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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. We no longer have insurance that covers the Mayo Clinic. My wife continues to do
very well.
"We have the best neurosurgery clinic in the
world." My wife Linda was in a conversation with a staff person at the
Mayo Clinic, and somewhere along the line that statement was made. Just a few
weeks earlier she had been diagnosed as having a growth hormone secreting
pituitary adenoma and we were in the process of looking for neurosurgeons. I
was concerned about that statement and wondered what the motivation was. I have
called a lot of clinics and never heard a statement like that. I had talked
with a lot of doctors and had never really heard many physicians talk like
that.
The pituitary fossa is a dark and dangerous place for even
a small tumor. Psychiatrists are generally familiar with the area because of
patients with microadenomas that have been discovered during evaluations for
what is usually hyperprolactinemia secondary to D2 receptor antagonists. In
Linda's situation it was a 1.3 cm diameter cystic lesion that involved the
cavernous portion of the right carotid artery. The surgery involves a
transnasal and transsphenoidal approach to remove the tumor through an
endoscope. Cutting into the carotid artery is a potential catastrophe. Damaging
the pituitary and needing lifelong hormone supplementation was also a possible
outcome. We wanted the best neurosurgeon for the job.
I had just finished reading a NEJM article on robotic
surgery that suggested that surgeons need to do 150-200 procedures with this
device to be proficient. There was no data available for endoscopic
transsphenoidal tumor resections, much less what might be reasonable
stratifications like size and type. I figured that the surgeon doing the most
was probably the best bet.
At Mayo we were given a timely appointment and met the
surgeon. He was confident, detail oriented and personable.
He assured us that his goal was to cure Linda, but that he
was not going to trade off safety at any point for a cure. He openly
acknowledged the potential problem of the carotid artery being involved with
the tumor.
He performed the surgery and the next day came by to
explain the results. They were uniformly good but would need confirmatory IGF
levels at 3 months. He carefully explained the possible post op complications,
how long we had to look for them, and exactly what to do about them. He told me
that if anything happened during recovery and I was not at the hospital, I
would be called immediately. At the time of discharge, he said that he was
available through the hospital operator, and that if we called from a cell
phone we might have to pull over and wait for him to call back.
While all of this was going on, I learned from other health
care providers in the state that the "Mayo Clinic option" was being
eliminated from some employee health plans. I had just spoken with a local
expert in health economics who said that this suggestion had been made in the
past and plan subscribers had rejected it. I thought about the implications for
all of the free market and "quality" hyperbole that we hear from
politicians and business leaders. If we have the best neurosurgical service in
the country, why are health plans limiting access to it? If it is the best on a
competitive quality basis, why aren't they rewarded rather than being penalized
by the market? Most of all, what are the implications for the most heavily
rationed health care, namely mental health care?
From a quality perspective, I was hard pressed to think of
the best psychiatric service in the state, and not because we lack great
psychiatrists. Most of the ·inpatient units I know of are pretty intolerable places. The emphasis is largely to put the patient on medications and discharge
them as soon as possible, even when many are highly symptomatic. By comparison
with medicine and surgery services, it is difficult to consider this as even a
minimal standard of care. Imagine the patient with congestive heart failure
being placed on medications and discharged, and making it the family's responsibility
to monitor the response and adjust cardiac medications. Imagine me doing post
operative neuro checks and monitoring urine volumes, labs, and pain medications
on my wife in a Rochester hotel room. In either example, medicine and surgery
patients are more likely to follow recommended discharge instructions compared
with over half of discharged psychiatric patients not recognizing that they are
ill.
What about actual time spent with a psychiatrist? The time
that my wife and I spent with her neurosurgeon probably exceeded the time that
many hospitalized patients see their psychiatrist. Inpatient settings are
usually very poor work environments for psychiatrists because the central fact
is that it is no longer an environment where high quality work can be done.
Unlike our neurosurgeon, psychiatrists have been marginalized to the role of
medication prescribers in both inpatient and outpatient settings. In many
inpatient settings psychiatrists no longer control crucial discharge decisions.
When I walked out of the hospital with Linda, we were
hopeful that she had been cured. We knew what we needed to look out for and
that there were future options. I noticed that the hospital looked like most of
the teaching hospitals I had worked at in the past. There was no valet parking,
massage or aroma therapy, harpsichord player, or high-end coffee shop. There
were 19 plaques on the wall showing that Mayo Clinic Neurology and Neurosurgery
was ranked #1 in the country for each of the past 19 years by US News and World
Report. But most of all, we knew that we had just encountered medical and
hospital staff with a high degree of expertise and professionalism and that
there was an administration supportive of their efforts.
We need to get that back in psychiatry.
George Dawson, MD, DFAPA
Supplementary 1:
Since writing this I read Neurosurgeon Henry Marsh’s book Do
No Harm. In it he describes how modern technology has reduced the risk of
neurosurgery but not eliminated it and how even operations that seem to have
gone well can have catastrophic results.
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