Sunday, June 12, 2016
Ophthalmology Styled Practice As A Goal For Psychiatry (And The Rest Of Medicine)
Over the years whenever I have thought of an ideal way to practice medicine ophthalmology comes to mind. I remember a good friend of mine telling me shortly before he became an ophthalmologist that the speciality seemed to have the ideal mix of medical and surgical interventions and they were mostly effective. He also had the great observation that no matter what field of medicine you specialize in - the information in that field will generally be contained in two or three large volume texts. The information always expands to that amount with specialization. My friend was a very bright guy.
Like most specialties, I have had my fair share of personal contact with them starting with a BB gun injury in the 8th grade. That's right - just like in the movie - I almost shot my eye out. And just like in the movie, my father told me shortly before the accident: "Be careful with that BB gun - you will shoot your eye out!" Within minutes, I was standing there in disbelief. A BB had ricocheted off a steel lamp cover in our basement and instantaneously hit me in the left eye. Within minutes I looked in the mirror and was more shocked to discover that my iris color had been replaced with blood inside the anterior chamber of the eye. The family doctor was called and advised my parents not to bring me to their office or the emergency room, but to see the new ophthalmologist in town. He was the only physician in town who could assess and treat this injury. I spent a week in the hospital with both eyes covered and eventually recovered with a traumatic cataract in the lens of my left eye. Every ophthalmologist since has said the same thing: "You are lucky that cataract is just off your visual axis and it does not affect your vision." Even more interesting, the last ophthalmologist I saw wanted to know about my experience of seeing with a traumatic cataract just off my visual axis. In what ways did it seem different than the other eye. After many questions he finally said: "I am just trying to find out what it is like for you to have this cataract." An ophthalmologist interested in my conscious state of vision?
These are some useful lessons from ophthalmology:
1. Precise assessments based on clear markers:
There is still room for interpretation. No two retinas are alike. As another example, an eye doctor told me recently that prominent retinal arteries may put you at risk for glaucoma. I saw a second eye doctor 2 weeks later who agreed that I may be in the subgroup of people with prominent retinal arteries but that does not put me at higher risk for glaucoma. In 50 years of annual eye exams my intraocular pressures have always been normal. I have also used the eye exam in lectures on diagnostic accuracy looking at the issue of the diagnostic accuracy of direct ophthalmoscopy versus indirect ophthalmoscopy, basically ophthalmologists versus everyone else. The ophthalmologists win by a wide margin when it comes to detecting retinal pathology. The odds that a primary care physician can detect these changes with direct ophthalmoscopy as a screening exam are no greater than chance. In the days when I did a lot of direct physical examinations of patients, I was convinced that most physicians either did a poor job of using an ophthalmoscope or were just focusing on major landmarks. They also seemed to ignore the general clinical status of the patient. I recall an agitated, hypertensive, young stroke patient and clear hemorrhages in the retina. I diagnosed the retinal hemorrhages and nobody else did, but they could confirm when I told them where to look. Like all of medicine the subjective factor is there, even in what appear to be objective assessments, but ophthalmology seems to have some of the greatest potential accuracy and reproducibility.
2. Interventions that are fast, safe and effective:
About 8 years ago I was interviewing a patient and looked down at the wood grain of the table. It started to swirl and move in one visual field. I was part of a big multidisciplinary clinic at the time. The information flow among the specialists was the best I have ever seen it. I called the ophthalmology clinic spoke with an ophthalmologist. After about 30 seconds of symptoms he said: "You have a retinal migraine. We can get you in this afternoon, but I doubt there is much else." I went with that advice and have had no similar problems since. A few years ago a family member called me on a Saturday morning and said he had sudden onset of veiled vision and floaters. He lives in a town of about 50,000 people. He was able to see a retinal specialist and get laser surgery on his torn retina in a matter of hours. I have had three other relatives with retinal surgery - all very successful. In my case about one month ago, I had a sudden onset of eye aching, massive floaters, and large bright halos surrounding the entire visual field of my left eye. I was triaged to ophthalmology in a few hours and diagnosed with an acute vitreous detachment with a plan to observe for any retinal damage in two weeks.
3. Interventions that clearly enhance quality of life:
Saving someone's vision needs to be at the top of anyone's list when it comes to quality of life. Surgical specialties are generally a very active intervention by physician with very good outcomes and some complications. From what I have seen the complication rates of eye procedures are very low and in some cases the advertised procedures being done are in excess of 10,000 - 100,000. In many cases there is an expectation that you will be seeing the doctor 2 or 3 times and that the chances of a good outcome that will improve your life are very high.
4. A clear path to getting well:
The majority of patients seeing ophthalmologists, don't have to do much to get well. Recognize the problem, discuss the treatment plan and risks/benefits of the surgical procedure and make the follow up appointments. In the case of medical treatment - use the required eye drops, visual aids, diet, and protective equipment and participate in the monitoring plan. In the patients I see with eye problems I know that many of them do not follow up. I routinely ask about a personal history of eye trauma, visual problems, glaucoma, and macular degeneration. In some cases I call their ophthalmologist directly about whether the medication I am about to prescribe would affect their treatment. But generally an optimal path to care with a good outcome is outlined form most ophthalmology patients and the burden of adherence is relatively low.
Contrast that with a patient walking into a psychiatric clinic. By that I mean a patient who gets a direct appointment with a psychiatrist. There is no precision in the assessment. There is a diagnostic manual that gives the appearance of precision, but it is fairly worthless unless the physician knows how to get at it and that generally involves having seen many patients with the problem. It also involves concluding that many DSM-5 categories are so nonspecific or unrealistic that it makes no sense to make the diagnosis. With a diagnostic manual that imprecise, markers are sorely needed and I am optimistic that we are on the verge of some. I am optimistic that with the correct markers we will be able to define categories and clearly define treatment paradigms on those categories, but I don't expect that to resemble a DSM or an RDoC for that matter. The burden of adherence is much higher. Polypharmacy and keeping all of those medications straight is certainly as big a problem in primary care and the medical specialties. Nobody else wants to see people back on an hourly basis for weeks, months, and years.
One of the fastest and safest interventions in psychiatry is electroconvulsive therapy. In many parts of the country it is unavailable. The FDA has some continuous program afoot to "reclassify" it. This is the second iteration of that program since I responded to the first one years ago. The only logical conclusion is that this is some kind of political maneuver being played out in a regulatory context. My understanding is that reclassification would mean new sets of clinical trials to get FDA approval for devices. It should not be surprising that very few places offer it, and thousands of patients go through endless clinical trials of antidepressants with no remission of their symptoms. TMS (transcranial magnetic stimulation) and VNS (vagal nerve stimulation) seem far less impressive in treatment resistant populations. Just last week a colleague also pointed out that there are probably thousands of patients who might benefit from ketamine infusions and that seems to be another procedure in limbo pending FDA considerations. Without FDA approval, health insurers will deem a treatment experiment and not pay for it. That is when treatment usually grinds to a halt.
Quality of life considerations should be high on any psychiatrists agenda since we learned that we treat conditions that are listed in the Top 10 of the World Health Organizations list of disabling conditions. Unless we get robust treatment responses, quality of life is not likely to improve. There are vast numbers of patients who are disabled and maintained on medications. They clearly need more than the medication but the only service offered by their health plan is a series of brief visits with a psychiatrist or a prescriber, generally focused on polypharmacy. There is no attempt at cognitive or vocational rehabilitation. Those services are available to stroke patients but not psychiatric patients.
The path to getting well and recovering from a mental illness or addiction is often not clear. The message has been oversimplified to "Take your medications as prescribed." The same patient may hear "Don't do drugs or alcohol." but typically only after a problem has been identified for a while. The average person with an addiction (according to survey literature) does not disclose that to a physician. Most people after an acute episode of a mood disorder or psychosis - don't know where to start. They don't know what happened to them and they don't know how to prevent it from happening again. They may hear that they need "therapy" or "counseling" and realize that after 5 or 6 sessions, they don't like the therapist or the sessions aren't going anywhere. What is left at that point? Go back and see the prescriber in 15 minute lots about medications that seem to hardly have an effect or a seemingly endless series of medication trials?
Instead of parsing words in somewhat meaningful categories we need to pick up the pace. In my experience the people who are willing to see psychiatrists for a long period of time for pharmacotherapy, psychotherapy or both are in the minority. It is clear that many psychiatrists end up seeing patients three or four times a year in what appears to be interminable treatment. All the while the patients have varying degrees of disability and problematic quality of life.
All of this care is delivered by 19,216 ophthalmologists who are addressing an impressive array of eye diseases and injuries. As previously noted there are 49,070 psychiatrists also addressing a lot of illness and disease. Just like my previous argument about orthopedic surgeons, I have never heard of any shortage of ophthalmologists.
Ophthalmology teaches us that there is a much better way and we should be designing those paths of care instead of the giving it over to the business people and politicians. A critical question on the idea of a shortage of psychiatrists is how much of that is due to the inefficiencies suggested above including interference from politicians and business organizations.
George Dawson, MD, DFAPA