medicine these days is run by corporations rather than physicians. That makes it harder to establish long term relationships with physicians. In the above narrative I hope that I outlined the advantages of that relationship as opposed to one that may be more like being asked 20 questions about a medical condition by different people every time you go into a clinic.

George Dawson, MD, DFAPA

Sunday, June 14, 2020

Depression Prevalence and Other Checklist Limits

I finished reading a paper last night about estimating the prevalence of depression using the PHQ-9 (1). The paper had 76 authors including one of the most well recognized epidemiologists in the world. It was focused on the differences in estimating depression prevalence using a structured research interview specifically the SCID (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders versus the PHQ-9 - a nine item checklist based on the DSM criteria for major depression. If you ever need a reference paper for how to write an epidemiology paper based on a literature search this is probably a good one to have.

The authors did an extensive literature review in the end found 44 (n=9,242) studies that looked at comparisons between the PHQ-9 and the SCID.  The result was that the pooled results showed that depression prevalence estimates with the PHQ-9 (total score ≥ 10) were about 25% and for the SCID it was 12%.  Modifying the criteria for the PHQ-9 to a score of ≥ 14 and using a separate PHQ-9 diagnostic algorithm resulted in a lower prevalence estimate but a wide margin of error.  The authors conclude that structured interviews are the best approach to prevalence estimates largely because they are closer to clinician style interviews and through clarification, they can limit confounding variables. Nobody ever seems to comment on the restrictive aspects of both checklists and structured interviews.  After all,  DSM criteria that are embedded in the matrix of questions and elaborations in the SCID are basically converted to nine unidimensional questions in the PHQ-9. It should be obvious that there would be a correlation between the two when the PHQ-9 is validated against the SCID, but instead it is accepted as an academic exercise.

The first thing I thought about when I saw these numbers and read the paper was “even the SCID prevalence figures are too high”.  I base that on numbers available in a standard textbook on psychiatric epidemiology (2).  Reviewing much larger sample sizes across 25 countries yields one-year prevalence figures for depression of 2.6-10.3% (median 5.3%) lifetime prevalence figures of 2 to 16.2% (median 8.6%). In that table the variation in very large community samples ranging from 5000 to 42,000 subjects in the United States seem to depend on the research methodology more than anything and structured interviews other than the SCID were used.

The selected samples from reference 1 are detailed in table 1 and very few of them are community samples. They are relatively small outpatient samples of identified medical patients or people seeking medical services for themselves or another person. Many of the conditions have known comorbidity with depression. The authors list this as a study limitation particularly “where the presence of transdiagnostic somatic symptoms and adjustment to illness or injury may have contributed to error variance”.  They also comment on the heterogeneity of the study settings and how that might affect the data. That is certainly my concern for post stroke patients, multiple sclerosis patients, Parkinson’s disease patients, epilepsy outpatients, and other neurological conditions for depression is a common comorbidity. The implicit message from this paper is that depression prevalence estimates from clinical samples will be higher than estimates from epidemiological community surveys.

But there is a much larger lesson here than differences in depression prevalence estimates based on methodology or clinical sample. For me the heart of the matter is the difference between a psychiatric interview, a structured clinical interview, and a checklist.  I have expressed my concerns over the years that checklists are currently surrogates for psychiatric interviews and I can confirm this on a weekly basis. Most the patients I see have seen primary care physicians or nonpsychiatrists and they tell me how they are given a PHQ-9, a diagnosis based on that rating scale, and a prescription. That model of care is promoted by some organizations as “evidence-based medicine”. In some cases it is called “measurement based medicine”. The state of Minnesota for example has a project were all PHQ-9 scores are collected from any clinic treating patients with a diagnosis of major depression. This was supposed to be some kind of quality measure even though an analysis of all the cross-sectional data has never been done.

When I talk with people who have taken these checklists and asked them about depression it is common to hear the question “What do you mean by depression? I am still not sure about what that means and the difference between depression and anxiety.” I hear those questions from people who have been filling out the rating scales and getting medications prescribed to them based on those scores and yet they are uncertain about the concept of depression. How can that happen?

The obvious way is by limiting choices. If a nine-item checklist is given to a person and they are told to answer a specific question as one of 4 choices, most people will check a box.  In the case of the SCID – there is more elaboration.  People are asked about whether there was a time in the last month when they felt “depressed or down most of the day nearly every day?”. They are asked to elaborate and whether or not it affected their interest or pleasure in activities. They are asked if it lasted as long as two weeks. At that point there is a qualifier that says the interviewer is not supposed to include symptoms “that are clearly due to a physical condition, mood-incongruent delusions or hallucinations, incoherence are marked loosening of associations, or that are clearly part of the residual or prodromal phases of schizophrenia”. Additional questions about symptoms of the depressive syndrome follow.

Many clinics use electronic health record (EHR) templates that include checklists about all of the major classes of psychiatric syndromes. They are a variation on the SCID but they generally result in more spontaneity and elaboration than a checklist but not as much as the structured interview. What is lost along the way?  I would suggest – a lot.

The rationale for structured interviews is reliability or consistency in responses.  If any population is given a matrix of the same questions to differentiate different conditions – no matter how exhaustive - there will be a pattern of responses that has internal consistency. Viewed from that perspective, the PHQ-9 is just a very abbreviated and less specific version of the SCID – hence the difference in prevalence estimates.

Although prevalence estimates are often the focus of criticism (too high, too low, just right) what is typically missed is that they really have limited application to good clinical psychiatry. Psychiatrists do not do SCID interviews on patients and the reasons may not be that apparent. Psychiatric diagnoses depend on a lot more than a symptom checklist and the total time to administer a SCID (2-3 hours) is prohibitive. There is also a question of efficiency.  In practice the psychiatrist has to be able to focus on all relevant aspects of the identified problem not areas that are not considered to be a problem.  Most importantly – the psychiatric interview needs to recognize that the person in the conversation has a unique conscious state that is interpreting their emotional, cognitive, and physical experience. The psychiatrists has to understand how that is happening.

There is probably no better discussion of this crucial aspect of the interview than that provided by Nordgaard, Sass and Parnas (3). These authors use the term “a conversational, phenomenologically oriented interview, performed by am experienced and reliability-trained psychiatrist.”  as the more optimal and preferred approach.  After reading their work, I realized that it is what I have been doing for the past 35 years.  In a more recent article, this group has compared American phenomenology to a simple study of signs and symptoms and suggested their use of the term is more consciousness based:

“It refers to a faithful exploration, description, and conceptualization of the patient’s contents and structures of subjective life and modes of existence (eg, not only the content of the delusion but its mode of emergence and articulation and ways of experiencing the delusion)” (4)

They suggest this requires an interview that maximizes self-description and a knowledgeable physician with a “rich conceptual repertoire”.  Since the DSM approach is intentionally atheoretical – it speaks to the need to be trained in a variety of psychopathological theories.  Andreasen (5) has previously written about the death of phenomenology as being an unintended consequence of the DSM approach.  In my experience it is easily approached in residency training as the need for a empathy based formulation that makes sense to the patient.  In their article (3) the authors provide a table comparing what is elicited with a structured interview as opposed to a phenomenologically based conversational interview.  In the table below I provide my own example for a patient with depression. I will add that in most electronic health records these days there are templates that are essentially structured interviews requiring brief responses and very little discussion about the process or content of those responses. Those templates are further limited by the fact that all of the information needs to be entered by the psychiatrist doing the interview - a further inefficiency.

Structured Interview
Conversational Interview
She has been depressed all of her life with very few periods of neutral mood. The depression includes periods of extreme irritability.  The depression worsens from time to time.
She had had long term depression but it is clearly worsened in specific contexts. There are situations that specifically make her anxiety worse and when this happens, she “spirals down” into a depression and will often spend the entire weekend in bed. A lot of these episodes are associated with a stressful job and a specific interpersonal conflict at work.
She describes a motivational deficits and anhedonia.
During the episodes of worsening depression and isolation – she watches TV all day long. She is not motivated to exercise but occasionally will push herself to go for a jog. She was the high school state record holder in the quarter mile. Even though it is initially difficult she feels much better afterwards and the activity reminds her of the importance of exercise in her life and how she used to work out in high school.
Decreased concentration and memory problems
She has had life long concerns about her memory and at one point considered “getting tested” for ADHD. She got a degree in molecular biology and graduated summa cum laude. She is currently working in a professor's lab and thinking of applying for a PhD program. She has no problem reading and retaining information from highly technical journals and devising lab protocols or her favorite science fiction. She attends meetings where her mind wanders.
Depressing thoughts
“I am a perfectionist and am my own worst critic.” She was encouraged from an early age to get A grades in school and had a nearly catastrophic reaction when she got a B in high school.  She still remembers that teacher who told her that getting a B would be “good for her”. Her parents were always critical and she realized at some level she has internalized some of these criticisms especially when it comes to body image and weight: “I don’t think being petite and wearing the latest fashions makes me a better scientist”. Despite fairly constant self-criticism it never gets to the point where she feels worthless.  
I have some suicidal thoughts but have never made a suicide attempt or an attempt to hurt myself.
“I read a journal article somewhere that looked at the prevalence of suicidal thoughts and they are fairly common.” She describes intrusive thoughts about suicide that are obsessional in nature. “I drive across this bridge every day.  If I am having a bad day, I think about cranking the wheel at the half way point and driving off. But I know I will never do it.  I am too chicken and I have too much going for me.  I want to hang around and see what happens.”

The conversational interview is information rich and allows for more extensive pattern matching.  The PHQ-9 and even the SCID describes a very limited pattern or as Kendler (6) describes indexing of major psychiatric disorders.  That is the primary (and limited) intent of the DSM.  But Kendler points out that it is really a jumping off point for the additional study of psychopathology.  I would also point out that it ignores what is the elephant in the room for psychiatrists – human consciousness.  Consciousness in psychiatry tends to be mentioned only when it is grossly impaired rather than existing as the every day moderator of everything.

When the additional pattern matching takes place, the only real limit is the interviewer’s ability to recognize it and what it means. In the ideal world that should lead to further elaboration of the patient’s concerns, education based on the psychiatrist’s understanding of the general problem and more specifically how it affects the unique patient, and specific treatments that have worked before.  It can extend to a unique approach to the associated DSM disorder that would not have been possible with a highly structured interview.  One of the best examples I can think of are life long sleep problems that become anxiety and depressive disorders as an adult – because the development of those disorders and the sleep disorder is not covered in detail.  There are a lot of examples.

In closing this post, prevalence estimates for psychiatric disorders vary greatly.  That is the expected result of the screening methodology that includes the instrument used, the population sampled, and the prevalence of the disorder being screened in the population. Very basic screens like checklists used as a proxy for diagnoses will have the highest prevalence estimates. More comprehensive structured interviews will be somewhat lower. The gold standard for epidemiological work (structured interview) is not the gold standard for clinical work (the semi-structured phenomenologically oriented interview).  It is also the reason psychiatrists need to know psychopathology, phenomenology, and case formulations based on those disciplines.

George Dawson, MD, DFAPA

1:  Levis B, Benedetti A, Ioannidis JPA, et al. Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis. J Clin Epidemiol. 2020;122:115128.e1. doi:10.1016/j.jclinepi.2020.02.002

2:  Hasin DS, Fenton MC, Weissman MM.  Epidemiology of depression disorders. In: Tsuang MT, Tohen M, Jones PB, editors.  Textbook of Psychiatric Epidemiology, Third Edition. West Sussex: Wiley Blackwell, 2011: 289-309.

3:  Nordgaard J, Sass LA, Parnas J. The psychiatric interview: validity, structure, and subjectivity. Eur Arch Psychiatry Clin Neurosci. 2013;263(4):353364. doi:10.1007/s00406-012-0366-z

4:  Parnas J, Zanderson M. Rediscovering disordered selfhood in schizophrenia. Psychiatric Times.   Jun 08, 2020

5:  Nancy C. Andreasen, DSM and the Death of Phenomenology in America: An Example of Unintended Consequences, Schizophrenia Bulletin, Volume 33, Issue 1, January 2007, Pages 108–112,

6:  Kendler KS. DSM issues: incorporation of biological tests, avoidance of reification, and an approach to the "box canyon problem". Am J Psychiatry. 2014;171(12):12481250. doi:10.1176/appi.ajp.2014.14081018

Saturday, May 30, 2020

Twin Cities Riots

I watched the 1 hr press conference that was convened by Gov. Tim Walsh at 1:30 AM last night.  The mayor of Minneapolis Jacob Frye, the Commissioner of the Department of public safety John Harrington and the commanding office of the National Guard Maj. Gen. Jon Jensen were all present and spoke.  There was a strong unity message.  I was impressed that so far nobody has been killed despite people shooting at the National Guard.

There was a clear message that what started out as a protest against police brutality and killing has morphed into something else at this point.  I use the term morphed loosely because there is no real evidence that there is continuity between protesters and rioters.

There was evidence for example that drug cartels were operating to secure their distribution networks and that criminal enterprises were behind a lot of the looting and general chaos. I received an email that large retail pharmacy networks were closed and in many cases they were looted and prescriptions and other pharmaceuticals were stolen.  There was information that armed white supremacists were in the area and a photo of armed men standing in front of a Target store. There is video evidence that white men wearing all black clothing and face masks are vandalizing buildings and being confronted by protesters.  St. Paul has previous experience with anarchists from 2008 when they disrupted police operations at the time of a Republican National Convention.

There is probably a significant element of people who have the general solution to "burn everything down".  I encountered them during Vietnam War protests. They were the driving force behind the radicalism of the 1970s that led to 1900 domestic bombings in 1972 and the single most destructive act of sabotage in American history up to that point - the bombing of Sterling Hall on the University of Wisconsin campus.

I think it is a reminder to all of us how tenuous civil order can be.  We have all observed these behaviors in one way or another.  At the societal level, Americans are far too self-congratulatory as being "the best" when we clearly have done a very poor job of correcting racism and other forms of discrimination, mass shootings that are so routine they are part of the culture, and economic inequality. Addressing all of those dimensions lead to a preference over social order than not - and keep the opportunists in check.

The lesson from the call to violent revolution in the 1970s was that it eventually fell flat because nobody was interested apart from a few of the leaders of the radical organizations at the time. They made an active effort to expand and recruit more members to do more bombings and kill more people. The average man and woman on the street just wasn’t interested.  Life in general could be problematic but it was clearly preferable to anarchy.
Religious and civic leaders are making broad appeals today to their constituencies to remember the triggering event and actively work on reforming the associated factors of police brutality, racism, and justice for the victim and his family. But they are also reminding people to stay off the streets and remember that these changes need to occur in the context of community and cooperation.  

At the time I am writing this, the Governor has apparently mobilized the entire Minnesota National Guard or a total of 13,000 members.  That number was just 1,000 yesterday.  Given the effort and current uncertainty, I hope that it will be possible to look at the anatomy of this riot and draw clear markers around some of the elements involved.  I am sure that will not be an easy task.  But there is going to be political pressure to blame peaceful protesters for the riots and try to detract from their cause. That gives criminals and agitators a pass and it can also be used to emphasize some of their own pro-chaos messages.

The righteous protest that an innocent black man was detained using excessive force and killed by the police cannot be obscured by the subsequent riots.  Those responsible need to be prosecuted. Peaceful law-abiding protesters are not rioters.

And this cannot happen again in the state of Minnesota or anywhere else.

George Dawson, MD, DFAPA

Graphics Credit:

Minneapolis Riots map was apparently compiled by a number of anonymous users. I am posting it here because it is being used by some Twin Cities newspapers.  There is an extensive list of businesses that have been looted.  Many of them are pharmacies.  See the list at this link.

Current Evidence:

1.   St. Paul Mayo Melvin Carter: "Every single person arrested last night was from out of town".

2.  Not the first time that protesters have attacked the Twin Cities.  Here is a 2008 incident where "anarchists" attacked St. Paul and "took control" of the city for several hours:

Saturday, May 2, 2020

Telepsychiatry - Week 7

It is week seven of telepsychiatry.  Things have been going reasonably well. I am as productive doing telepsychiatry as when I was sitting in an office. The constraints are becoming more evident as time goes by and I have the opportunity to confirm some of them with colleagues.   I have about 50-minute commute one way and doing telepsychiatry saves me that time every day. That is about 50 hours of time saved in the past 7 weeks. I also don’t have the additional expenses of purchasing food, coffee, and snacks at the workplace and that is a significant savings as well as the gasoline costs.

It is very convenient to sit in your office all day, click a tab, and immediately see your next patient. I do get notifications of people are running late but that is rare. The photo at the top of this post is what my desk looks like. The Mac Pro is the large monitor in the background. That is what I use for the telepsychiatry software. It is a high-resolution monitor with good sound quality but it is only as good as the monitor and sound quality on the other end. The small Dell laptop in front is what I use to access the VPN and secure networks and all of my previous notes. I only have access through this computer. The Surface Pro on the far right provides access to everything else I need including FDA package inserts, UpToDate, NLM searches, drug interaction software, an outside lab server that contains all the lab results on patients I am seeing, and the searches I need to locate a patient’s primary care clinic and psychiatrist. That is the information I commonly access during sessions with patients.  It turns out I am a lot faster with the additional computers than working on one computer in my office.

I have a number of documents that I present to patients in interviews that I have posted on this blog.  When I use web casting software for work related conferences, I have the option of posting material from Word, Excel, or PowerPoint right in the working field.  So far, I do not have that capability in my telepsychiatry software and I will be a lot more comfortable when I can do this. One of the critical documents is my standard list of psychiatric medications. It does prompt recall of many more medications than most people can recall spontaneously. 

I put up an earlier post on some of the limitations of telepsychiatry visits. I have had some further observations on that issue some of which have been confirmed by colleagues. Complex movement disorders for example are difficult if not impossible to assess in a telepsychiatry visit. The one I am thinking of was a combination of spasticity from a known neurological diagnosis, possible dyskinetic movements, and possible chorea. Asking a patient about their subjective experience of movements is useful to some degree but not absent an examination. I made the provocative suggestion to some colleagues that “telepsychiatry is not real psychiatry” to point out that there are both favorable and unfavorable consequences.

One of the unfavorable consequences is that telepsychiatry is not universally accepted by patients. With the recent security problems in a popular teleconferencing platform people are more aware than ever of this issue and how it may affect personal discussions with a psychiatrist. There seems to be a general belief that everyone accepts security risks as the cost of doing business but that is not true. There are some people who refuse telepsychiatry visits. There are others who go along but are obviously anxious about it and may not disclose sensitive material. It is an issue that should be explicitly discussed especially if the patient is obviously stressed or the information flow in the interview seems restricted. I had one colleague state that his practice of psychodynamic psychotherapy was going well with telepsychiatry visits. Another variable may be whether the psychotherapy started before telepsychiatry or not.

Even though it is a different kind of psychiatric assessment it does tend to expand the horizon. I started to think about seeing people anywhere in the United States or the rest of the world. I started to think about people I would see from rural Minnesota who would have to drive 150 miles to see me, until they eventually decided it was too inconvenient. Now I can potentially see them immediately right at their home. My mind wandered to the current pandemic and a recent story about depression and suicide in physicians who are on the front lines. I could potentially volunteer my time and help these colleagues.  A critical question is what are the barriers to that kind of practice or volunteerism? A good place to start is looking at an ideal telepsychiatry practice in the state of Minnesota. In that practice a very highly-respected psychiatrist has been a consultant to several southern Minnesota counties for years and has provided their psychiatric care. He has a very well-defined model that includes seeing patients only in clinic settings after they had been roomed and their vital signs have been determined. He has nursing and clinical staff on the other end who know the patients well.  He also sees everyone in his practice on an individual basis every year. His computer system and software are state-of-the-art and high definition. I have seen him give two presentations on his practice, but until the pandemic it never thought I would be using that model.

For now, I will consider a pared down model that would allow volunteer psychiatrists help their colleagues in the current and subsequent pandemics. The first consideration is licensing. Currently physicians are licensed in their own states and that license is not typically allowed treatment in a neighboring state. The only exception I am aware of is licensing through the Veterans Administration for physicians working in that system of care.  A central licensing body or state waivers could potentially bypass state licensing in this situation. It would also allow a large number of retired or semi-retired psychiatrists to volunteer their services. Some of those psychiatrists have let their licenses expire or in some states there is a active but retired status.

The second issue is malpractice. One of the deterrents to opening a private practice or transitioning to a private practice prior to retirement is malpractice insurance and tail coverage. Tail coverage is malpractice premiums that carry it on in retirement, until the window for civil litigation has expired. That would typically involve a two or three year malpractice premium payment during retirement with no associated income. Some states make an exception to malpractice insurance for volunteer physicians. I would argue that consultation to front-line physicians is a priority not only in terms of medical care but also national security. I would suggest that volunteer psychiatrists in this model should be indemnified by the federal or state government.

The third problem is centralized documentation. All clinical encounters should be documented - even in the case of free volunteered care and those records need to be confidential. I would argue for a central authority that would record and house those records. Ideally there would be access to an electronic health record so that any necessary prescriptions could be routed to the appropriate pharmacy.

All three of those prerequisites are considerable obstacles to a volunteer psychiatric workforce. The United States has a government facilitated private system of care that is dominated by large healthcare companies. Their networks are largely expensive and exclusive. The Veterans Administration is a good example of a government run system with its own information technology and networks. It may be a potential system for the addition of the elements necessary for a volunteer telepsychiatry workforce in the event of national emergencies. One of the issues made apparent by the current pandemic is a lack of public health readiness in the country. A volunteer telepsychiatry workforce may seem like a good idea right now but what happens when the pandemic ends? I would suggest that the infrastructure and volunteers could still be effectively used in areas where there were shortages of psychiatrists or after natural disasters when care for people with ongoing mental illness is disrupted. In order for that to occur, there need to be substantial changes in government philosophy and creating systems that are more people centric than business centric. The system like the one I am suggesting would not survive as a football for the two-party system.

If I think of an ideal science-fiction approach to telepsychiatry the possibilities increase greatly. I can envision a time where psychiatric appointments can occur anywhere or when a psychiatrist posts their availability online and see people who sign in. My current system displays all of the necessary legal documentation at the first visit. I think that all the details of what is necessary for telepsychiatry informed consent are still not clear at this point. Standard wrist worn activity monitors at some point could post the relevant vital signs in the physician’s software. Billing and payment is always an issue. In the past 20 years I have not really seen any progress in that area. There is no reason why a physician visit should not be as easy to pay as buying a mocha at a coffee shop.
I have some concerns about abuse of the format. It would be fairly easy to set up a prescription mill to prescribe stimulants, benzodiazepines, and opioids. Those operations certainly exist today and there are many ways to get those drugs from nonmedical sources. Confidentiality is a potential problem. If there is a telepsychiatry visit at home are there going to be other people listening or recording what occurs on the patient end? That does not occur in an office setting but I see it as a potential problem if the patient end of the visit is at home rather than a clinic.

Those are some of my thoughts after week seven of telepsychiatry. Despite the limitations I do think it is effective. If it wasn’t, I would have stopped by now and in this era of a pandemic of uncertain length - retired.

George Dawson, MD, DFAPA

Wednesday, April 29, 2020

Admit What You Don't Know - An Unmentioned Organizing Principle

Everybody has ideas about medical ethics.  Often that is their own version.  There are medical ethicists who routinely comment on it in the media. There is endless speculation about what is ethical and what is not.  That speculation frequently focuses on financial compensation and reimbursement for physicians from outside services like pharmaceutical companies. Every physician in the United States is monitored by their state medical practice board who have varying ideas about what is ethical and what is not. Those ideas can even change over time. When I started out, it was common for physicians to prescribe various medications for friends and family members. At some point that was determined to not be a good practice for several reasons and it became a general rule adopted by most medical practice boards.

Ethics debates frequently are political debates and other common areas have to do with abortion, resuscitation, and unnecessary prolongation of life. Many of these debates played out in public arenas and resulted in legislation, court rulings, and practical applications like living wills and advanced directives in the event that the decision-maker is compromised and decision-making is limited.

I am constantly thinking about my training and how it relates to what I do every day. That means that from time to time I revisit what happened to me during that time frame and what it means today. I always seem to come up with something new even though I have thought about it many times before. Just yesterday I was contemplating the scenario where President Trump talked about disinfectants and ultraviolet light being used to kill coronavirus in humans. There are many places where you can view that videotape as well as the responses to it. In a politically charged partisan atmosphere many of those responses are predictable. The President and his allies are certainly in a spin control mode since this happened. They are contemplating having less frequent news conferences which I would agree with. Political opponents have seized the opportunity to characterize this as a lack of leadership and irresponsible statements. One of the physicians working with the president has suggested that he was simply “problem-solving” and “thinking out loud”with physicians in the Department of Human Services.

I think there is a more parsimonious explanation that will take me back to the third year in medical school. It should be fairly apparent to any trained physician that the President does not really know much about medicine. The clearest example would be his quote that we don’t really know much about nature of the coronavirus pathogen, when of course we do. There has never been a better time to study viruses and their molecular biology than right now. The President has made many other errors when talking about the pandemic and the associated medical problems. He approaches it like he does political rhetoric. He makes contradictory statements to gain some time and then sweeps in at the end with the correct position even though it is often in opposition to what he said in the first place. In medical school that would not get you past the third year.

Third-year medical school is an exciting time. Everyone is starting intense clinical rotations. You are scaling up in your ability to see more patients per day. You are getting more efficient in conducting the elements of the patient evaluation, differential diagnosis, and treatment planning. You are learning more about relevant laboratory and imaging testing. But there is also important ethical element that you need to discover right away or you rapidly get into very deep trouble. Simply stated that element is - know what you know and what you don’t know and clearly state whether you know something or not. The corollary is that time is of the essence and there is no time for equivocating. If you are asked directly by an attending physician or a senior member of the team and you draw blank - the correct answer is “I don’t know”. There is no room for guesswork or rhetoric.

During my training I saw some relatively brutal enforcement of that rule. One conversation went like this:

Attending: “Do you know this patient’s calcium level?”
Intern: “I think it was 10.8…”
Attending: “Do you know or not? Are you just guessing?”
Intern: “No I am pretty sure it was 10.8.”

In this brief scenario, the correct answer was “I don’t know”. It turns out the calcium level was not 10.8. That led to a fairly intense private conversation between the attending and the intern about his expectations of patient care and how they were not being met. The intern was subsequently asked to leave the program.

I witnessed several scenarios like this and they are tense situations. The expectation of course is that individual team members will know everything about the patient particularly all the relevant evaluation and testing that occurs in the hospital and that they will be able to synthesize that for the attending during rounds. It is a high-pressure situation because all eyes are on the person being questioned. I can still recall being in ICU with a fairly intense pulmonary medicine staff person who decided he wanted to question my favorite Internal Medicine intern on pulmonary function testing in various lung disorders. For anyone not familiar with this testing there are a set of esoteric terms and concepts that vary across lung diseases and the attending in this case wanted an extemporaneous summation. He provided no structure whatsoever for the intern. The other four members the team took a deep breath and focused on the intern. In his southern drawl he provided a perfect description of pulmonary function testing and how it varied in the pulmonary conditions of interest. It was pretty amazing.

Similar high-pressure situations don’t go that well. I had just started out on a cardiology team in the same hospital and rounded on a patient and went to present to one of the cardiologists. It seemed to be going pretty well until he asked me to show him the chest x-ray. In those days, we had to go to Radiology and collect all of the films we needed, check them out, carry them around all day and then return them. I did not have a chest x-ray and for the next several minutes fielded a few sarcastic comments like “You didn’t think a chest x-ray was important in a cardiology patient?” In similar situations it was always better to say “I don’t know” rather than trying to bluff your way through a barrage of questions from an attending physician. Not having a chest x-ray is relatively easy one.  It is harder if it is a question about specific history or data or information that you are expected to know.

An important part of the lesson is that even though it may be emotionally painful to say “I don’t know.” it must be said if you really don’t know. There is no spin after the fact in medicine. The patient and everyone else on your team depends on you being able to make that statement. When you complete your training - it is equally important to make that statement to your coworkers and the patients you treat.  I have never really heard much comment about it in the media or by the ethicists but for me it is a central organizing value. There is a ripple effect. If you don't want to end up with that statement - you do everything possible to prevent it.  But most importantly you recognize the vast information base of medicine and you recognize the uncertainty of the day to day decisions.

This post is not supposed to be a lesson for politicians. It is not a suggestion that politicians should adopt ethics that are useful to physicians. It is a simple observation that being able to admit that you don’t know something even when it seems like you should is transformative. It is better to be brutally honest with yourself upfront than having to do it later to deal with the complications. All medical decision-making and professionalism hinges on this ethic. 

When it comes to medicine - you can't just make something up or think you know something - when you don't.

George Dawson, MD, DFAPA

Full Disclosure:

I am a small "i" independent.  Yes - I am one of those guys who does not hesitate to "waste" his vote on a non-major party candidate, but at times have voted for those candidates.

Saturday, April 18, 2020

COVID-19 No "Worse" than The Flu?

It is very common these days for people with varying motivations to make the argument that that COVID-19 the current pandemic caused by the SARS-CoV-2 virus is no worse than seasonal influenza.  After presenting that premise, the conclusions are typically that there is really no reason to implement social distancing, stay at home orders, and all of the additional precautions currently in place to prevent the spread of the virus.

The important qualifier here is the need to include how deaths from both illnesses are estimated.  The CDC is very clear that it does not know the exact number of influenza deaths each year but it estimates them from statistical models. This is nothing new and they have been using this procedure for decades.  The reasons include the fact that influenza deaths are not reportable at a national level, although pediatric influenza deaths are.  It is also not possible to know if influenza is the proximate cause of death because the death may occur weeks later as a result of a secondary infection or an exacerbation of a chronic medical condition by the influenza infection.  In these cases, influenza may not be listed as a secondary infection.  Finally - not everyone who dies from an influenza-like illness (ILI) has influenza and not everyone who dies from ILI is tested for influenza. The influenza death estimates are not based on death certificates for that reason.  

There is considerable variability in mortality estimates based on the model being used.  A description of their current methodology and its limitations is available at this link.   There is a similar limitation of COVID-19 related deaths and the CDC has a specific reporting procedure suggested for that process.  CDC clinical criteria and lab testing is further specified to determine if COVID-19 is an underlying cause of death. COVID-19 can be reported as "probable" or "presumed" based on clinical judgment.  Three examples are given in the linked document in how to fill out the death certificate. The main difference is that COVID-19 mortality depends on deaths certificates and influenza mortality does not.  At least for now.

Looking at the CDC death rate estimates for influenza over time looks like this (click to enlarge any graphic):

But looking at the raw data based on death certificates looks like this:

Looking at the typical influenza season going from 2019 (week 43) to 2020 (week 15) shows that the raw death certificate data for pneumonia is 90,369 and for influenza it is 7,591.   

The argument typically is made looking at disease mortality and the raw number of deaths are not used. The CDC and other agencies report rates per 100,000 to correct for differences in population.  The current mortality rate for COVID-19 as of today is shown below - even though the lead graphic illustrates that deaths are continuing to increase at this point.:

COVID -19 Deaths  CDC Page

Total Deaths: 37,158

Death Rate/100,000: 11.3

First Case January 21,2020

Influenza Deaths

Total Deaths:  24,000 - 62,000  2020 estimate based on above data and methodology

Death Rate/100,000:  7.3 - 18.9

First Case October 2019

The second consideration is that the COVID-19 pandemic is clearly not over. Different geographic areas in the US are at different points in the curve that depicts new cases.  The key point on that curve is the inflection point where the new cases per day go from a linear increase to an exponential one.  A panel of 20 experts in infectious disease modeling was referenced as the source for a recent White House estimate of 240,000 deaths by the end of 2020 (8).  If you look at that reference there is a wide confidence interval.  That is four times the CDC estimate of 2020 influenza deaths.  For comparison there were 675,000 deaths in the USA in the 1918 pandemic.

How does this information assist with the analysis of rhetoric?

1.  COVID-19 is no worse than seasonal flu: 

First off, influenza is a severe infection and can't be trivialized. Everyone who is able to should get an influenza vaccination. Based on the available data - is certainly seems that COVID-19 is as bad and much worse in the worst case scenario.  It is at least on par with modern CDC influenza death rates estimates over the past 20 years and based on the current number of deaths is likely to exceed the 2020 estimate for influenza deaths.  The outliers for the White House estimate in the survey are much higher - in some cases exceeding the mortality from the 1918 pandemic.  These estimates are also based on current rates and if the country is "opened" and stay-at-home orders, wearing masks and social distancing guidelines are abandoned it is very likely that there will be secondary spikes and prolonged exposure to the virus. Does anyone really want to take the chance of this virus killing more people than the 1918 pandemic?  

2.  COVID-19 rates are inflated based on inaccurate reporting:

This meme was reinforced by a physician appearing on a conservative talk show who stated that he only reports what he considers to be the underlying cause of death on death certificates.  The example given was that if the patient died of pneumonia - the cause of death was pneumonia and would not speculate on what caused the pneumonia.  The implication being that death certificates are highly accurate and the suggested reporting guidelines for COVID-19 will result in over-reporting the condition.  The information clearly shows that this is not the case. The actual numbers of deaths due to influenza as reported on death certificates are a fraction of the number estimated by the CDC.  The CDC plainly states that they have no idea how many people actually die from influenza and for decades they have estimated the number based on hospitalizations, hospital mortality, and other surveillance numbers.  COVID-19 death counts are made on the basis of death certificates.  Even though death certificates are not perfect, it is likely that many more people who die from COVID-19 are tested than people who die from influenza. It will be interesting to see if the CDC develops statistical models for COVID-19 to see if the current deaths are an underestimate like influenza. 

That is my brief look at these two arguments that are being used to suggest that the current environmental approach to virus containment are unnecessary.  I am also reminded of an old statistical concept called face validity.  Briefly stated that would mean the null hypothesis of no difference in death rates makes sense.  Given that COVID-19 has risen to the highest daily cause of death in the US, that hospital and ICU beds in many locations are overwhelmed, that there is a catastrophe in New York City at this point, and it has led to the only mass shortage of personal protective equipment, ventilators, and medical gear that I can recall in my 3 decade career - I don't think that it does make sense.

And this is exactly not the time to trivialize this pandemic.

George Dawson, MD, DFAPA


1: CDC:  Frequently Asked Questions about Estimated Flu Burden.  Link

2: CDC:  Estimating Influenza-Related Deaths.  Link

3: National Center for Health Statistics. Guidance for certifying deaths due to COVID–19. Hyattsville, MD. 2020. Link

4: Reed C, Chaves SS, Daily Kirley P, Emerson R, Aragon D, Hancock EB, et al. Estimating influenza disease burden from population-based surveillance data in the United States. PLoS One. 2015;10(3):e0118369

5: Rolfes, MA, Foppa, IM, Garg, S, et al. Annual estimates of the burden of seasonal influenza in the United States: A tool for strengthening influenza surveillance and preparedness. Influenza Other Respi Viruses. 2018; 12: 132– 137.

6: Centers for Disease Control and Prevention. Estimated influenza illnesses and hospitalizations averted by influenza vaccination – United States, 2012-13 influenza season. MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62(49):997-1000.

7: Reed C, Kim IK, Singleton JA, Chaves SS, Flannery B, Finelli L, et al. Estimated influenza illnesses and hospitalizations averted by vaccination–United States, 2013-14 influenza season. MMWR Morb Mortal Wkly Rep. 2014 Dec 12;63(49):1151-4.

8:  Thomas McAndrew Spring March 25, 2020 COVID19-Expert ForecastSurvey6-20200325.pdf 

Graphics credit:

Lead graphic is from Our World in Data licensed under Creative Commons BY-SA and may be freely used for any purpose. 

All others are from the CDC under public domain.