Friday, August 21, 2015
What Have I Learned So Far?
I started writing this blog over three years ago. I decided to start writing it for a number of reasons. First and foremost was the constant stream of inappropriate criticism aimed at psychiatry that contrasted with my real life experience working in the field and working with very competent colleagues in the field. The second reason was to strike back at managed care and its various forms that I would include today as pharmacy benefit managers, government bureaucracies and even politicians. All of the individuals and organizations continue to promote and institutionalize rationing strategies that are supposed to be "cost effective" but basically route hundreds of billions of dollars away from patient care to unnecessary business managers. The third reason is the disproportionate impact that the first two have on patient care. The care of patients with psychiatric problems has been decimated by this mindset that is both hypercritical but ignorant of psychiatric care and at the same time rationing the resources to the point that incarcerations are commonplace. Even if a person with a serious problem gains entry into a system of care, there is no guarantee that they will receive any - as administrators with no expertise at all make critical decisions about whether they are hospitalized, whether they get detoxification services, what medication they take, how intensively they are seen in clinics, and whether they get the additional supportive services that they need. A related fourth issue is that even though systems of care define "dangerousness" as essentially the only reason people need to be hospitalized these days, they do a very poor job of assessing and treating it. It needs to be addressed at a public health level as well and aggressive and homicidal behavior associated with mental illness needs to be systematically addressed rather than being swept under the rug as "stigmatizing". Teaching is something that I am good at and I take an informational rather than process based approach. What I post here is more likely to be high in information content and unique rather than entertaining. In that area, I have wide interests in the field and how they apply to patient care and theory. I post some scientific articles and clinical strategies that I hope will be clinically useful by my colleagues and in many cases they have already been vetted by some of my fellow psychiatrists. Human consciousness is a related issue that I think has essentially been ignored by modern psychiatry and some of what I post here are examples of consciousness and how it works - both my own and other peoples. That is the basic matrix that I am working from. Other points that I have observed and what might be useful information for other potential psychiatric bloggers follows:
1. Nobody really cares about your blog: Blogs are a dime a dozen and everyone writes one these days. My initial goal was getting my viewpoint out if people are interested or not. An additional corollary in psychiatry is that in order to maximize the readership, the odds are better if you are criticizing the field or provocative rather than debunking a lot of the unrealistic criticism. I hope it is clear that I am writing no matter what and will keep doing that as long as I care about what happens to psychiatrists, physicians, and their patients and and I continue to know exactly what the problems are. As far as I can tell - there is very little of that perspective available in the blogosphere, the press, or even the editorial section of professional specialty journals.
2. Thirty years of practicing medicine saps your creativity: Most physicians realize this, but I have not heard many actually come out and say it. I was a fairly skilled writer at one point, at least according to my undergrad professors. Tens of thousands of pages of medical documentation later, much of it meaningless bullet points added for administrative purposes that mind numbing exercise has taken its toll. Most physicians consider writing to be a burden for that reason. My prose has become obsessive at times and (thanks to the electronic health record) grammatically incorrect. I have been fortunate to have a regular reader here send me corrections and ideas on how to improve and greatly appreciate that advice. Medical schools select bright and creative people to become physicians. When those same medical schools are unconcerned about a deterioration in the practice environment that stifles creativity and dumbs down medical practice they are doing a disservice to medical students who they select for those qualities.
3. Ignoring the haters: This has never been a really big problem of mine. Once you discover that a substantial number of people dislike psychiatrists and their reasons are irrational, they are easy to ignore, My only initial mistake here was allowing several of these posts onto my blog when I should have just rejected them all. I have seen what happens to threads and blogs where this irrational corrosive opinion is allowed to persist under the guise of "freedom of speech" or "freedom to criticize". Any collegial atmosphere that I have ever trained in allowed rational criticism delivered in a manner that was acceptable to everyone. Any post sent in my direction that I don't think would fly in a meeting of physicians, will not see the light of day here. A good example would be attempting to post that I am a "drug company whore." That is inappropriate first and also wildly inaccurate. Some of the most notorious critics clearly do not know what psychiatrists do and have glaring deficits in scholarship on the subject. For those who are inclined to ethical arguments, I would argue that it is unethical to allow a serious discussion by trained medical experts to be disrupted by people who are basically there to be disruptive and have nothing else to offer.
4. Ignoring the numbers: It is always difficult to figure out what the Blogger statistics mean. They vary by a factor of 10 on a day to day basis. In some cases, I have gotten 900 page views in less than one minute and doubt those represent anything real. In many cases, the referring URLs are clearly spam sites or originate in countries where the youth are encouraged to become hackers and steal money from foreigners. There are the occasional referrals from sites that seem to be legitimate, like valid educational sites. I don't get too excited about the statistics - aggregate or parsed. Anybody reading this and having a sense of solidarity with my statements and goals whether they say so or not is good enough for me.
5. Analyze the rhetoric: One of the most consistent dynamics that can be observed is how the most criticized branch of medicine is handled with a total lack of accountability on the part of the critics. They of course can say whatever they want to and often loudly proclaim this as their right. There is an inevitable group of hero worshipers that back them up like they have some new insights. In fact, they have a collection of vague and inaccurate observations that they cling to like they know something about medicine or science. Some real experts uncritically lend credence to some of these off-the-wall ideas. One of the leading authors in this area had his book endorsed by an editor who was herself very critical of psychiatry. It doesn't seem much different than coalescing around the concepts of Intelligent Design. No science or even rational analysis. Only an understanding of rhetoric prevents one from falling into this trap.
6. You can only save yourself and maybe your patient: Much of the heat when it comes to psychiatric criticism flows from business and ethical problems with pharmaceutical companies and associated physician conflict of interest. There are entire blogs where this seems to be the only topic of interest. One of those blogs claimed that they were "keeping psychiatry honest." The implied claim in these sites is that complete transparency of all drug trials and no contact between physicians and the industry will lead to a new idyllic state, where we will only have completely safe and effective drugs. Maybe we will also be able to stop studying neuroscience and hearken back to the psychotherapies and psychosocial interventions of the 1970s. Those ideas are so naive that I could barely stand to type them out. That line of thinking completely ignores the corrupt elephant in the room (Congress) and the fact that the FDA is clearly politically influenced to the point that they can ignore the recommendations of their own scientific committees and put any drug on the market that they want. It ignores that fact that American governments are pro-business to the detriment of the individual and that corporations readily accept the model of paying civil penalties as a reasonable risk for pushing the business envelope. It also greatly ignores that fact that psychiatrists are really minor players in the pharmaceutical and medical device industry, but nobody in the press seems too worried about that.
7. There appears to be little solidarity among physicians: Physicians have been divided for decades now by splitting and political factors both between specialties but also within the same specialty. I think that is part of what fuels the cultural norm of criticizing colleagues even though the vast majority do good work and have no apparent or appearance of ethical problems. See my post on monolithic psychiatry rhetoric. I think that the critical component of scholarship is also frequently ignored when some adopt the posture that any criticism is the equivalent of criticism from within the field. To me that is a falsely modest position when you have been rounding with physicians who are clearly well read and have the associated clinical experience. Medicine is not something that you can learn from reading snippets on the Internet. I don't know if there is widespread knowledge that physicians are actively managed to maintain them in a fractioned state. When productivity units were first introduced, managers everywhere suggested it was because there was tremendous variation in productivity and some physicians were not pulling their weight. After everyone was being measured and pilloried about their "production" every month, it was apparent that was a lie. But what better way to foster an "every man/woman for themselves" attitude and destroy any semblance of professional solidarity? Let me say this here for future reference, the "management" of physicians is really psychological warfare against physicians and the motivation for those strategies is varied but certainly not benign.
8. An ethical climate is well ..... an ethical climate: Part of the business of manufacturing news and headlines includes constructing an ethical climate and applying it to the people being criticized. There are generally set-ups for provocative articles that seem scandalous. In fact, most of the ethics is debatable and the debates are typically one-sided. That is the best way to both win an argument and successfully smear an opponent. There are many an ethical environments and straw men set up against psychiatrists. If it is clear that a physician has broken the law or the medical practice rules in their own state that constitutes proof of wrongdoing. I have lost count of the times I have referred people to the Medical Board when they were complaining about a physician. That generally marks the end of the discussion. Most seem to have the expectation that publicly shaming a physician through ridicule means something. It doesn't mean anything to me.
9. Physician professional organizations are weak and ineffective: I am a 30 year member of the APA and AMA. That does not prevent me from criticizing these organizations or recognizing their shortcomings. Psychiatry organizations are no different than the AMA or other physician organizations. They have been very ineffective in the area of mental health policy especially countering managed care tactics to ration and restrict care. They no longer advocate for state of the art care. As I recently critiqued their guideline, it was not clear that you had to be a trained psychiatrist to use it. That said, they have supported a few good initiatives like banning the participation of psychiatrists in torture and the resumption of Clinical Guidelines. I am committed to speak out against APA positions that I think are problematic like their support of the American Board of Psychiatry and Neurology (ABPN) position on recertification, collaborative care, the use of rating scales to establish quality of care parameters, and their participation with managed care entities to establish guidelines or quality parameters. The APA has to do far more in establishing criteria for inpatient care of psychiatric and addiction problems and be actively critical of proprietary guidelines that facilitate the rationing of care. But the commonest distortion is that the APA or the AMA have some kind of power to influence the politicians and businesses that run medicine in this country. Nothing is farther from the truth.
10. Developments in the field are important: The psychiatric literature is better than it has been at any point in my lifetime. There is a lot more to it than clinical trials and the current state of clinical trials seems like a dead end to me due primarily to a lack of sophistication. Certain buzzwords like evidence-based medicine, controlled clinical trials, and collaborative care have been coopted by non-physicians to the point that they are often meaningless. I critiqued a massive Medicare guideline that included a 40 page description of the evidence necessary for basic documentation. In addition to the literature, there are excellent educational conferences widely available across the country. People often lose sight of the fact that life is not a clinical trial, the clinical method is faster and probably safer, and that clinical trials both real and proposed are not necessarily the best use to time and energy.
11. Trying to be creative: Creative commentary and creative writing is possible and it is part of the tradition of psychiatry. I have added a few things along the way that illustrate important concepts in a non-technical way and I am trying to add more graphics. Some of these pieces are also there to illustrate stream-of-consciousness concepts - either mine or somebody else's.
12. Supporting other bloggers: I am quite happy to support other psychiatrists who are bloggers and any bloggers who I consider to be useful sources of information. The blogosphere is immense and I am sure I have missed some people. I try to include them in the list of blogs I follow and consult that list regularly. If you are a psychiatrist, I encourage you to start your own blog, find your voice and add it. I am very familiar with the work of hundreds of psychiatrists in the Midwest and know that my opinion reflects the opinion of many of them. If your experience is my experience, you know that psychiatrists deal with impossible problems with minimal resources, put up with some of the most obnoxious administrators and managed care bureaucrats and we still get good results for our patients. Add your voice to the realistic information about psychiatry on the Internet and I doubt that you will regret it.
13. Staying non-commercial: Bloggers are encouraged to add on commercials and in some cases make money by blogging. That seems like a potential conflict-of-interest to me, especially if you are marketing additional products like books, CDs, and speaker fees that espouse your personal viewpoints. That is good because it may allow an appreciation of what it is like to attract paying customers including what needs to be said and the manner in which it is said. It can also be a laboratory for the forces similar to the corrupting influences in the business world that can affect the delivery of health care. Either way that is an influence on a blog's content. Many posters seem to view blogs as their own method of advertising and attempt to design posts that bring readers to their own sources of advertising. I think it makes sense to avoid avoid that advertising like you can avoid talking with pharmaceutical company sales staff and carefully consider what you are reading on a blog that is trying to sell you other products.
Paying attention to all of these things and more will hopefully keep me on track and keep me posting what is really going on in psychiatry as well as information that is useful to psychiatrists, other physicians, trainees, and anyone really interested in some of these topics. I am not enough of a megalomaniac to believe that I can change the trends I am attending to, but I will not let them slip by without some realistic commentary.
That's about all I can say.
George Dawson, MD, DFAPA