Wednesday, July 23, 2014

Normal ≠ Perfect

I wanted to address a common problem in treatment, especially any treatment that involves a medication and that is the issue of setting a goal for treatment and when to know when that goal has been reached.  This seems like a very basic proposition that should be easy to do.  The reality is that it is not and a lot of that comes down to the subjectivity associated with the human conscious experience.  I am already on record here that I think subjectivity is a very good thing.  I am glad that everyone in the world has a unique conscious experience.  In many ways we communicate in broad brush strokes, but the reality is that all 7.2 billion of us have a unique conscious experience of basic phenomenon.  From the consciousness literature one of the basic examples is the unique experience of the color red.

What happens when a person discusses  their unique conscious experience with their friends and family?  The first threshold is whether there is any interest in the discussion.  People have varying levels of empathy, patience, and psychological mindedness and it is entirely possible that there are people who cannot have that conversation.  The people who can have that conversation make common mistakes.  The first is that they are some sort of diagnostician and can diagnose problems based on what they hear.  This can happen even though most people do not want a diagnosis - just someone to listen to their problems.  Over the years I have seen a lot of people who come in for an evaluation based on these conversations with friends and family.  The identified patient is often in a quandary because they either disagree or are confused about the amateur diagnosis from their friends or family.  Their presenting statement often is:  "I am here because my spouse thinks I am depressed."  Today the presenting complaints may seem more sophisticated: "My wife thinks I have adult ADHD because she saw a checklist on a doctor's show on TV and told me that I have all of the symptoms."   Clearly the wife has an expectation that there is a problem, a treatment, and expected improvement over the current situation.

All of these events can happen independent of other observers.  People are inundated with various sources of information and are concerned about whether they have developed certain problems.  They are concerned about whether they have a problems that can be easily fixed by medicine.  There are many biases that occur in that scenario and play out in the relationship between the patient and the physician and two examples are instructive:

1.  The chronic pain patient and opioid analgesics:  The operative bias here is a very common one and that is:  "If this doctor would raise the dose of this medication enough - my pain would be gone."  The reality is that there really is no opioid dose that will do that and non-opioid medications offer the magnitude of pain relief.  There is no known perfect degree of pain relief for chronic forms of pain.

2.  The case outlined above of the adult with possible ADHD:  Let's say that an evaluation confirms the diagnosis of ADHD - combined type and medical treatment is recommended.  Whether the treatment is stimulant medication or atomoxetine, how the patient assesses the adequacy of treatment is critical.  There is often a discussion about "expectations" of treatment in terms of the outcome.  The patient in this case, may not have a good idea of their capabilities.  The physician treating the patient has hopefully identified target symptoms that seem to be the most important or urgent that allows the patient to be followed.

In both examples, there is a problem at the upper boundary of treatment.  As the dose of medication is increased, will the symptomatic changes as assessed by the patient get to the point that they are satisfied with the result?   In order for that to happen, the patient has to have a conscious and unconscious idea about what they want the result to be so they can compare what has actually happened to the idealized result.  The idealized result often incorporates the wishes of friends and family.  That is the extreme positive end of the Likert scale, depending on how the questions are phrased.  A common example that I use in teaching is the 10 point pain scale where 10 usually indicates the worst possible pain.  In every seminar that I give medical professionals I ask if anyone has said that their pain was a "14" on that ten point scale.  Members of every seminar have gotten that response.

In the case of ADHD, doing a similar assessment of the target symptoms is similarly problematic.  Many physicians find themselves in the position of prescribing the maximum dose of Adderall, seeing clear improvement, and the patient expecting even more improvement when that result is really uncertain.  The common correlate of this problem is higher than recommended doses and irrational polypharmacy.  I was discussing this issue with a colleague who is a board certified child and adolescent psychiatrist and he said something I had never heard before, but it seems very accurate:

"The goal is to get them functional and not to perfect their functioning."

One of the many errors in the philosophical approach to modern psychopharmacology is the idea that we can tune up the human brain by adjusting various medications.  The patients involved certainly expect this and some of the physicians involved go along.  There is often an implicit goal that the patient will be restored to their "normal" or "baseline self" - whatever that is. Measurement based care seems to assume this when they suggest that the mood extremes of 7.2 billion unique conscious states can be characterized by a 21 or 27 point scale.  A further assumption is that the numbers on this scale mean the same thing across the population, as though this scale is really a quantitative measure when it is not.  Certainly there are very problematic symptoms that should require a best effort approach to get rid of by whatever means necessary.  But there are many others that are resistant to treatment, transient or for which we have no clear treatment approaches.  In that scenario, a discussion of expectations from the outset, a discussion of what constitutes meaningful change for the person, and a discussion of possible non-medical approaches to the problem seems like the minimum for developing realistic ideas about outcome.

George Dawson, MD, DFAPA        

Tuesday, July 15, 2014

Stigma Rhetoric

I have always been skeptical of the value of the stigma concept in advocating for the rights of people with mental illness.  It seems to imply that a person with a mental illness is obvious to everyone and nothing could be further from the truth.  The usual advocacy groups certainly jumped on it and it was later picked up by professional organizations.  My basic problem with the entire argument is that nobody should know that you have a mental health problem anymore than people should know that I have asthma.  It is a problem of medical confidentiality rather than a problem with stigma.  Anyone who thinks that is not the case just needs to consider what prospective employers think about hiring people with back pain, asthma, or any pre-existing condition that potentially impacts their group health insurance coverage.  Any confidential medical condition is potentially stigmatizing and it certainly is nobody else's business.  If people want to disclose that information that is certainly up to them and as I have posted here in many cases it can be a useful public service.  And I do realize that health insurance companies force you to disclose pre-existing conditions using various methods but that does not mean that your employer should know.

The other problem is that there has been broad and systematic discrimination against people with mental illness and addictions at all levels of government and the business community.  These are the people who have access to protected medical information and make decisions about health care based on it.  That discrimination occurs with full knowledge of a diagnosis and often a recommended treatment plan.  Multiple posts here document that problem and yet nobody comes right out and attacks that issue.  If anything social activism with a stigma focus seems to cast a wide discrimination net rather than focusing on the few people and agencies that can make a critical difference.  It  suggests that the general public is the problem and that educating the general public will solve the problem.

This morning a friend of mine posted this link on Facebook and asked me for my impressions of the argument that neuroscientific explanations potentially lead to more stigma.  That is probably what has me fired up.  If you are trained in science, you realize that there are  internal politics but in general that is not the same as the politics of the barbarians at the gate.  The problem is that all types of science from climate science to neuroscience gets co-opted and interpreted by people who don't know what they are talking about.  I think that is illustrated by one of the summary points in this article:

"As this revolution gathers force, we need to be mindful that biogenetic explanations for mental health problems can have troubling implications for the people who suffer them."

I think it should be obvious that there will be "troubling implications" for anyone who is ignorant on either end of a "biogenetic explanation".  Further, it is really impossible to separate allegedly biogenetic explanations from decades of conditioning by governments, businesses, and the media.  Troubling implications start when you realize that your employer's health plan does not have coverage for mental illnesses or addictions and you have a family member that needs that insurance.

What are the take home points about stigma in all of this?

1.  Businesses that discriminate against mental illness by rationing current services and destroying any infrastructure necessary to treat mental health are stigmatizing.  The message is clearly that they can't be bothered to treat these problems seriously by offering much of anything beyond a crisis stay in a hospital and a 10-20 minute "med check" by a "provider or prescriber" in an outpatient clinic every 3 - 6 months.   No research proven modalities to treat mental illness and a severe push to send people with addictions and serious mental illnesses to county detox, jail, or the street.

But even the businesses not involved can get into the act.  Practically every local market has a business some who is offering "crazy deals."  If you doubt it, Google "crazy deals" or the equivalent "insane deals" and see what you come up with.  Don't forget to look at some of the images.

2.  Governments that ration and destroy the mental health infrastructure and collude with rationing by businesses are stigmatizing.  Examples include empowering insurance companies to decide how they can deconstruct the billing and services of mental health providers and clinics to their advantage (the arbitrary insurance company audit),  empowering business to discount services, legitimizing utilization review and prior authorization (tools for arbitrary denials), and allowing for proprietary business guidelines to dictate who can receive treatment and who can not.  What could be more stigmatizing than to have a business suggest that a person is not "dangerous" enough to be treated and use that as a basis for medical decision making?  Why aren't there any rules about admitting only the "dangerous" myocardial infarctions and sending everybody else home?

3.  Court systems that treat the mentally ill like they are criminals are stigmatizing.  This includes practically all court systems because as any forensic psychiatrist will tell you, despite the myths about the so-called insanity defense - it is practically impossible for anyone to get off with that defense.  There are significant numbers of people who are incarcerated for minor nonviolent crimes that were the product of mental illness.  Ask yourself if it is more stigmatizing to have a confidential diagnosis of a mental illness or be listed in the paper as being incarcerated or having been convicted of a crime?

4.   The press has a very poor track record in the area of stigma.  It is well known that the press covers psychiatry more than other medical specialties and has a consistently negative view about the specialty.  How would you feel if you had an illness that resulted in you being seen by a physician whose specialty is consistently portrayed negatively in the media.   For the past two years the press has produced nonstop political arguments about a diagnostic manual that is practically little more than a guidebook for billing codes with many of the esoteric codes only of interest to researchers.  One of the main arguments in those articles was that the diagnostic manual led to arbitrary diagnosis and treatment for the benefit of the pharmaceutical industry.  For anyone with a serious mental illness, could there be a more stigmatizing argument?

5.  The entertainment industry never hesitates to make a buck off of mental illness.  The film Halloween is classic example of equating mental illness with an evil so unstoppable that the psychiatrist involved has to pack a .44 magnum.  That same message has been carried forward in recent television shows.  Some of the efforts in this area are so bad that it takes an incredible bias to justify the product as entertainment.

These are all much better examples than suggesting that science somehow stigmatizes people.  The associated problem is the misunderstanding of science.  We all understand that the media needs to sell stories and the truth about science is that it is a process and not the ultimate truth.  Every story about new fads based on an experimental finding that will never be replicated in the absence of a discussion of scientific method is corrosive to the public's confidence in science.  In this case using "chemical imbalance" as a scientific theory is about as ill informed as anyone could be about the neurobiology of mental illness or normal brain functioning.  At that level this story is more about press induced stigma than anything that neuroscience or neurobiology has to say.

The lesson for today is that the brain is not a sack full of neurotransmitters that is balanced or unbalanced.  If you believe that, you can either stay ignorant about the problem and talk about "chemical imbalance" as though it means something, educate yourself about neuroscience (there are many free sites on the Internet) or you can join any number of psychiatry bashing web sites that claim that psychiatrists believe there is a chemical imbalance.  Your first neuroscience assignment is to read about Eric Kandel and why he got the Nobel Prize.

And where does conflict of interest enter into the stigma equation?  In other words who benefits from mental health stigma as an operative social concept?  Advocacy organizations certainly do.  In many cases is it their raison d'ĂȘtre.  Interestingly concern over stigma has prevented some advocacy organizations from dealing effectively with the issue of people with mental illness who are violent.  They considered violence and aggression to be stigmatizing rather than a fact of some mental illnesses.  Professional organizations like the American Psychiatric Association benefit in that it enhances their credibility with the advocacy organizations but any counterattacks on the forces that ration and deny mental health services have been weak and ineffectual.  Those rationing entities including politicians, government agencies, pharmacy benefit managers and managed care companies benefit tremendously.  After all they have added hundreds of billions of dollars to their bottom lines by basically denying or rationing treatment and in many cases denying that there is any problem at all.

Stigma rhetoric makes it seem like this is a problem inherent in our society with no better solution than an enlightened public.  We will not be able to solve it until enough people are enlightened while the rationing schemes continue.

At that level you could say that stigma is a concept that can be spun for everyone, but let's agree that science has nothing to do with it.

George Dawson, MD, DFAPA

Supplementary 1:  I was asked by a reader to summarize the above post.  Here it is:

There are societal wide biases (business, government, legal, entertainment, etc) that stigmatize the mentally ill.  Some aspects of that process involve the distortion of science (e.g. "chemical imbalance theory").

Now what happens if I decide to run an experiment that asks people about how happy they would be if they had a biologically determined mental illness in that culture? Of course they would react strongly because:

a)  They are from a culture that stigmatizes people with significant mental illness.  They know how the various players would react if they found out that a person has a significant mental illness. Mental illness by itself does not produce a stigma. People are stigmatized by other people with biases and clear agendas.

b)  They really don't know what the scientific implications are because they have been hearing about false theories or reading overt propaganda or they don't know enough about the process or implications of science.

Friday, July 11, 2014

"Good News - Your Care Today Was Free"

"The bad news - we don't know how to make this diagnosis".

I woke up on Monday morning with a 2 inch diameter bright red rash on the inside of my right ankle.  It was mildly pruritic (itchy).  I could not recall any exposure to insects or trauma of any kind and it did not appear to be infected, so I applied some topical corticosteroid cream and went to work.  That night at home the rash seemed very mildly improved but it still itched.  I decided to get some medical input at that point.  The usual choices in my area are the Emergency Department or Urgent Care, but recently my health plan started to offer online consultation through a combination of limited diagnoses and procedures,  an algorithmic set of questions, the ability to upload images, and consultation with a nurse practitioner.  I looked at the list of conditions they were set up to diagnose and treat, noted that "rash" was one of them and logged on.

Health care IT is still in its infancy so nobody should be surprised that it took me much longer than expected to log in to the appropriate interface.  At first the program suggested I could just use my existing login and that would also integrate previous test results and conditions into the current evaluation.  After needing to call them I established a separate login and password for this episode.  Rather than the expected details up front, the program started to ask me all of the usual questions about the rash.  There were 28 screens in all, including some that forced an answer.  That question was "What do you think is causing the rash?".  Possible answers were: insect bite, infection, allergy exposure, poison ivy, etc.  There was nothing on that list that seemed likely.  That was after all the reason I was calling in.  I could not proceed past that point without giving an answer so I clicked "insect bite".  After completing 28 screens there was a text field and I entered: "Even though I answered "insect bite" on question #8, I only did that because I could not proceed if I did not provide an answer."

Next came the expected demographic data.  I live in a town that the U.S. Postal Service never gets right.  If I list a Zip Code the wrong town name pops up.  This software was not exception.  It took me extra time to enter and reenter data that was already there somewhere in my healthcare company's database.  The final screen was the billing and financial data including credit card information.  More data that my healthcare company has know for the last five years.  At this point I am about 20 minutes into the process and it is time to upload the photos.  I had 4 photos of the ankle and the program accepted 3 of them.  Sign off occurred at the 25-30 minutes mark.  As I waited for the return e-mail or call,  I marvelled at how health care companies have transferred all of this clerical work to physicians over the last 20 years and now they are transferring it to the patient.  I just did the work of the intake person and financial person in any clinic or hospital.

In 20 minutes I got a call from the nurse practitioner.  She said that although it was clear that I had a rash, it was not a rash they could diagnose in the system.  I told her that I was applying a potent corticosteroid and she said to just keep doing that but to go into a primary care clinic and get it checked out by my primary care physician.  Within 2 minutes, I got an e-mail from them:

Dear George,

Thanks again for taking the time to talk with us on the phone. Your health and safety is our top priority. Based on the information you shared with us, we think that an in-person visit is the best way to handle this specific condition. And, please know that you will not be charged for your visit today.

We're sorry we couldn't help you this time, but please keep us in mind the next time you're feeling ill. Thanks for choosing us.

Good to know I guess, but no diagnosis or specific treatment plan.  I continued the corticosteroid and the next night after work I stopped into an urgent care clinic after work.  I saw a family medicine physician who inspected and palpated the rash, took my pulses and determined that they were good in the area, and asked me clusters of questions that were clearly designed to rule in/out various pathological processes.  His conclusion:  "Well it's not an infection and its not due to trauma, but it clearly is an inflammatory process like atopic dermatitis.  So at this point I would keep applying the corticosteroid."  He asked me for questions.  My mind was preoccupied with tales of devastating spider bites lately so I blurted out:  "This does not in any way look like a brown recluse spider bite does it?"  He laughed and said: "Absolutely not."

So what have I learned from all of this and how do those lessons apply to psychiatry?  First off, it appears that human diagnosticians are safe for now.  Keep in mind that the system is set up to diagnose and treat a restricted list of conditions that are considered to be the least complicated in medicine.  Second,  the human diagnostician's superior capabilities depend on pattern matching and that in turn depends on experience.  It reminded me of a course I taught for 15 years on how to avoid diagnostic errors and pattern matching was a big part of that.  The two examples were rashes and diabetic neuropathy.  Dermatologists were much faster and much more accurate in classifying rashes from pictures than family physicians.  Ophthalmologists are much more accurate using indirect ophthalmoscopy than family physicians using direct ophthalmoscopy in diagnosing diabetic proliferative retinopathy.  In fact, the family physicians were slightly better than chance.

The lessons for psychiatry are two fold.  Remember the idea of a restricted list of conditions that are not considered complex?  It turns out that depression and anxiety are on that list.  Even though there is no call center where you can call and complete the paperwork like I did,  it would probably not be much of a stretch to say that many if not most primary care clinic diagnoses of depression and anxiety are keyed to some rating scale.  Like the studies of Dermatologists and Ophthalmologists, there are no expert pattern matchers looking at the patient.  That can result in a diagnosis that is essentially dialed in.

The second aspect here is the design of the algorithm and its implications.  My rash algorithm had a forced choice paradigm.  I could not proceed to the end unless I picked an answer that was clearly wrong.  That is the way it was set up.  That is the problem with so-called "measurement based" care.  There is the appearance of a quantitative result.  The Joint Commission called the 10-point pain scale "quantitative" in the year 2000 with their pain treatment initiative in the year 2000.  I have spent a good deal of my adult life talking with patients about their moods, sleep and appetite patterns, and other symptoms.  The most important part of my job is coming up with a plausible scenario for their current distress.  I can say without a doubt that over half of the people I see cannot describe discrete episodes of mania or depression.  The usual description of depression I get is that it is life long with no remissions.  Certain personality characteristics predict descriptions of symptom severity in the initial interview.  Some people completely minimize symptoms and other people will flat out tell me that they do not want to discuss their inner thoughts even if they are experiencing thoughts that may place them in danger.  Map those response patterns onto a psychiatrist and hopefully that will result in a diagnostic formulation and a plan to deal with the nuances.  Map those response patterns onto a PHQ-9 and suddenly you have a number that somebody believes has meaning.   Looking only at Question 9:

"Thoughts that you would be better off dead or of hurting yourself in some way."  

Suddenly people are alarmed with the person with a personality disorder and chronic suicidal thinking or chronic obsessions involving suicidal thinking endorses "nearly every day" as their response.  We are falsely reassured when the patient who has a significant personality change and depression endorses "not at all".  We have forced them to make a choice and they have, rather than using all of the information necessary to make an evaluation.

As a discipline - we should be moving in the direction of using all of the relevant information in clinical situations and not less.  My rash today is an example of what can happen in an organ governed by much less genetic, metabolic and signalling information than the human brain.  Even in that situation a diagnosis with no clear etiology or diagnostic features can present itself.

Forcing choices reduces the information flow rather than facilitating it.  If primary care physicians find this checklist approach to diagnosing anxiety and depression useful I would see no problem with that, but it might be useful to look at the medications being used based on the PHQ-9 and the kind of impact this approach is having on medication utilization.  It also might be useful to have a seminar or two on the problem of over prescribing medications.  The correlation between overprescribing opioids and the use of a "quantitative" scale to measure everyone's pain is undeniable.

The question that applies in all of these circumstances is whether a number on a subjective rating scale is ever enough of a reason to prescribe a medication.

You already know what I have to say about that.

George Dawson, MD, DFAPA

Monday, July 7, 2014

Alkermes And The Pharmaceutical Company Dynamic

I was reading this month's Journal of Clinical Psychiatry and came across a dimension of the psychiatrist - pharmaceutical company  dynamic that is rarely the object of analysis.  I can't put the ad here because it appears to be copyrighted so I will have to describe it and you can see the graphic here.  There is a picture of a man in a brown pullover sweater in the middle.  His hands are pressed together and he has a concerned look as he looks toward a younger man who is slightly unkempt to his right.  The younger man is staring away and making no eye contact.  To the far left behind a counter is a woman wearing a white coat and protective gloves as she swirls an Erlenmeyer flask containing bluish liquid.  My theory of the mind says the man in the middle is a psychiatrist, the man to his right is the patient and the woman is some kind of biomedical researcher.  The copy reads:

"Your challenges are our challenges.  At Alkermes, we're inspired by the challenges that psychiatrists face every day.  We share your dedication to patients living with schizophrenia, depression or addiction.  So when we develop new treatments, we begin with a compassionate understanding of your real world needs.  We stand ready to improve the health of your patients."

I am sure that most psychiatrists can see this for what it is - advertising and would have suggested that Alkermes take a less melodramatic approach.  Alkermes is relatively new to CNS pharmaceuticals but it has drugs in the pipeline for both schizophrenia and depression.  Many addiction psychiatrists are used to seeing their version of long acting naltrexone called Vivitrol.  I have never seen a sales representative from the company.  Pharmaceutical company reps have taken a hit with the new anti-Pharma religion and they are banned from most clinics, hospitals, and academic settings in my area.  The rap against them has been that they were essentially influencing physicians to prescribe their products by financial incentives in the form of gifts or in many cases personal relationships, or a combination of both.  A secondary issue was that some of the Pharma associated educational activities were more or less well disguised advertising in a number of forms.

This new approach by Alkermes taps into an area with psychiatrists that I have not previously seen as an area of focus.  It is basically saying to the most beleaguered physicians: "We understand what you are up against and we are on your side."  Although it seems like a clumsy first attempt, the message is powerful.  If you are a senior psychiatrist and have practiced as long as I have - you realize that apart from any good colleagues that you might have from time to time - there is nobody on your side.  Many psychiatrists are professionally isolated and may see their colleagues at an annual meeting.  Others in larger organizations are mismanaged to the point where their colleagues are seen as competition rather than resources.  There is nobody on your side professionally or in your attempts to treat your patients.  In fact as I have illustrated here, there are many people in your way when you try to provide care to patients.  They are incentivized to get you to ration care and in many cases that comes down to providing no care.

The Alkermes approach captures at least a part of the unconscious reason for affiliating oneself with a friendly entity.  My guess is whoever is behind it does have an understanding of what is going on with physicians and psychiatrists in particular.  A pharmaceutical company ad will never make it explicit,  but there is also an asymmetry in the relationship they are  discussing.  Bundling the cost into a pharmaceutical product is a much more effective way to get reimbursed than bundling cost in the form of a psychiatrist.

Even though they appear to feel our pain - they don't really have to.

George Dawson, MD, DFAPA

Supplementary 1:  Breaking news from the U.S. Patent office:

Aripiprazole lauroxil: patent app 13/607,066 covers methods of treating schizophrenia, mania, bipolar disorder, anxiety or depression by administering a broad class of compounds including aripiprazole lauroxil.

ALKS 5461: patent app 13/715,198 covers composition of matter.

ALKS 3831: patent app 13/215,718 covers the attenuation of weight gain associated with olanzapine in patients with schizophrenia by administering the combination of samidorphan (formerly ALKS 33) and olanzapine.

ALKS 7106: patent app 14/169,305 covers composition of matter.

For full details read the press release from the Alkermes web site.

Saturday, July 5, 2014

The Fifth Inconvenient Truth

Thomas Insel, MD the current head of NIMH captured a few sound bites in a recent edition of Psychiatric News.  In it the following Inconvenient Truths were mentioned:

1.  The field has failed to “bend the curve” in the prevalence and cost of mental illness;

2.  More people are getting more treatment, but outcomes are not getting better.

3.  The current knowledge base is insufficient to ensure prevention, recovery, or cure for too many people with serious mental illness.

4.  A transformation of diagnostics and therapeutics is necessary to make significant progress in treating mental illness.

Any head of a politically funded agency has to carefully parse his or her rhetoric in a manner consistent with his main goals.  I would see his main goal as getting funding for NIMH and in that role he needs to speak to the politicians who hold the purse strings.  That is really the only reason why cost is included in his first sentence.  The cost estimates both within the United States and world wide have been calculated many times and they are staggering.  There are well known estimates of disability that show the disability due to mental illness and addictions are routinely in the top ten causes.  But what  about the cost of treatment?  The cost of treatment has been flat to decreased for about three decades now largely as a result of managed care rationing with a disproportionate hit being absorbed by psychiatric services.  I have argued repeatedly that cost needs to be taken off the table in these discussions at least until the mental health infrastructure gets on even par with cardiology or oncology.  The whole idea that you can produce equivalent results with practically no resources strikes me as absurd.  The only thing more absurd is that we are supposed to be even more cost effective.  Compared with the rest of medicine we are looking at cost effective in the rear view mirror.  We crossed into the "on the cheap" zone a long time ago.  As expected, cost effective is synonymous with low quality.  Since we have abandoned quality reviews with managed care we have abandoned that word.  A more appropriate observation would have been:

The field has failed to “bend the curve” in the prevalence and quality of care of mental illness.

The second issue is a brief lapse into rhetoric of vagueness.  Who is "the field" here?  Are we referring to psychiatry, other mental health professionals, primary care physicians who do 80% of the psychopharmacology,  or the managed care systems and systems with the same techniques that rigorously ration mental health care?   The meaning of the sentence changes dramatically by substituting each of those words.

To the second point on more treatment not leading to better outcomes it is fairly easy to show why this is the logical outcome of rationing.  I have posted many times about how inpatient psychiatry has become sham treatment based on dangerousness criteria and corporate priorities.  You don't need any research to show that if you are cycling people with serious mental illnesses in and out of short stay psychiatric units in 3 - 5 days and basing their stay there on whether or not they are "dangerous" and using treatments that take weeks to work that by definition you are appearing to treat many more patients but providing adequate treatment to very few.  You don't need any research to show that when you shift mental health care from psychiatric units run by psychiatrists to county jails that the outcomes will be worse.  You don't need any research to show that when people do not get research based psychotherapies in the manner that they were designed and instead get a few crisis oriented sessions that do not address their basic problems that outcomes cannot hope to be better.  When your attitude is that all mental health treatment can proceed by treating common problems with definite social etiologies with medications as fast as possible and not having an intelligent conversation or working alliance with the person affected - it is logical that treatment outcomes will not improve.  Treatment outcomes do not improve if you do not provide effective treatment and that is the mental health landscape at this time.

Dr. Insel's third point should read:

The current knowledge base is not used to ensure prevention, recovery, or cure for too many people with serious mental illness.

I am not by any means suggesting that it cannot be improved upon.  There is no place in medicine where that is not the case.  When services are globally rationed and we are still beating the drum about "cost-effectiveness" we cannot expect inmates to have access to DBT or GPM to treat their borderline personality disorder.  We cannot expect them to get exposure therapy to treat PTSD from psychological trauma.  We can also not expect managed care patients to get this from 2 or 3 sessions of crisis counseling when they need a more specific research based psychotherapy.

The fourth statement is the only one that I have no issue with.  It is a statement that is generally true for most chronic illnesses.  I have many posts here about asthma for example.  Asthma is an illness that many primary care physicians believe that they really have made inroads in treating.  It is a great comparison for mental illness and even chronic mental illness because the fact is that most asthmatics are chronically symptomatic despite treatment.  The reason is a combination of a biologically complex disease, partially understood disease mechanisms, and a medical treatment model that involves seeing the patient every 3-6 months and prescribing them medications that are often partially effective at best.  There is really minimal medical intervention beyond that except for acute hospitalizations.  That is the exact level of care that we provide for mental illness in this country.

A lot of people fault Dr. Insel for being an advocate of neuroscience.  I may be one of the few who does not.  As a student of the brain and brain plasticity things are incredibly complex.  As politics get projected onto that complex system - science is often left in the lurch.  People see the results of a complex situation simplified as a meta-analysis and see the results as supporting both ends of a political argument.  I would go back to the asthma example.  The signaling in that disease is much less complex than signaling in the brain and there are far fewer cell types involved.  Asthma endophenotypes followed the elaboration of endophenotypes in schizophrenia and so far nether has resulted in clinical innovation.  I would argue that the treatment outcomes in most mental illnesses are on par or better than the treatment of asthma.  And yet there is no national research administrator of Dr. Insel's stature talking about the lack of progress.  I think the reason is clear - there are not nearly as many political arguments projected onto asthmatics.

If I fault Dr. Insel for anything it is for not knowing what has happened to the mental health system of care in the USA.  It is not due to a lack of technology, but an obstruction of current technology transfer.  He is not alone in routinely ignoring this as the central problem with psychiatric services today.  Any number of people do and in the process usually promote their own theories of why we are mired in the current environement.

That Fifth Inconvenient Truth?  Must be obvious by now but in the event that it is not:

Ration mental health and addiction treatment, ignore current research proven treatments, and reduce treatment to the prescription of medications and poor outcomes will follow.

You can take that to the bank.

George Dawson, MD, DFAPA

Friday, July 4, 2014

A Toxic Work Environment For Physicians

I posted my opinion on burnout interventions for physicians on another blog.  That opinion was that mental health interventions to address the product of a toxic work environment that is increasingly toxic seems futile to me.   The author agreed with me, but stated that her program was designed to help residents survive their residencies and nothing more than that.  She pointed out and I agree that residents can't change the structure of their work environment and they can't quit.  That is one advantage that more senior physicians have - they can do both.   The additional rhetoric on the thread suggested that there was no definition of a toxic work environment.  Based on what I have posted here,  I thought it would be fairly easy to pull together a few elements of that definition.

Before I proceed there are a few qualifiers.  As a more senior clinician it is possible like other areas in life, that younger colleagues do not have the same experience and therefore do not relate to what you are posting.  In this case it would have to do with whether or not they worked and trained in managed care environments.  I think that it is entirely possible that if you have worked and trained exclusively in a managed care environment, that your experience is entirely different.  That could make it more difficult to identify the cause of distress or it might make it easier to tolerate all of the non-medical intrusions into the daily work environment.  There are documented personality factors and cognitive styles like perfectionism and obsessiveness that have been implicated in burnout, but they tend to be traits that are inherent in most physicians so I am focused here on immediate environmental factors that are the cause of this widespread problem.   They are really quite straightforward and they can all be attributed to mismanagement:

1.  Sleep deprivation:  The adverse effects of sleep deprivation on cognition and emotional health are well documented.  The expectation that physicians will be sleep deprived is a well known tradition.  While there have been some improvements with restrictions in residency training on the number of hours of continuous work, current practices have in many ways led to a worsening of this problem.  The hospitalist movement had led to the 7 days on and 7 days off schedule that creates fatigue and decreased work performance toward the end of that stretch.  I have interviewed hospitalists about their experience and they have told me that their work slows down, largely due to cognitive inefficiency the last two days.  That slowing adds an additional 2-3 hours of added time to complete all of the work.  It seems like a questionable practice to extend working hours to the point of cognitive inefficiency and fatigue for the sake of the administrative simplicity of not having to schedule cross coverage for weekends.  Outpatient physicians are no less immune when they are expected to sit in their clinics long after hours to complete what are essentially administrative tasks.  Many of these administrative tasks are unnecessary from a medical standpoint.  In both cases the electronic health record (EHR) places a large burden on physicians everywhere and access to it from home can create a 24/7 work environment.

2.  Excessive workload:  The invention of RVUs has given administrators unprecedented leverage in establishing a high volume, low quality production line of physician services.  Markedly different quality of service can be provided by different physicians submitting the same billing code, but there is an unquestionable race to the bottom from the administrative side.  There is no better example than the annual review conversation where physicians are told where they are on the global productivity scheme and one of two things happen.  They are told that they should target a higher decile (or two) next year or they are simply given an RVU expectation that they need to meet in order to "justify" their salary.  In some cases there is just an arbitrary expectation of a percentage increase in RVUs with no theoretical upper limit.

3.  Changing work load:  There has been no accounting for the fact that physicians have taken over more and more work tasks in the past thirty years that were previously done by other people.  Transcriptionists and billing personnel have been replaced by the hundreds of thousands.  The burden for generating detailed medical documents and accurate billings falls directly onto physicians and it is a heavy price.  After seeing all of the patients in a day, physicians generally settle down to do all of this documentation with the associated phone calls and billing.  The expectation that physicians need to know about matching their documentation to a purely subjective billing and coding scheme that can change from year to year within an organization is a reminder of the absurd administrative burden paid by all physicians.

4.  Uncertainty:  Medicine is a demanding field that is mapped onto significant biological variability that increases with the age of the patient.  Coping with that uncertainty is one of the baseline tasks of physicians.   The best way to cope with it is to stay current with the best diagnostic and treatment practices of the speciality being practiced.  Business and government intrusions into this field based strictly on cost and regulatory changes introduce much more uncertainty.  These intrusions take the form of case managers or external reviewers demanding that ill people be discharged from hospitals based on an arbitrary length of stay figure,  those same reviewers denying a recommended therapy by the physician who has seen and is personally responsible to the patient, denied medications based on expense or contracting, or treatment based on guidelines promulgated by business organizations rather than medical or professional organizations.  There is also a broad movement to train physicians as basically customer service representatives through the use of very basic interpersonal techniques.  Many organizations use "customer" feedback as another piece of the algorithm that determines compensation.  The  important physician task of telling patient what they might not want to hear is not "incentivized".

The other relevant dimension here is that the staff who are ordering the physicians around are frequently not physicians and have no real responsibility to the patient.  They are frequently working from proprietary guidelines devised by people who are also not physicians and have no direct responsibility to the patient.

5.  The expectation of free work:  There is no better example of free work than looking at all of the employees in health care organizations that physicians have replaced, but it doesn't stop there.  Teaching medical students and residents is another good example.  Lectures and lecture preparation is not only not reimbursed but there is usually the expectation that the same number of patients needs to be seen that day or made up at some point during the week.  The teaching tasks are typically unsupported and lecturers and teachers are responsible for the lecture content and even getting the necessary copyright permissions.  Before managed care, medical education was more of an integral part of the work and physicians typically got credit for it and department support.  The current work environment emphasizes RVU productivity as the sole measure of reimbursement.  This has become problematic in academic environments that are supposed to emphasize teaching.  In many cases those academic goals have become secondary to so-called productivity.

Managed care has added an immense amount of additional free work for physicians.  It comes in the form of all of the additional work due to utilization review, medication prior authorizations, and a blizzard of additional paperwork.  In the case of medication prior authorizations it takes a minimum of 35 minutes a day and additional staff to do all of the paperwork, but I am sure that most physicians have spent that kind of time on a single case.  The initial impetus for these measures was supposed to be cost effectiveness, but it should be apparent at this point that making money for managed care companies is the real priority and physicians are forced into the role of rubber stamping these measures.  That rubber stamping comes at a significant time cost.  Aggressively holding physicians to a productivity standard, while wasting significant amounts of their time is probably the single most toxic factor in what is already a toxic environment.

5.  Overt abuse: With the unprecedented leverage that business administrators have over physicians and the proliferation of administrators there have also been additional strategies developed to get rid of physicians who are dissenters or don't fit with corporate expectations.  A familiar one is the disruptive physician concept and its many forms.  The corporate interest is in taking any complaint about a physician whether it is substantiated or not and using it to manipulate that physician.  There are many possible sources.  The 360 evaluation solicits complaints from all of the coworkers in the environment where the physician works.  Making those complaints anonymous will predictably results in more significant and negative complaints.  These may be reviewed in an annual review and used for compensation purposes or disciplinary action.  There are variations within organizations like a "three strikes and you're out" rule.  In all of these procedures the physicians involved have no recourse other than filing a lawsuit or defamation suit.  These procedures become tools that can be used by any administrator against any physician who is viewed as a dissenter to the latest and greatest idea by that administrator.  I have seen physicians subjected to firing and onerous rehabilitation schemes like meeting with an administrator and the supposedly aggrieved employee to help them get along on an ongoing basis.  Those exercises in manipulation are superimposed on the physician who is already trying to keep his or her head above water in the sleep deprived assembly line environment.

6.  The not so covert war against the medical profession:  Let's face it - business administrators would obviously love physicians to act the way they treat them - like production workers rather than knowledge workers.  They would really like to replace physicians with less expensive providers or prescribers and will eventually make the argument that a corporate structure with various computerized whistles and bells will be superior to trained medical staff.  The only reason there is any tension at all at this point is that some physicians have skills learned in medical school and residency that have been codified to a certain degree in the legal and regulatory landscape.  The only reason that behavior inconsistent with corporate behavior is tolerated is that a particular physician probably has skills that nobody else does.  That does not prevent administrators from threatening entire blocks of physicians with either disenfranchisement or firing.  The disenfranchisement can occur along the spectrum of decreased reimbursement, additional work expectations without additional resources, or both.  Additional sorties include campaign to teach physicians basic interpersonal skills learned many times in medical school and residency.  Bringing in consultants to tell physicians how to perform their work in a manner more consistent with what administrators want and ignoring the often considerable internal expertise in the department is another familiar strategy.  The legislative front has been exploited to the maximum already with business tactics like utilization review and prior authorization included in many state statutes.  The resulting business friendly legal and regulatory environment leaves very little room for criticism by physicians or their patients.

These are a  few of the examples of a toxic work environment for physicians.  I realize that many are not unique and that other assembly line workers may be subjected to the same abuses.  The problem of course is that physicians are not trained to work on an assembly line.  They are trained to be scientifically inquisitive and intellectually active.  That dimension alone requires many hours apart from work.  In addition to family life that intellectual aspect of being a physician suffers the most from the currently toxic work environment.

George Dawson, MD, DFAPA

Supplementary 1:  This blog is full of posts on the mismanagement of knowledge workers and the abuse of physicians by business systems.  Here are a few examples:

Mismanagement of knowledge workers

Mismanagement of knowledge workers

Demoralizing micromanagement of physicians

Monday, June 30, 2014

Riding The "L" Train

My wife and I went to the Edward Hopper exhibit at the Walker Arts Museum last Saturday.  Hopper is one of my favorite artists because I consider him to be the artist of chronic insomniacs.  I am a chronic insomniac.  By that I mean, many of his most favorite paintings depicted scenes that were seen either directly through a window at night or the perspective of seeing a room illuminated by two or three lighting sources at night.  Reading the informational displays next to the art, I learned that may have been from riding the "L" train in New York City late at night and peering into offices where people were still working.  Some of his paintings are very natural night time occurrences like his famous painting of a diner at night called Nighthawks.  In some of his paintings displayed in this exhibit there were annotated drawings with clear attention to the light and sources of light in his paintings.  In Office At Night for example is a notation about light coming in (at night) from the window, from an overhead office light, and from a lighted adjacent room.

Nighthawks has always interested me just in terms of its form and attention to lighting details.  It interests me even more after reading Kandel's book on art and what the viewer brings to the viewing situation.  I suppose there are a lot of people just seeing a diner at night.  But if you are an insomniac, night is an entirely different proposition for you.  Many insomniacs dread the night because they equate it with no sleep.  But many of us see it as the most exciting part of the day.  It is like a different world where your perceptions are much clearer.  I have actually cataloged some of my nighttime experiences, and they remain as vivid today as they did decades ago.  For example, I remember one night, I was wide awake at 10 PM and decided I was probably not going to sleep that night.  What better time than to go to the chemistry lab where I was working at the time and continue some experiments I was working on?  It was about -5 degrees and a three mile walk.  About two inches of snow had fallen and it crunched and squeaked every time I took a step.  I was past an old decrepit sandstone block hotel at the half way point and more snow started to come down.  Across the street was a large white marble bank building flashing the time and temperature.  There were at least four lighting sources, the flashing time and temperature, the street lights, light coming out of the shops and rooms in the hotel, and light reflecting up off the fresh snow.   I walked for three miles in these unusual lighting circumstances hearing and feeling that crunching and squeaking under my boots the entire way.  It was thoroughly invigorating.  I reached the lab, did a few experiments.  As the sun came up, I found a couch in the building and fell asleep.  That may not sound like much to someone who is used to sleeping at night, but it is what I bring to viewing a Hopper painting of a diner at night.  I find myself very excited about it, when it probably does not have that effect on others.  I could easily walk into that diner at night and talk with my fellow insomniacs.  We would all be in a fairly good mood.

All of this also reminded me of Kandel's recent book  The Age of Insight and his focus on beholder's experience.  The main idea is that viewer experience is critical to the completion of the work of art.  This idea originated with Alois Reigl, an art historian who developed a formal method for analyzing works of art.  The corollary is that each new generation of artists has the implicit task of educating the public about new ways to view art.  Some of Kandel's focus was on Viennese modernist painters - Klimt, Kokoschba, and Schiele and their role in educating the public about unconscious instinctual urges through their paintings during the time that psychoanalysis was being developed.  The theory of the viewer's experience also looked at the issues of inner and external coherence.  In the case of inner coherence, the painting has a clear narrative that does not require the viewer to complete the story.  In the case of less clear narratives the viewer may respond to the physical or emotional space of the painting, social equality with the people in the painting, and emotional and empathic equality with the people in the painting.  According to Kandel: "The ambiguity in the image elicits both a conscious and an unconscious process of recognition in the viewer, who responds emotionally and empathically to the image in terms of his own life experiences and struggles."  This is a critical but rarely recognized aspect of art.  I have been out of college for some time at this point, but recall no classes that were either specifically art classes or liberal arts courses on the interpretation of art that discussed the response of the viewer as necessary to complete the art, even though that idea had been out there for over 50 years.

These considerations also highlight the artistic aspects of other media - like photography.  There are many common criticisms of photography as art.  Many consider the creative process to be too truncated: "It's just a picture after all anybody can do it."  Some consider it to be a predictable way to elicit an emotional response, such as the Humane Society and Save the Children commercials that are broadcast on late night television.  But photography is a lot more than that.  As an example, I posted this sequence of pictures of 4 sisters over a span of 37 years years to my Facebook feed.  I found these pictures especially in sequence to be emotionally stunning and I wanted to see what some of my friends who were photographers thought.  To my surprise, I got two responses: "wow" and "very cool" from friends who do not seem particularly interested in photography - at least based on what they post on Facebook.  In this case the only narrative is implicit and partial and that is sisters as they age.  The body language and facial expressions seem to change over time.  I think it would be very difficult for the average viewer to not respond emotionally, empathically and construct their own theory of the mind interpretation for what is going on.  Photography can clearly be as compelling as painting or other forms of visual art.

Being a neuroscientist, Kandel is a wealth of information on the neurobiology of the beholder's experience.  On the chapter focused on that issue, he talks about unconscious determinants of beauty and attractiveness.  He discusses activation of the reward system both at the level of the ventral tegmental area and orbitofrontal cortex (OFC) in response to attractive faces, especially smiling faces and beautiful images.  He points out that one experiment showed that beautiful pictures activate the OFC more than the motor cortex and with ugly pictures it is the opposite suggesting that seeing ugly or fearful faces sets up the brain to prepare for a fleeing response.

Kandel's approach to the discussion of the artist and the beholder and their necessary relationship to complete the art and now the underlying neuroscience makes a lot of sense to me.  The most compelling aspect of this story (apart from loving the art) is the idea that you can look at this problem from the perspective of neuroscience and not get carried away.  Kandel is as comfortable discussing the neuroscience as his is the qualitative and subjective aspects of the creation and perception of art.  One does not necessarily explain the other.  At some point in psychiatry subjective became a dirty word and the illusion was created that in the extreme our unique brains can be measured and characterized by a simple collection of symptoms.  Any student of consciousness knows that it is absurd to think that 7 billion unique people with unique brains can be broken down to a relatively few disorders or personalities or executive functions or IQs or however else we might want to approximate their neurobiology.  Art and the beholders experience is a great example of that.  I have a good idea of why I like Hopper's work.  My theory of the mind is that he was a fellow insomniac who did not mind being an insomniac.  I have other speculation about his work, especially the people he included that I will hold for now.  Another thing I have learned over the years is that people are not necessarily interested in one anothers interpretations of art.

My favorite art and the art that I collect is pure abstract art and I hope to develop a detailed post about that in the not too distant future.

George Dawson, MD

Eric R. Kandel.  The Age of Insight: A Quest To Understand the Unconscious in Art, Mind, and Brain, From Vienna 1900 To The Present.  Random House, New York City, 2012.