Saturday, March 5, 2016

At The Edge Of My Notes........

For all of my professional life I have done my original notes the same way.  There is usually some kind of form anywhere from 4 to 8 pages long.  I list a few things on it, but for the majority of the interview I flip it over to the blank side and write free hand.  I have to write fast and my handwriting is bad - no cursive, just a crude combination of capitals, lowercase, and symbols that only I know the meaning of.  At some point back in the 1990s when I was studying medical decision making and reading how experts move between chunks of data - I started to draw out chunks of data on the paper.  Circles, squares, timelines, triangles with various connectors to show relationships.  There is a rhythm to it depending on how fast the person I am interviewing is talking and how much information is being discussed.  I have as much time if the person is mostly silent as I do if the person is rambling and including far too many details.  When you write that much, the feel of the pen in your hand and how it moves over the paper can be extremely important.  I only use Pilot G-2 pens.  I alternate between the 1.0 and 0.7 mm tips in black, red, and blue.  The red and blue are only for highlighting and editing.  Gel ink has a perfect feel as your hand is gliding across the page but it is messy.  At the end of a busy day my hands are smeared with ink.  After writing it all down the next step is dictation.  I have to translate all of my non-linear scratchings into a very linear and coherent report with a formulation, various diagnoses, and recommendations for a treatment plan.

The diagram at the top of this post is an example of one collection of words and symbols that are in the corner of one page of my notes.  It took me about 38 seconds to draw it, in pieces as I heard the various elements being described.  The HR in the middle of the circle here is heart rate.  Arrows in the up direction mean increasing and the down direction is decreasing.  I don't like to see elevated heart rates.  I have seen too many middle aged stimulant users with cardiomyopathy and had too many conversations with Cardiologists about whether or not sinus tachycardia is a benign finding or not.  I have obsessed far too long about who I can treat with medications based on their heart rate being greater than 100 beats per minute (bpm).  I am not reassured by the latest review in UpToDate on idiopathic sinus tachycardia and benign outcomes (1).  I doubt that the people in those studies are the same people I am seeing on stimulants, antidepressants, antipsychotics, street drugs, alcohol, caffeine and plenty of tobacco.  In the middle of trying to construct an impossible timeline of insomnia, anxiety, depression, childhood adversity, adult psychological trauma and multiple medical problems I am drawn temporarily to the little heart rate circle and I am trying to figure it out.  It all starts with THC and proceeds clockwise.

I have been impressed by the number of daily cannabis smokers who at some point notice that they are getting anxious and panicky from it.  Despite all of the hype by the pro-marijuana contingent, most people can relate to augmented heart rate and increased intensity of heart beats when smoking marijuana.  It happens when THC drops the blood pressure and your heart acts reflexively.  That is typically ignored by young smokers, unless they have had a panic attack.  In that case, it feels like they are starting to have a panic attack and they start to feel very uneasy.  In many cases they start to develop panic attacks every time they smoke.  That often leads to them discontinuing the use of cannabis, since panic attacks are very unpleasant experiences.  So THC can lead to increased heart rate.

Caffeine is ubiquitous in American society.  It affects too many dimensions in psychiatry to not be asked about.  The answers are often shocking.  With the availability of espresso in most places, I often get an estimate in shots of espresso per day.  For filtered coffee fans, I learned to ask the question: "If you are home alone - do you ever drink the whole pot of coffee by yourself?"  And then there are the additional estimates of mg caffeine in terms of black tea, green tea, and every form of esoteric energy drink.  I can usually track down the mg caffeine using some online resource.  The DSM-5 suggests that caffeine consumption "...well in excess of 250 mg" can be a problem.  I find myself routinely advising people on how to get their caffeine consumption down to less than 1,000 mg/day and use it in the mornings - as a starting point.  In some cases, I am told that people are drinking beverages that combine alcohol, caffeine, and some other questionable compounds.  The pharmacokinetics of caffeine are important.  Most people know what happens if they get wired or precipitate a panic attack with a triple shot of espresso, but they don't know what can happen to sleep with steady state levels of caffeine.

Exercise can be an important source of accelerated heart rate.  In most cases it is just rushing to get the vital signs done, but there are  other important causes.  There are the deconditioned folks who decide that they are going to turn over a completely new leaf by starting to exercise vigorously.  I may be seeing them a day after and exercise session and they still have an elevated heart rate.  There are the conditioned folks who still overdo it.  That has led me to ask people if they are wearing a heart rate monitor and what their goals are.  Some of the responses are shocking.  I have had many people tell me that they are running their heart rate well beyond their age-determined maximal heart rate for a long time.  I have never had a person tell me why that might not be a good idea.  It is an opportunity to educate people on how to not overdo it and either maintain conditioning or start some basic conditioning.  It also leads me to consider some people who may have undiagnosed intrinsic heart disease and what further evaluations need to be done.

Medications can be an important direct or indirect cause of tachycardia.  As a group, older medications like tricyclic antidepressants and anticholinergics were more reliable causes.  Of current day medications stimulants are probably the most important cause of increased heart rate.  In general stimulants increase heart rate 3 - 10 beats per minute (bpm) and increase blood pressure by 1.5-14 points.  More recent generation medications are rarer causes, but it is always important to look for that one person in a hundred or a thousand.  Is that really an idiosyncratic reaction or is it a sign of something worse like neuroleptic malignant syndrome or serotonin syndrome?  In my current line of work withdrawal from medications is a more important cause of tachycardia than a direct effect of the medication itself.  Coming off of benzodiazepines, barbiturates, and clonidine are important causes. Tachycardia and various rare cardiovascular effects are still listed in most package inserts and that is an important reason for monitoring vital signs and electrocardiograms.

A lot of people seem to think that anxiety is a potent cause of tachycardia.  That may be true for panic attacks but on an ongoing basis I have found that anger is much more likely to elevate pulse and blood pressure.  I have seen persistent tachycardia in the 120-130 bpm range due to anger.  I have seen patients started on antihypertensives because of this and I think it is a good idea as long as there is a plan to decrease and stop the medication when the anger resolves.  I always tell my patients that an explanation (a white coat, life stressors, too much caffeine, etc) only gets you so far.  If you are still running a high pulse and blood pressure at home it should probably be treated and closely followed.  I personally don't like to see people running systolic blood pressures in excess of 150, diastolics greater than 95, or pulses greater than 100 while they wait for "lifestyle changes" to take effect, but I know for a fact that there are primary care physicians out there who disagree with me.

Anxiety especially the persistently panicky person can have elevated pulses.  Many of these folks look thin and hypermetabolic.  They are routinely checked for hyperthyroidism and they are always negative.  I listened to a NASA physician lecture about a subgroup of patients with this body habitus many years ago.  He said that thin people with arachnodactyly can be bothered by anxiety and panic and the best treatment was moderate levels of exercise like walking rather than medication.  He defined the condition as anyone who can grasp their wrist with their thumb and middle finger and notice that they overlap at least to the most distal joint of the middle finger.

Epidemiological studies show that people who are sleep deprived or have their circadian rhythm disrupted have poorer cardiovascular health.  There are many people who develop tachycardia in this setting.  Sleep disordered breathing disorders can also be an important cause of tachycardia in the daytime.  These folks often have an associated problem like undiagnosed atrial fibrillation.  Many of the commercial automatic blood pressure machines do not detect irregular pulses, so it is important to check pulses and pulse deficits in the office.  All psychiatrists should have access to lab facilities where electrocardiograms can be run and referral facilities to do the necessary testing and management of the identified conditions.

All of that and more flows from a little 2 x 2 inch drawing on one of my intake notes.  I would have thought by now that some enterprising software developer would have come up with a system of icons that I could just point to and grow on a computer tablet, but so far it seems that electronic health record developers really are not designing software with physicians in mind.  They would rather have us enter full text or more commonly very choppy phrase based notes than using icon based full information approaches.  My little HR circle contains a lot of information and the only way I have seen the information content estimated is by constructing all of the possible text based narratives and then measuring the amount of text.

That method has its limitations because when I (or any other physician) makes a drawing it is connected to our own unique conscious state.  There is certainly overlap with all physicians to some extent or at least the ones with an HR icon in their notes.  The overlap gets closer among those of us who are looking for arachnodactyly.      

George Dawson, MD, DLFAPA


1:  Homoud MK .  Sinus tachycardia: evaluation and management.  In: UpToDate, Cheng A, Downey BC (Eds), UpToDate, Waltham, MA. accessed on March 5, 2016.


  1. Hi, George. I read and enjoy many of your blog posts: fun and informative. The recent one (below) re use of notes and work flow was quite revealing . . . a topic I’ve seen very little of in training, literature, M2M, etc. A large segment of my practice is evaluative in nature so I’ve had to fine tune assessment and associated work flows. Like you, I have my favorite tools and much of it a mixture of art, science and personal preference. The interview, note taking, dictation, report/note prep all interweave and I’ve enjoyed setting it up for maximum efficiency.

    There is no one way to do it but, for me, I have a 1 page template that I take notes into . . . kind of an outline and, like you, I use a lot of codes, abbreviations (kind of like my own shorthand) and some sketching. The general flow of the session is top to bottom but with a lot of exceptions driven by the patient/physician interaction. As things come up that I think are important, I put a dot in the margin then come back and drill down on the dots . I take photos of the patient and their ID/DLic and execute releases as needed.

    Later, I dictate to my ‘virtual assistant’ (off site); we use a report/note template similar to the one I use to take the notes and use a lot of codes, phrases, macros, auto text, etc. This can be taken to the next level via a macro program; Pathagoras ( is my favorite and especially helpful on those occasions when I choose to do the report/note prep without dict/transcription assistance. Post transcription, the draft comes back to me (online encrypted) in less than 24 hrs; I add color photos of the patient and their ID/DLic, edit to final and attach relevant medical/psych literature to support the Dx, conclusions and recommendations. I’ve worked with my off site assistant long enough that we are to the point where I can often fax/scan my raw notes to her and she can produce 80-90% of the report cutting out dictation time and leaving me to complete the Summary & Recommendation section on my end. The next step that I’m working on is to have the patient log into my web site and complete a detailed history for my review before the initial session.


    1. Hi Wandal,

      Thanks for your detailed reply and technical pointers. I have used Dragon to dictate into a large EHR, with some success. In a subsequent system it was a total nightmare and that system would dump entire dictations so that they would need to be done again. I spent an entire summer redoing notes because of that incompatibility. I am currently using the system described above on the front end and dictating via phone line to a service that apparently uses a sophisticated voice recognition program to rapidly complete the dictation and file them securely into the EHR. It remains a huge waste of time, especially when I recognize that most physician employees do not get separate time for dictation. On another thread I was told that natural language recognition software would not be at the stage I want it to be for another decade or two. That dooms another generation of physicians to part time stenography.

  2. There is also this:

    1. Thanks for that link Simon.

      That NASA physician I referred to had the same theory about blood pooling. They used a MAST suite like device to see if that was effective for anxiety and I think they found that walking seemed to work as well. That was back in about 1992.

    2. Simon,

      Thought about it for a second and blood pressure drops and blood pooling may be a common precursor for anxiety in a number of situations - the cannabis smoking (heart pounding and anxiety) comes to mind.

    3. I personally have joint hyper-mobility and issues with anxiety but have not found compression type devices to be terribly helpful. I suspect that the anxiety most related to blood pooling and responsive to specific treatments there would be somatic.

  3. I am not a physician but I am attentive to physical symptoms and try to explain possible connections to lifestyle and mental health issues. As an addiction and eating disorders counselor I was very glad you addressed the risks of over exercise. Most healthcare professionals praise patients who engage in excessive exercise and reinforce the use of monitoring devices, not asking the right questions. The overlap between compulsive behaviors, anxiety associated with these behaviors and distorted goals, inefficient sleep, malnutrition (often disguised as "healthy") and use of weed/alcohol/ xanax to stop the thoughts at the end of the day has to impact many systems in the body. I know my limitations as a licensed mental health counselor so when I have a possible concern I want to collaborate with their physician. If a client is not responding to the medical recommendations perhaps consulting with a mental health professional would be helpful - it's too easy to miss the small window of opportunity to help people. Thank you for this comprehensive article. Lena Sheffield, LMHC, MAC, CAP Miami, FL