Showing posts with label practice environment. Show all posts
Showing posts with label practice environment. Show all posts

Monday, April 18, 2022

Knowledge Workers

 


I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. Since then, things continue to go in the wrong direction.  Some knowledge workers get more recognition from the business managers than others but it is based on income generation rather than the cognitive aspects of the job. And of course, psychiatrists are managed as if there is no cognitive aspect as all.  In an interesting development at the time, I was contacted by Canadian physicians after this editorial was published in the newsletter, but no American physicians.

 

Imagine working in an environment that is optimized for physicians. There are no obstacles to providing care for your patients. You receive adequate decision support. Your work is valued and you are part of the team that gets you immediate support if you encounter problems outside of your expertise. In the optimized environment you feel that you are working at a level consistent with your training and current capacity. That environment allows you to focus on your diagnosis and treatment of the patient with minimal time needed for documentation and coding and no time wasted responding to insurance companies and pharmacy benefit managers.

As I think about the problems, we all encounter in our work environment on a daily basis I had the recent thought that this is really a management problem. Most of the management that physicians encounter is strictly focused on their so-called productivity. That in turn is based on an RVU system that really has no research evidence and is clearly a political instrument used to adjust the global budget for physicians. Current state-of-the-art management for physicians generally involves a manager telling them that they need to generate more RVUs every year. Managers will also generally design benefits and salary packages that are competitive in order to reduce physician loss, but this

is always in the larger context of increasing RVU productivity. Internet searches on the subject of physician management gener­ally bring back diverse topics like "problem doctors", "managing physician performance", "disruptive behavior", "anger manage­ment", and "alcoholism", but nothing about a management plan that would be mutually beneficial for physicians, their patients and the businesses they work for.

In my research about employee management, I encountered the work of the late Peter Drucker in the Harvard Business Review. Drucker was widely recognized as a management guru with insights into how to manage personnel and information going into the 21st century. One of his key concepts was that of the "knowledge worker".  He discussed the evolution of managing workers from a time where the manager had typically worked all the jobs he was supervising and work output was more typically measured in quantity rather than quality. By contrast knowledge workers will generally know much more about their work than the manager. Work quality is more characteristic than quantity. Knowledge workers typically are the major asset of the corpora­tion and attracting and retaining them is a corporate goal. Physicians are clearly knowledge workers but they are currently being managed like production workers.

The mistakes made in managing physicians in general and psychiatrists in particular are too numerous to outline in this essay. The current payers and companies managing physicians have erected barriers to their physician knowledge workers rather than optimizing their work environments. The end result has been an environment that actually restricts access to the most highly trained knowledge workers. It does not take an expert in management to realize that this is not an efficient way to run a knowledge-based business. Would you restrict access to engineers and architects who are working on projects that could be best accomplished by those disciplines? Would you replace the engineers and architects by general contractors or laborers? I see this dynamic occurring constantly across clinical settings in Minnesota and it applies to any model that reduces psychiatric care to prescribing a limited formulary of drugs.

I think that there are basically three solutions. The first is a partial but necessary step and that is telling everyone we know that we have been mismanaged and this is a real source of the so-called shortage of psychiatrists. The second approach is addressing the issue of RVU-based pay directly. I will address the commonly used 90862 or medication management code. As far as I can tell, people completing this code generally fill out a limited template of information, ask about medication side effects, and record the patient's description of where they are in the longitudinal course of their symptoms and side effects. I would suggest that adding an AIMS evaluation or screen for metabolic syndrome, an in-depth probe into their current nonpsychiatric medications and how they interact with their current therapy, adding a brief psychotherapeutic inter­vention, case management discussions with other providers or family, and certainly any new acute medical or psychiatric problems addressed are all a la carte items that need to be assigned RVU status and added to the basic code. Although there are more, these are just a few areas where psychiatrists add quality care to the prescription of medicines. The final solution looks ahead to the future and the psychiatrist's role in the medical home approach to integrated care. We cur­rently have to decide where we fit in that model and make sure that we don't end up getting paid on an RVU basis while we are providing hours of consultation to primary care physicians every day.

Overall, these are political problems at the legislative, bureau­cratic and business levels. It should be apparent to anyone in practice that when political pressure succeeds in dumbing down the profession, it necessarily impacts adversely on work environ­ment, compensation, and most importantly the ability to deliver quality care. The continued mismanagement of psychiatrists by businesses and bureaucrats who have nothing more to offer than a one-size-fits-all productivity-based model, is the biggest threat to psychiatry today and a much more enlightened man­agement strategy is urgently needed. The Minnesota Psychiat­ric Society and the APA need a strong voice in that change.

 

George Dawson, MD, DFAPA

Committees and Stakeholders

 


I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. It was subtitled: "A new approach is needed and I think that approach needs to be psychiatrists redesigning the system."  Since then, things continue to go in the wrong direction. I still find the term "stakeholders" to be cringeworthy. The only stakeholders as far as I am concerned are physicians, patients, and their families. 

 

Who are the real stakeholders when you are face to face with your patient and you are being coerced into doing something that is not in the patient's best interest? Where does the profession stand on this? For almost two decades now we have been complacent while insurance companies, government bureaucrats and politicians, and pharmaceutical companies have directly intruded on the physician-patient relationship in a way that has seriously impacted the resources available for patient care and the quality of that care.  The operative word is complacency. I still have a habit that I learned from my freshman English composition professor. I compulsively look up word definitions to make sure I am using them correctly. I think you develop a lot of insight into your changing knowledge base when you look up words that you think you know very well and find that they seem to have taken on more important meaning. For me complacency has become such a word. Looking it up in several dictionaries, the definition I like the best is: "self-satisfied and unaware of possible dangers". With few exceptions, that seems to be the position we have been in for the past 20 years.

I can't think of a better word to describe how physicians were duped into believing that an RVU based pay system would somehow result in better reimbursement for cognitive specialists. Or that coders could determine who was submitting correct billing based on documentation, much less committing fraud. Or that utilization review for inpatient stays and prior authorization for medications is a legitimate practice. Or that managed care com­panies and behavioral carveouts reduce health-care inflation. Or that the focus of psychiatric assessment and treatment involves the prescription of a pill in roughly the same time frame that an antibiotic could be prescribed for otitis media. The list of things that we've been complacent about is long and it is growing every day.

For those psychiatrists working in institutions, committees are often a starting point. Much of the time, committees and meet­ings focus on issues that are peripheral to patient care and quality care. They rarely focus on the actual practice environment for the psychiatrist and the patient. In many cases, the fatal flaw is that the people making the major decisions are not in the meetings. The meetings are frequently held to make it seem like physicians actually have input into what is going on. At times the physicians are prepared by someone telling them that the old days in medicine are dead. The implication is that physicians used to be all powerful, now they are not, and in fact they should expect to have the equivalent input of any other employee.

The strategies we have observed for dealing with a broad array of stakeholders at the table have all been inadequate. We have allowed stakeholders with clear conflicts of interest to suggest that we are more conflicted than they are. The only solution is to be clearly differentiated from everyone else. We are squarely focused on assessing and treating patients in an ethical manner and any political initiative that we endorse or participate in should be consistent with that focus.

What does this mean in a practical sense? First off, it means coming into a meeting with a clear position rather than showing up to broker a deal. It means prioritizing patient care over profits from rationing or political gain from rationing. It means pointing out that the physician-patient dyad is in no way equivalent to any other political agenda in the room. It means not signing off on the status quo when we are the only people in the room speaking to the interests of physicians and their patients.

The recent changes to the way that psychiatric care is delivered to the state's low-income population illustrate all of the problems. Patients with GAMC have significant psychiatric comorbidity, and, even prior to the cuts by Governor Pawlenty, were also subjected to more rationing by private and government payers than other patients. The ultimate change, in the form of Coordinated Care Delivery System (CCDS) clinics, takes this rationing to a whole new level. At the same time the state has attempted to reinvent the state hospital system. Both of these changes disproportionately affect patients with severe mental illness. Any rational analysis would show that these patients did not have enough treatment resources before the new rationing initiatives. A new approach is needed and I think that approach needs to be psychiatrists redesigning the system. That needs to happen through the MPS because we have psychiatrists with the knowledge and focus to accomplish this task. Rather than endorse a rationed and blended version designed by people who are not providing the care, psychiatrists need to articulate a clear statement of what public mental health should be like in the state of Minnesota.

 

George Dawson, MD, DFAPA

Tuesday, January 19, 2021

Are There Any Good Jobs Left for Psychiatrists?


I quit my job last Thursday night at about 9:30 PM.  My term of employment was officially over at the close of business today – Tuesday January 19, 2021.  It happened during an exchange of fairly terse emails with my immediate supervisors. Those emails occurred in the context of a flurry of daytime emails that were critical and could easily be interpreted as making me look as bad as possible.  I have no plans to disclose the nature of these conflicts or the content of those emails.  

I know from experience that responding to the content of these messages at face value and ignoring the meaning is a mistake that you can never recover from. It is also a mistake because it assumes that the people representing corporations have a genuine interest in you as a human being.  People – no matter how good they are – are always expendable to the modern corporation and there is no better example than healthcare companies. I also believe that because several of my previous supervisors said it directly to my face.

I was very clear in my email that the reason I was quitting was a decision that happened that day.  It is good to maintain clear boundaries when it comes to these decisions.  Sometimes there is a lot of emotion involved and when that happens a lot of charged rhetoric.  By the time 9:30 PM rolled around – I was very cool.  I had been in a heightened emotional state all day.  That tends to happen when people say things about me that are not true and try to make it seem like I am personality disordered.  By heightened emotional state I generally mean a hyperadrenergic state. Anxiety, stress, tachycardia rather than anger.  That distressed state resolved as soon as I realized the situation with the administrators was hopeless and all I had to do was quit.  As soon as that occurred, I was able to relax and fall asleep like nothing had happened.  A complete cessation of the emails was also helpful.

That decision in the last paragraph was very important to me.  As the son of a railroad engineer, I was socialized to be very wary of any special interest (whether it was a company or a union) that could affect your work or personal freedom. Being very clear on what you want to experience was all part of that socialization and at times it was fairly stark. There is a long learning curve.  I did not really become an expert at it until I walked away from a previous job 12 years ago. I thought I was going to work at that job my entire career and retire – much like my Dad viewed his railroad job.

I recall my father showing me the front of his Brotherhood of Locomotive Firemen and Engineers trade paper and angrily making the following statement: 

“Do you see this big house?  That is where the President of the Union Lives!  Do you think he cares about what happens to us?”  (Fairly certain my Dad would have probably used much more colorful language  but I don’t want to embellish).

Of course not, Dad.  I heard a radio program several years ago about first-generation white-collar workers from blue collar families.  According to the speaker, they were much less likely to integrate their business lives into their social lives.  The example given was that they would not invite their boss over for dinner.  But nobody stated the reason – and that is basic working-class distrust of management.  Second-generation white-collar workers may also have a much higher tolerance for bullshit than blue collar folks. In my family of origin, bullshit was not a humorous or value free word.  It was generally a pejorative.  

There is also the way you exist in the work place.  Some people need the social aspect at work for many reasons including reassurance that they are in good standing.  A lot of us like to keep our heads down, do the work, and not comment on all of the social behavior in the workplace.  We don’t want to hear about other peoples’ problems – not because we don’t care about our fellow man but because we were raised to mind your own business.  I am in the latter category and find that it works very well.  People I work with over time know they will be treated fairly and they know that I am very loyal to them.  That may be another reason why I react so strongly when people make things up about me.

The boundaries are significantly less clear in a white collar setting, especially with institutional rules and training on what constitutes civility. Unless you are fired precipitously and escorted out by security there are the superficial niceties – even if you are dying the death of a thousand cuts.  “Oh you’re leaving? We are sorry to see you go! Let’s have some cake in the break room! Don’t be a stranger!”  All the while stories are being spun about what happened to either make it seem like you were basically a jerk or you were never there in the first place. At a previous job I endured months of gaslighting and abuse.  At one point I asked my primary care doc for a prescription for a beta blocker just to control my heart rate and blood pressure from the stress. I joke about taking them like M&Ms, but at the time it was no joke.  That was not going to happen again.

When I think about the range of normal and pathological workplace dynamics I always come back to the work of the late Peter Drucker.  He was described as the world’s greatest management thinker.  One of his key concepts is the knowledge worker.  In other words, employees who were trained in a profession – in many cases an independent professional. Drucker pointed out that these employees need to be managed differently by virtue of the fact that they know more about the business than their boss does.  Further that they are not managed for widget production as productivity.  In the current healthcare environment, the most highly trained employees are physicians. They are treated like production workers and clerical workers rather than knowledge workers and in many cases replaced en masse by other workers who can do some of what they do.  As an example, I recently did a search through my health care system looking for a primary care internist in the event that my current internist retires.  The search pulled up 50 practitioners and only 2 were physicians.  The way health care systems deal with knowledge workers is to either get rid of them or ration them.  All part of the unending death spiral of low-quality care in America.

One of the big human-interest stories of the pandemic is that medical school applications are apparently way up.  The reason given is the presence of Anthony Fauci, MD in the news.  In all of these clips, only a tiny fraction of Dr. Fauci’s expertise and body of work is visible but his demeanor and consistent references to science make him easy to identify with. He is a physician that others want to emulate.  The problem for all of these prospective medical students is that there are very few places any more where a physician can practice at the top of what they were trained to do.  There are practically no physician environments that maintain an academic focus that was common in every setting that I trained at in the 1980s.

Apart from the workplace politics and all of the completely unnecessary stress it produces my immediate consideration is finding a new job.  I do not need to work. I could simply retire.  When I was working a burnout inpatient job – I fantasized about retiring early just to escape the place.  Since then, I have concluded that I am still at the top of my game and have an excellent skillset to offer people with significant psychiatric problems.  These services are clearly needed. In addition, I have a unique approach to psychiatry that I think needs to be out there to counter the low-quality checklist approach that has very little to do with psychiatry.  The problem is finding the ideal environment to utilize that skill set.  The figure below gives an example of the practice environments that I have worked in and whether my skill set was utilized or marginalized.

 


Drawing on that experience whether I get another job at this point or retire depends on the following factors:

1:  Malpractice coverage: I could easily set up a private practice in the era of telepsychiatry but any psychiatrist planning to retire at some point needs tail coverage.  That is malpractice insurance through the statute of limitations for malpractice in the state you practice in.  In Minnesota that is three years and would costs tens of thousands of dollars.  That’s right - three years paying out a good deal of money on the hypothetical that you might be sued during that time – whether you have previously been sued or not.

2:  Practice environment:  The graphic below shows how badly the practice environment has deteriorated with the invention of managed care, pharmacy benefit managers, and an expensive labor-intensive electronic health record (EHR).  That means I have a choice again between setting up my own office, hiring staff, buying and setting up and EHR or going to work for a managed care company who has all of this but expects me to become a template monkey and fill out 20-30 patient visit templates per day.  I use the term template monkey out of respect for one of my colleagues who is a proceduralist and told me at lunch one day that is what she had become.  She presented it as a joke, but it is a fairly depressing self-observation from one of the most highly trained MDs in the profession and the hours it takes her to complete arbitrary forms that have nothing to do with quality medical care.



While I am at it my inpatient and outpatient workflow is 30 minutes per patient follow up and 60-90 minutes for initial evaluations with some time in between for documentation and coordination of care.  That coordination of care typically involves acquiring and reviewing records and speaking to the patient’s treating physicians.  I also need to be able to dictate all of the notes rather than type them in to a template. I have yet to see dictation software work seamlessly enough, but I have seen transcription companies with industrialized versions do excellent job for a very low price. I need help from clerical resources, I don’t need to become a clerical worker.  

3:  Availability of necessary equipment, tests, and specialists:  For 22 years I worked in a very collegial environment that was full of medical and surgical consultants. I knew all of them and they knew me.  There was mutual respect and plenty of information exchange.  We consulted informally at lunch.  If I had a patient with complex problems – I would just do the evaluation, order all of the tests, make a diagnosis and then call a consultant if necessary.  I have not been in that environment for a while and I am not used to leaving things hanging and depending that people will follow my advice and see a cardiologist.  In fact, I know that people rarely follow through.  Anyone who suggests that you can just kick the can down the road, doesn’t really understand the practice of medicine or psychiatry.  In order to offer treatment, I need to determine that the patient does not have serious underlying illness and that I am not making any pre-existing conditions worse.   So, I need a medically intensive environment.  I thought I could do without it but that was a big mistake.

Apart from my current situation, this is a problem across the entire country.  Medically trained psychiatrists and neuropsychiatrists are unable to find suitable practice environments.  Managed care companies are quick to offer appointments with any prescriber for anxiety and depression or even more complicated problems. This is a system wide problem even though there is no organized system of mental health care in the country.  If I get lucky and find the resources I need – the system will be lucky – at least in the geographic area where I can serve patients.  It is a basic fact that the necessary practice environment for most medically intensive psychiatrists has become a fantasy in the United States.  That fantasy could easily be remedied by a national work force supplying psychiatrists with what they need and paying them as employees.

If I am not fortunate enough to find the right practice environment – I will be enjoying retirement and to me a lot of that will still be studying psychiatry, medicine, and science.  It is what I do and I enjoy doing it.

Old patterns of behavior die hard – at least for me.

George Dawson, MD, DFAPA



Supplementary 1:

My official last day was the close of business on Tuesday January 19 and that is why this is being posted later that same day.

 Supplementary 2:

I do wish my fellow former employees the very best (including the administrators) and hope that everything goes well for them.  After I announced my resignation, I received at least 50 very positive emails telling me that they liked working with me and wishing me well in the future.  In many cases they were extremely complimentary. We all worked together to help people solve very difficult problems in a highly constrained environment. We were typically successful to some degree. For all of the compliments all that I can say is thank you and:

“The light that shines on me – shines on you”.

 

 

 


Monday, September 7, 2020

Happy Labor Day 2020




Over the years that I have been writing this blog - I have written a Labor Day greeting to my physician colleagues generally documenting the lack of progress on the work environment. This posts range from discussions about the importance of knowledge workers and their characteristics to how physicians are treated. The most important one of those characteristics is that they cannot be treated like production workers. That is of course the way most physicians are treated these days and it is not a new development. Another important dimension has been the intrusion of business interests on the physician-patient relationship. Those business interests rationed the level of care in order to make corporate profits and prevented physicians from providing the best possible care. All of these intrusions happen across the board but my particular specialty is affected more than others. I learned just this year that when managed-care companies decided to target psychiatry 30 years ago, their goal was double their stock price. No access or quality goal - just more money in the pockets of shareholders and company officials. The end result has been a seriously eroded practice environment, decreased access, County jails being used as psychiatric hospitals, lack of availability of substance use treatment and detoxification, and very brief hospital stays where hardly any treatment is provided or the patient ends up being committed and staying far too long on a short stay unit that almost resembles a jail. None of this is good news for laboring physicians and none of it is changing. 

There was one recent bright spot. The headline in Psychiatric News on August 21 announced that the APA Presidential Task Force on Assessment of Psychiatric Bed Needs in the United States had been created by Jeffrey Geller, MD, MPH the president of the APA. Dr. Geller correctly identified a current “public mental health crisis” but he failed to describe its chronicity. There are apparently 30 members on this task force and they will be delivering a white paper in December that “includes a workable model for determining hospital bed needs within a community that can be refined and updated over time”. There are six subgroups including a modeling subgroup. There is a panel describing “how we got here” and stating “inpatient care falls prey to economic forces, ideology”. Nowhere in the article did I see the words “managed-care”. Instead - I see a number of managed-care friendly quotes especially from the panel. The APA has a long history of task forces and boards with so many conflicts of interest that either nothing gets done or something gets done that is in direct opposition to the needs of clinical psychiatrists who go to work every day and typically have to tolerate a very difficult work environment. 

I have written about how other groups have assessed the bed problem. An obvious but innovative way is to look at the beds necessary to prevent committed patients from staying long periods of time in acute care hospitals, the beds necessary to prevent emergency department bottlenecks, and beds necessary to prevent patients with obvious severe mental illness from being incarcerated for minor offenses. Another obvious deficiency in practically all cities is treatment for substance use problems. We need acute detox and people are often sent to a nonmedical detox unit until they develop medical complications. Adequate environments to accomplish all these tasks are needed and support the physicians doing it are critical. I will be interested in the eventual white paper but considering the APA track record against 30 years of managed-care, utilization review, and prior authorization I am not optimistic at all. 

I can’t let this catastrophic year slide without commenting on telepsychiatry. As readers can tell from my previous posts I am fairly enthusiastic about it even though I do prefer talking to people in person. I also take my own vital signs and do brief examinations as necessary and that just can’t happen over a computer network. I suppose there are people who have much better integration with the EHR, clinical systems, and electronic prescribing than my current system and I think that is where hope lies. I have three state-of-the-art computers that are much faster than medical software I am using. There are still plenty of glitches and communication problems that need to be solved but I am hopeful that they eventually will be. There is an associated regulatory burden and that is a wildcard when the pandemic recedes. Specifically will there be a rollback and telemedicine and less development. I am hopeful that better systems and more integrated systems will evolve to the point that there are no delays and the physician work environment is much more seamless. Like most things that physicians deal with we still have to dedicate our time to support software that is supposed to be supporting us. 

The tide has turned on the burnout industry. I am seeing more and more colleagues not accepting blame for their burnout. Burnout is not a yoga or meditation deficiency. It is a direct product of an inadequate and at times hostile work environment. The pandemic highlighted many deficiencies and many questionable administrative decisions. Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) - still loom largely in the background. Dr. Geller has apparently stated one of his goals is to get rid of MOC but I will believe it when I see it. I recently read a document that the APA gets to million-dollar year payment from the American Board of Psychiatry and Neurology (ABPN) - the MOC body. That is a significant conflict of interest from the membership perspective. The ABPN is currently collecting $500/yr from all of its certification holders in additional to fees necessary to access required reading. If 30,000 psychiatrists are paying these fees every year, that exercise generates $150M for the ABPN very ten years. There is no evidence anywhere that investing this significant time and effort produces a superior psychiatrist. The ABPN response is” “The public demands it!” In fact, the public still doesn’t know the difference between a psychiatrist, psychologist, or nurse practitioner. Burnout will end when physicians can stop doing the work of billing and coding specialists, typists and other clerical workers, IT workers, and surrogate employees of pharmaceutical benefit managers and managed care companies. No physician can be expected to do all of that additional work and work a full time stressful job. That is the real unstated problem of burnout. 




 Is there a high ground left for psychiatrists? I have often closed a post with the statement that: “Psychiatry needs to be focused on innovation and the future. The best position to be in is looking at everyone else in the rearview mirror?” Is there still a way to do that? I think that there is. A survey of many of my posts on this blog focus on what is really irrelevant criticism from the past. I have lived through the era of the biological psychiatrists versus the psychotherapists. I have lived through the era of brainless versus mindless psychiatry. I have survived the Decade of the Brain. It seems that both our detractors and internal critics tend to focus on false dichotomies or irrelevant history from the past. The way forward is to stay focused on modern theories and forget about the rest. 

 What will that take? I would suggest – a firm shift to an all-encompassing view of the field that makes us more resistance to petty criticism but at the same time more focused. When I say focused -  on clinical care, research, and theory. We have at least two models of that as elaborated by S. Nassir Ghaemi (1) and others. The most modern all-encompassing theory comes from Kandel as interpreted by Ghaemi (1). In his book, Ghaemi makes a compelling argument for pluralism as the defining approach in psychiatry over eclecticism and the biopsychosocial model of Engel. Pluralism essentially means that multiple methods are necessary to treat mental illness and that there are no single methods that will work. He cites several traditional theories in psychiatry about how to diagnose and treat mental illness as well as the theorist who suggest more than one approach is necessary. He provides a checklist (p. 308) to determine if you might be a pluralist. It contains questions like: “Can you accept the absence of a single overarching theory in psychiatry, yet also reject relativism and eclecticism?” Thinking about that question I don’t know why psychiatry would be different from the rest of medicine. Is there a single overarching theory in medicine? Why would we expect to see it in the most complex organ in the body? He is clear that he sees psychiatry stuck at the point of dogmatism and eclecticism.

He describes integrationism as an approach that removes the barrier between the mind and the brain as opposed to pluralists believing that there may be some differences between the mind and the brain. Integrationists believe that the brain is required for mental phenomenon but not sufficient. The brain can affect mental phenomena and mental phenomena can affect the brain. It is reminiscent of emergent properties that consciousness theorists tend to talk about. Stochastic factors or genetic factors in the brain that randomize expected behavioral outcomes may also prove to be important at some point. Ghaemi outlines a 5 principle integrationist model of psychiatry that looks at all mental processes/mental disorders being derived from the brain, the effect of genetic and environmental factors on the brain and these processes, and the effect of both biological and psychological treatment affecting the brain through mechanisms of brain change. 

 Although this all sounds fairly basic at this time – it is not. The discovery of brain plasticity or experience dependent changes in the brain was a major revolution in seeing the brain as a dynamic organ that could be altered easily by practicing the violin or lifting weights or talking to a therapist. There are ways to measure these changes. Everyone trained as a physician and a psychiatrist – sees the effects of structural changes in the brain from observing the effects of trauma, various brain diseases, and global brain dysfunction. An integrationist approach is practically intuitive but the model is not widely taught as the basis for clinical work. With that model there would be more uniformity in clinical approaches to the patient and standardization of clinical care. Patients could expect more than just a discussion of medication for example. They could expect psychotherapeutic discussions along with the medication and possibly more time and more visits with their psychiatrist. Instead of the rare research paper discussing this type of session – exchanges about it and innovation would be commonplace. It would also help to establish the necessary environment (physical, administrative support) for this kind of work to be done. 

Labor Day is a reminder for me that where we labor and what we can do for our patients is meaningful. A better work model might help that irrespective of political success in changing the system or not. The work model itself can also be invigorating if it includes elements of clinical work and basic science and helps us to make continuous sense of what we are seeing and expected to treat. 

George Dawson, MD, DFAPA

References: 

1.  S. Nassir Ghaemi. Concepts of Psychiatry – A Pluralistic Approach to the Mind and Mental Illness. The Johns Hopkins University Press. Baltimore; 2003. 

Graphic Reference: 

Carpenter, F. G. (ca. 1920) Paris, France. France Paris, ca. 1920. [Photograph] Retrieved from the Library of Congress, https://www.loc.gov/item/2001705736/. No known copyright restrictions.


Thursday, June 29, 2017

Ophthalmology versus Psychiatry Part 2.




Spoiler Alert: Ophthalmology always wins!

I was driving home last Friday night and for several minutes it seemed like there was a bug in my right eye.  I did the upper lid over lower lid trick a couple of times and that didn't work so I pulled over and tried to rinse it out with artificial tears.  No change at all with that maneuver and then I started to see familiar floaters and small black dots in my visual field but only on the right.  I had the exact same symptoms a year ago that led to a diagnosis of a vitreous detachment with no retinal problems.  Later that night I started to see flashing halos in the upper right visual field.  I got in to see an optometrist through my health plan and was referred immediately to a vitreous and retinal specialist today.  At a about 2PM today, I had a laser surgery procedure to fix a small retinal tear in the periphery of my right retina.

The specialist explained pathophysiology, the rationale and the expected success rate.  There is age-dependent liquefaction of the vitreous humor and in that process it can pull away from the retina.  That process can be benign like it was for me a year ago or it can lead to a "traction-event" on the retina and cause a tear.  The main reason for the laser surgery is to spot weld the tear by forming a photcoagulation scar where the laser hits and prevent a more extensive tear that could require open surgery of the eye and the risk of infection and further vision loss.  The decision for the laser surgery was an easy one, especially because I have known many people who required variations of the open surgery.  I sat in an ophthalmology exam chair with my head in a fixed position.  This video illustrates the exact procedure that I underwent today.  The laser light was green and at the end of the procedure I was completely blind in the eye for about 10 minutes and then transitioned to a violet vision and then back to normal.  This phenomenon is cause by saturation of the photoreceptors by laser light.  The procedure I underwent was much faster with repeated pulses of the laser.  If I had to estimate, I would say about 150-200 pulses of light were used.  The specialist kept me posted: "30% done.... 50% done, etc)" and also coached me on how I was doing focused on the extreme limits of my visual field.    

I had some observations about ophthalmology and orthopedic surgery last year and this year is no different.  First, I am amazed at how many of these vitreous retina specialists exist across the country.  Given my previous estimate of the total number of ophthalmologists and the numbers of people that they treat,  the distribution must be very good across the country.  Their services are certainly in demand.  Retinal and vitreous disease is clearly an age related problem.  There were 15 people in the waiting area and there was one person younger than me.  Most were considerably older and many were there to get injections to slow the progression of macular degeneration.

I am no stranger to ophthalmologists.  When I was in the 8th grade I shot myself in the eye with a BB gun and have had appointments every year to follow up on that injury.  That has also allowed me to follow the way that ophthalmologists practice.  Back in the 1960 to 1980s they did everything.  They started out with visual acuity tests, then visual fields, the intracranial pressure by tonometry and eventually the slit lamp approach.  They did the entire refraction and tried to get the visual acuity as good as possible. They proceeded to the slit lamp exam and at some point started doing retinal exams using hand held lenses and lens in conjunction with the slit lamp.  If an ophthalmologist was really flying and had a patient who was able to  cooperate - it might be possible to get all of this done in 20-25 minutes.

Things have changed drastically since that time.  I was roomed by a medical assistant who recorded the history and  took my vital signs.  In Room 2, I saw another medical assistant who took additional history, cursory social and family history (only eye diseases and diabetes in parents and siblings) and a cursory review of systems (have you had a heart attack or stroke? do you have chest pain today?).  She did visual acuity, visual fields by confrontation, and ocular motility and recorded it in the chart.  She did a slit lamp exam.  She measured intraocular pressure by some kind of digital hand held tonometer that I had never seen before.  She got my eyeglass prescription off the new lenses and did not need to do a refraction.  In Room 3, I was introduced to a scribe who told me that she would be taking notes for the specialist.  She set up twin displays with the EHR spread across.  The specialist walked in and performed indirect ophthalmoscopy by both slit lamp and standing hand held lenses.  He told me that I had a retinal tear and we discussed the surgery.  The scribe reminded him how it needed to be worded in the chart and how she was going to record it.  I electronically signed the consent form.  In Room 4, I saw a person who only did retinal scans with a blue light.  Finally in Room 5, the laser procedure was done.

This was a significant display of efficiency in terms of division of labor with a sole focus on problems related to the eye.  The social history is not that important in this case - they were only interested in marital status, offspring, and occupation.  They were not really interested in a review of systems other than a more detailed review of ocular symptoms - including my history of the BB gun injury.  They efficiently proceeded to laser my torn retina (at about the 45 minutes mark) and if the quoted statistics were correct - greatly reduce the likelihood or a major retinal tear and the need to open surgery or in the very worst case partial or complete blindness.      

Unfortunately in psychiatry we have nothing like this.  I am still doing what I have done for the past 30 years - an obsessive 240 plus point interview that included a detailed history.  My medical history, review of systems, social and family histories are all comprehensive and customized for the situation.  If I want vital signs or some examination - I have to do it myself.  In some clinics I can get checklists - but despite all of the hype about collaborative care or measurement based psychiatry those rating scales are a poor excuse for detailed questions about the problem.  The people who believe they are actually using quantitative metrics to measure care with these scales are fooling themselves.  In order to make up for the stunning lack of efficiency in psychiatric practice we have the workarounds of more and more prescribers - all asking their own questions and making their own diagnoses or we have the collaborative care psychiatrist advising primary care physicians on how to treat their patients based on rating scale scores or the questions of those physicians.

The other limiting factor is the lack of value assigned to the psychiatric evaluation.  I have not seen the bill for laser eye surgery - but I can speculate that it will be many times what I am paid for a comprehensive evaluation in roughly the same period of time that it took to diagnose and repair my retinal tear.  With the division of labor, the ophthalmologist was seeing 7-8 times as many patients in an hour than I can see.

To me that is both the most positive aspect of clinical psychiatry, but also its downfall.  Psychiatry is too complicated to commoditize.  Don't get me wrong - it happens all of the time.  Very few psychiatrists who are not in private practice have the luxury of talking with people for an hour.  That makes patient experiences highly variable.  We have to find a model that takes us out of the 1970s but also provides more clear cut results.  Ophthalmology has clearly been able to do that.  Science and treatment in medicine is better with precise measurement.  There is nothing about rating scales that I would call precise.

With my retina and vitreous problems I have come to another conclusion.  Training in Geriatric Psychiatry is designed to increase sensitivity to ageism and and biases against the elderly.  I have had plenty of that training.  Now that I am technically a geriatric person myself, I can speak with authority -  aging is an inescapable disease.  I hope someday there is a better solution.

But that is a topic for another post.



George Dawson, MD, DFAPA        





















  

Monday, September 15, 2014

Will The Real Neuropsychiatrists Please Stand Up?

Recent dilemma - one of several people around the state who consult with me on tough cases called looking for a neuropsychiatrist.  He had called earlier and I advised him what he might discuss with the patient's primary care physicians that might be relevant.  I suggested a test that turned up positive and in and of itself could account for the subacute cognitive and behavioral changes being observed by many people who know the patient well.  I got a call back today requesting referral to a neuropsychiatrist and responded that I don't really know of any.  I consider myself to be a neuropsychiatrist but do not know of other psychiatrists who practice in the same way.   There is one neuropsychiatrist who practices at the state hospital and is restricted to seeing those inpatients.  There is one who sees primarily developmentally disabled persons with significant psychiatric comorbidity.  There are several who practice strictly geriatric psychiatry.  One of the purposes of this post is to see if there are any neuropsychiatrists in Minnesota.  My current employment situation precludes me from seeing any neuropsychiatry referrals.

Neuropsychiatry is a frequently used term that is the subject of books and papers.  Several prominent psychiatrists were identified as neuropsychiatrists.  I went back to an anniversary celebration for the University of Wisconsin Department of Psychiatry and learned that early on it was a department of neuropsychiatry.  It turns out that the Department of Neuropsychiatry was established in 1925 and in 1956 it was divided into separate departments of Psychiatry and Neurology.  One of the key questions is whether neuropsychiatry is an historical term or whether it has applications today.  The literature of the field would suggest that there is applicability with several texts using the term in their titles, but many don't even mention the word psychiatry.  As an example, a partial stack from my library:



A Google Search shows hits for Neuropsychiatry and basically flat during a time when Neuroscience has taken off.  Both of them are dwarfed by Psychoanalysis, but much of the psychoanalytical writing has nothing to do with psychiatry or medicine.






What does it mean to practice neuropsychiatry?  Neuropsychiatrists practice in a number of settings.  For years I ran a Geriatric Psychiatry and Memory Disorder Clinic.  Inpatient psychiatry in both acute care and long term hospitals can also be practice settings for neuropsychiatrists.  The critical factor in any setting is whether there are systems in place that allow for the comprehensive assessment and treatment of patients.   By comprehensive assessment,  I mean a physician who is interested and capable of finding out what is wrong with a person's brain.  In today's managed care world a patient could present with seizures, acute mental status changes, delirium, and acute psychiatric symptoms and find that they are treated for an acute problem and discharged in a few days - often without seeing a neurologist or a psychiatrist.  There may be no good explanations for what happened.  The discharge plan may be that the patient is supposed to follow up in an outpatient setting to get those answers.  That certainly is possible, but a significant number of people fall through the cracks.  There are also a significant number of people who never get an answer and a significant number who should never had been discharged in the first place.

Who are the people who might benefit from neuropsychiatric assessment?  Anyone with a complex behavioral disorder that has resulted from a neurological illness or injury.  That can include people with a previous severe psychiatric disability who have acquired the neurological illness.  It can also include people with congenital neurological illnesses or injuries.  One of the key questions early on in some of these processes is whether they are potentially reversible and what can be done in the interim.  Some of the best examples I can think of involve neuropsychiatrists who have remained available to these patients over time to provide ongoing consultation and treatment recommendations.  In some cases they have assumed care in order to prevent the patient from receiving unnecessary care form other treatment providers.  Aggression is a problem of interest in many people with neurological illness because it often leads to destabilization of housing options and results in a person being placed in very suboptimal housing.  Treatment can often reverse that trend or result in a trained and informed staff that can design non-medical interventions to reduce aggression.

What is a reasonable definition?  According to the American Neuropsychiatric Association neuropsychiatry is "the integrated study of psychiatric and neurologic disorders".   Their definition goes on to point out that specific training is not necessary, that there is a significant overlap with behavioral neurology and that neuropsychiatry can be practiced if one seeks "understanding of the neurological bases of psychiatric disorders, the psychiatric manifestations of neurological disorders, and/or the evaluation and care of persons with neurologically based behavioral disturbances."  That is both a reasonable definition and a central problem.  In clinical psychiatry for example, if a patient with bipolar disorder has a significant stroke what happens to their overall plan of care from a psychiatric perspective? In many if not most cases, the treatment for bipolar disorder is disrupted leading to a prolonged period of disability and destabilization.  Neuropsychiatrists and behavioral neurologists practice at the margins of clinical practice.  That is not predicated on the importance of the area, but the business aspects of medicine today.  If psychiatry and neurology departments are established around a specific encounter and code, frequent outliers are not easily tolerated.  Patients with either neuropsychiatric problems or problems in behavioral neurology can quickly become outliers due to the need to order and review larger volumes of tests, collect greater amounts of collateral information, and analyze separate problems.  In any managed clinic, the average visit is typically focused on one problem.  Neuropsychiatric patients often have associated communication, movement, cognitive and gross neurological problems.  Some of these problems may need to be addressed on an acute or semi-acute basis.

Where are they in the state?  Neuropsychiatrists are probably located in areas outside of typical clinics.  By typical clinics I mean those that are outside of the HMO and managed care sphere.   They can be identified as clinics that are managed by physicians rather than MBAs.  The three largest that come to mind are the Mayo Clinic, the Cleveland Clinic, and the Marshfield Clinic.  Apart from those clinics there are many free standing neurology and fewer free standing neuropsychiatric clinics.  Speciality designations in geriatric psychiatry or neurology, dementias, developmental disorders, and other conditions that overlap psychiatry and neurology are good signs.  There will also be psychiatrists in institutional and correctional settings with a lot of experience in treating difficult to treat neuropsychiatric problems.  There may be a way to commoditize this knowledge and get it out to a broader audience.  Since starting this blog I have pointed out the innovative pan in place thought the University of Wisconsin and the Wisconsin Alzheimer's Institute (WAI) network of clinics.  They have impressive coverage throughout the state and provide a model for how at least one aspect of neuropsychiatry can be made widely available through collaboration with an academic program.      

What should the profession be doing about it?  The American Psychiatric Association (APA) and just about every other medical professional organization has been captive to "cost effective" rhetoric.  IN psychiatry  that comes down to access to 20 minutes of "medication management" versus comprehensive assessment of a physician who knows the neurology and medicine and how it affects the brain.  The new hype about collaborative care takes the psychiatrist out of the loop entirely.  The WAI protocol specifies the time and resource commitment necessary to run a clinic that does neuropsychiatric assessments.  I have first hand experience with the cost effective argument because my clinic was shut down for that reason.  We adhered to the WAI protocol.

What the APA and other medical professional organizations seems to not get is that if you teach people competencies in training, it is basically a futile exercise unless they can translate that into a practice setting.  The WAI protocol provides evidence of the time and resource commitment necessary to support neuropsychiatrists.   It is time to take a stand and point out that a psychiatric assessment, especially if it has a neuropsychiatric  component takes more than a 5 minute checklist and treatment based on a score.  A closely related concept is that total time spent does not necessarily equate with the correct or a useful diagnosis.  I have assessed and treated people who have had 4 hours of neuropsychological testing and that did not result in a correct diagnosis.

If those changes occurred, I might be able to advise people who ask that there are more than two neuropsychiatrists in the state.

George Dawson, MD, DFAPA

1: Benjamin S, Travis MJ, Cooper JJ, Dickey CC, Reardon CL. Neuropsychiatry and neuroscience education of psychiatry trainees: attitudes and barriers. Acad Psychiatry. 2014 Apr;38(2):135-40. doi: 10.1007/s40596-014-0051-9. Epub 2014 Mar 19. PubMed PMID: 24643397.

Monday, September 1, 2014

Happy Labor Day III

This is the third Labor Day of this blog.  I usually take the opportunity to mark the lack of progress in the physician work environment and this year is not much different.  All of the usual corporate and government buzzwords being promoted to suggest why physicians need to be managed by somebody who knows nothing about medicine.  All of the hype about computerization and how the grossly overpriced electronic health record will save us all, even as the printout from that record looks less and less coherent.  I just read a copy of The Institute from the IEEE on Big Data.  From that report:

"It's is estimated that the health care industry could save billions by using big-data health analytics to mine the treasure trove of information in electronic health records, insurance claims, prescription orders, clinical studies, government reports, and laboratory results.

Analytics could be used to systematically review clinical data so that treatment decisions could be based on the best available data instead of on physicians' judgment alone...."

The state of current electronic health records as the worst value in the information technology sector is is probably not too surprising given the above observations or the following:

"Instead of seeing only 20 patients a day, doctors are able to see 75 to 100 people and get ahead of the wave..."

I don't know what kind of doctor sees 75-100 patients a day or what the quality of these visits is, but I have never met a physician who wanted to see that many people in a day and wonder if it would not trip a billing fraud flag somewhere in the CMS data base.  I have talked with many physicians who were overwhelmed by coming into the office and having 200 tests to review and sign an additional 30-50 orders in addition to seeing 20 patients that day.  We are decades away from any machine intelligence being incorporated into the medical record.  The current EHR has destroyed the narrative, especially in psychiatry and converted the basis of care to a checklist.  Instead of higher order machine assisted decision making the electronic health record has not resulted in the expected savings or utilization of technology.  Paying tens of millions of dollars in licensing fees per year and larger IT departments with thousands of PCs running 24/7 to access the sever farm has not produced a nickel of savings and has added large recurring costs.

So I have not noticed any striking improvements in the practice environment.  At the same time, it is at such a low level that it is difficult for me to say that it has deteriorated any further.  The American Psychiatric Association (APA) the largest professional organization for psychiatrists still supports collaborative care - a managed care model of psychiatric care that in some cases eliminates any direct access to psychiatrists.  The American Medical Association also seems managed care friendly largely due to their support of the PPACA.  Both organizations support the onerous recertification process mandated by the American Board of Medical Specialties.

The only bright spot I can think of this year was being seated at the same table with 3 younger colleagues at at a Minnesota Psychiatric Society CME event.  They had all been practicing for 10 years or less.  They were all in private practice to one degree or another.  They were all women and although I haven't seen it studied I think that women may have a greater skill level (at least relative to men of my generation) in setting up and managing a private practice.  I was quite interested in their experiences and they listed all of the positives.  The overwhelming positive that I took away from that meeting was that their practice environment was very positive because they ran it and had eliminated all of the toxic administrators along the way who were supposed to manage them.  They did not have to tolerate the notion that just because they were an employee that they suddenly needed supervision from somebody who was not qualified to supervise them.  Near the end of our conversation they tried to talk me into going into private practice myself.  I have always been an employee, but my current vocational trajectory has been predicated on fleeing toxic administrators.  I gave the usual excuses about being one bad cold away from retirement and an old dog not being able to learn new tricks.

If I was starting out today - I would only be working for myself and I would try to design the practice to reflect my interests in neuropsychiatry and severe mental illnesses.   Any resident reading this should consider this career path.  The decision may be as easy as contemplating seeing 75-100 patients a day and meeting with an administrator who suggests that you could see more.

Happy Labor Day to any physician reading this whether you are in private practice or on the assembly line in a clinic or hospital somewhere.  And good luck to physicians everywhere in avoiding unnecessary administration.


George Dawson, MD, DFAPA

Kathy Pretz.  Better Health Care Through Data.  The Institute September 2014.  p 6 - 7.

Tuesday, August 26, 2014

Psychiatrists Implicitly Asked To Fill In Large Gaps

I didn't realize this until relatively late in my career and it has been interesting to counsel several younger colleagues about not making the same mistakes.  Psychiatrists are continuously called upon to make up for significant deficiencies in the system.  Any one of these gaps can lead to a crisis situation that the psychiatrist has to address immediately or lapses in the quality of care.  In the extreme case they can render care impossible.  Many of these deficiencies also require a considerable time commitment by the psychiatrist.  That time is usually not compensated and often takes valuable time away from spouse and family.  The deficiencies are the direct result of rationing resources and not having enough resources available.  Another variation is that some of the staffing personnel available have no training or experience in how to assess and treat mental health problems or even discuss problems with psychiatric patients.  There are many people who are assigned to that role and I am convinced they make things worse rather than better.

Community mental health centers are often places where the deficiencies exist.   They depend on government funding sources and the bureaucracy involved with some of these sources is only exceeded by the lack of adequate funding.  In many places, the managed care model is adapted and that means that nearly all patient concerns are translated into medication complaints of the form "I am having problems because I am not taking enough medication(s)."  Frequently the patients adapt to saying the same thing.  Any astute psychiatrist walking into this setting may see all of the usual markers including most drugs being prescribed at or above the manufacturers suggested maximum dose, far too many benzodiazepine and sedative hypnotic prescriptions, drugs being prescribed for questionable indications, medications being prescribed for a condition that should be treated first with psychotherapy (and the affected patients never received that therapy), and a lot of medications being prescribed to patients who clearly have a substance use problem.   There is generally a lackadaisical approach taken to the medical side of monitoring the patients including no monitoring or intervention for the metabolic side effects of medication, no attention to drug interactions, and no diagnosis and treatment of the neurological effects of medication.  Psychiatric practice is simplified to a contracted practitioner prescribing medications for a broad array of problems.  In many cases staff from the mental health center will call that practitioner when they are not on site and the request and/or response will be an increase in medication dose or a new prescription for medications.

Inpatient psychiatric units tend to attract psychiatrists with a lot of medical expertise and an interest in those matters.   The first problem is often a lack of medical services in terms of consultants or the necessary hardware.  Unless there are medical consultants and a clear delineation of responsibilities this may result in a significant additional time commitment to psychiatrists.  Thinking of admissions, the first step is who does the history and physical.  After a comprehensive psychiatric assessment it might only take an 20 minutes to do a medical review of systems and physical exam.  Depending of the medical complexity of the patients it may take an additional hour or two.  The second point is what is now called medication reconciliation.   That means that all of the medications the patient taking for medical and psychiatric purposes.  That is very easy in the case of one medication.  It is not so easy when a patient cannot accurately report their medications or they are taking up to 20 medications.  Those medication may include several apiece for chronic medical conditions like hypertension and diabetes mellitus.  There are also decisions that need to be made about which medications can be restarted and which medications need to be acutely discontinued.   That can lead to hours of time for an admission procedure that in a typical system of care is supposed to take an hour or less.  There is a strong incentive for administrators to have the same physician cover both the medical and psychiatric side of inpatient treatment.  It is far more cost effective for medical consultants to see patients elsewhere in the hospital.   Young psychiatrists wanting to do both jobs should be aware of the fact that most places would be more than willing to have you commit that kind of time.

Other residential settings can lead to problems similar to inpatient psychiatric units, but tend to be less intense on the admission side.  In many cases psychiatrists are consultants to a number of facilities like corrections, drug and alcohol treatment facilities, and nursing homes.  All of these settings present unique challenges to rational psychiatric care ranging from subtle to more obvious.  In many cases the obvious problems seem to escape notice by many of the people in charge today who have no clinical training.

An example of some of the most subtle but disruptive problems are the psychodynamics of treating groups of people in an environment with a significant number of treatment staff.  In that setting some of the characteristic psychodynamics of people with personality disorders occurs and leads to significant problems.  A  couple of good examples include staff splitting and projective identification and I will deal with these defense mechanisms extensively in a second post.  In this post I will give a hypothetical example of how disruptive these defenses can be in a staff and an administration that is poorly set up to deal with them.

Consider Dr. A. a seasoned inpatient psychiatrist with many years of experience.  Dr. A is highly regarded by the inpatient staff and her colleagues, but not so by administrators in her department.  With administrators, she is regarded as having a length of stay that is too long, because she refuses to discharge patients with inadequate evaluations or evidence that they will not be able to adequately function.  She has had several meetings with department administrators on this subject but stands her ground on what she sees as professional standards as opposed to managed care guidelines.   Nevertheless, she does feel the pressure from the administrators and does end up discharging a young man to a group home.  He has difficult to treat bipolar disorder and diabetes mellitus Type II and she made the difficult decision to treat him with an atypical antipsychotic despite the metabolic warnings for this class of medication.  He did not have all of the markers of adequate progress for discharge that she likes to see but he was sleeping well and no longer grandiose.  

The patient in question is discharged and returned in 3 weeks.  He is agitated and manic.  Dr. A notes that the patient saw a practitioner in the time he was out of the hospital and the dose of medication was cut in half.  That acute dose reduction was associated with the recurrence of manic symptoms.  Dr. A ordered the full dose of the medication and to contain the patient also ordered 1:1 staffing to redirect him from conflicts with other patients.  There was a hospital wide initiative to reduce the amount of 1:1 observation time.  On of the nursing staff suggests that the patient is getting special treatment because Dr. A has the "hots" for him.  The patient was regarded as attractive and referred to Dr. A as his "girlfriend".  None of the nursing staff notice that the staff person doing the 1:1 observation was verbally accused by the patient of stealing money from him during the previous hospital stay.  Part way through the shift the patient punches the staffer in the arm with a good amount of force.  The staff person is not injured, but an inquiry is held.

Dr. A walks into the inquiry and notices the administrators, some of them from the various disciplines on the unit.  The administration of disciplines in this hospital is in a silo manner like most hospitals with separate administration for physicians and nurses.  The question the group will consider is apparently the accusation by the nursing staff that Dr. A was prescribing an "inadequate" amount of antipsychotic drug even though the orders clearly show that the patient was given a dose that was beyond the maximum FDA recommended dose and the patient has diabetes - a reason for caution when using this class of drugs.  None of the staff in the room was aware of the previous confrontation that the patient had with the staff that was assaulted.  By making these points Dr. A seemed to be able to satisfy the requirements of the inquiry but suddenly out of left field, one of the nursing administrators suggested that Dr. A had a "communication problem" with the nurses and had in fact "ignored" one them.   The entire room of administrators seemed to be in agreement about this despite the fact that all of the nursing staff working that day had been interviewed an none of them had seen this pattern.

The final result was that the panel decided that Dr. A would meet with the inpatient director and the aggrieved nurse on a regular basis to focus on the "communication problem" that Dr. A allegedly had.

The case of Dr. A is an excellent example of staff splitting the resulting very negative outcome for Dr. A.  The reality of the decision is that Dr. A had done nothing wrong.  She is very competent and used to making tough decisions in impossible situations like the one described above.  Her professional competence includes neutrality toward patients and she has never acted in an inappropriate manner with any patient.  In this case the process results in her being treated like a novice and punished for something that never occurred.  All of this is the result of treating a patient with difficult problems, and a lack of understanding on the part of the staff and the administrators about what was happening in terms of interpersonal dynamics.  Dr. A ends up being scapegoated and her confidence in decision making is temporarily affected until she can put the pieces together and figure out what happened.  Watching how the key staff interact in similar situations in the future is also helpful. 

What gap occurred in the scapegoating of Dr. A?  The best psychodynamic hospitals have group meetings for staff to examine the dynamics especially in the treatment of patients with complicated problems or complicated developmental histories.  Most acute care hospitals have no team meetings at all.  The basic premise is that the wards are short term holding tanks until the medications kick in and the patients can be discharged.  These days the medications don't even have to kick in as patients are discharged with a significant amount of symptomatology.  There is no analysis or discussion of defense mechanisms and projection that results in threatening behavior is generally handled as an acute psychotic symptom with medication.  I have really never seen any hospital administration recognize that this is a shocking deficiency and in many cases the splitting is worsened by administrative maneuvers.  Having an administrator with no clinical training  dictate how complicated patients with aggressive behavior are handled is a great example.

These large gaps also translate into a lack of quality in psychiatric care.   It is what happens when businesses and governments marginalize the role of physicians and exaggerate the importance of business administrators.  The practical implications are that psychiatrists should really avoid practice situations with these obvious gaps.

It would be great if the American Psychiatric Association would step up and comment on how these gaps should be closed but they appear to be disinterested in what is happening to the practice environment for psychiatry.

George Dawson, MD, DFAPA



 

Friday, December 6, 2013

MCAT Hyperbole

The Medical Education issue of JAMA came out today with two articles discussing the new and improved Medical College Admission Test (MCAT).  I read both articles and they reminded me of the new and improved MCAT that I took back in the day when I applied to medical school.  I think that we were about two years into the new and improved version then.  I could not tell the difference between physicians selected on the basis of the old version, the new version or no versions of the MCAT.  I am sure that many of the professors that I identified with had never taken an MCAT.  Many were not trained in the United States.  Good doctors are good doctors and the idea that a multiple choice test will pick them seems about as likely as making accurate diagnoses of depression using a multiple choice questionnaire.

At the time I took the exam, there were all sorts of ideas about how you could select a "good" doctor.  They were in a trend where science was being deemphasized.  Somebody had the idea that you had to be "well rounded" with a liberal arts education.  Pure science majors might be frowned upon.  As a Biology/Chemistry major - did I stand a chance?  They had just phased out the General Knowledge section of the MCAT.  The rumor was it discriminated against students born and raised in rural areas with no access to museums, art, and theater.  As a Jack Pine Savage (I like the loose definition of a native from the natural range of Pinus banksiana) - I probably dodged a bullet there.  Critical thinking was emphasized.  It always is in these tests.  I took the GRE and they said the same thing.  It seemed like the critical phase of the admissions process was the interview.  I was interviewed by a Cardiologist who wanted to know if I was "aggressive" enough.  I did not know what he meant and stammered for quite a while.  Then he learned I was in the Peace Corps and said: "Anyone sitting in the bush for two years is aggressive enough for me."  He gave me a favorable rating.

The new MCAT promises to pick doctors of the future better.  It is described as being the product of a survey of 2700 shareholders.  It is supposed to be designed to test the competencies suggested in two reports - The Scientific Foundations for Future Physicians and Behavioral and Social Science Foundations for Future Physicians.  In the current JAMA article one of the authors defines 4 signals that the new MCAT sends for the future of medicine as summarized in the Table below (per reference 2):

Signals Sent by the MCAT Revision
1.
Focus on foundational competencies required of future physicians rather than specific undergrad courses.
2.
Candidates must be able to learn and think like scientists.
3.
Behavior interacts with biology.
4.
Critical thinking will be emphasized with a balanced testing between natural sciences and social/behavioral sciences.

None of these ideas seems revolutionary to me.  Looking at the second signal:  "Candidates must be able to learn and think like scientists."  I can think of no better way to do that than take a senior level chemistry or physics course from an interesting professor.  For me it was Physical Chemistry, the dreaded course of Chem majors.  You either were or you were not a Chem major based on whether or not you passed PChem.  It was the most mentally strenuous course I have ever taken and there certainly were no medical school courses that came close.  I can still recall studying thermodynamics and learning how Maxwell and Gibbs thought about things.  Our professor even digressed to talk about how long it took Linus Pauling to learn thermodynamics.  I still have thermodynamics swirling in the background whenever I see crystals dissolving in a solution, whenever I have to bring my car battery in the house to warm it up, and whenever I am thinking about complicated pharmacodynamic interactions.  Keep in mind that at the time I took the MCAT, science majors were out of favor.  The thinking at the time was that you would develop critical thinking from a liberal arts education with only the core science course (general chemistry, organic chemistry, quantitative analysis, and physics) being specified.  Unless you are Gauss, I think that generally involves some level of advanced training beyond what are generally the rote courses.

What actually happened to the cohort of physicians trained under the previous iterations of MCAT?  I am thoroughly biased by my undergrad training and always like to hear about other undergrad chem majors.  In the department where I previously worked there were two and they are excellent psychiatrists.  There are chem majors in every medical and surgical speciality and they are excellent physicians even if they did not have the same amount of humanities courses.  At the same time I have encountered excellent physicians from practically every undergraduate major ranging from music performance to applied mathematics.  The only logical conclusion is that the undergraduate medical education system can turn any reasonably bright group of people into physicians irrespective of their undergraduate majors or MCAT results.  It seems to me that some of these documents emphasize the MCAT as the limiting factor when there is no evidence to suggest that is true.  How can it be considered a signal when the signals are the same ones that have been important since formal education of physicians began?

The real area where physicians are produced is in medical school and if you want physicians to think like scientists that is also the logical place where it happens.  Recalling my biochemistry course in medical school - there was practically no memorization.  We had a seminar group (in addition to lectures) where ten of us were expected to discuss state-of-the-art biochemistry experiments at the time and on an ongoing basis.  Volumes of these papers were assigned - each emphasizing a specific concept.  We had to know the experimental methods and the limitations.  We were also expected to have a subscription to the New England Journal of Medicine and discuss any relevant research there.  The exams were essays about these experiments and methods.  They were 7 points apiece and you had to get a 6 or a 7 on each exam to pass.  There was an undercurrent of dissatisfaction by many with the typical complaint being that we would go into the board exams at a disadvantage because we were not memorizing metabolic pathways. 

During the clinical years, the formative process was seeing and identifying with professors who were excellent clinicians and scholars.  They did not have to be scientists in the Kandel sense of the word, but they needed to be scholarly, well-read, and experts in their field.  For me the most engaging process was being on a team with one or two of these folks, senior residents and me as the medical student. That dynamic learning environment was absolutely the best way to acquire the skills, attitudes, and knowledge base requires to be a physician.

So where does that leave me with regard to the messages of the main article and the opinion piece?  I think the science aspect of the MCAT is overemphasized but not for the reason that Cohen suggests in the editorial.  I have always believed that physicians should think like scientists and we are ethically obliged to provide scientifically based treatment.  The problem is that physicians are currently practicing in an unscientific environment.  Any scientist would be appalled at the number of pseudoscientific guidelines and quality markers that physicians have to adhere to.  They range from the purely financially based to management decisions negating any critical analysis that a physician may come up with.  The wringing of science out of medicine is a direct result of the political theory that funding private businesses to ration health care is an effective way to reduce health care inflation and it certainly is not.  I don't think it is honest to build medicine up as an intellectual endeavor when physicians will be routinely second guessed by administrators who often have only business training.  We need to tell the people who are truly interested in science to go into science and engineering and avoid medicine.  And if that is really true why are we interested in physicians thinking like scientists at all?   

Cohen's editorial has two issues that I would like to comment on.  The first has to do with what he describes as "skills previous generations of physicians had scant use for" among them "how to use resources parsimoniously".  As a member of the medical specialty that has been viciously rationed over the past three decades to the point where there are marginal resources to treat the most ill patients, I say it is time to get rid of the "cost effectiveness" argument.  It has been the battle cry of the managed care industry and you only have to look as far as your nearest emergency department to see the result.  Pricing is the largest single economic problem in American medicine and the best way to address it is to get the prices on par with other efficient health care systems (like Japan) and to suggest that managed care companies owning the means of production (MRI scanners, cardiology clinics, hospitals, etc) is a massive conflict of interest resulting in prices that are much higher than they are anywhere else in the world.

The second issue is Cohen's multidisciplinary team concept.  His view is that physicians need to "demonstrate antihierarchical teamwork".  His ideal team of the future eschews individual accountability and ability to function as a leader but also as an equally valuable member.  Like most other areas of medicine, psychiatric expertise and experience in this area is ignored.  I had a multidisciplinary team that met on a daily basis for 23 years.  We met during a time when the dark forces within managed care were telling us we didn't need to meet and we met during a time when they wanted us to meet so that they could put case managers on the team and tell us what to do.  Apart from the expected negative influences of managed care, teams depend on a number of practical issues including the number of full time employees and who is present when patients are admitted, discharged, and when their family members show up.  In those 23 years there were no other team members present for the time that I was present and I viewed it as my job to communicate what happened to everyone else.  The other practical matter and a significant cost factor that Cohen may wish to compensate for by parsimonious use of resources is defensive medicine and all that entails.

In conclusion,  I don't have a favorable view of either of these articles for the previously stated reasons.  The  best way to assure that future physicians have what it takes is to make sure that they have a practice environment that is intellectually and professionally stimulating.  Can you really expect that medicine can continue to attract high quality candidates from all undergraduate majors if the practice environment remains stagnant or deteriorates further?  You can't expect to have people thinking like scientists when they are managed like production workers by people with no knowledge of medicine or science.  At the very best, you will end up with highly frustrated overtrained professionals or at the worst a much wider range of skills than currently exists in the field.  By that I mean the spread of applicant qualifications will increase and the brightest people will go to any school that can get them placed outside of the current managed care environment as the health care system evolves into two tiers of care.

When that day comes, the nature of and scores on the MCAT will be meaningless.

George Dawson, MD, DFAPA

1: Cohen JJ. Will changes in the MCAT and USMLE ensure that future physicians have what it takes? JAMA. 2013 Dec 4;310(21):2253-4. doi: 10.1001/jama.2013.283389. PubMed PMID: 24302085.

2: Kirch DG, Mitchell K, Ast C. The new 2015 MCAT: testing competencies. JAMA.  2013 Dec 4;310(21):2243-4. doi: 10.1001/jama.2013.282093. PubMed PMID: 24302080.