Friday, July 11, 2014

"Good News - Your Care Today Was Free"

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

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

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

Next came the expected demographic data.  I live in a town that the U.S. Postal Service never gets right.  If I list a Zip Code the wrong town name pops up.  This software was no exception.  It took me extra time to enter and reenter data that was already there somewhere in my healthcare company's database.  The final screen was the billing and financial data including credit card information.  More data that my healthcare company has know for the last five years.  At this point I am about 20 minutes into the process and it is time to upload the photos.  I had 4 photos of the ankle and the program accepted 3 of them.  Sign off occurred at the 25-30 minutes mark.  As I waited for the return e-mail or call,  I marvelled at how health care companies have transferred all of this clerical work to physicians over the last 20 years and now they are transferring it to the patient.  I just did the work of the intake person and financial person in any clinic or hospital.

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

Dear George,

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

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

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

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

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

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

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

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

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

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

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

You already know what I have to say about that.

George Dawson, MD, DFAPA


  1. Medical and psychiatric information should be on encrypted thumb drives, not on the Internet. The whole concept of EHR as a cloud based or server based system is deeply flawed in the age of Wikileaks. But that doesn't matter, EHR vendor GE pays 100K day for lobbying, created MSNBC to be court flatterer of the administration and is raking in the bucks big time for something that doesn't work.

    1. Agree completely - the cloud to me is a concept out of a science fiction movie. There is the illusion you you have access, but of course health care companies never give you complete access to your records because it is their property. More importantly - they want the trend to be that your financial and health acre information at some point to be as accessible to corporations as your Facebook page and that movement has been building since the 1970s. Right now businesses have easier access to healthcare records than physicians do. The evidence is as obvious as the hundreds of thousands of records lost from the laptops of these businessmen. Congress is basically an organization for creating businesses out of thin air and there is no better example than the electronic health record sold on the lie that it was going to save us all billions.

    2. Here's the big lie no one talks about...the government is good enough to keep your health information secure, but not good enough to keep the names of their double agents in Pakistan secure.

      I just assume everything that gets on EHR is eventually going to be for public consumption. Which is a good reason for psychotherapists and psychiatrists to go off the grid completely.

  2. To your knowledge, are there similar online consultations via insurance coverage that use a PHQ-9? It's a scary thought.
    It reminds me of a lecture I went to years ago, about Autism, where they showed this video of a little triangle moving around a large rectangular area, followed by a big triangle. Everyone in the audience went, Awww, what a cute little triangle, being chased by that big, mean triangle. And then we were told that all the autistic people who had been shown that video described a smaller triangle, a larger triangle, and a rectangular area.
    I know MIT has some very sophisticated, and presumably expensive, AI that might be able to pick up on the discrepancy between a patient's answer on the PHQ-9, and how that patient appears. But given the cost limitations in psychiatry, I doubt that type of technology is available.
    So it amazes me that the powers that be have been able to convince themselves that a PHQ-9 plus a case manager is "just as good" as an experienced psychiatrist interviewing the patient. Or maybe they haven't convinced themselves, and they just don't care.
    Hope your ankle's better soon.

    1. I think it is just a matter of time.

      In fact, I think it has already happened, but the company who did it changed their mind. I will know enough to take a screen shot of the first company I see with that service and post it here. There is a measurement based care initiative within psychiatry that is a proponent not just of these measures but many more. I see it as a reaction to the business community: "They criticize us because we claim that we cannot be measures like everyone else."

      If there was enough honesty around, there would be an admission that many specialists doubt the importance of measurement or dispute the measures. An internist told me that his group was being "paid for performance" on a BMI in the 26-27 range. When he produced current research saying that a BMI of 28-30 did not result in any increased mortality it was dismissed out of hand.

      I think that people may come to see performance for what it really is - political leverage.

    2. More reason that psychiatric records should be old school SOAP and process notes on paper in a locked file cabinet.

      Using an numerical code instead of names would even stop a breach if there were an Ellsberg type break in.

      Sometimes low tech is superior.

    3. Or even old school crime. The VA hunted me by down via tax records to let me know my medical records may have been compromised when one of their workers took home a laptop full of medical records that was later stolen.

      Meanwhile at this time, managers where I worked were hounding me about how I needed to maintain data privacy because of government regulations (also while ignoring that the only content I currently worked with was being displayed on the firm's website). The irony wasn't lost on me.

  3. Most of the numbers used to measure "health" are as irrelevant to the health of the patient as the body counts used to measure the "success" of whatever the latest war is.

  4. Occasional commenterJuly 12, 2014 at 10:27 AM

    I would guessed it was a bite from a sac spider. Brown recluse spiders do not live in Minnesota. I usually won't fill out that questionnaire you refer to. It doesn't ask how intense the symptoms are, only how often. What a stupid form it is!

  5. From the ur-time of Max Hamilton who developed psychiatric rating scales for anxiety and depression back in the late 1950s it has been understood that they are for tracking severity of symptoms, not for making diagnoses. Why? Because most symptoms are nonspecific. First you make the diagnosis, then you use the rating scale to obtain a baseline from which you can follow progress. In recent years various entrepreneurs have pushed to skip the first step and to reify the number from a scale.

  6. Someone sent me this link I had to share given the topic: