An Excursion into the Psychiatric News - Blurred Lines Between Business and Professional Organizations

Psychiatry Eclipsed

Before anyone says that this is me going off the rails again - consider one small factor.  For over 30 years I have been paying the American Psychiatric Association (APA) significant amounts of money in annual dues.  Last year it was about $935.  During some of those years, I thought it might be useful to also donate to their political action committee and I gave them significantly more money.  All the time, I was expecting something to reverse the inexorable deterioration in the practice environment  and the rationing of mental health services.  During that time, I witnessed first hand the deterioration of psychiatric services in the state of Minnesota to the point that there is now a mandate that county sheriffs have priority in admitting their mentally ill prisoners to state psychiatric hospitals.  The psychiatrists in the state have no say in who gets admitted to these facilities or the severely rationed number of inpatient beds in the state.  The reason for professional organizations as I understand them is to speak for and advance the profession, support its members and advocate policies that benefit the people that interact with the profession.  In the case of psychiatry that is the patients that we treat, their families, and the larger society.  All I have to do is pick up a copy of the Psychiatric News to doubt that these mandates are very relevant anymore.

I will say in advance that in my assessment the APA does a fair job in terms of education and professionalism.  I have criticized them in this area in the past for not keeping the treatment guidelines up to date and relevant.  Subsequent to that there was a new guideline published.  Access to the educational materials is not contained in the membership dues.  A subscription to Psychiatry Online or the CME Journal Focus are additional charges as are CME credits for reading articles in the American Journal of Psychiatry.  There is also a CD version of courses and presentations at the APA Annual Meeting that is available for a significant cost.  The educational and professional materials are definitely available and some of them are first rate - but they do come at a price.

My biggest problem with the APA has been the total lack of rigor in countering the deterioration of the practice environment and in many cases seeming to directly participate in initiatives that are counter to the interests of psychiatrists and their patients.  Thumbing through the September 16, 2016 edition of the Psychiatric News provides some ready examples.

On page 1, there is a story Everett Appointed head of New SAMHSA Office.  The story is all about APA President Elect Anita Everett, MD assuming a new position as chief medical officer at SAMHSA - the lead federal agency for mental health and substance use treatment.  A direct quote from Dr. Everett: "Having a psychiatrist as a member of the leadership team at SAMHSA will enable psychiatrists to join other mental health and public health professionals in guiding the federal component of the nation's behavioral health systems."  My emphasis on behavioral health.  As far as I am concerned SAMHSA is a pro-managed care government bureaucracy - like most of them.  Secondly, there are plenty of psychiatrists out there who have been chief medical officers for managed care companies and I would challenge anyone to tell me why they are necessary and what they have accomplished.  Managed care companies tell psychiatrists what to do.  They are not interested in a reasonable practice environment, reasonable inpatient settings of even professional standards.  They are interested in cheap, rationed care by overworked clinicians.  I don't doubt Dr. Everett's qualifications or good intentions.  I don't think I am going out on a limb too far to say that she is going to be severely restricted by the current bureaucracy with a strong managed care bias.  That is not good for psychiatrists and it certainly is not good for patients.

The other story on page 1 seems worse - Are Psychiatrists prepared for Health Care Reform?  Yes and No.   I really can't think of a more nauseating term in the medical literature than health care reform.  I have been hearing those hot little words for the entire length of my career.  I heard them from the Clintons back in the days when Hillary Clinton headed up the health care reform efforts during the first Clinton presidency.  Some students of the topic like to recall that for one reason or another the initiative worked on by Hillary Clinton was not successful.  I think that depends on the standard.  There certainly was no expected global program, but it did make managed care a household word and set managed care as the predominant bias in all further discussions of health care reform.  Like most history - people seem to have forgotten this and the Clinton administration (and all that followed) as having a strong managed care bias.  The article suggests that psychiatrists need to get on board with the collaborative care model - another managed care rationing technique.  In the span of 3 decades psychiatry has gone from protesting managed care rationing (especially because it affects us and our patients the most) to suggesting you really have to get on board with this.  The usual buzzwords like further workforce development and merit-based payment reforms are evident.  When professional standards are abandoned what is merit-based payment reform? In all likelihood it has to do with rationing techniques rather than quality medical care.  Paragraph after paragraph in this article read like a managed care playbook.  Maybe the only way to see through all of this pro management rhetoric is to have actually worked in one of these systems of care.  Try working in one with a manager who is reimbursed to extract the maximum amount of productivity while not providing resources to physicians in the system.  In that case I believe the management buzz word is creativity.  In a rationed environment there is often an audacious statement about creativity as a solution rather than additional personnel.  Most reasonable people would be shocked at what constitutes merit-based payment or the hold back procedures before you can get to that level.  Just another in a long line of meaningless cliches flowing from health care reform.

As you might imagine I was a little tense and clammy as I went on to page 2.  There I was an editorial piece by APA President Maria A. Oquendo, MD.  It was title Why 'Physician Heal Thyself' Does Not Work.  I was mildly optimistic that she might come to the same conclusion that I have about physician burnout - it is not a disease it is just bad management.  Dr. Oquendo began  with a description of the recent suicides of a psychiatric resident and a medical student.  She presents the epidemiology of physician suicide and suicidal ideation.  She points out for example that suicide is the second leading cause of death for physicians between the ages of 24 and 35.  She discusses the stigma of a psychiatric diagnosis and the gap between problems and who gets treated.  Her solution is self identification of depression and excessive alcohol use.  There seem to be other factors that are operative.  She quotes a six fold jump in PHQ-9 scores during internship - using that as a metric for depression.  I can't help but think how physicians and trainees are more isolated now than ever.  No matter what the setting we had great teams when I was an intern and resident.  We took care of one another and we had attending physicians who cared.  I addressed some of that in my previous burnout article.  Nobody discusses what it is like to train in a managed care and rationed environment today compared with medical care as usual in the past.  During my last stint in a hospital I did not see well developed teams anywhere.  Most of the senior physicians who did a lot of the teaching and tended to view themselves as affiliated with residents had been replaced by hospitalists.  Entire teaching services had been replaced.  Non-medical management has left many medical institutions very arid places with few personnel and limited collegiality.  That is exactly the wrong environment for depressed and stressed physicians.   Training programs everywhere can help residents by making sure they build collegiality and that team factor in all of their rotations.  They need to provide highly motivated faculty who have the interests of trainees in mind as a priority.  The teams I am referring to here are teams of physicians, not teams that contain administrative staff telling physicians what to do.

The article most directly related to managed care hegemony was "Medical Necessity in Psychiatry: Whose Definition Is It Anyway? by Daniel Knoepflmacher, MD.  The title is of course purely rhetorical.  Like many things in medicine today medical necessity has nothing to do with medicine.  It is a pure business definition designed to give the appearance of legitimacy to what is a pure business driven decision.  The decisions are made by people with no appreciation of human biology or its complexity.  They are people who seem to think that a lot of meaningless business metrics somehow apply to the practice of medicine.  At the worst (and most probable) they are simply rationing to make a profit.  I would call them nerds but I really don't think that they are that smart.

In the article, Dr. Knoepflmacher makes that point.  There is not even a standard business definition of medical necessity.  Companies can basically say and do whatever they want.  He traces the history of the term and how various groups define it today.  Interestingly one of the largest managed care companies states that it is for payment purposes only.  He points out the overemphasis on acute or crisis care rather than professional guidelines or standards.  I would argue that in psychiatry, managed care companies do a very poor job of addressing acute care by using only a dangerousness metric.  The term cost effectiveness is incorporated into some of the definitions in the 1960s.  The acclaimed Mental Health Parity and Addiction Equity Act of 2008 lacks any definition of medical necessity or a more useful definition of medical appropriateness.  That may explain why this legislation has had negligible impact.  Dr. Knoepflmacher's thesis can be best summarized in the sentence:

"Without universal medical necessity criteria for mental health care, clinicians and their patients are saddled with a concept highly susceptible to abuse by insurers."

I would take it a step further.  The abuse has been institutionalized at this point.  Clinicians find themselves abused at every fork in the road.  Any time a psychiatrist refills a medication for a colleague or because the treatment setting has changed they are subjected to abusive prior authorization processes that are in place purely to harass physicians into giving up and patients to the point that they are paying out of pocket instead of using the insurance they have paid for.   In that case Congress is directly responsible for erecting two multibillion dollar industries and inserting them between the physician and their patient.  I would also propose a much better limit than arbitrary medical necessity criteria.  It should be apparent that any managed care company can get around legislation and rules that they lobbied to pass.  I propose that physicians recommend a course of treatment to patients and that they are totally removed from the payment process.  No more wasting time with insurance company employee-reviewers.  No more conflict of interest in favor of big business.  The physician recommends treatment.  The insurance company tells the patient if they will pay for it.  Other than civil action by the patient, the only oversight should be a panel of physicians carefully screened for conflict of interest at the state level to mediate disputes (sorry no insurance industry insiders).

Highlighting these four articles creates a portrait of what is wrong with the APA.  Like other professional organizations it has clearly bought into the pro-management zeitgeist that is generally sold by American businesses and government.  The general idea is that there are business managers that know more about what you do and can tell you what to do - irrespective of your professional training and experience.  That idea is a mile wide and an inch deep.  Anyone with middle school analytic skills should have come to the same conclusion as Dr. Knoepflmacher - about 20 years ago.  His article is there now as a necessary reminder that there is a much better way to do things.  Instead of affiliating with these outrageous business practices - they should be actively resisted at every level.  That should include the practice and training environments.  There is nothing worse for physicians and patients than wringing the humanity out of medical practice.

And there is nobody better at doing that than current healthcare business managers.


George Dawson, MD, DFAPA



Attributions:  The graphic is all me.  It is supposed to represent a progressive overlap by government and business interests with the profession.  There are psychiatrists that work in the overlap areas and some who work just in the black and gray zones.  The field is still plodding along as though it is an autonomous profession.  

Ethics, Law, and Politics In Psychiatry

I just spent yesterday at the 2016 Minnesota Psychiatric Society Ethical Issues In Mental Health for 2016.  It was a long day, especially for a guy who wants lectures and information.  About 1 1/2 hours was dedicated to a group discussion of cases.  I am always more interested in what the experts have to say - that is my comfort zone at CME courses and meetings.  The first lecturer was Rebecca Weintraub Brendel, MD, JD from the Harvard Medical School Center for Bioethics.  She was also the Chairperson for the Ad Hoc Work Group for the American Psychiatric Association on Revising the Ethics Annotations.  That resulted in the document APA Commentary on Ethics In Practice from December 2015.  A complete listing of the members of that working group is available in the document.  She started out by talking about the Trolley problem and reviewing the various approaches to this issue.  The ethical theories that applied were briefly reviewed including deontology, consequentialism (utilitarianism), virtue ethics, and principalism.  She said that the field has evolved to the point where principalism is the dominant paradigm.  Principalism includes the broad areas of autonomy, beneficence, non-maleficence, and justice.  At this time any search on bookselling websites will pull up a number of references on principalism, including critiques of the concept.  I will probably pick up a copy of one of these books to see just how heavily  the justice component in medicine includes social justice and concepts like global warming.  I have always been amazed at why physicians would expend valuable energy on these issues when they have been unable to protect the integrity of their profession.

A lot of time was spent discussing professional boundaries with some focus on electronic media and communicating with patients.  The afternoon cases discussion focused on two psychiatrists with multiple ethical problems some of which included clear ethical issues involving both social media and electronic communication.  In Minnesota, the consensus is that e-mail communication with patients using typical insecure e-mail is not a good idea, but many psychiatrists are employed by organizations that use secure e-mail through a health system portal.  One of the hypothetical case examples given was membership on Facebook of group therapy members and all of the problems that involves.  One of the key aspects of treating patients like psychiatrists involves not just interpersonal boundaries but also boundaries around the therapy like contact and phone calls outside of the sessions.  Online contact with either frequent e-mail or social media creates the illusion that the psychiatrist is always online and available.  That every comment will be noted, analyzed and responded to.  This is not only unrealistic availability, but also unrealistic analysis.  Psychiatrists more than any other physician should know that typed statements online are very poor substitutes for analyzing the emotional content of communication especially where aggression, suicide, and other critical aspects of judgment are the focus.

The second lecture was given by Colleen M. Coyle, JD General Counsel for the APA and it was titled When Law And Ethics Collide....   Privacy rules, informed consent and substituted consent were the early issues.  A suggested authorization form that covers all of the contingencies was suggested.  I can recall signing several including the standard recredentialing forms that authorizes multiple unknown parties complete access to any and all information about me.  The coercive nature of these forms was not discussed.  I see even the most standard consent to treatment form as fairly coercive these days, especially the sections that cover requirements for disclosure by state laws.  A comparison of attorney-client privilege vs. physician-patient privilege would have been instructive.  I think it would point out the obvious - once again that physicians have done a poor job of protecting their profession and that lawyers have succeeded in making legal decisions (Tarasoff) part of the psychiatric code of ethics.  Some of the vague situations of disclosure under the more liberal HIPAA versus the more restrictive CFR42 were discussed.

The discussion ended on prescription drug monitoring programs, the ethics and the current legal landscape.  The legal landscape was most interesting in terms of who inputs the data and whether mandatory accessing of the database exists.  Thirty one states require that prescribers access the database and 11 of those also require a query.  Nineteen states do not require mandatory access.  There are criminal and civil penalties for not reporting controlled substance prescriptions in the database.  Twenty six states and D.C. provide some immunity from civil liability for not accessing and using the database.  Minnesota has a very reasonable approach.  Pharmacy data populates the database and accessing the database is not mandatory.  As a physician I can't imagine having to treat patients, do all of the necessary documentation and orders/prescriptions and then access a separate database and re-enter the prescriptions.  If that is happening to any extent in other states that is another serious abuse of physician time.  It is also part of the general trend of dictating how physicians practice medicine.  Learning what rules apply to you in your particular state is critical irrespective of how rational the process may or may not be.

Ruth Martinez, MA Executive Director of the Minnesota Board of Medical Practice was the third presenter.  Her emphasis was on documentation, boundary issues, informed consent, and response or lack of response to the treatment plan.  An important concept that I have always used is documentation of the informed consent process.  A written and signed document is not needed (with the exception of ECT and antipsychotic medications in the state of Minnesota), but documentation of the discussion is useful.  In situations where the discussion covers a lot of contingencies, it is useful to come back to that part of the document in terms of treatment planning and what the next step might be.  The only potential problem is that when everyone has access to your thinking, suddenly everyone is an expert as in: "I noticed in your note that if this antidepressant was not effective your plan was to change to antidepressant B.  I discussed this with the patient and he wants to try B now."

The part of the presentation that I was in disagreement with was the discussion of the power differential in the physician-patient relationship.  The rhetoric of power is an interesting one that I hear discussed much more frequently outside of medicine than inside.  In my experience social workers tend to discuss power in relationships.  To me,  power is a nonspecific word.  When I am obsessing about making the right decisions in very uncertain situations - being some sort of omnipotent authority figure is the farthest thing from my mind.  All of the psychiatrists I know operate from a therapeutic alliance model and that can be captured by two sentences:  "The therapeutic alliance means that you and I are working to solve your problems.  In that context it is my job to give you the best possible medical advice on how to do that and your job to decide about whether you want to use that advice or not."  Even in the cases where substitute consent is required like civil commitments or guardianships, the physician involved basically brings the problem to the attention of a judge who makes the determination.  Physicians do not want to run patients' lives.

Steve Miles, MD from the University of Minnesota Center for Bioethics gave the scientific part of the program on the epidemiology of gun violence.  It had striking similarities to some of the positions I have posted here on how to approach this problem that I plan to discuss that as a separate post.  He also reviewed the political timeline on how research into gun violence was eventually defunded courtesy of heavy lobbying by the pro-gun forces in Washington.  

I thought that politics was the important word that was left out of the ethics discussions.  As an example, the issue of torture was discussed and how the American Psychiatric Association came to the position that psychiatrists should not participate in torture.  That was a lengthy discussion that eventually came down to a line in the sand - psychiatrists should never participate in torture.  That is not true for two other ethical dilemmas discussed in this conference - managed care utilization review and collaborative care.  Instead hypotheticals were discussed.  If you were this managed care reviewer and your company wanted you to deny specific care that you knew was indicated - what would you do?  Similarly - if you were in this collaborative care arrangement and your salary and bonuses depended on what you were using to fund the "at risk" population that you were seeing - what would you do?   So basically being a military psychiatrist asked to perform torture there is a clear ethical guideline and in the managed care and collaborative care situations you are on your own.  You can call me concrete, but if I was king, the latter two situations would also be forbidden by the ethical code of psychiatrists.  In the case of collaborative care the APA recently announced (1) it received a federal grant to "train 3,500 psychiatrists in the clinical and leadership skills needed to support primary care practices that are implementing integrated behavioral health programs."  Instead of questioning the ethics of a practice that limits the direct assessment of patients by psychiatrists and potentially creates financial conflicts of interest - at the organizational level the APA celebrates this grant and making the practice it more broadly available to all psychiatrists!

Calling the APA Ethics Committee with your ethical dilemmas was encouraged and they clearly take it seriously, but I think these inconsistencies do not make the organization popular among clinicians who deal with these problems on a day by day basis.  They are as easily solved as the questions about physician participation in torture and executions.


George Dawson, MD, DFAPA


References:

1:  Mark Moran.  APA Receives Federal Grant to Train Psychiatrists In Integrated Care.  Psychiatric News - November 6, 2015.  v50(21): p.1.

The grant to train 3,500 psychiatrists was $2.9 million over 4 years or about $828 per psychiatrist.  Each psychiatrist is expected to support up to 50 primary care providers and consult on the care of 400 patients per year.  The ultimate goal is to support 150,000 primary care providers and consult on the care of a million patients a year.  Does anyone see the problems here?     



                     

The New APA Practice Guideline

I got a link to the new American Psychiatric Association (APA) Practice guideline today in my Facebook feed.  It was entitled Practice Guidelines for the Psychiatric Evaluation of Adults.  It is an updated version of a previous guideline by the same name.  I have pointed out on this blog that the APA seems to have all but abandoned the production of these guidelines with the exception of some extensive work for CMS to determine whether or not administrative guidelines about billing and coding were adequate.   When I complained to APA officials about the fact that they were not producing any new or updated guidelines I was told two things.  The first was to wait for this current guideline.  The second was that guideline production and updating did not seem to be a wise use of limited resources.  My interpretation of that remark was that it was defeatist and probably related to the fact that everyone is currently producing guidelines.  I guess that nobody at the APA recognizes the need to set limits on pro-business and pro-government guidelines that actively discriminate against psychiatrists and their patients.  Apart from a single APA President, that seems to have been the conventional wisdom that they have been using for the past 30 years.

I read the entire relevant section of the Guideline and that involves the first 52 of 170 pages.  The last section includes references, abstracts and methodology like bar graphs showing how many experts agreed that a certain type of assessment needed to be done in an initial assessment.  The introductory release explained that the guideline was based on an Institute of Medicine (IOM) publication entitled Clinical Practice Guidelines We Can Trust.   I have not been impressed with some of the work done by the IOM in the past and after reading three of their previous books wonder if it makes sense to read a fourth.  There are additional references on the methodology in the introductory sections of the document.  The release describes the guideline as modular so that each of the nine different modules can be updated regularly and separately.   That is a good idea that will hopefully add timeliness to the process.  One of the goals is to have the guideline widely disseminated.  Apparently anyone can download the document and read it.  There are the usual legal qualifiers pointing out the limitations of a broad document like this one and why it cannot be considered a standard of care.  I did not see the most obvious reason mentioned and that is that this concept is a legal one used for the determination of medical malpractice and that it really has no application in medicine.  Guidelines are referenced in Gutheil and Appelbaum's text:  "Third, another source of information about standards of care is the growing number of practice guidelines.........  It must be remembered, however, that even well-designed guidelines  do not necessarily address all possible approaches to a clinical issue." (1).  So the guideline disclaimer is clearly debatable in court.

As I read through the guidelines several things jumped out at me.

1.  It was not clear that this guideline was written for psychiatrists -  Some may say that this is implicit, but I am bothered by the fact that in the first 52 pages the word "clinician" pops up 34 times and the word "psychiatrist" pops up 17 times.  What would prevent any clinician from claiming that they have done everything listed in this document and therefore their evaluation is the equivalent of a psychiatrist's evaluation.  This is more than a guild or political issue as I will elaborate below.

2.  It was not clear what type of expertise was necessary to use the guideline - I suppose this is a minor variation of the first point, but technical expertise to me has always been a critical issue.  The guideline gets around this by saying it is not a "comprehensive" document.  I would not consider the recognition of acute medical and neurological problems or even chronic ones to be beyond the scope of a psychiatric evaluation.  I would not consider an abbreviated list of these conditions to necessarily render this a comprehensive document and it would certainly have more clinical value than a tedious list of all of the survey results.  The document also discusses tests in terms of the optimal ordering of tests and also specific kinds of tests.  What about who interprets those tests?  As a very basic example, I would go back to the days of the oral board exam in psychiatry and frequent questions about the use of lithium.  Board examiners were interested in what tests needed to be ordered to initiate and follow lithium maintenance therapy.  The goal of that exercise was to certify a safe practitioner of psychiatry.  In today's world, there is a much larger number of tests, interpretations and plans based on those tests.  This is a critical line of demarcation in some practice settings that seek to limit the medical role of psychiatrists.

It is apparent that the APA wants this guideline to be widely disseminated.  A related concern is that they may have not learned much from the wide dissemination of the DSMs over the years.  Although there is a partial financial incentive with DSM releases, the APA may be oblivious to the downside of everyone having a copy of this manual.  The pre-DSM-5 release rhetoric illustrates that a lot of critics had a very poor understanding of what the DSM-5 was and how it would be used.  Wide dissemination of a vaguely written practice guideline may have the same effect.  There is a common bias than anyone with a social brain who can speculate about the motivations and goals of others can do what psychiatrists do.  There are endless examples of various writers speculating about which public figure may have Asperger's or narcissistic personality disorder.  The sentiment in some circles seems to be: "If I have a copy of the DSM - I can diagnose people."  What is to prevent a similar co-opting of the Practice Guideline?

3.  There is nothing really surprising in the document - The assessment techniques are either obvious things that psychiatrists and psychiatric trainees do on a regular basis.   There are so many qualifiers that many approaches can be taken.  For example, the issue of coming back to an initial point to clarify the diagnosis if it could not be appropriately done in the initial interview was mentioned several times.  That is useful in cases when a patient is embarrassed or defensive about a particular aspect of their history.  In this regard, the document represents both content and process variables of the interview.  

4.  Tip of the cap to evidence based medicine - even when it is not needed - A common refrain throughout the guideline was:  The strength of research evidence supporting X is low, where X is the guideline of interest.  I summarized the guidelines and statements in the table below.  The numerical and letter designations can be translated as follows.  The numeral 1 is a recommendation.  The numeral 2 is a suggestion.  The letters A, B, and C are degrees of evidence reflecting high moderate or low degrees of evidence respectively.  The table basically reads as a recommendation or a suggestion backed by low degrees of evidence.

Using research evidence as a criteria for standard clinical methods is taking evidence based medicine to its absurd conclusion.   I am not talking about refinements in the way the history and physical has been done over the years, but the basic idea that a physician has to make a diagnosis and come up with a treatment plan.  Is there really any question that there are currently thousands of clinical trials that document positive treatment effects based on inclusion criteria that include a standard evaluation of the patient and the recognition of certain medical exclusion criteria?  The Guideline includes an explanation about why it is unethical to do certain double blind placebo controlled trials such as the study of suicide and aggression.  It does not comment on the important clinical question: "When does the anecdotal become statistical?"  To illustrate, if I am currently an inpatient psychiatrist and 100% of the patients I see are admitted for suicidal/aggressive ideation/behavior and my post discharge complication rate is very low (1 incident of suicidal or aggressive behavior every 500 discharges) - what is the likelihood that I am no more effective than placebo?  Do I really need a clinical trial to prove that I am doing something?  Are there any statisticians out there willing to speculate on that problem?    

5.  The information aspects of the evaluation - this critical aspect of the evaluation has not been studied in the field and the lack of these studies leads to a number of vagaries in the guideline.  It should be possible to illustrate the range of information exchange across a number of interviews and the optimal amount of information exchange in terms of diagnostic yield and enhancing the diagnostic and therapeutic aspects of the interview.   It is a way to advance the technical aspects of the field without deference to neuroscience.  Psychiatry has been stuck in essentially the same interview technology since the 1940s with no significant advances.  Looking at the information exchange that occurs in the interview is a long standing omission and it is probably the best way to advance this central part of clinical practice.

6.  A well deserved shot at the electronic health record  - After about two decades of hearing nothing but praise for the EHR and how it will revolutionize the practice of medicine and "save" us all hundreds of billions of dollars, its shortcomings are so obvious and so severe that even the APA gets it.  From page 44 of the Guideline:

"With the increasing use of electronic record systems, the structured but fragmented information that is common in electronic record notes can increase cognitive workload and reduce the quality of communication among those caring for the patient..."

That is a diplomatic way of saying that if you follow the suggestions for collateral information in the Guideline and are unfortunate enough to get either a printout or have direct access to an EHR, you might spend hours reading through hundreds of pages only to discover that the document has no discharge date, that it contains minimal information or that (in the case of lab testing) you can't determine the dates that any of the testing was done.  You will probably also encounter an EHR template approach to documentation that provides a series of "yes-no" responses where real information is traditionally used.  The current EHR is a plague on those specialists who require high quality information and plenty of it.  It should be apparent from the general requirements of this guideline that psychiatry is at the top of the list.

7.  Inconsistencies are present in many places - One of the better examples is several qualifier paragraphs that point out how descriptions may be necessarily vague and how to negotiate that in the assessment itself.  There are terms having to do with time as well as clinical descriptions.  The guideline says that it does not encourage stereotypical questions to complete the assessment, but at the same time suggests "quantitative measures" like standard checklists.  I cringe when I see that term because it was a term that was included in the Joint Commissions 2000 statement on pain assessment and treatment and we all know how that turned out.  To an old chemist, asking a person where they are on a ten point scale that rates pain or depression or anxiety is far from a quantitative measurement.  At some point, psychiatrists and physicians lost sight of the fact that certain organ systems (the brain in particular) by its very structure,  precludes quantitative analysis - and that is a good thing.  The authors of this guideline should at least attempt to explain how an obviously subjective and flexible evaluation can eventually lead to rigid "quality" measures that are also being used as if they are quantitative.  At some point, some professional organization needs to point out that most if not all of these measures are fabrications of the business community and government and they have little to do with medicine or science.  If the APA can say that about all of the points in their guideline, why can't they point out that the same "quantitative measures" are used in collaborative care and they mean the same thing.

8.  The serious dimension of the diagnosis - There are a lot of reasons why patients and families tend not to take a psychiatric diagnosis as serious as they should.  It took me a number of years in clinical practice before I realized that any informed consent discussion I have with a person should include whether or not that diagnosis is life threatening to them.  In some cases like talking with a survivor of a near lethal suicide attempt it is obvious.  In other cases like a major psychiatric disorder and a number of close calls due to a substance use disorder, it is less obvious.  I will tell a person that the condition they have is life-threatening and the treatment plan and their part in the overall treatment needs to take that into account.  There may be an associated discussion of voluntary and involuntary treatment as well as a clarification of my position in the patient's treatment and the associated rationale.  I think it is critical that this assessment is made and carefully documented for continuity of care purposes.

These are a few of my initial comments.  The new treatment guidelines is far from perfect but it is a start to get the APA back on track again to establish reasonable guidelines written by psychiatrists about the practice of psychiatry.  The introductory material suggests that the method will be to modify the various sections, but what is needed is another section or probably a new guideline on treatment planning and how that interfaces with the Evaluation Guideline.   

George Dawson, MD, DFAPA

1:  APA Work Group on Psychiatric Evaluation.  The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults — Third edition.  American Psychiatric Association, 2015.

2:  Thomas G. Gutheil,  Paul S. Appelbaum.  Clinical Handbook of Psychiatry and the Law,  3rd Edition.  Lippincott, Williams, and Wilkens, Philadelphia, 2000. p. 299.      

APA's Feelgood Move of the Year?

I noticed on another blog that there were expected praises and a few sarcastic comments for the American Psychiatric Association (APA) announcement that they had signed on with another 600 organizations to support the AllTrials initiative.  In case you are unaware of this initiative, Google the name and it will bring you to the web site.  The web site will give you more than enough information on why transparency and enforcement of pharmaceutical company behavior is important and why you should sign the petition.  It will even provide you with a section on "Myths and Objections"  to dispel any concerns that you might have about - well, myths and objections.  It really did not address my concerns about the fact that clinical trials technology as we know it is incredibly crude, they are practically all short term, and they have little to do with how the medication is used in clinical practice.  To me it seems like an exercise to try to keep the pharmaceutical companies honest.  If it also succeeded in keeping the useless meta-analyses of flawed studies out of the literature and prevented the same people who produce those studies from drawing even more flawed conclusions about psychiatry, I would be all for it.  But I doubt that is going to happen.  I also doubt that it will have any effect on the drugs marketed in the USA.  It should be fairly clear from observing FDA behavior that their decisions aren't based on good studies or even the reviews done by their own scientific committees.  You could list any study in the AllTrials database and it could lead to FDA approval whether it was positive, equivocal or negative.

My biggest objection to the APA using its vanishing street cred to sign on to this feelgood initiative is that doesn't do me any good as an APA member, it doesn't do my patients any good and it has no implications for the future of the field.  It is like signing on to any feelgood initiative, you seem to get credit along with all of the other do-gooders, and all you have to do for it is sign your name.  That would bother me a lot less if I did not pay the APA $935/year for professional membership and if they would return my calls once in a while.  It would also bother me a lot less if they actually addressed real problems that their membership was concerned about.  The kind of heavy lifting that might really cost something.  Ignoring these problems is also costing them something right now in terms of members who are walking away.  It doesn't take too many members walking away at $935 apiece to have an impact on the organization.   I have discussed the problems many times before on this blog but here are a few items that should be APA priorities:


1.  MOC/MOL -

The maintenance of certification issue is not fading away with benign neglect at this time.  Interestingly, the revolution in this area is being led by the generally more conservative internists and internal medicine specialists who have eloquently described how little sense it makes to oppress the most oppressed and most accountable professionals out there and pretend that "the public" is demanding more testing and arbitrary exercises to maintain board certification.  As if that is not enough, the idea that this MOC can be converted into a necessary step in licensure (Maintenance Of Licensure would really put a lock on that unnecessary industry.  Until very recently the APA has been completely deaf to member's efforts in the area.  I don't know some recent interest reflects members voting with their feet and just walking away or the message that some specialists are not going to cave in on this issue and will go so far as starting their own organization for MOC.

2.  Managed care - utilization review -

Managed care companies and pharmaceutical benefit managers harass psychiatrists to  greater degree than other physicians.  These companies have destroyed the infrastructure for inpatient care and any concept of quality in psychiatric care.  Practically all psychiatric care in this country is now dictated by these companies and the arbitrary rules they have set in place to ration it.  The APA made some initial attempts to explain managed care and advise their members about how to "get along" with these methods.  At no point was it suggested that there was a severe ethical problem with allowing for profit companies to dictate psychiatric care.  At no point was there any strategy to illustrate the difference between quality care and rationed care.  Instead, we read stories of the mentally ill being incarcerated by the thousands and the inappropriate care they receive in jail.

3.  Managed care - PBMs -

Billions of dollars are wasted every year as pharmaceutical benefit managers ration generic drugs and tie up physicians and their office staff in order to make more profits.  There is no other group of professionals anywhere who are basically forced to work for a managed care company for free in order to help them ration medications and turn a profit.  The only action I have seen from organized psychiatry was a half measure about a standard prior authorization form that for some reason could never be adequately enacted.  There is always something within federal law that favors managed care companies and gets in the way of addressing this.

4.  Organization wide support for models of care other than collaborative care -

There are massive problems with the collaborative care model that is being promoted by the APA along with SAMHSA, the managed care industry and their partners in government.  The hype is at about the same level as the promotion of the managed care industry was in the 1980s and '90s.  It is obvious how that turned out.  The reason people train as specialists is to provide specialty care, not to sit in a primary care clinic and supervise the prescription of antidepressants based on a rating scale without personally assessing patients.  The real pipe dream here is that primary care clinics under the accountable care organization model will hire psychiatrists to provide the academically proven cost savings to their primary care clinics.  I guess that was a media moment lost on the APA; the models used to hype the care model and sell it to politicians are not the ones eventually implemented by the "managers".   Expect the same rationing and either the complete elimination of psychiatric services to save money or psychiatrists offering their services on their own.  The APA should at least be prepared for that and be involved in preparing their members.

5.  Lack of recent professional guidelines -

Contrary to what a lot of people think, the DSM-5 has nothing to do with treatment.  The APA has treatment guidelines, most of which are in need of a serious update.  They also need guidelines to cover most specific practice situations such as the treatment of aggressive or suicidal patients.  A serious update and an ongoing effort to stay current is necessary in order to prevent the illusion that some guidelines put together by a business organization is as good as and somehow represents professional standards.


These are a few of the things that psychiatrists and the members of the APA need right now!  I doubt that any of us are going to be impressed with the sign on to the AllTrials initiative.  I would not be surprised to find out that most APA members haven't heard about it.  I am a member and I am on the APA listserv and the APA Facebook feed and did not get any notification about this happening.

I don't see anything wrong with the APA signing on to a feelgood initiative on the face of it.  But over the years the membership has paid a lot of money for an organization that supports professional education, standards and advocacy.  Signing a mass petition for an initiative that is not likely to do anything to advance the science or patient care is a politically correct symbolic gesture.

We need a lot more than that and we have for years.



George Dawson, MD, DFAPA

What Can The APA Learn From UpToDate?

By way of introduction UpToDate is a highly successful online internal medicine text.  It has associated features such as handouts for patients on medications, procedures, and medical conditions.  It also has an online drug interaction feature that allows a limited set of preferences on the part of the physician.  CME credits are available for reading online.  The text covers a broad range of diseases and conditions.  I have asked them for more specific data on the extent of their coverage and total number of pages, but they refused to give it to me citing that it was proprietary information.  I noticed that they currently say that they have 77,000 pages updated by 5100 physicians.

I have been a subscriber to this service for a number of years and the subscription rate is currently about $500/year.  To illustrate how important that number is I need to compare UpToDate to what it replaced.  Ever since graduation from medical school I purchased a new internal medicine textbook about every 4 - 5 years.  I was also a 20+ year subscriber the the Medical Clinics of North America.  I considered it all a part of keeping up on general medicine while practicing psychiatry.  The cost of a typical medicine text like the last one I purchased Textbook of Internal Medicine (William N. Kelley, MD, ed) was somewhere in the $200+ range.  Searching Amazon it looks like my text is out of print by the two comprehensive texts are available for $224 (Harrison's) and $151 (Goldman-Cecil).  Doing the math shows that for $200 you can get a serviceable text that might last you for 5 years (it goes without saying that you always have to do additional reading) and at the end of the day - you still have text in your hand and a valuable reference.  That same 5 year period as a subscriber to UpToDate will provide you with online access of updated data and at the end of that time unless you renew - it is all gone.  Granted it is handy to have this available online if you are working in a hospital setting on different units and the CME feature is very nice - but the cost is about $2500 or twelve and a half times as much as a text every 5 years.

The premium cost in UpToDate relative to a medicine text probably has many things driving it.  The advent of the hospitalist in combination with the electronic health record are probably two of the most significant factors.  If you have internists working 10 hour days 7 days on and 7 days off across large hospitals suddenly there is not time to go to libraries and do research.  All of the information needs to be available as they are essentially word processing documents in the EHR at computer terminals.  In case you haven't tried it, it is also much easier to electronically search a textbook than to heft its considerable weight and keeping flipping flimsy pages back and forth from the index.  Many large groups now provide UpToDate online to their hospitalists and medical specialists in order to keep them working right at those word processing terminals.  These same hospitalists consulting on my inpatient psychiatric unit introduced me to UpToDate when it first came out.

How does all of this this apply to the currently dated and I am guessing infrequently used American Psychiatric Association (APA) Practice Guidelines?  Just looking at the dates of these guidelines shows that applying my approach to internal medicine by purchasing a new text every 4 or 5 years, would have left me more up to date with a psychiatry text than the current APA Practice Guidelines.  What about content in UpToDate?  There are 13 chapters on the major psychiatric disorders that psychiatrists treat.  There are several subheadings under the major headings.  For example, under the heading Anxiety Disorders there are chapters on acute procedure anxiety, acute stress disorder, agoraphobia, combat operational stress,  comorbid anxiety and depression, co-occurring substance use disorder and anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and social anxiety disorder.  There are separate chapters on the pharmacotherapy and psychotherapy of these disorders including fairly esoteric approaches to treatment like deep brain stimulation for obsessive-compulsive disorder.   The sections are all detailed and frequently updated.  Not only that but the recommendations section is essentially written as treatment guidelines.  As an example from that section (1):

"We recommend that patients with obsessive-compulsive disorder (OCD) be treated with cognitive-behavioral therapy (CBT), a selective serotonin reuptake inhibitor (SSRI) medication, or both (Grade 1A)."

Their definition of  Grade 1A Recommendation is:

"A Grade 1A recommendation is a strong recommendation, and applies to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present."

This is the general outline of the psychiatric disorders section in UpToDate.  From the sections I have read their literature review and section updates are all within the last 1-2 months and some of the sections are written by top experts in the field.  The detail is well above what an internist or family physician would need but I would not say it is less than what most psychiatrists need.  It gives practical advice on what is known about the treatment of psychiatric disorders and it is condensed down to about 4 - 12 bullet points at the end of each section.  Solid recommendations are made on management where possible and the recommendation is also graded as to whether or not there is good research to back it up.

What is the importance of these developments for psychiatrists, organized psychiatry, and medicine in general?  I think there are a number of important points.  First, psychiatry is represented in a text that is read by internists and family physicians to a greater extent and in more detail than ever in the past.  This is good for several reasons.  It provides some guidance to primary care physicians in considering the treatment of patients with complicated psychiatric problems at time when there may be fewer psychiatrists covering their patients.  It provides them with technical details that are needed to provide care.  It makes it easier for them to assume the care of patients who have be correctly diagnosed but can no longer be followed by a psychiatrist.  Overall it is good for the idea that psychiatry is a mainstream speciality in the field of medicine.  Second, it brings up the critical question of why the APA has a web page with the APA Practice Guidelines listed at all?  Most are hopelessly out of date.  They have little public visibility.  There have been some opinions that the time for practice guidelines by professional organizations are a thing of the past.  After all, managed care organizations and governments write the guidelines now don't they?  A secondary question is what is the purpose of a professional organization?  In my most read post on this blog, I suggest that it is to propose and disperse state-of-the-art treatments to its membership ("There is a responsibility to establish professional standards for patients referred to psychiatrists for the assessment and treatment....").  Certainly there was a recent opportunity.  An expensive effort bringing together top experts in all fields from around the world was done to compile the DSM-5.  The public was clearly confused about this project when the press and several critics equated the DSM-5 to treatment rather than diagnosis and misread the DSM-5 as being something more than it really is - a guidebook to the International Classification of Diseases.  I have seen experts from that collaboration speak at two conferences now and they happen to also be experts in the treatments of these conditions.  Would it have been wise to update the treatment guidelines in the manner of UpToDate rather than leaving the effort at the level of the DSM-5?  I think that it probably would have.

I brought this issue up recently and was told by people at decision making levels in the APA that they are rethinking the Practice Guidelines from a cost effectiveness standpoint.  My thinking on this is very clear.  If the APA does not want to represent the membership as a union dedicated to advancing the rights and interests of the members from that perspective then it really needs to present itself as a professional organization.  APA members certainly don't enjoy the benefits typically seen when businesses or unions lobby Congress.  If anything psychiatry and medicine has been in an unchecked downward spiral of overregulation and exploitation from businesses for about 30 years now.  The argument is typically made that we are a professional organization and focus on professional education and accountability.  Practice guidelines demonstrate that you have the expertise and wisdom to make that claim.  The APA can no longer say that.  There are more succinct treatment recommendations written by experts and more frequently updated in an online text that targets nonpsychiatrists.

I will be the first to suggest that  this is bad for the profession for a number of reasons and further evidence that the APA is doing very little to advance the profession and the plight of its members.  The current guidelines should be removed (at least the dated ones) and the organization needs to think about a streamlined process to construct new ones or get out of the practice guideline field.  



George Dawson, MD, DFAPA    

References:

1:  Simpson HB, Stein MB, Hermann R.  Pharmacotherapy for obsessive-compulsive disorder.  In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 21, 2015.)


        

How Should APA Guidelines Work?

The guidelines of the American Psychiatric Association (APA) are an interesting story in how guidelines are important if used correctly by professional organizations.  The whole idea behind a profession is that the practitioners in that area have special expertise and that the expertise is standardized to some degree.  Standardization is useful in the case of physicians to assure the safety of the practitioners and so that people have some idea of what to expect in terms of safe and effective care.  Over a decade ago the APA began producing guidelines for practice in various areas of the field.  I thought it was an exciting development.  The guidelines were initially sent along with the monthly copy of the Journal of the American Psychiatric Association.  All of the guidelines are available publicly on this web site, but hardly anyone knows about them.  I make this statement because one of the many red herrings that the critics of psychiatry use is that psychiatry has no standards of care.  They seem quite shocked to find that these guidelines exist and address their complaints directly.  

I was asked to critique one of the existing guidelines and suggest how these guidelines could be used more effectively.   In looking at the guidelines web site, it is apparent that some of the guidelines have not been updated in quite a while.  Publication dates range from 2000 - 2010.  Given the pace of clinical research 5 years might be somewhat acceptable, but 10 - 15 is probably not.  Another issue that the APA needs to grapple with is the diagnostic manual versus treatment approaches.  There is widespread confusion about whether or not the DSM-5 is a guidebook for treatment as opposed to a guidebook for diagnoses.  The APA actually two approaches to treatment guidance - the guidelines themselves and a text entitled Treatment of Psychiatric Disorders (TPD).  TPD is currently in its 4th edition and it has gone from a series of two volume detailed text to a more basic single volume text.  That text was published in 2007.  Some of the chapters in the previous editions provide some of the most detailed information on the pathophysiology and treatment of certain disorders that could be found anywhere.  At that level of analysis, the APA has gone from providing outstanding information on the pathophysiology and treatment of psychiatric disorders to a relative vacuum over the past 10 years.

For the purpose of a more detailed analysis I will consider the Practice Guidelines on Substance Use Disorders and the associated Quick Reference Guide and Guideline Watch - a 2007 update of the original 2006 guideline.  I looked at the Guideline Watch first because it should reflect the latest literature reviews and treatment guidelines.  The document reviews medication assisted treatment of tobacco and alcohol use disorders with varenicline, naltrexone and acamprosate.  The document was a good summary of the literature at the time but it needs a serious update.  Since then there have been more extensive studies of the genetics, combination therapies, re-analysis of existing studies and side effects of naltrexone, acamprosate, and varenicline including use in specific psychiatric populations.  In at least one case, the current literature supports a course of action that is exactly the opposite of what is recommended in this document.  That course of action is: " Given its high potency and partial agonist activity at central nicotinic acetylcholine receptors, varenicline should not be combined with alternate nicotine replacement therapies."  An inspection of the references for varenicline notes that additional research has been done in this area and should be discussed.      

The Quick Reference Guide contains extensive tables from the original guideline so I will go directly to that document.  At first glance it looks like a significant document more than 200 pages long.  But about 177 of the 276 pages of the document are relevant text.   The rest are references and polls of various expert groups on what they consider necessary for a guideline.  Looking at the Table of Contents, the first thing that is apparent is that only a subset of substance use disorders is being considered.  Although it is likely that nicotine, alcohol, marijuana, cocaine and opioids represent the majority of abused substances psychiatrists treating addiction see a broader array of compounds being abused.  The full gamut of abused compounds should probably be addressed in the guideline whether or not there is a consensus about treatment methods or not.  The safety of users and treatment setting considerations will still need to be considered as well as the need for further assessments.  A good example would be Hallucinogen Persisting Perceptual Disorder and what might be the best assessment and treatment.  If the guidelines are supposed to apply to clinical practice then patterns encountered in clinical practice need to be addressed.  If the APA does not address them - governments and managed care companies will, most frequently to the detriment of patients.

The guideline uses the following conventions for the treatment recommendations.  They are conventions frequently see in professional guidelines:

[I] Recommended with substantial clinical confidence.
[II] Recommended with moderate clinical confidence.
[III] May be recommended on the basis of individual circumstances.

The introductory section does not suggest who the guidelines are written for.   This is a critical aspect of the document.  There is an implication that it is for psychiatrists based on the statement about a comprehensive psychiatric evaluation but I think that needs to be more explicit.  It is not uncommon for managed care companies to send letters that deny care to psychiatrists.  The letter often contains a list of guidelines that an insurance company reviewer used to deny the care.  The APA needs to be explicit that these guidelines are intended for use by the psychiatrist who has personally assessed and is treating the patient and not by an insurance company employee or contractor who is sitting in an office reading through paperwork.  Somewhere along the line professional organizations seem to have lost track of the concept that only direct assessment and treatment of the patient was considered the correct way to do things.  Putting it in all guidelines is a critical first step.

The next thing I would change in terms of guidelines is breaking out the treatment setting recommendations into separate sections in table form.  For example the Hospitalization guidelines are copied into the Supplementary section of this post.  They are all very appropriate and I doubt that there are any reasonable clinicians that would have a problem with them.   The problem is that these services are rationed to the point that it is difficult for any reasonable clinician to implement them.  By that I mean that a psychiatrist cannot get a patient meeting these criteria into an inpatient detox or treatment setting based on these criteria.  As an example, consider the patient who says they are drinking 1 liter to 1.75 liters of vodka per day for 6 months.  They describe uncomplicated symptoms of alcohol withdrawal (shakes, sweats, hangover symptoms and drinking in the morning to suppress these symptoms).  I think the person in this vignette meets criteria 2 for hospitalization and detox at least.  A significant number of patients presenting to emergency departments with this pattern of findings are not hospitalized.  Many are sent out with a supply of benzodiazepines to detoxify themselves.  Many are sent to county detox facilities where there is no medical coverage or so-called social detoxification settings.  None of these non-hospitalization options are realistic approaches to the problem.  Giving a person with an alcohol use disorder a bottle of benzodiazepines for home detox ignores the uncontrolled use and cross addiction aspects of the primary disorder.  It is highly likely that person will ingest the benzodiazepines all at once or use them to treat the morning withdrawal symptoms of the disorder.  Social detoxification is an equally suboptimal approach.  It depends on probabilities.  It is more likely that the person transferred to that setting will leave due to the adverse environment and go back to drinking or undergo withdrawal and not experience delirium tremens or withdrawal seizures.  Over the past 30 years, the managed care industry has refused to consider admissions in practically all of these situations often whether there was psychiatric comorbidity or not resulting in the rationing of care at the initial assessment in the Emergency Department.  There must be an awareness that clinical guidelines don't operate in a vacuum.  Having a guideline in place that nobody can use is not the best approach to providing quality care.   Managed care companies can deny inpatient care on practically any of the 7 inpatient criteria simply by saying that they do not exist.    

On the treatment side there are inconsistencies noted in the recommendations and editing problems.  For example, there are 49 references to "12-step" and 2 references to 12 steps.  One of the first statement one encounters is:  "The efficacy of treatment is related to the amount of psychosocial treatment received. The 12-step programs, hypnosis, and inpatient therapy have not been proven effective."  That characterization of 12-step recovery is inconsistent with just about every other reference in the document.  Where it is suggested it is footnoted with a "I" designation or "substantial clinical confidence."

Rather than critique other sections based on data that was not available at the time that this guideline was posted, I thought I would end with a comment on the process and general philosophy of professional guidelines.  Right at the top of this guideline is a section entitled "Statement of Intent".  The crux of that argument is contained in the paragraph (p. 5):

 "The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed
or to serve as a standard of medical care. Standards of medical care are determined on
the basis of all clinical data available for an individual patient and are subject to change as scientific
knowledge and technology advance and practice patterns evolve. These parameters of
practice should be considered guidelines only. Adherence to them will not ensure a successful
outcome for every individual, nor should they be interpreted as including all proper methods
of care or excluding other acceptable methods of care aimed at the same results........"

I don't really agree with that approach.  The concerns about saying that these are standards of care is a medico-legal one and I have rarely found that to be a sufficient basis to practice medicine.  An example would be litigation against a psychiatrist for not following the stated standards of care in a malpractice suit.  This may seem protective of psychiatrists for varying practice styles but it also has the more insidious effect of basically allowing any standard of care to apply.  A walk down the street to a different hospital results in an admission for medical detoxification when the first hospital discharges the patient with a prescription of lorazepam and a promise to follow up with their primary care MD.  The resulting business incentive practice creep results in a complete lack of detoxification and a lack of any standards of medical care.  The default standard is whatever businesses decide to pay for.  My observation is that results in an unacceptable level of medical care.  And further:

"The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment
options available....." 

I agree with the statement but let's face it,  the judgment of the psychiatrist frequently has very little to do with the judgment of the psychiatrist or what options are ultimately considered in the working alliance with the patient.  Practically all inpatient and residential care these days is dictated by managed care companies and insurance companies irrespective of what a psychiatrist would recommend or a patient would accept.  These are standards of care that are forced on psychiatrists and patients rather than the prospective quality based standards.

Stepping back from that fact medical standards play a peripheral role to what businesses want and that unacceptable standard has been present to one degree to another for the past 30 years, I don't think a new approach in guidelines is too much to ask for.  I don't think it is too much to ask that APA guidelines be up to date, internally consistent, inclusive, actually apply as a standard of care as opposed to using business standards as the default, and be used to advocate for the best possible treatment settings for psychiatrists and their patients.  There are a number of specific methods that can be used and I will discuss them when the draft version of the latest  Practice Guidelines for the Psychiatric Evaluation of Adults comes out this year.


George Dawson, MD, DFAPA


References:

Work Group On Substance Use Disorder.  Practice Guideline For TheTreatment of Patients WithSubstance Use Disorders,  Second Edition.  American Psychiatric Association.  This practice guideline was approved in December 2005 and published in August 2006.


Supplementary 1:   These are the hospitalization guidelines from the APA Substance Use Disorders Guideline.

"Hospitalization is appropriate for patients who 

1) have a substance overdose who cannot be safely treated in an outpatient or emergency department setting

2) are at risk for severe or medically complicated withdrawal syndromes (e.g., history of delirium tremens, documented history of very heavy alcohol use and high tolerance); 

3) have co-occurring general medical conditions that make ambulatory detoxification unsafe; 

4) have a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient); 

5) have a level of psychiatric comorbidity that would markedly impair their ability to participate in, adhere to, or benefit from treatment or have a co-occurring disorder that by itself would require hospital level care (e.g., depression with suicidal thoughts, acute psychosis); 

6) manifest substance use or other behaviors that constitute an acute danger to themselves or others; 

or 

7) have not responded to or were unable to adhere to less intensive treatment efforts and have a substance use disorder(s) that endangers others or poses an ongoing threat to their physical and mental health [I]."      (p.  11).

Question For APA Candidates? OK Here It Is.

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"


I got a message today that I should craft a question for the American Psychiatric Association (APA) candidates.  It is election season and the LinkedIn forum is apparently the place for political debate.  I can recall asking a question last year along with James Amos, MD (The Practical Psychosomaticist).  The questions had to do with Maintenance of Certification (MOC) and the arduous recertification schedule that was essentially invented by the American Board of Medical Specialties.  Dr. Amos has done more to maintain this issue at a high level of visibility than any other psychiatrist.  That includes looking at the paucity of evidence that it is superior to life-long learning and CME as we all know it.  I  went to LinkedIn to look for my post from a year ago and it wasn't there.  The earliest post is from April 29, 2013.  This is a forum that was suggested to replace the long running member-to-member (M2M) listserv managed by the APA.  It was in M2M that members learned their concern about the MOC issue would be ignored despite overwhelming support on the basis that only 25% of the members voted and a 40% vote was required to pass the measure (see supplementary info below).

The events associated with that vote continue to bother members greatly.   It is seen as a continuing symptom that APA membership does not translate into any support for front line psychiatrists.  We have witnessed decades of increasing rationing and onerous regulations that have been basically brushed off at the level of the APA.  There has been minimal activity in responding to politicians, regulators, and businessmen.  It seems that whatever these special interests want to do - the APA is willing.  We had a billing and coding debacle in the 1990s with the rest of medicine.  Instead of pointing out that this was a purely subjective scheme designed to allow the persecution of any physician, the stance of both the APA and the AMA was "we will give you what you need to be better billers and coders."  We have had three decades of managed care utilization review, prior authorization, and pharmacy benefit managers and the response from the APA has been literature on how to be a better managed care psychiatrist.   There was a lawsuit against some managed care payers for a lack of parity but I don't think there is any evidence that the members who were forced to provide free care have gotten much benefit from that.

The most telling event about where the APA and AMA are at is their full scale cooperation with the PPACA (aka Obamacare) and so-called collaborative care.  In many if not most of those models of care, a psychiatrist collaborates with primary care physicians in treating depression or anxiety in their clinics.  In many of the models, the diagnosis hinges on a rating scale determination of depression or anxiety.  The rating scale score is the diagnosis.  The treatment modality is a medication - usually an antidepressant.  In some models the psychiatric consultant never sees the patient.  I just realized it, but this is all eerily similar to managed care reviewers several states away telling attending psychiatrists how to manage their patients.  This is managed care - a business centered model of providing medical care.  A model that many (myself included) do not consider a valid method of providing medical care.  And yet, the President of the APA and several other psychiatrists promote this as a model of care.  What physician would do 4 years of residency training to sit in an office, look at rating scale scores, and recommend antidepressant doses?  Why would you train all of those years and know all of that theory for such a simple task?

That simplistic collaborative care model captures the primary problem in psychiatric leadership today.  Here we stand at a crossroads.  We are studying the most complex organ in the body and we clearly know more about it now than at any point in the past.  The literature in brain science as it applies to psychiatry is growing exponentially.  We have some of the best thinkers in the world in all areas of the field ranging from pure neurobiology to psychopharmacology to imaging to neuropsychiatry to medical psychiatry to community psychiatry to psychotherapy.  There is so much to learn about the brain and psychiatry and what are we doing with it at a global level?

Nothing as far as I can tell.  The leadership of the APA is locked into a mindset from the Clinton administration.  The APA is acting like we have a responsibility as a profession to address bloated mental health statistics and provide population-based psychiatric care to the masses.   We have a responsibility to provide cost-effective care to the masses.  We have a responsibility to fight stigma wherever we find it because this is the real reason why people, governments, and insurance companies discriminate against psychiatrists and their patients.  We have to grin and bear it when some clown attacks the profession despite the fact that thousands of our colleagues go to work everyday and many toil with inadequate resources, impossible conditions, a lack of cooperation and they still get the job done.  Thrown into the breech with no support, front line psychiatrists are still getting the job done.

The APA on the other hand has done very little to support that effort.  APA officials seemed to breathe a sigh of relief about the vote on the MOC issue.  I heard one of them speak about it at a local meeting.  She told us all about how the new certification fees were really not a windfall for the American Board of Psychiatry and Neurology (ABPN).  This was really an expensive process after all.  I finally learned that this was really an initiative by the ABMS and that participating boards did not really have a choice.  If most of the boards voted for recertification all of the boards had to participate even if they voted against it.  I had learned about 10 years ago that the American Board of Obstetrics and Gynecology ( ABO+G) had a robust program that consisted of didactic material every year that was designed to bring all members up to speed.  A test was taken every year on that well defined information.  At the time there was no MOC and to me it seemed like an ideal program to assure that all members of a particular specialty were up to date and studying relevant information about what was important for the specialty.  For a while, I promoted this model as the preferred model for ongoing professional learning.    The APA does provide a similar program called Focus that could naturally fill the same role.  Typical MOC exams are not on a focal body of material and the pass rates are high.  Candidates of all specialities typically take time off of work (an off of vacation) to study for these examinations in addition to paying high examination fees for a test that is designed for the test makers and not the test takers.  A test of random facts for the purpose of recertification is not the same thing as a test for professionals to assure they are all up to the same standard.

The APA has just completed a much criticized multi-year effort of revising the DSM and producing the DSM-5.  I think that has been a good effort and with the associated online material it is a definite advance relative to previous editions.  That does not mean I am in agreement with everything in the book, or think that all of the diagnoses in that text exist.  I do think that it covers all of the major diagnoses and severe mental illnesses that psychiatrists treat.  On an academic and clinical level the APA needs to do much more.  Hospitals and clinics currently are being run by administrators with mixed agendas.  We are seeing business people conduct psychiatric care.  The APA used to provide comprehensive guidelines for the treatment of aggression in inpatient settings.  It used to have timely treatment guidelines describing the role of psychiatry and what the standards of care are.  By abdicating that role, we now have business organizations and nonprofessionals dictating care for people with severe mental illnesses.  We have psychiatrists who have to defend their care against those nonprofessional guidelines every day.   That is hardly the expected behavior of a professional organization.

Any psychiatrist should be concerned about the fact that their professional organization does not seem to support the members doing the work of psychiatry.  Any psychiatrist should be concerned that the APA does not vigorously defend the profession and that it seems to have adapted the pseudoscientific methods of governments and managed care organizations.  Any psychiatrist should be concerned that the APA has adopted the questionably valid ABMS preparatory school model of professional education that is unfocused and a waste of time and money.  Any psychiatrist should be concerned about the fact that we have some of the greatest minds in American medicine in our medical institutions and our professional organization is lurching back to the Clinton administration of the early 1990s.  Back to the time when a few political insiders thought that managed care was a good idea.  All of these things considered the question I will post to the candidates is:  

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"
 
That is how I was trained and how every psychiatrist I know was trained.  It is time our professional organization consistently gives us what we really need.


George Dawson, MD, DFAPA



Supplementary 1:  This was the APA 2011 election report I got on the following referendum to basically eliminate patient feedback and maintain a cognitive exam very 10 years.  Although the APA maintains that it requires a vote of 40% of the voting members, the vote to support these measures exceeded the votes for the President Elect and the Secretary (both national candidates) by 1373 and 1388 votes respectively. (Reported February 18, 2011)

The APA was petitioned by members to hold a referendum on the issue of informing the ABPN as follows regarding its proposed maintenance of certification requirements.

1) The patient feedback requirements for the purpose of reporting to the Board is unacceptable, as it creates ethical conflicts, and has the potential to damage treatment.

2) The requirements other than a  cognitive knowledge examination once in 10 years, regular participation in continuing medical education, and maintenance of licensure, pose undue and unnecessary burden on psychiatrists.

Member Referendum	Support	5,525 (80%)
	Do not support	1,418 (20%)

The referendum did not pass. APA received ballots from 25% of the voting members.

The APA Operation Manual states the following regarding member referendums: “The adoption of a referendum shall require (a) valid ballot from at least 40 percent of the voting members, (b) the affirmative vote of at least one-third of all the voting members of the Association, and (c) the affirmative vote of a majority of those members who return a valid ballot.

Supplementary 2:  Another one of the sorry miscalculations made by the APA and its officers is the image it projects to potential trainees.  Applying the dynamic I point out in this post, any potential resident ends up asking themselves:  "Why would I want to join a speciality that seems to want its members to have less expertise than they used to rather than more?  What other speciality does that?"  I tried to address that as a response to a current resident written on his blog and for some reason the response was never posted.  You can read his original post here and my response below:


The most significant reasons why psychiatry has the image problem that you discuss is that the profession is politically inept and our largest professional organization is not addressing the problems that psychiatrists face on a day-to-day basis on the front lines. The biggest front line problem is that practically all systems where psychiatrists work have mercilessly slashed resources for treating the mentally ill. We also seem to attract a number of ideas from critics that are not helpful. The example you posted about a prescriber with watered down qualifications is a case in point. In what other specialty does anyone suggest that the practitioners of the future should be less qualified?

That type of nonsense only happens in psychiatry and it is completely inconsistent with current research. In this weeks’s Neuron there is a perspective on Computational Neuropsychiatry. As neuroscience becomes more relevant to daily practice psychiatrists need that level of training in addition to medical and psychotherapy skills. We seem to have a lack of visionaries right now who can put all of that together.

I would encourage psychiatrists of the future to be thinking more along these lines, than the rationed managed care model of care that is currently being promoted. It turns out that “cost-effective” psychiatric care is frequently the same as no care at all.

GD