tag:blogger.com,1999:blog-7772182113499451603.post2096178296678495788..comments2024-03-27T10:50:53.692-05:00Comments on Real Psychiatry: The Issue With Patient Management ProblemsGeorge Dawson, MD, DFAPAhttp://www.blogger.com/profile/03474899831557543486noreply@blogger.comBlogger7125tag:blogger.com,1999:blog-7772182113499451603.post-2470786256934259062014-06-04T11:50:34.341-05:002014-06-04T11:50:34.341-05:00Well put Steven. I agree with you on both the int...Well put Steven. I agree with you on both the intellectual/scientitic and political bases. I can recall the exhaustive medical student differential diagnoses and how by the time you wrote it down - you knew it was an irrelevant exercise. <br /><br />Your idea about an adequate test for experts is intriguing. I would imagine it is possible to have a real time interaction with a machine that has hidden diagnostic features and to document the heuristics used by the expert, If there isn't there should be and it would also be a good experiment to do an exhaustive examination of patterns to the correct diagnosis.<br /><br />The most important aspect of your post that I try to repeatedly emphasize here is the move to dumb down medicine and psychiatry to make it seem like experts can be replaced by checklists and that they are somehow equivalent.<br /><br />That is a clueless argument and unfortunately one that many physicians have fallen for and continue to do so. It is after all the reason why you practice medicine.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-45945113136155026992014-06-04T11:49:30.987-05:002014-06-04T11:49:30.987-05:00Well put Steven. I agree with you on both the int...Well put Steven. I agree with you on both the intellectual/scientitic and political bases. I can recall the exhaustive medical student differential diagnoses and how by the time you wrote it down - you knew it was an irrelevant exercise. <br /><br />Your idea about an adequate test for experts is intriguing. I would imagine it is possible to have a real time interaction with a machine that has hidden diagnostic features and to document the heuristics used by the expert, If there isn't there should be and it would also be a good experiment to do an exhaustive examination of patterns to the correct diagnosis.<br /><br />The most important aspect of your post that I try to repeatedly emphasize here is the move to dumb down medicine and psychiatry to make it seem like experts can be replaced by checklists and that they are somehow equivalent.<br /><br />That is a clueless argument and unfortunately one that many physicians have fallen for and continue to do so. It is after all the reason why you practice medicine.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-26415709087559424062014-06-04T10:27:35.762-05:002014-06-04T10:27:35.762-05:00These patient management problems assess a level o...These patient management problems assess a level of competence that ranks below expertise. Similar to the medical student write-up of a new patient, where completeness — making sure all the categories are considered — is the standard of excellence. At this level, intuition, i.e., expert heuristics guided by experience-based pattern-matching, is actively discouraged. After all, a novice is apt to be led astray by hunches.<br /><br />I agree this is the wrong test for an expert. The widespread, burgeoning use of such tests reflects a denial of medical expertise and the commodification of medical practice. The push to standardize medical practice with externally defined quality and performance measures helps to raise the practices of those at the bottom, while denying and blunting the brilliance of those at the top. No non-medical overseer of health care wants you to use your hard-earned expertise at pattern-matching. Simply follow the flow-chart of parallel differential diagnoses in the manner of any good medical student, and you will be a competent "provider," an interchangeable cog in the gears.<br /><br />It's interesting to ponder, by the way, what would constitute a good test for an expert, other than such "measures" as reputation among peers, word-of-mouth referrals, and the like.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-54746583486934230132014-06-03T22:36:40.329-05:002014-06-03T22:36:40.329-05:00No arguments from me David.
I trained in the hey...No arguments from me David.<br /><br />I trained in the heyday of the "biological psychiatrists". We had to do HAM-A and HAM-D ratings on all of our clinic patients. Depending on the inpatient service some people ordered daily Beck depression inventories. That is another reason I cringe when I hear the buzzword "measurement based psychiatry" and the associated political rhetoric. <br /><br />I don't see Big Pharma as the main proponent here. I think managed care systems, especially those who employ their own doctors, want to use all of these measurements as leverage against their doctors. Set arbitrary and meaningless numbers - more or less like they do with productivity numbers right now. What better fantasy can a manager have than a clinic fill of psychiatrists seeing 20 people a day and producing 20 rating scale numbers for his/her viewing pleasure.<br /><br />To your point about a lack of rating scale specificity, in training it was well known to all of us that patients with borderline personality disorder produced the most consistent "high" score that were resistant to any treatment intervention. They also maxed out the suicide scale and it often did not come down for months to years. <br /><br />The other faction who are trying to benefit from measure based care are the politicians who have to keep telling their constituents that they are "reforming" medicine and keeping doctors accountable. What better way to divert attention from their complete lack of leadership than to produce a massive volume of meaningless numbers and call it "pay-for-performance". George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-42786868502871186172014-06-03T22:18:12.765-05:002014-06-03T22:18:12.765-05:00I have treated many people who were a "12&quo...I have treated many people who were a "12" or "15" and that is the problem with calling this a quantitative measure. A quantitative measure is a gallon and it is the same everywhere. On that other end, I am sure there are plenty of Norwegian farmers and lumberjacks who don't even register pain until they are at least a "7. <br /><br />Belief system is also an important aspect of the pain scale. If you have the belief that the physician just has to increase the pain medication high enough and the pain will be gone, you will be less likely to rate small changes positively. The same thing is true of ADHD ratings.<br /><br />Maybe this is why they try to prevent science majors from getting into medical school. We know what quantitative analysis is.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-31052312376840170132014-06-03T20:55:59.789-05:002014-06-03T20:55:59.789-05:00Rating scales for affective disorder rountinely ig...Rating scales for affective disorder rountinely ignore the criteria that major mood disorder symptoms have to be pervasive and persistant, have to all take place at the same time, and have to be significantly different from the person's usual functioning. This fact makes them completely worthless in practice, and the example you give is a good illustration how Pharma bullcrap is being taken as Gospel by too many people in our profession. <br /><br />Hamilton himself railed against the use of his own rating scale for anything but screening people to determine who should have a more comprehensvie evaluation, because he knew that the symptoms rated on the scale are non-specific and appear widely in anxiety disorders. And don't get me started on Bipolar II. I've had several personal conversations with Hagop Akiskal.David M. Allen M.D.https://www.blogger.com/profile/06280912088483192599noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-84885606735937424452014-06-03T19:44:35.270-05:002014-06-03T19:44:35.270-05:00Today's post brought two shaking my head and l...Today's post brought two shaking my head and laughing moments. Thank you.<br /><br />"The patient management problem seems more like a standardized reading comprehension test with the added element that you have to guess what the author is thinking."<br /><br />When it was slow in the pharmacy one of the pharmacists used to quiz me using the little mini-CME multiple choice tests in the medical journals. I would never be able to pass a real CME test, but sometimes with the ones he used, I would be on a roll with all right answers. It was just knowing how to take a multiple choice test by ruling out two answers and guessing which one was right out of what was left.<br /><br />"Rating scales of subjective symptoms remain a poor substitute for a detailed examination by an expert "<br /><br />My neighbor had a reoccurrence of back pain due to slipped disks, and was fretting that her doctor wouldn't take her seriously. So I said that they usually ask how much pain you are in on a scale of 1 to 10 with 1 being barely noticeable to 10 being the worst you have had or can imagine having, and that she should think about it and let him know what level it was. She thought about it for all of 10 seconds and blurted out, "I'll tell him it's a 20!". To which I replied that I was positive he wouldn't take her seriously with that answer. <br /><br />BTW, being realistically accurate with pain scales doesn't help much either. I have always taken a 10 to mean the worst possible pain you could image; think nuclear radiation poison pain. So I am in the 2-5 range generally and I have never said anything over a 5. Hence, even though I can be in very bad pain, I am dismissed pretty quickly by my healthcare team at those low levels.RBnoreply@blogger.com