I Was Compassionate Today ........

I attended the Minnesota Psychiatric Society (MPS) Spring Scientific Meeting today entitled "Reclaiming Our Joy and Wonder as Healers."  The full program of that venue is available online at this site.  In the registration process I noted that a lot of the content seemed to be experiential and that is my least favorite kind of conference.  To make sure I did not miss anything I compared notes with a long time colleague and she agreed and had the same selection process - try to avoid the experiential components of the program.  I was generally successful, but more about that later.

The program did begin with three lectures and ample audience participation.  The presentations on happiness and burnout seemed to be an uncritical look at happiness and gratitude science.  The lead off speaker talked about his personal experience in a health care system that sustained 2 physician suicides in less than a year and how he led the effort to reduce physician burnout.  He discussed some straightforward exercises in gratitude and happiness as well as the importance of human relationships.  He encouraged psychiatrists at one point to help out their nonpsychiatric colleagues in this area.  He provided extensive resources for physicians to use through a web site.

I worked with the second physician for over a decade in my previous position.  He discussed the clash of professional values and expectations with what happened in the family and intrapsychically and how he negotiated some of those transitions including going to a clinical track from an academic- research track.  He read part of this piece by Jamie Riches, DO - an Internal Medicine resident at Sloan Kettering and the impact of resident suicides.  It contained the familiar refrain: "The work does not stop!"  No matter what catastrophe you encounter as a physician (and there are many) you are expected to take a deep breath and get back to it - immediately.  A resident I worked with completed his shift and the final admission note on 15 patients he had seen that night despite an upper GI bleed.  He did not seek medical attention until he had signed out at 8AM the next day.  Any bystander can look at these occurrences and other problems listed by Dr. Riches and see how physicians are shooting themselves in the foot.  You can't provide good care to patients if you can't take care of yourself.

The third morning lecturer was on the state hospital association and he discussed their attempts to address physician burnout.  They had graphed the degree of burnout in various medical organizations and concluded that interventions could be useful for decreasing burnout in general and burnout specifically due to the EHR.  I have seen first hand how survey data can be manipulated by health care organizations and I am skeptical that this data means much - especially when there was acknowledgement that the EHR itself has either not changed or the organization implemented the usual unhelpful EHR teams as the primary intervention.         

I was able to propose a thought experiment in an afternoon session on Compassion Training.  I am no stranger to Buddhism, meditation, or mindfulness techniques.  As a psychiatrist trained in the theory and maintenance of therapeutic neutrality, I was skeptical of emotionally loaded terms like "happiness" and "compassion" being used in the context of a therapeutic relationship.  Just about every definition of compassion includes terms like sympathy, pity, concern, and or sorrow for the plight of another person.  That seems a lot less precise than empathy.  The definition of empathy that I use is the technical version from Sims (1) : ".....empathy is a clinical instrument that needs to be used with skill to measure another person's internal subjective state using the observer's own capacity for emotional and cognitive experience as a yardstick.  Empathy is achieved by precise, insightful, persistent, and knowledgeable questioning until the doctor is able to give an account of the patent's subjective experience that the patient recognizes as his own."  Some definitions confuse empathy with passive understanding of another person's emotional state and compassion with understanding and a willingness to take action to help that person.  Psychiatrists trained like me use empathy to explore the person's subjective state for the purpose of understanding it and trying to help them.  It is anything but passive.  In the course, the various stages of meditations were also focused on developing a baseline compassion toward oneself.

I asked the instructor to consider the following thought experiment:

1.  In Room 1:  I am interviewing a patient with borderline personality disorder and proceeding by using the guiding concepts of therapeutic neutrality and empathy.

2.  In Room 2: A psychiatrist with compassion training is interviewing a patient with similar problems.

Question:  How would an observer compare the psychiatrists in Room 1 and Room 2?  Would there be any discernible differences between the two?

The response I got was quite interesting.  She suggested that the main difference would be after the interview was terminated - the compassion trained clinician would be less distressed after the interview than I would.  The problem with that response is that I am not distressed at all interviewing patients.  I have plenty of experience across a wide array of scenarios.  At some level, I am much more comfortable talking to people in my office than just about anywhere else.  The expectations are clear.  I know what I have to do and have done it tens of thousands of times in the past.  I can talk about anything a person wants to talk about including how they perceive me in that  situation.  In the interest of time and not wanting to appear argumentative, I did not bring that up.  It does raise the issue of whether the new interventions for burnout have much to add over appropriate training from the past.  I have practiced mindfulness techniques and meditation and like a lot of the patients  I see - they don't seem to add much.

In the summary session I requested the microphone.  I don't come across well in a potentially contentious environment.  When I speak people think that I am irritated or angry and that probably affects my message.  I consider myself to be passionate - but I am not really angry about anything.  It would be foolish to be angry about various things that haven't changed in 20 years.

At the micro level my emphasis was on direct connections. I described a scene from my internship, where another intern and I were responsible for a patient on a balloon pump in an ICU setting.  At one point we looked at one another and realized there was nothing more we could do.  I knew from the look on his face at 4AM that he was as distressed about the situation as I was. We did not know enough at the time to realize that there was nothing anyone could do - but it would have been very useful to have somebody tell us that.   In those days, there was an implicit rule that attending physicians should probably not be called at night and that everything in the hospital could be resolved by you and your Internal Medicine PGY3.  I only heard one attending ever give us explicit instructions and that was "I don't want to be surprised in the morning."  My resident had to translate it for me: "We need to call him if somebody is going down the tubes."  As an attending physician myself, I wanted to make  sure that never happened.  I got called by a resident who had a very confusing patient presentation and went in and made the diagnosis of serotonin syndrome and had the patient transferred to the ICU.  My emphasis at the micro level was that there has to be clear communication that you don't mind discussions and consultations about cases even when you are out in practice.  I am consulted by and consult many psychiatrists by phone and email on an ongoing basis and any time of the day and it has been a great source of professional development and peer support.

At the macro level, my message was politics.  The speaker touched on the EHR as a burnout factor and what they might need to do about it.  Nobody mentioned maintenance of certification.  Some people seemed irritated that I mentioned either politics or MOC in this course that was supposed to be about preventing burnout and creating a more resilient workplace.  I don't know what a more resilient workplace is.  The workplace is resilient simply because it is out of physician control and completely resistant to change.  There are more ways to get the EHR and MOC changed than hope that a hospital association will do it with survey data.  I proposed that physicians consider political activism at the level of the practice environment and the government level and that they consider defeating MOC.

At the end one of my colleagues told me she appreciated the approach to providing residents support and wished she had it in her training program.  I was glad I got that message out.  No takers on the EHR or MOC.

I will keep going and adding my two cents - even though my anxiety seems to be getting higher and higher every time.  At some level I probably realize that there are very few people who see the psychiatric world the way I do - and I know my time is limited.  I also know that I don't see anybody coming along who is prepared to challenge the status quo that seems to keep dictating our deteriorated practice environment.


George Dawson, MD, DFAPA


References:

1:  Sims A.  Symptoms in the Mind, 3rd Edition.  Elsevier Limited, London (2003): p 3.



Graphic Credit:

Incense burner is from Shutterstock per their standard licensing agreement.

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?     



                     

DSM-5.0

I finally saw a copy of the DSM-5 today.  It was sitting on a table at a course on the DSM put on by the Minnesota Psychiatric Society.  The DSM-5 portion of the course was about 3 1/4 hours of lectures (98 information dense PowerPoint slides) by Jon Grant, MD.    Dr. Grant explained that he was in a unique position to provide the information because he and Donald Black, MD had been asked by the American Psychiatric Association (APA) to write the DSM-5 Guidebook.  In this unique position they were privy to all of the notes, minutes, e-mails and documents of the DSM Work Groups.  In the intro it was noted that Dr. Grant had written over 150 papers and 5 books.  He was probably one of the best lecturers I have ever seen with a knack to keep the audience engaged in some very dry material.  There were times that he seemed to be riffing like a stand up comedian.  The content was equally good.  I thought I would summarize a few of the high points that I think are relevant to this blog.

The first section was an overview of the history.  The original DSM was published in 1952, but before that there were several efforts to classify mental disorders dating back to ancient times.  Some of the systems persisted for hundreds of years.  He credited Jean-Etienne Esquirol (1772-1840) as one of the innovators of modern classification.  The philosophical approaches to the subsequent DSMs were reviewed and they generally correlate with the theories of the day.

The development of DSM-5 began in 1999.  The original goals included the definition of mental illness, dimensional criteria, addressing mental illness across the lifespan, and to possibly address how mental disorders were affected by various contexts such as sex and culture.  Darrel Regier, MD was recruited from the NIMH to coordinate the development of DSM-5 in the year 2000.  Between 2003 and 2008 there were 13 international conferences where the researchers wrote about specific diagnostic issues and developed a research agenda.  This produced over 100 scientific papers that were compiled for use as reference volumes.  As far as I can tell the people on the ground on this issue was the DSM Task Force and the Work Groups.  The Task Force addressed conceptual issues like spectrum disorders, the interface with general medicine, functional impairment, measurement and assessment, gender and culture and developmental issues.  The Work Groups met weekly or in some cases twice a week by conference call and twice a year in person.  The work groups had several goals including revising the diagnostic criteria according to a  review of the research, expert consensus and "targeted research analyses".  No cost estimate of this multi-year infrastructure was given.

Like any volume of this nature the originators had some guiding principles including a focus on utility to clinicians, maintaining historical continuity with previous editions, and the changes needed to be guided by the research evidence. The most interesting political aspect of this process was the elimination of people closely involved in the development of DSM-IV in order to encourage "out of the box" thinking.  This was a conscious decision and I have not seen it disclosed by some of the professional critics out there.

Final approval of the DSM occurred after feedback was received through the DSM-5 web site.  There were thousands of comments from individuals, clinicians and advocacy organizations.  Field trial data was analyzed and discussed.  A scientific committee reviewed the actual data behind the diagnostic revisions and confirmed it.  Hundreds of expert reviewers considered the risks in revising the diagnoses.  The APA Assembly voted to approve in November 2012.

Some of the criticisms of the DSM-5 were discussed in about 4 slides.  Dr. Grant was aware of all of the major criticisms and I have reviewed most of them here on this blog such as the issue of diagnostic proliferation.  Dr. Grant's lecture contained this graphic for comparison:

Rather than repeat what I have already said, it should be apparent to anyone who knows about this process that it was open, transparent and involved a massive effort of the part of the psychiatrists and psychologists involved.  It should also be apparent that the DSM process was clinically focused and that safeguards were in place to consider the risk of diagnostic changes.  I have not seen any of that discussed in the press and don't expect it to be.  For all of you DSM-5 conspiracy theorists, more than enough people involved without a sworn oath to assure that no secret would ever be kept.

What about the final product?  The DSM-5 ends up including 19 major diagnostic classes.  Some of the highlights include moving some disorders around.  Obsessive-compulsive disorder and Post Traumatic Stress Disorder were moved out of the Anxiety Disorders section to their own separate categories.  Bipolar and Depressive Disorders each have their own diagnostic class instead of both being placed in a Mood Disorders class.  Adjustment Disorders have been moved into the Trauma and Stress Related Disorders class and there are two new subtypes.  As previously noted here, all of the Schizophrenia subtypes have been eliminated.  The Multiaxial System of diagnosis has been scrapped.  One of the changes impacting the practice of addiction psychiatry is the elimination of the categories of Substance Abuse and Substance Dependence and collapsing them into a Substance Use Disorder.  Panic attacks can now be used as a symptom of another disorder without having to specify that the person has panic disorder and that is a pattern I have observed over the course of my career.  The controversial Personality Disorders section is unchanged but there is a hybrid diagnostic system that includes dimensional symptoms, the details of which (I think) are in the Appendix.  Mapped onto all of the diagnostic classification and criteria changes are a number of subtypes and specifiers as well as a number of ways to specify diagnostic certainty.  As with previous editions since DSM-III there is a mental disorder definition that indicates that behavior or criteria are not enough.  There must be functional impairment or distress.  The definition specifies that socially deviant behavior or conflicts between the individual and society do not constitute a mental illness unless that was the actual source of the conflict.

The overall impression at the end of these lectures was that this was a massive 18 year effort by the APA and hundreds and possibly thousands of volunteer psychiatrists and psychologists.  None of those volunteers has a financial stake in the final product.  Many of the criticisms were addressed in the process and many of the critics have a financial stake in the DSM-5 criticism industry.  The criticisms of the DSM-5 seem trivial compared with the process and built in safeguards.  The DSM-5 was also designed to be updated online instead of waiting for another massive effort to start to make modifications, hence this is not DSM-5 but DSM-5.0.

If Dr. Grant is lecturing in your area and you are a psychiatrist or a psychiatrist in training, these lectures are well worth attending.  If you have a chance to look at his Guidebook, I think that it will be a very interesting read.

George Dawson, MD, DFAPA

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders". 

Psychiatric opinion on same-sex marriage is more acceptable than an opinion on violence and aggression

I was surprised to see an insert in my psychiatric newsletter this month describing the efforts of four major mental health professional associations in opposing an amendment to the state constitution that would exclude same-sex couples from legal marriage.  The Minnesota Psychiatric Society, the Minnesota Psychological Association, the Minnesota chapter of the National Association of Social Workers, and the Minnesota Association of Marriage and Family Therapists produced this document that in essence says that there are no research findings to suggest that children from same-sex parents differ from heterosexual parents in outcomes.  The newsletter editor's column explains that there is apparently no policy on the MPS taking a stance on political and societal issues.  She put that question out to the general membership.  MPS President Bill Clapp, M.D. stated the issue succinctly:

"The MPS Executive Committee was painfully aware that the development of a consensus statement regarding marriage amendment could not possibly represent the diverse opinions of all Minnesota psychiatrists.  On the other hand we felt a responsibility to act faithfully in representing our many patients who believed the marriage amendment violated their civil rights and was overtly discriminatory". 

I think there are a number of issues relevant to this opinion that are interesting to contemplate.  First and foremost is bias in the media.  Over 2 years ago the MPS partnered with two other mental health organizations The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education in producing a statement on violence prevention.  That statement highlights the lack of mental health resources, lack of training in dealing with these incidents, and the lack of quality standards in assessing and treating patients having problems with violent and aggressive behavior.  That statement was rejected by the newspaper editor. The only reason given was a potential conflict of interest because we were advocating for research and that nonspecific advocacy was viewed as a problem.  In the two years since the statement was produced, it is clear that the issues we raised are as important as ever.  My first question is why that statement pertaining to issues that mental health clinicians and the organizations involved deal with on a day by day basis was not acceptable and a statement on a purely political issue was.

I personally voted against the constitutional amendment and think that any reasonable person would.  None of my criticisms of this initiative outweighs the value of getting the research literature out there for public consumption.  It may have been useful to provide a link to all of the available research in an easily accessed format like Medline.  

On the other hand after treating violent and aggressive people and people with severe mental illnesses and addictions for 23 years, it seems like using a professional organization to take a political position on same sex marriage is a stretch.  One could argue that anything that affects the nurture of individuals is relevant to psychiatry, but there are probably few psychiatric societies that take positions on those topics.  I do think this illustrates that the media is much more willing to accept psychiatric opinion on a purely social and political issue, rather than an issue that is immediately relevant to the practice of psychiatry.

I have two minor objections about this initiative. First, it is too easy. The majority of psychiatrists are Democrats and psychiatry is the only medical specialty where that is true. It is fairly predictable that the majority of psychiatrists would support this initiative.  It is good to know that the position is supported by scientific data but I don't think that fact or the fact that psychiatrists support a political measure would carry any weight with voters.  Given the negative press associated with psychiatry and the tendency of the press to to cast psychiatry in the worst possible light, there is also the question of possible backlash against any measure supported by organized psychiatry.  The negative press about the DSM5 and antidepressants are two good evidence based examples.

My second objection is that there are numerous problems that affect psychiatric practice on a day-to-day basis where there should be immediate and very aggressive political action. Some of these topics have been ignored for decades at both the state and national levels. If I had to come up with a top 10 list (no particular order) it might look something like this:

1.  The intrusion of managed care into the practice environment.

2. The intrusion of pharmacy benefit managers into the practice environment.

3. The intrusion of managed care practices into government-funded programs.

4. Mismanagement of public facilities.

5. Mismanagement of quality measures at the population level in the state of Minnesota.

6.  The lack of timely care of acute psychiatric problems (considerable overlap with number one above).

7. Poorly thought out guidelines for reimbursement of psychiatric care emphasizing low quality high volume medication focused practices as opposed to psychosocial treatments that are often as effective.

8. Lack of uniform application of civil commitment statutes on a county by county basis.

9. Lack of crisis intervention services in more than half of Minnesota counties.

10. Inadequate residential services for people with chronic mental illnesses, addictions, and children with psychiatric problems.

In terms of a guiding principle, a professional organization needs to advocate for what adversely impacts its members every day. When you have issues on the above list that are not only pressing but have been pressing for two decades the question becomes: "Why has nothing been done?"  It is much more uncomfortable to do something relevant to every practicing psychiatrist than something that most psychiatrists would have done anyway.

The other factor is that none of the issues on the list was ever voted on.  This is a key dimension in American politics.  Business lobbyists working behind the scenes at the state and federal levels generally get what they want flying under the radar.  They are there every day pushing a pro-business and in many cases pro-government agenda.  The last thing they want is any political reform that actually tips the balance in the direction of patients and physicians.

There were no referendums or amendments put up for a vote when the Minnesota statutes were rewritten to favor managed care companies.  That is where the heavy lifting is for professional groups in American politics and that is where MPS needs to be.

George Dawson, MD, DFAPA

Daniel Christensen, Kathleen Albrecht, Bruce Minor and Bill Clapp.  Children parented by same-sex couples do just fine.  StarTribune October 28, 2012

Why Do They Hate Us?

The title of this column weighed heavily on the minds of some Americans immediately after the terrorist attacks of 911. I was involved in some Internet forum political debates at the time that looked at this question.  The question itself implies a lack of self analysis and misunderstanding of rhetoric and political strategy. Those same basic concepts can be applied to an analysis of psychiatry and the common political and rhetorical strategies that are used against us.

At this point some readers may suggest that this is quite a tangent for me to take given the fact that psychiatry after all is part of the medical establishment and as such should have very little to complain about.  Four or five decades of complaints from anti-psychiatry cults and about two decades of complaints from competing professionals has done little to diminish the influence of psychiatry.  If that is really the case, why has psychiatry been disproportionately affected in terms of resources available to treat patients and why are psychiatrists blamed for that?  I suggest that the discrimination against psychiatrists and their patients occurs at every level as the direct result of an antipsychiatry bias.

I first came directly in contact with hatred of psychiatrists in an unexpected setting – an academic team rounding on medical surgical patients.  It consisted of an attending, a senior resident, two interns and two medical students.  When the attending learned I was going to do a psychiatric residency, it was an opportunity for ridicule.  Didn’t I realize that psychiatrists were lazy and did not know what they were doing?  Didn’t I know that nobody with a mental health problem should consult with a psychiatrist?  The special attention focused on me peaked when this attending challenged me on the correct diagnosis of acute abdominal pain.  The patient was middle aged, obese and had acute abdominal pain with nonspecific exam findings.  What was my diagnosis?  When I said “appendicitis” – the attending said I was wrong and gave all of the reasons why the diagnosis was cholecystitis.  Several hours post op we had the diagnosis of acute appendicitis.  I learned more about what some physicians think of their psychiatric colleagues than the diagnosis of the acute abdomen during that rotation.

I came across an illuminating piece in the British Journal entitled Advances in Psychiatric Treatment. The author Claire Bithell of the Science Media Center in London showed that psychiatry was less likely to be reported on in the popular press and when it was, received treatment that was four times as negative as other medical specialties.  In an associated piece based on meetings with journalists, academics, clinicians and journalists she found problems at all levels in terms of engaging the media and one of the conclusions was that experts need to engage with breaking news stories to get important messages across to the public.

  

It is easy to prove to yourself that the same problem with the press exists in the US.  It is as easy as going to the New York Times web site and doing a quick search on psychiatry.  The search returns the articles and several commentaries on how psychiatrists are turning to medication management rather than psychotherapy,  an article on how the man accused of the mass shooting at Fort Hood was a psychiatrist, Radovan Karadzic was a psychiatrist, and an article about Carl Jung.  One of the central articles “Talk Doesn’t Pay So Psychiatry Turns Instead To Drug Therapy” gives the specific detail: “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session”.  But at that point the author incorrectly concludes that competition from other mental health providers is the reason that psychotherapy is so poorly reimbursed.  He should have just applied his earlier conclusion that the dominance of large hospital groups and corporations in combination with the government essentially fixes insurance reimbursement to whatever the payers want to pay.  They do not want to pay for psychotherapy despite the fact that it is clearly an evidence based therapy.

The origins of bias against psychiatry are varied and include the continued misunderstanding of what we do and what our training is, fear of mental illness, and in many cases the pursuit of political goals.  We have seen attacks on psychiatrists by politicians, Hollywood stars, other psychiatrists, and of course anyone who wants to write an antipsychiatry book.  It can be very subtle such  as recognizing that there is no practical way that psychiatric services can be provided and shutting them down.  In this case it is common to blame psychiatrists for the “lack of access” rather than inconsistent and unrealistic reimbursement by payers.   I was talking to a highly reimbursed proceduralist one day who said that she didn’t mind that some of their margin was used to pay for psychiatry because it seemed like a needed service.

 At times the sheer amount of noise out there about psychiatry is deafening.  I don’t think we are alone when it comes to negative publicity.  Teachers and law enforcement come to mind.  I do not think that there is any doubt that public perception is affected by what is often false information about psychiatry. 

Apart from what is purely propaganda,  most people have an innate tendency to see themselves as armchair psychologists.  Artificial intelligence philosophers came up with the term folk psychology to discuss this tendency and its benefits.  If you are a folk psychologist you might conclude that it is so easy that a psychiatrist has nothing to add, especially when you watch other folk psychologists on television all day long.  Some of the people who have hated us the most have had their theories rejected by organized psychiatry.

From an organizational standpoint,  how do we respond to the hate?  Although it would serve us well,  I doubt the public is very familiar with the philosophical criticisms of folk psychology any more than they know the difference between a psychiatrist and a psychotherapist.  What can we do when we are being smeared on a routine basis?  Ignoring the attacks is a strategy that the APA has used for years.  From a strategic perspective – it is effective to a point.  That point is where some of our detractors gain either political advantage or there are sudden and unexpected changes.  Before that happens we need to be much more aggressive.

Since my early days of involvement with the Minnesota Psychiatric Society,  we have always believed that getting our message out to the public was a critical first step.  I was the Public Affairs Director in the 1990s and coordinated several of the initial National Depression Screening Days.  Today the majority of depressed people I see have been treated for at least 10 years by family physicians and although they were reluctant to see a psychiatrist , they really had no idea that I was a medical specialist.  MPS recently tried to get a letter published by local media on the mass shooting phenomenon.  We co-authored the letter with two mental health public service organizations and it was rejected at a time when there was peak speculation about whether or not the alleged perpetrator was mentally ill and others  were identifying heroes and suggesting that we move on.   Depending only on a biased press is a recipe for continued failure.

We need to start by recognizing that we all have a common interest here and it is called the psychiatric profession.  That is true if you are employed by a health care organization, the government or self employed.  That is true if your job is primarily research, patient care, or administration.  That is true if you are a medical student who has just been accepted to psychiatric residency.  When we are under constant attack – a short term solution is to cut and run.  That will not work in the long run.  We are currently the standard bearers for the kind of care that is possible and apart from our colleagues in other countries we are often shouting alone in the woods.  It is very clear that state and national governments and their allies in the business world do not care about reasonable standards of psychiatric care and in many cases have codified that.  Other advocates are often left to play one side against the other on an artificial playing field of constrained resources.  Psychiatrists have a common interest in making a stand against unfair treatment by both the government and the health care industry.

The other issue is how to make that stand.  We currently have political strategies with politicians and other groups with similar interests.  Those groups are not interested in our standards and we need to take those arguments directly to the public.  We have to let them know what inpatient units and state hospitals are capable of doing.  We need to let them know what state of the art community psychiatry looks like.  We have to let them know that outpatient psychotherapy for depression is actually more than a session or two and coming back every month or two to see somebody about medications.  We have to speak out on every topic of mental health interest in the media and presenting it ourselves rather than expecting the media to pick it up.  That is our job in the near future.

That is also in part what this blog is all about.

Why This Blog?

I thought that a blog written by a psychiatrist who has no stake in bashing psychiatry and who has successfully treated patients for over two decades is long overdue. In the absurd world of today's media and their completely unrealistic portrayal of psychiatry and psychiatrists, political arguments can be advanced against the field and that leads to a rapid acceleration of bashing of the field fueled by others who frequently don't know a thing about psychiatry. I plan to post a few examples in the days that follow about that process and also about the political motivations for that process.

I also do not want to set myself up as a guru or somebody who is unique. That is often the viewpoint taken by critics of the field. At this point in my career, I personally know hundreds of technically competent psychiatrists who are every bit as skilled as me. In fact, I like to provide the example of a patient who came to see me for geriatric consultation. At the end of the visit she produced a previous evaluation from a colleague who trained with me at the University of Minnesota. That note right down to the diagnostic evaluation and plan was identical to what I had in my handwritten notes to that point.

Finally, the viewpoints expressed here are probably not mainstream psychiatry. Psychiatrists in general like to avoid conflict and attempt to resolve problems in a non confrontational manner. Physicians in general seem to ascribe to this tactic. While I agree completely that it is necessary to be neutral in all interactions at a clinical level, that does not extend to politics - especially in an era where an activist government and a managed care cartel are restricting psychiatric care at a much higher rate than they are restricting access to medical and surgical care.

What follows here is strictly my opinion and not the opinion of any of my current or past employers or of my professional associates.