How Physicians Think

One of the more interesting aspects of my career has been contemplating how physicians make decisions on both the diagnostic and therapeutic side. Early in my career there was an explosion of activity in this area. Much of it had to do with internal medicine. There were computerized programs that were designed to assist physician decision-making. There were also entire courses taught at the CME level by experts in the field. At the time those experts included Jerome Kassirer, Stephen Pauker, Harold Sox, Richard Kopelman, Alvan Feinstein, and others.  The New England Journal of Medicine has a long-standing feature entitled Case Records of the Massachusetts General Hospital that showcases both diagnostic reasoning and the associated clinicopathological correlates. They added additional articles and a long standing feature on diagnostic decision making. After studying the subject area for about 10 years, I started to teach my own version to 3^rd and 4^th year medical students. It was focused on not mistaking a medical disorder for a psychiatric one.  It included a complete review of cognitive errors in that setting and how to prevent them. I taught that course for about 10 years.

There are a lot of ideas about psychiatrists and how they may or may not diagnose and treat medical disorders. Systematic biases affect the administrative and environmental systems where psychiatrists work.  Many psychiatrists are very comfortable at the interface of internal medicine or neurology and psychiatry. The most common bias about psychiatrists is that other medical conditions need to be “ruled out” before the patient is referred to a psychiatrist. From a psychiatric perspective the real day-to-day problems include inadequate assessment due to an inability to communicate with the patient and considerable medical comorbidity. Psychiatrists who work in those problem areas need to be competent in recognizing new medical diagnoses and making sure that their prescribed treatment does not adversely affect a person with pre-existing medical disorder.

Against that backdrop I decided to read 2 relatively new books. Both of them have the same title “How Doctors Think”. One book was written by Jerome Groopman, MD hematologist-oncologist by clinical specialty. The other book is written by Kathyrn Montgomery, PhD – a professor of Bioethics, Humanities, and Medicine. As might be expected from the writers’ qualifications Groopman is writing more from the standard perspective of a physician with an intense interest in medical decision making and Montgomery is describing the clinical process and analyzing it from the unique perspective of philosophy and the humanities. It follows that even though the titles are the same these are two very different books.

Groopman’s approach is to use a case-based style of looking at medical decision-making from the perspective of several clinicians-including his own work. The mistakes that occur are teaching moments and are explained from the perspective of heuristics or common cognitive biases. It is the approach I used in my course on preventing cognitive errors associated with psychiatric diagnoses. To cite one example, he describes an athletic forest ranger in his forties. The kind of a guy an internist might say: “I am not worried about his heart – he does his own stress test every day.”  He noticed increasing chest discomfort for a few days without any associated cardiopulmonary symptoms. He presented for an assessment on a day when the pain did not go away. He was seen and thoroughly examined.  There were no physical symptoms, exam findings, or laboratory finding to suggest a cardiac problem and he was released from the emergency department.  He returned a few days later with a myocardial infarction.  Discussions with the attending physician indicate that there were two issues associated with the missed diagnosis of cardiac chest pain – the generally healthy appearance of the patient and a lack of any positive tests indicating coronary artery disease.  Groopman discusses it from the perspective of representativeness bias (p 44) or being affected by a prototype – in this case the patient’s apparent level of fitness and attributing the chest pain to musculoskeletal pain rather than pain of cardiac origin. 

This case also allowed for a discussion of attribution errors especially if the patient fits a negative stereotype.  In the next case, a 70 yr old patient with alcohol use presents with and enlarged nodular liver on exam.  The presumptive diagnosis is alcoholic cirrhosis and the team’s plan was to discharge him back home as soon as possible. Closer examination confirmed that the patient was not drinking that much and searching for other causes of liver disease resulted in a diagnosis of Wilson’s disease.  For most of the book, Groopman uses this technique to illustrate substantial errors, the kind of cognitive bias that it reflects, and corrective action. The reality of “making mistakes on living people” comes though.

He recognized the importance of pattern matching and pattern recognition in clinical practice. There is an initial conversation with a physician that collapses pattern recognition to stereotypes and their associated shortcomings.  He elaborates on the concept and quotes a cognitive scientist to illustrate that pattern recognition may not require any conscious reasoning at all.  An expert can arrive at a diagnosis in about 20 seconds that may take a medical student or resident 30 minutes. Experts begin collecting information about the patient on contact and are immediately considering diagnostic possibilities. I have personally had this experience many times, typically for acute neurological syndromes (strokes, cerebral edema, encephalitis, meningitis) in patients who were referred for me to see in a hospital setting. Pattern matching clearly occurs in the diagnostic process, but it is more difficult to write about and discuss than verbal reasoning.

A major strength of the book is a fairly detailed look at uncertainty in medicine. The diagnoses are not etched in stone and no outcomes are guaranteed based on the accuracy of the diagnosis or not. He introduces a pediatric cardiologist who advances the argument that most of his cases are novel and that there are no set guidelines for what he treats. Even more complicated is that fact that what may appear to be sound science-based treatments like closing an atrial septal defect with a 2:1 shunt in kids it can be an illusion.  Many of those children do well without the surgery and many have had unnecessary surgery. The cardiologist also points out that study of this kind of problem is impossible because of the length of time it would take to do a randomized study.

Another major strength is advice to patients about how to keep the doctor they are seeing thinking about their case.  Numerous examples are given ranging from seeing large number of healthy patients where abnormalities are rare to seeing patients with real problems who have been stereotyped for one reason or another. Groopman is very specific in coaching prospective patients in how to overcome some of the associated biases.  This advice centers on the fact that biological systems are complex and don’t necessarily support logical deductions.  The astute doctor needs to be systematic, evaluate the data for themselves including the elicitation or more history, and question their first impressions. The patient aware of these limitations can ask the correct questions along the way to assist their physician in staying on track. He advises the patient to express their concern about the worst-case scenario to get that out there for discussion and to keep their doctor focused.  The patient is informed of how their history, review of systems and exam may need to be repeated along with some tests that have been previously done. The physician may have to ignore common aphorisms or maxims that are designed to focus on common problems and consider the complex – like more than one diagnosis being suggested. Business management of the medical encounter is seen to impair and obstruct this interactive process.

Groopman’s book is very good both as a guide to patients and a review for physicians who have been educated in diagnostic thinking. In the body of the book technical jargon is avoided and the case scenarios thoroughly explained. There is an excellent list of references and annotations for each chapter at the end of the book. 

How Doctors Think by Kathryn Montgomery takes the unexpected form of a philosophical argument against medicine as a science. She qualifies her criticism by being very clear that she is considering Newtonian or positivist science and not biological science. She recognizes several features of biological science that make it an integral part of medicine, but also not at all like the criteria for science that she sets as the premise for her argument. This is problematic at two levels. First, deterministic and reductionist physicists like Sabine Hossenfelder are very clear that everything is reducible to known subatomic particles and that particles in a brain are deterministic.

“Biology can be reduced to chemistry, chemistry can be reduced to atomic physics, and atoms are made of elementary particles like electrons, quarks, and gluons.” (5)

So for at least some scientists – reductionism is not a problem and the boundaries are not very clear between physical science, biology, and medicine.  Second, it is now known that biological organisms have a wide array of stochastic mechanisms that by virtue of their own nature produce apparently random results. With that range of possibilities, it is not very clear if the standards of physical science are that much different than the biological science necessary for medicine.

Montgomery makes the argument about science and the damage that the idea of medicine as science does to both medicine and its practitioners at several levels.  First, she describes science in medical training. Medical students encounter the basic science curriculum in the first two years of medical school. It is not physical science but biological sciences relevant to understanding pathophysiology, pharmacology, and epidemiology/evidence-based medicine.  She suggests this exposure to science is less relevant as the student transitions to a clinician with adequate clinical judgment – almost to the point that the basic science is an afterthought. This aspect of training is also used to point out that medical students are not being trained as scientists and the remainder of their formal education is spent learning clinical judgement.  At places she describes the preclinical years as fairly bleak period of memorization peripherally related to clinical development.  Second, the uncertainty of biology and medicine is part of her argument.  She extends the argument from the patient side to the side of the doctor. Patients want and need certainty and therefore they want doctors who are schooled in the best possible science who can provide it. Patients want an answer and all they get is statistics. Third, she suggests that the moral and habitual practice of medicine although dependent on human biology and the associated technical advances is not really science.  Physicians are taught to practice medicine and the don’t question “the status of its knowledge” (p. 191). She describes medical practice as a set of rational procedures that are shared with many other professions in the humanities and social sciences.  Fourth, the notion of medicine as a science is “clinically useful” in that it reassures the patients that physicians are engaged in a rational process like they were taught in science classes rather than a contextual, interpretive, narrative process used by non-scientists.  She cites numerous examples of maxims and aphorisms used in medicine to guide this process like Peabody’s famous: “The secret of the care of the patient is in caring for the patient.” 

 Montgomery’s writing is as sophisticated as you might expect from a bioethics professor with a doctorate in English and extensive exposure to medical training. Her critique depends a lot on verbal reasoning and the application of that model to numerous disciplines. Philosophical critiques of medicine and psychiatry that I have responded to in the past are typically presented as arguments with the premises being set by the author. As I read through these arguments being repeated across chapters there were clear points of disagreement.  Here is a short list:

1:  The argument about medicine not being a physical science – that is a good starting point if you want to be able to attack the scientific aspects of medicine, but does anyone really accept that premise? No physical science is taught in the basic science years of medicine.  The basic sciences are focused on human anatomy and physiology. An associated argument is that biological sciences have no overriding laws like physics and that is given as further evidence that medicine is not a science. There is an entire range of science within the basic science of medicine that cannot be explained by physical science but it is necessary for clinical medicine and innovation in medicine.  Finally science is a process that is subject to ongoing verification. That is as true for biological science as it is for physical sciences. While there appear to not be as many absolutes for biology progress is undeniable even within the boundaries of medicine.

2:  Uncertainty in biological systems and medicine - the author makes it seem like defining medicine as a science gives the false impression of certainty. I don’t think that certainty is misrepresented or minimized in clinical medicine.  Every physician I know experiences the uncertainty during informed consent and prognosis discussions. It is built into surgical consent forms and in situations involving medical treatment or testing – the discussions are even more complex. In a typical day, I will advise patients on side effects that occur at rates varying from 4 out of 10 patients to 1 out of 50,000 and tell them what to look for and when to call me.  I have had patients tell me after those discussions that they would prefer not to take a medication or do the recommended testing. I will also discuss life threatening problems with patients, and let them know I cannot predict outcomes but can advise them on how to reduce risk. The only way medicine can practiced is by having appropriate informed consent discussions that fully acknowledge uncertainty and the associated biological heterogeneity.  From the patient side, everyone has a friend, acquaintance, or family member who was healthy until the day there were not. The uncertainty of physical health and medical outcomes at that point are widely known by the general public.

An additional and lesser known aspect of the effect of uncertainty on physician behavior is encouraging the correct answer or treatment as soon as possible. Montgomery attributes some of this to the moral dimension of the physician-patient relationship and doing the right thing for the patient.  But a critical part of uncertainty is that physicians eventually learn to project their decisions out into the future. Those projections are all taken into account in developing the current treatment plan. The outcome of an idealized plan can be viewed as the direct result of the uncertainties involved.  

3:  Physician detachment is a likely consequence of characterizing medicine as a science – At points Montgomery makes the point that physician can emotionally protect themselves by assuming the detached rationality of science. It follows that abandoning medicine as a science would result in a more realistic emotional connection with patients. She has a detailed discussion of the physician-patient relationship being more as a friend or a neighbor.  She concludes that neighborliness has a number of virtues to recommend it as the relationship for the 21^st century. Two concepts from psychiatry are omitted from this discussion – empathy and boundaries. Empathy is a technical skill that is typically taught to physicians in their first interviewing courses in the first year of medical school.  It is a technical skill that allows for a more complete understanding of the patient’s emotional and cognitive predicament. In my experience what patients are looking for is a physician who understands them. That is generally not available from a friend or neighbor.  The basic boundary issue is that it is very difficult to provide care to a person who is emotionally involved with the physician. There are degrees of involvement, but any degree is important. A physician who is empathic, had a clear awareness of the relevant boundaries, and has a solid alliance with the patient is far from detached.  But I would not see them as neighborly or a friend.  The physicians job is the be in a position where they can provide the best possible medical advice. That can only happens from a neutral position where they can give a patient the same advice they would give anybody else.  That also does not mean that physicians are not emotionally affect when bad things happen to their patients or when their patients die.

4:  Do ancient Greek concepts still apply? – The author uses Aristotelian definitions of episteme and phronesis several times throughout the text. Episteme is scientific reasoning and phronesis is practical reasoning.  Aristotle’s view was that since there are no “fixed and invariable answers” to questions about health, every question must be considered an individual case.  In those cases, practical reasoning that considers context and additional factors or phronesis applies.  That allows the author to compare medicine to a number of social science disciplines that use the same kind of reasoning.  The question needs to be asked: “What would Aristotle conclude today?”  In ancient Greece there were basically no good medical treatments and medical theory was extremely primitive. Over the intervening centuries medicine has become a lot less imperfect. Uncertainty clearly exists, but the scientific advances are undeniable.  It is possible to say today that there are now fixed and invariable answers to large populations of people. Medicine has always been a collection of probability statements – but those probabilities in terms of successful outcomes have significantly improved.  One the corollaries of  Aristotle’s work is that there can be “no science of individuals” and yet the current goal is individualized or personalized medicine.

5:  Is science relevant to clinicians on a day-to-day basis? -  I think that it is.  I have certainly spent hours and even entire weekends researching patient related problems to find the best solution to a problem and to be absolutely sure that my recommended course of treatment would not harm the patient. All of that reading was basic or clinical science.  On the same day that I received Montgomery’s book, I got my weekly copy of the New England Journal of Medicine.  I have been a subscriber since my first year of medical school based on the recommendation of my biochemistry professor. Our biochemistry class was designed around research seminars where we read and critiqued basic science research. There was also the assumption that you were reading the text cover to cover and attending all of the lectures.  He encouraged all of us to keep up on the science of medicine by continuing to read the NEJM and in retrospect it was a great idea.  In that edition I turned to the Case records of the MGH (6): An 81-Year-Old Man with Cough, Fever, and Shortness of Breath. It was a detailed discussion by an Internist about the presentation and differential diagnosis of the problem. And there on page 2336 was a diagram of the ventilation perfusion mismatch that occurs with a pulmonary embolism and acute respiratory distress syndrome. I have seen this science at the bedside in many clinical settings.  

The clinical competency of pattern matching, pattern recognition, and pattern completion is left out of Montgomery’s description of how doctors think and it is an important omission.  It is a good example of non-verbal and unconscious reasoning that can be a critical part of the process. The answer to the question: “Is this patient critically ill?” and the triage that follows depends on it.  Pattern matching is also experience dependent with experts in their respective fields being able to more rapidly diagnose and classify problems that physicians who are not experts. Biases affecting verbal reasoning can negatively impact the diagnostic process, but so can the lack of experience in seeing patterns of illness and an inadequate number of cases in a particular specialty.

I consider both of these books to be good reads, especially if you are a physician and have had no exposure to thinking about the diagnostic process.  Both authors have their own ideas about what occurs and there is a lot of overlap. Both authors have the goal of stimulating discussion and analysis of how physicians think and educating the general public about it. Physicians will probably find Groopman a faster and more relatable text. Physicians may find the references and vocabulary used in Montgomery to be less recognizable. I would encourage any physician who is responding to initiatives to change the medical curriculum or critique it to read Montgomery’s book and work through her criticisms.  Both books have excellent references and annotations listed by the chapter for further reading. Non-physicians especially patients who are working with physicians on difficult problems may benefit from Groopman’s tips on how to keep those conversations focused and relevant.  As a psychiatrist who is sensitive to attacks (even philosophical ones) from many places – you may find my criticism of Montgomery’s work to be too rigorous. I tried to keep that criticism down to a level that could be contained in a blog post.  I encourage a reading of her book and formulating your own opinions. It is an excellent scholarly work.

Finally, the area of expertise in medicine and the associated clinical judgment of experts is still a current research topic.  The research has gone from basic experiments about who can properly diagnose a rash or diabetic retinopathy to a clear look at brain systems responding during that process. Those changes have occurred over the past 30 years. At the descriptive level it remains important to be aware of the possible cognitive biases and what can be done to overcome them.

 

George Dawson, MD, DFAPA

 

References:

1:  Groopman J.  How Doctors Think. Houghton Mifflin Company, New York, 2008.

2:  Montgomery K.  How Doctors Think. Oxford University Press, New York, 2006.

3:  Kassirer JP, Kopelman RI.  Learning Clinical Reasoning. Williams and Wilkens, Baltimore, 1991.

4:  Sox HC, Blat MA, Higgins MC, Marton KI.  Medical Decision Making. Butterworths, Boston, 1988.

5:  Hossenfelder S.  The End of Reductionism Could Be Nigh. Or Not.  Nautilus June 18,2021 (accessed on June 18, 2021) https://nautil.us/blog/the-end-of-reductionism-could-be-nigh-or-not

6:  Hibbert KA, Goiffon RJ, Fogerty AE. Case 18-2021: An 81-Year-Old Man with Cough, Fever, and Shortness of Breath. N Engl J Med. 2021 Jun 17;384(24):2332-2340. doi: 10.1056/NEJMcpc2100283. PMID: 34133863.

 

How Do So Many People End Up on Stimulants?

There is no question that thousands if not millions of people end up taking stimulants unnecessarily these days.  Addiction psychiatrists,  have a unique perspective on this that I thinks goes beyond a typical approach to the problem.  I like to consider it to be grounded in behavioral pharmacology and neuroscience.   For the sake of this essay I will limit my remarks to all adults who are college aged or older and should not be taking stimulants.  Neuroscientific discoveries in the area of brain maturation suggest that a significant portion of the college-aged individuals might not make the same decisions they make a decade later, but the practical consideration is that there are millions of people in college making decisions about stimulants every day.  There are several ways to look at the problem.  The best approach I can think of is to look at the various ways that patients present for treatment.  The request for stimulant treatment can be subtle or overt.  Unlike some the papers in the current literature, I don't think that the diagnostic questions here are subtle.  During an initial clinical assessment - diagnosis and treatment commonly overlap and in some cases that I will illustrate treatment considerations become primary in the initial minutes of the interview.

The general psychiatric interview has always been a screen of sorts.  My recollection is that it was typically more problem focused in the past.  Over time, that interview started to incorporate more disorders as a focus of inquiry.  On the outpatient side the disorders added been primarily Post Traumatic Stress Disorder and Attention Deficit-Hyperactivity Disorder in non-geriatric populations.  Any time a screening is being done whether it uses a symptoms checklist or a lengthy interview there is always the chance of missing the true diagnosis or adding a diagnosis that is probably not there.  Here are a few examples.

1.  "I have been depressed for the past ten years...."  An inquiry about mood disorders at some point will focus on concentration.   Impaired concentration and attention span occurs in a number of psychiatric disorders.  Combined with some developmental history and a history of chronicity it is easy to see the problem as a missed diagnosis of ADHD and initiate treatment for that disorder in addition to the primary mood disorder.  There are problems with that approach especially when the history of the mood disorder is clear and it has never been adequately treated.

2.  "I have a diagnosis of bipolar disorder - manic and these medications aren't working...."  ADHD in adults rarely presents as hyperactivity so severe that it could be mistaken for mania.  Manic episodes are also phasic disturbances making it very unlikely that there would be many patients in any single practice who were both manic and had ADHD.  In the cases where it does happen stimulant treatment complicates the treatment of bipolar disorder and can lead to worsening mania, delusional thinking and hallucinations.

3.  "My son/daughter has ADHD....."  There are two variations in this interaction.  In the first, the parent is told about the high heritability of ADHD and advised that they also probably have it and can be assessed for it or mention to their primary care physician that they may need treatment for it.  In the second, the parent of a child with an ADHD diagnosis reads the diagnostic materials and comes into an appointment and says: "You know, I have read the symptoms and think that I have them.  Should I be treated for ADHD?"

4.  "I have always had a problem reading and I was  never any good in school..."  A common approach is to view this as ADHD, do the screening and proceed with treatment.  Physicians in general have had very little training in the assessment or treatment of learning disorder and although there is comorbid ADHD and learning disorders there is also a significant population of people with pure learning disorders who do not have ADHD.

5.  "I took my friend's Adderall and felt like I could concentrate and study for the first time in my life.  I did a lot better on that test...."  The population-wide bias is that stimulants are a specific treatment for ADHD rather than a drug that will temporarily improve anyone's energy level and attention span.  There is also the cultural phenomenon of cognitive enhancement or using stimulants as performance enhancing drugs that may be driving this request.  It is known that the availability of stimulants on campuses and in professional schools is widespread.  This is associated with students selling their prescriptions for profit and availability of stimulants illegally obtained for the purpose of cognitive enhancement.  The issue is further confused by position statements in scientific journals that support this practice.  I have not seen it studied, but it would be interesting to see questions and responses about cognitive enhancement asked at student health centers and practices that see a lot of college and professional students.

6.  "I have ADHD and need a prescription refill...."  It may be true that the patient has a clear-cut documented diagnosis prior to the age of 12 (DSM-5 criteria).  But what has happened since that initial diagnosis in childhood and now is critical history.  Has there been continuous treatment since then or has the treatment been disrupted.  Common causes of disruption include stimulant side effects, symptom resolution with age,  and co-occuring substance use problems.  A detailed history of the course of treatment since childhood is needed to make the decision to continue or reinitiate treatment.

7.  "I heard you had a test for ADHD...."  This question often initiates screening at a higher level.  There are any number of places with extended neuropsychological batteries, brain  imaging tests, or EEG tests that they claim will definitively diagnose ADHD.  In fact, there are no tests with that capability.  I have heard one of the top experts in the world on ADHD make that same statement and he was also a neuropsychologist.  I have had several years of experience with quantitative EEG machines and know their limitations.   At this point several hours of extended testing adds nothing to a detailed interview, review of collateral information, and symptom checklists to basically assure that all of the questions have been asked.

8.  "My meds need to be adjusted....."  This could be a question from a person in treatment for another problem or a person already being treated for ADHD.  The unstated issue here is the underlying belief that by adjusting a medication one's mental processes will be closer to perfection.  A child psychiatrist that I work with said it best:   "The goal in treating ADHD is to get them more functional, not to perfect their functioning."  I think the unrealistic goal of perfection drives a lot of prescriptions that exceed the recommended FDA limits.  It also explains a lot of "rescue medications" superimposed on sustained release preparations like Adderall.  Anyone familiar with the pharmacokinetics of sustained release drugs should realize why rescue medications (like immediate release Adderall on top of sustained release Adderall XR) are unnecessary.

9.  "I can't stay sober if I can't get treated for ADHD....."  This can be a complicated and confusing situation.  The child psychiatry literature had suggested initially that children with treated ADHD were less likely to have substance use disorders as adults than children with untreated ADHD.  As the evidence accumulates that is less clear.  Many adult psychiatrists and some addiction psychiatrists have extrapolated those equivocal findings to mean that treating a known or new diagnosis of ADHD in an adult will improve treatment outcomes for ADHD.  There is no evidence that is true.  Some addiction psychiatrists believe that the opposite is true, that there is a cross addiction phenomenon and that treating a person with an addiction makes it more difficult to stay sober from their drug of choice.  If the person is addicted to stimulant medication and has a clear history of accelerating the dose of stimulants or using them in unorthodox ways (intravenously, smoking, snorting, etc) it is very unlikely that person will be able to take a stimulant prescription in a controlled manner.  It is also very possible that the person making this request has a long history of experiencing prescription or street drugs as being necessary to regulate mental functioning.  That can be highly reinforcing even if the effects are sustained for hours or less.

10.  "I have been sober for one month and can't focus or remember anything......" Subjective cognitive problems are frequent during initial sobriety.  The substance used and total amount used over time probably determine the extent that the cognitive changes persist, but it is a difficult problem to study for those same reasons.  Clinicians know that there are cognitive effects but there is no standard approach to the problem.  From my experience, I think that two months sober is the absolute minimum time to consider evaluating subjective cognitive problems.  Even at that time getting collateral history about the person's cognitive and functional capacity and problem solving with them on work arounds would probably be the biggest part of the treatment.

The above scenarios are not exhaustive and I probably could come up with another 5 or 10 but they are illustrative of pathways to questionable stimulant use.  The common thread here is that anyone in these scenarios can endorse all of the symptoms of ADHD.  Figuring out what those symptoms are is fairly obvious on many checklists.  One of these checklists shows the symptoms and checkboxes necessary to make the diagnosis in grayed out panels.  It is easy to fake the symptoms in an interview or on a diagnostic checklist.  It takes a lot of hard work on the part of the physician to figure out not only who might be faking but also who has the symptoms but not the diagnosis.  One of the features of the DSM that was attacked by several critics during the pre-release hysteria was the "generic diagnostic criterion requiring distress or disability" to establish disorder thresholds (DSM-5 p 21).  In the case of ADHD that is Criterion D "There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning."  (DSM-5 p 60).

The diagnosis of ADHD is generally not the diagnosis of a severe functional disorder.  As a psychiatrist who practiced in a hospital setting most of the people I assessed clearly met the functional criteria by the time I saw them and diagnosed severe mood disorders, psychotic disorders, substance use disorders or dementias.   Many of them were by definition unable to function outside of a hospital setting.  It is an entirely different assessment when faced with a successful professional who has worked at a high degree of competence for 20 years who presents with any one of the above problems because they think they have ADHD.  It takes more than a review of the diagnostic criteria.   It takes an exploration of the patient's motivations for treatment.  What do they hope to accomplish by treatment?

It also takes a conservative prescribing bias on the part of the prescriber.  Stimulants are potent medications that can alter a person's state of consciousness.  They are potentially addicting medications and that can result in craving or wanting to take the medication irrespective of any therapeutic effect.  The wide availability of stimulants led to the first amphetamine epidemic in the United States.   When I first started out in psychiatry, I was still seeing people who became addicted to stimulants when they were widely prescribed for weight loss.   It is well known that the medications were ineffective for weight loss but people continued to take them at high doses in spite of the fact that they had not lost any weight.  In talking with people about what drives this many people feel like they are only competent when taking stimulants.   They believe that their cognitive and functional capacities are improved despite the fact that there is minimal evidence that this is occurring from their descriptions of what they are doing at work or in their family.

There are a number of strategies in clinical practice to avoid some of the problems with excessive stimulant prescriptions that I will address in a separate post.  My main point with this post was to look at some ways that people with mild subjective cognitive concerns, addictions, people seeking cognitive enhancement, people who have been functioning well but believe that they can function better come in to treatment for ADHD and get stimulant prescriptions.


George Dawson, MD, DFAPA

Supplementary 1:  Literature was used to construct these hypothetical scenarios.

"Good News - Your Care Today Was Free"

"The bad news - we don't know how to make this diagnosis".

I woke up on Monday morning with a 2 inch diameter bright red rash on the inside of my right ankle.  It was mildly pruritic (itchy).  I could not recall any exposure to insects or trauma of any kind and it did not appear to be infected, so I applied some topical corticosteroid cream and went to work.  That night at home the rash seemed very mildly improved but it still itched.  I decided to get some medical input at that point.  The usual choices in my area are the Emergency Department or Urgent Care, but recently my health plan started to offer online consultation through a combination of limited diagnoses and procedures,  an algorithmic set of questions, the ability to upload images, and consultation with a nurse practitioner.  I looked at the list of conditions they were set up to diagnose and treat, noted that "rash" was one of them and logged on.

Health care IT is still in its infancy so nobody should be surprised that it took me much longer than expected to log in to the appropriate interface.  At first the program suggested I could just use my existing login and that would also integrate previous test results and conditions into the current evaluation.  After needing to call them I established a separate login and password for this episode.  Rather than the expected details up front, the program started to ask me all of the usual questions about the rash.  There were 28 screens in all, including some that forced an answer.  That question was "What do you think is causing the rash?".  Possible answers were: insect bite, infection, allergy exposure, poison ivy, etc.  There was nothing on that list that seemed likely.  That was after all the reason I was calling in.  I could not proceed past that point without giving an answer so I clicked "insect bite".  After completing 28 screens there was a text field and I entered: "Even though I answered "insect bite" on question #8, I only did that because I could not proceed if I did not provide an answer."

Next came the expected demographic data.  I live in a town that the U.S. Postal Service never gets right.  If I list a Zip Code the wrong town name pops up.  This software was no exception.  It took me extra time to enter and reenter data that was already there somewhere in my healthcare company's database.  The final screen was the billing and financial data including credit card information.  More data that my healthcare company has know for the last five years.  At this point I am about 20 minutes into the process and it is time to upload the photos.  I had 4 photos of the ankle and the program accepted 3 of them.  Sign off occurred at the 25-30 minutes mark.  As I waited for the return e-mail or call,  I marvelled at how health care companies have transferred all of this clerical work to physicians over the last 20 years and now they are transferring it to the patient.  I just did the work of the intake person and financial person in any clinic or hospital.

In 20 minutes I got a call from the nurse practitioner.  She said that although it was clear that I had a rash, it was not a rash they could diagnose in the system.  I told her that I was applying a potent corticosteroid and she said to just keep doing that but to go into a primary care clinic and get it checked out by my primary care physician.  Within 2 minutes, I got an e-mail from them:

Dear George,

Thanks again for taking the time to talk with us on the phone. Your health and safety is our top priority. Based on the information you shared with us, we think that an in-person visit is the best way to handle this specific condition. And, please know that you will not be charged for your visit today.

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Good to know I guess, but no diagnosis or specific treatment plan.  I continued the corticosteroid and the next night after work I stopped into an urgent care clinic after work.  I saw a family medicine physician who inspected and palpated the rash, took my pulses and determined that they were good in the area, and asked me clusters of questions that were clearly designed to rule in/out various pathological processes.  His conclusion:  "Well it's not an infection and its not due to trauma, but it clearly is an inflammatory process like atopic dermatitis.  So at this point I would keep applying the corticosteroid."  He asked me for questions.  My mind was preoccupied with tales of devastating spider bites lately so I blurted out:  "This does not in any way look like a brown recluse spider bite does it?"  He laughed and said: "Absolutely not."

So what have I learned from all of this and how do those lessons apply to psychiatry?  First off, it appears that human diagnosticians are safe for now.  Keep in mind that the system is set up to diagnose and treat a restricted list of conditions that are considered to be the least complicated in medicine.  Second,  the human diagnostician's superior capabilities depend on pattern matching and that in turn depends on experience.  It reminded me of a course I taught for 15 years on how to avoid diagnostic errors and pattern matching was a big part of that.  The two examples were rashes and diabetic retinopathy.  Dermatologists were much faster and much more accurate in classifying rashes from pictures than family physicians.  Ophthalmologists are much more accurate using indirect ophthalmoscopy than family physicians using direct ophthalmoscopy in diagnosing diabetic proliferative retinopathy.  In fact, the family physicians were slightly better than chance.

The lessons for psychiatry are two fold.  Remember the idea of a restricted list of conditions that are not considered complex?  It turns out that depression and anxiety are on that list.  Even though there is no call center where you can call and complete the paperwork like I did,  it would probably not be much of a stretch to say that many if not most primary care clinic diagnoses of depression and anxiety are keyed to some rating scale.  Like the studies of Dermatologists and Ophthalmologists, there are no expert pattern matchers looking at the patient.  That can result in a diagnosis that is essentially dialed in.

The second aspect here is the design of the algorithm and its implications.  My rash algorithm had a forced choice paradigm.  I could not proceed to the end unless I picked an answer that was clearly wrong.  That is the way it was set up.  That is the problem with so-called "measurement based" care.  There is the appearance of a quantitative result.  The Joint Commission called the 10-point pain scale "quantitative" in the year 2000 with their pain treatment initiative in the year 2000.  I have spent a good deal of my adult life talking with patients about their moods, sleep and appetite patterns, and other symptoms.  The most important part of my job is coming up with a plausible scenario for their current distress.  I can say without a doubt that over half of the people I see cannot describe discrete episodes of mania or depression.  The usual description of depression I get is that it is life long with no remissions.  Certain personality characteristics predict descriptions of symptom severity in the initial interview.  Some people completely minimize symptoms and other people will flat out tell me that they do not want to discuss their inner thoughts even if they are experiencing thoughts that may place them in danger.  Map those response patterns onto a psychiatrist and hopefully that will result in a diagnostic formulation and a plan to deal with the nuances.  Map those response patterns onto a PHQ-9 and suddenly you have a number that somebody believes has meaning.   Looking only at Question 9:

"Thoughts that you would be better off dead or of hurting yourself in some way."  

Suddenly people are alarmed with the person with a personality disorder and chronic suicidal thinking or chronic obsessions involving suicidal thinking endorses "nearly every day" as their response.  We are falsely reassured when the patient who has a significant personality change and depression endorses "not at all".  We have forced them to make a choice and they have, rather than using all of the information necessary to make an evaluation.

As a discipline - we should be moving in the direction of using all of the relevant information in clinical situations and not less.  My rash today is an example of what can happen in an organ governed by much less genetic, metabolic and signalling information than the human brain.  Even in that situation a diagnosis with no clear etiology or diagnostic features can present itself.

Forcing choices reduces the information flow rather than facilitating it.  If primary care physicians find this checklist approach to diagnosing anxiety and depression useful I would see no problem with that, but it might be useful to look at the medications being used based on the PHQ-9 and the kind of impact this approach is having on medication utilization.  It also might be useful to have a seminar or two on the problem of over prescribing medications.  The correlation between overprescribing opioids and the use of a "quantitative" scale to measure everyone's pain is undeniable.

The question that applies in all of these circumstances is whether a number on a subjective rating scale is ever enough of a reason to prescribe a medication.

You already know what I have to say about that.

George Dawson, MD, DFAPA