Social Media Discovers Managed Care and Rages - Or Not?

I watched TMZ last night and they were fascinated about the homicide of Brian Thompson the CEO of United Healthcare in New York City the night before.  The hosts could not approach that topic directly so they brought on Taylor Lorenz who they described as a social media expert.  She made some posts about healthcare companies.  She claims that the “entire internet left and right” was united in celebrating the death of this CEO because “Somebody stood up to this barbaric, evil, cruel violent system.”  Her rational is that if you see a loved one die because an insurance company denied care it is natural to want to see that person dead and this is not advocating homicide. It is a justice fantasy.  She went on to say that United Healthcare has murdered tens of thousands of Americans by denying healthcare.  She sees this as a revolution and it is a problem that should be addressed without violence.  She suggests letter writing and possibly politicians and journalists getting a clue and seeking to correct this imbalance. 

I have been aware of United Healthcare for at least 30 years.  They are renowned in Minnesota for their initial emphasis on not funding psychiatric care and moving on from there.  Physicians like me have been railing against United Healthcare and other managed care companies for decades.  And nobody - and I mean nobody cares. No politicians, nobody in the media, and nobody in physician professional organizations.  There has been an occasional activist state Attorney General suing these companies into a temporary correction that they can easily wait out.   The American Medical Association just recently came out against prior authorization one of the main forms of managed care denial – just a few years ago.  It has been in place along with utilization review – the other main form of denial for at least 40 years.

These business practices have transformed the practice of medicine into a high productivity and low-quality enterprise where medical judgment is replaced by the judgment of middle managers with no medical training and company profit in mind. Physicians have been displaced in their roles in managing the treatment environment and now it is staffed by business people concerned only about the bottom line. If a company decides it is not going to cover a medication or a procedure or a hospitalization – the general message to the patient is “you are out of luck.”  I worked at the same hospital for 22 years and during that time we went from providing care to anyone who walked in the door to care based on businesses telling us what to do.  At one point to make things less contentious (and after we were bought out by a managed care company) – the external review was replaced by the same kind of decisions made by internal staff.  Some physicians became "managed care friendly" in order to move up the corporate ladder.

How did these organizations get so much power over healthcare?  A lot of it depended on lying to gullible politicians.  The original sales job was that physicians were just too expensive.  They order too many tests.  They were going to close down or buy out the expensive specialists and greatly expand primary care.  That primary care expansion would lead to more prevention and reduce the overall costs of medicine. But once these organizations were granted all the power they wanted, they began acquiring specialists and providing their own specialty care.  They also greatly expanded middle management to micromanage staff and basically tell them to work harder.  The result is a system that is much more expensive rather than more cost effective.  Shareholder profits and CEO salaries require a lot of denied care to fund.  This article about the company is an indication of the amount of money that we are discussing. We are talking about executives that are making tens of millions of dollars in an organization that rations health care.

Of course, people are angry about the situation of rationed health care. But it is more about how things are organized and all the associated politics. I think we can all agree that there do not seem to be many bright politicians out there and that low bar took an even more precipitous drop in the last election. Even managed care companies know more than to ration vaccines or give everyone hydroxychloroquine for COVID.

 Politicians have invented this system at every step of the way and made it impossible for the average citizen to get any satisfaction when their health care is denied. Federal and state governments both side with healthcare companies to support the denial of care and (incredibly) indemnify them from liability when their denials result in bad outcomes.  Death is just one of many bad outcomes. 

The press does not get it. I am tired of writing about it for physicians.  The only bright idea that group seems to have come up with is not contracting with these companies and either charging cash or asking the patient to seek their own insurance reimbursement after paying their bill. This obviously has limited application and doesn't work if the patient needs more resources like operating rooms or rehab facilities.  So - Ms. Lorenz’s solution of writing letters certainly will not work.

Some news services seemed to connect a policy reversal by Anthem Blue Cross/Blue Shield (ABCBS) to the homicide. Some of the original stories claimed that anesthesia time per procedure would be limited and the patient might need to pay the balance. Subsequent stories state that the insurance company planned to pay the time allotment indicated in the estimated relative value units (RVUs) for the surgery.  They claim their reversal was based on misinformation. RVUs are another form of rationing – paying only a set amount irrespective of the complexity of the case.  It is another way that psychiatric services were also rationed by reduced reimbursement.  In some cases, it leads clinics to stop seeing all the patients from a particular insurer based on low reimbursement to the physicians and providers.  Lorenz posted a caption of the ABBCBS story with the additional line:  ‘And people wonder why we want these execs dead.'     

This is the state of medicine in the US today. We have just had an election that puts the most rational parts of the fragmented healthcare system (the ACA or Obamacare, Medicare, and Medicaid) at risk.  The party in power espouses gun extremism and uses political tactics that direct violence and aggression toward specific individuals or groups. The party in power favors the top wage earners rather than production or knowledge workers. That includes large healthcare conglomerates that all function by rationing care and access to medications and procedures. And in that context, we have a social media expert claiming that we now have bipartisan rage against these health care companies who have murdered tens of thousands of people by denying their care.  I certainly know many people who have been harmed by the denial of care.  In some cases, I spent hours advocating for them and trying to get the care they needed but I was simply ignored.   

At this point, the crime is being analyzed like it is just another true crime TV show. Endless analysis about the perpetrator’s behavior and possible motivations.  It is all highly speculative but made as controversial as possible.  All the analyses I have seen so far seem way off the mark – but I am not going to add mine at this point.  I am more than a little suspect about all the social media rage. Is it real or just generated by a few provocative trolls?  Will it lead to a typical Congressional show hearing where members manufacture outrage and nothing changes. One thing is for sure – the current state of events is not a good sign.  It is a sign of just how corrupt, ignorant, and not self-correcting the American political system is - and just how much those politicians collude with businesses.

In the end, Americans end up paying top dollar for a healthcare system that may refuse to treat them, an airline system that may refuse to fly them, a financial system with excessive charges and minimal interest payments on savings, and a system for workers that disproportionately pays the people who do not do any of the brain or physical work.  Is it any wonder that 4 people in the US possess more wealth than 50% and that 50% are essentially left hoping for changes that never come.

 

George Dawson, MD, DFAPA

References:

Jeremy Olsen.  Shooting of UnitedHealthcare CEO revives criticism of company’s medical claim denials.  Some mourn the shooting of chief executive but still have scorn for the insurance company he ran.  StarTribune.  December 5, 2024.  https://www.startribune.com/why-unitedhealthcare-is-a-four-letter-word-to-critics/601191492

 

Addendum:

As any reader of this blog can attest – I do not consider homicide as a solution to any problem.  The two main features of homicide that I consistently observe on this blog is homicide as a primitive value and a primitive solution.  It has no place in civil society.  In the anthropological literature homicide as a solution dates to prehistoric times when minor conflicts escalated from individuals to entire villages.  Modern man has not uniformly progressed very far as evidenced by every active war in the world right now and ever.  The shooting of Brian Thompson is no exception. Given everything, I have listed in the above post – it changes nothing.  It was a cowardly, immoral act, and unlawful act. I hope that the perpetrator is caught and punished.  I hope that the privacy of Brian Thompson’s family is respected.  

What Is Missing From The Divisiveness Debate?

Migratory routes of Homo heidelbergensis from East African origins (numbers are approximate years in past) - see attribution for reference.  Homo heidelbergensis is thought to be the common ancestor for Neanderthals, Denisovans, and modern humans - Homo sapiens.

The recent high profile incidents involving the shooting deaths of young black men and police officers and the associated news coverage and involvement by high profile celebrities and politicians has sparked a social activism, debate, and dialogue.  Like any complex issue, there are people who have opinions that mirror their political party lines, people who have their own opinions and they are not interested in changing them and people who are more open to a dialogue.  Practically all of the dialogue seems focused on high risk incidents that happen in a matter of seconds that involve deadly force.  I have seen some neuroscientific ponderings about how unconscious or implicit biases can affect those split second decisions.  I thought that was possible until I went to the web site and took the tests involving implicit bias.  There was not a single case where I could not predict the outcome ahead of time based on what I already know about myself.  To me it appeared that unconscious bias was not operating in the decision.  Since I am a white psychiatrist and not a police officer, I am not going to suggest specific solutions for police officers or the black community.  I do see a number of scientific dimensions that nobody or very few people are talking about so it is time to add my two cents:

1.  We are all from Africa -

Practically all of the debate centers on race.  There are statistical studies that show black drivers are stopped at higher rates than white drivers.  There are more white people killed by the police but as a proportion of the population black people are overrepresented.  The numbers are real and require serious analysis, but the larger picture is ignored.  That larger picture is that race is a social and cultural convention and not a scientific one.  On a scientific basis, everyone in the world - all human beings originated in East Africa about 200,000 years ago.  At some point, different races were described but at the time this genetic evidence was unknown.  The genetic evidence for racial and ethnic differences is still an area of active investigation.  Those studies illustrate the difference in skin color for example may come down to mutations in two genes (1, 2).  At the proteomic level, a recent study (3) looked at an analysis of interindividual variation in the total number of proteins that could be identified in cerebrospinal fluid (CSF) and urine and found considerable variation between individuals.  There was a 26% difference across 968 urinary proteins and a 18% difference for 512 CSF proteins.  Those numbers are very large compared with the difference between 1 or 2 skin proteins.

Although the total number of proteins identified in the human proteins is 10,500, estimate of the true size has varied from 10,000 to several billion (4) making the number of proteins responsible for skin color differences even less significant.  More skin specific information is available from the Human Protein Atlas.  Their analysis shows that there are 95 skin enriched genes and 412 genes with enhanced expression in the skin.  Only three of these genes MLANA, DCT, and TYR involve melanin synthesis or skin pigmentation.  Person to person variation on an arbitrary racial classification based on skin color is obscured by the expected genetic variation among members of the same race.

Further evidence is available to anyone by sending their DNA for analysis by the National Geographic Genographic Project.  You will receive a map of how your ancestors migrated from East Africa and information about marker that you share with other ethnic groups across the world.  The analysis will also include information about DNA that you share with ancient humans specifically Neanderthals and Denisovans.  The current project also estimates regional ancestry based on markers that appeared over time if migration from Africa occurred.  All of these science considerations should point to the fact that what we have generally considered to be racial boundaries may have political and cultural meaning to people - but there is no scientific meaning.  Every human being on the planet is descended from a small group of ancestors in East Africa.  Time to put the cultural and political stereotypes about race behind us.        

2.  Every person in the world has a unique conscious state -

One of the concepts that I am careful to mention whenever I am discussing aspects of psychiatric diagnosis is human consciousness.  From a neurobiological perspective the human brain has evolved to be a very efficient information processor.   Plasticity leads to experience dependent changes in the brain.  Experience can have a biasing effect of the general form that "my experience is everyone's experience" or "my experience is more valuable than anyone else's experience" or in the extreme case "my experience is the only one that counts."  Fortunately the human brain also has top-down controls like empathy, the ability to recognize that other unique conscious states exist, and the ability to correct its own erroneous biases.  Just the fact that every person on earth has a unique conscious state has significant ethical and moral implications for how one person interacts with another.  Those individual ethical imperatives are seriously watered down by political and legal limits that often target the lowest common denominator.    

3.  Anger has a predictable biasing effect -

Let me start off by saying that this paragraph is not meant to discount anyone's anger.  Anger is a universal human emotion, but the analysis of anger usually stops at the point of whether it is justified or not.  The analysis seldom looks at how anger biases subsequent decisions or how it might affect the initial encounter between the police and suspects.  Any student of social media can observe the very predictable polarizing arguments that occur following these incidents.  Partisans will frequently post arguments and counterarguments followed by statistics and counter statistics.  In many cases the arguments are rhetorical at at some level fallacious.  The dynamic driving these arguments is never mentioned and that dynamic is anger.  Anger has been studied by cognitive scientists and it functions to squarely focus blame on a specific person whether that is accurate or not.  This is as important for the police officer on the scene as it is for the secondary clashes between protesters, the public and the police.  When police officers confront a suspect and start swearing angrily at him/her to comply with their demands - that may be part of their training, it may be something that happens spontaneously, but in either case any real anger on the part of the officer implies that the subject has done something wrong and that the officer's decision-making capacity may be affected by his/her emotional state.  Emotions are critical in human decisions, but not all emotions result in a focus on another person as a source of wrongdoing.  

4.  Human reaction time is a limiting factor - 

The human nervous system takes time to process information.  There is surprisingly little public data available on how much time there is to make a decision to shoot an armed suspect.  The only study I could find (6) involved a simulation where an untrained armed suspect was either holding a handgun to his own head because he was allegedly suicidal or holding a handgun at his side when confronted by a police officer.  In the case where the suspect decides to fire a shot at the officer instead - it took an average of 380 msec.  Highly trained officers shot in 390 msec.  That translated to inexperienced suspects shooting first or tying the officers in 60% of the scenarios.  An interesting article in the literature also suggests that shooting errors in high threat situations persist even after weeks of practicing these scenarios (7).  For comparison, this web site allows for a determination of reaction time in a scenario that is completely free from distractions and noise - like anxiety and trying to determine if what the suspect is holding is really a firearm or not.  It is obvious that these decisions to fire by both officers and armed suspects are not like they are portrayed in television programs and films.  In real life there are no prolonged standoffs with officers and suspects pointing firearms at one another while they talk.    


5.  Human beings have a long history of solving difficult problems through violence and aggression -

One of the major lessons of human history is that lives matter only up to a point and if nobody agrees at that point - people will die.  In human history there are very few exceptions to that concept.  The best analysis of the situation that I have seen comes from anthropology (8) and the detailed study of modern and ancient warfare.  Several authors have written about the attractiveness of war to some of the participants - most prominent Chris Hodges (9).  The powerful combination of war and winning a conflict by force and being reinforced by the secondary aspects of camaraderie, teamwork, meaningfulness, and the political illusions of what an armed conflict can accomplish are all powerful incentives to avoid peace and conflict resolution.  The last time there was as serious peace movement in the USA it was largely a reaction to a prolonged and unnecessary war in Vietnam.  Since then there have been three unnecessary wars and no corresponding peace movements.

The war metaphor doesn't stop at the level of nations fighting nations.  At the next level it is always local governments and police departments fighting drug dealers, gangs, terrorists and various criminals.  I don't think that the reinforcers that occur at a global level stop just because the conflict is at a local level.  Americans in general want to see the bad guys stopped in any way possible.  With that attitude there are invariably serious mistakes.    


6.  Widespread availability of firearms ups the ante -

I have written about firearm related issues in many places on this blog.  My primary focus have been to suggest that violence, especially firearm related deaths including suicide, homicide, and mass shootings can probably be stopped by public health measures.  Very few people agree on those points and there are various political reasons why they do not.  Stopping firearm related violence does not necessarily require addressing firearms availability, but make no mistake about it - firearms access rather than mental illness is the number one cause of these deaths.  The problem with high risk scenarios involving either firearms or the threat of firearms with the police is even more obvious.  Statistics are available for the number of people killed by the police in a number of countries and the numbers are skewed in the expected manner toward the US.  It is clear that widespread availability of firearms is dangerous for both the police and the people who are being policed.  A lot of that comes down to being able to assess the threat and react in less than a half second.  That is the time a police officer has in a high threat scenario.

The six dimensions I briefly described are critical but unmentioned in the current debate.  The current debate is framed in terms of race, immutable interracial relationships, and a lack of scientific consideration at several levels.  At the cultural level, the notion of race having some specific meaning needs to be put to rest forever.  There is no scientific basis for classifying people based on skin color or other so-called racial characteristics.  Racial diversity is nothing compared with genetic diversity and that needs to be the new standard.  The second scientific consideration is based on the unique conscious state of humans.  This important concept should form the basis for everyone being treated with respect and consideration.  That is not to say that will preclude criminal conduct or violent acts against bystanders, but it should be a standard for everyone else.  The expression of anger especially sustained anger has a particular biasing effect that is never mentioned.  We hear that anger is appropriate or justified, and therefore it should be expected.  Appropriate, justified and expected anger still affects human decision making in a predictable way.  The angry - no matter who they are need to realize that they may not be seeing things clearly due to the predictable and biasing effects of that emotion.  The technical aspects of human reaction time and the fact that decision making in high threat situations does not improve - even with training is a sobering fact that all police officers need to deal with.  Given the quoted statistics, in high threat situations when a subject is armed - the outcome of that confrontation will essentially be a coin toss.  The only logical approach to the situation is to design a new situation where it does not come down to reaction time and every officer knowing they have a 50:50 chance of being able to shoot first.  There is an innate human tendency for conflict resolution by aggression and choosing sides on how that plays out is not the best way to resolve the problem.  All that I have seen in social media and the press highlights a string of arguments designed to support one side or the other.

Considering the science behind this problem will lead to permanent, long term solutions.          



George Dawson, MD, DFAPA


References:

1: Murase D, Hachiya A, Fullenkamp R, Beck A, Moriwaki S, Hase T, Takema Y, Manga P. Variation in Hsp70-1A Expression Contributes to Skin Color Diversity. J Invest Dermatol. 2016 Apr 16. pii: S0022-202X(16)31047-8. doi: 10.1016/j.jid.2016.03.038. [Epub ahead of print] PubMed PMID: 27094592.

2: Yoshida-Amano Y, Hachiya A, Ohuchi A, Kobinger GP, Kitahara T, Takema Y,Fukuda M. Essential role of RAB27A in determining constitutive human skin color. PLoS One. 2012;7(7):e41160. doi: 10.1371/journal.pone.0041160. Epub 2012 Jul 23. PubMed PMID: 22844437; PubMed Central PMCID: PMC3402535.

3: Guo Z, Zhang Y, Zou L, et al. A Proteomic Analysis of Individual and Gender Variations in Normal Human Urine and Cerebrospinal Fluid Using iTRAQ Quantification. Pendyala G, ed. PLoS ONE. 2015;10(7):e0133270. doi:10.1371/journal.pone.0133270.

4:  Elena A. Ponomarenko, Ekaterina V. Poverennaya, Ekaterina V. Ilgisonis, et al., “The Size of the Human Proteome: The Width and Depth,” International Journal of Analytical Chemistry, vol. 2016, Article ID 7436849, 6 pages, 2016. doi:10.1155/2016/7436849.

5:  Skin specific proteome.  The Human Protein Atlas.  Accessed on 7/16/2016.

6:  Blair JP, Pollock J, Montague D, Nichols T, Curnutt J, Burns D.  Reasonableness and reaction time.  Police Quarterly Dec 2011; 14: 323-343 (especially pages 15-20).

7:  Nieuwenhuys A, Savelsbergh GJ, Oudejans RR. Persistence of threat-induced errors in police officers' shooting decisions. Appl Ergon. 2015 May;48:263-72. doi: 10.1016/j.apergo.2014.12.006. Epub 2015 Jan 16. PubMed PMID: 25683553.

8:  Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

9:  Chris Hodges.  War Is A Force That Gives Us Meaning. Public Affairs, New York, New York, 2002.

Attributions:

Attribution:  Graphic at the top is by Altaileopard SVG by Magasjukur2 [CC BY-SA 2.5 (http://creativecommons.org/licenses/by-sa/2.5)], via Wikimedia Commons at: https://upload.wikimedia.org/wikipedia/commons/4/41/Spreading_homo_sapiens.svg

Guns In Psychiatric Hospitals - Texas Has The Worst Possible Idea

Almost on cue, USA Today came out with a story at about the same time that I responded to a post about secure environments in psychiatric hospitals.  My response provided a specific reason why these places need to be a firearm free environment and why armed peace officers sitting at bedside or in the hallway are not really more of a deterrent to criminals with goal directed aggressive behavior or patients with mental illness who have aggressive behavior.  My personal experience with firearms in psychiatric settings is fairly extensive.  It varies from visiting a primary care physician in his office early in my career and being shown a closet full of firearms turned into him to working in settings where mental health professionals or law enforcement professionals were killed by the use of a firearm.  It has occurred in both inpatient settings and outpatient clinics.  Even without firearms I have worked on inpatient units with highly aggressive individuals that on several occasions basically rioted and took control of the hospital unit until enough law enforcement staff came on the scene to restore order.  In one situation an entire unit was disrupted by one individual and law enforcement had to be called.  Against this backdrop, I was more than a little puzzled by new legislation in the state of Texas that allows visitors to carry weapons on units in Texas psychiatric hospitals.  

The USA Today article states that although staff and patients are not allowed to have weapons, visitors are now allowed to openly carry firearms.  Signs suggesting that these weapons need to be left in cars or concealed needed to be removed.  A hospital spokesman quoted in the article makes the understatement of the year by saying that it is generally not a good idea to expose hospitalized patients to weapons of any kind.  Even police officers entering these hospitals do not carry in weapons, probably because it is standard police protocol to not carry weapons in an environment where there are large numbers of potentially aggressive people with impaired judgement in close proximity.  In my previous post, I also point out that firearms are not a deterrent to people who are aggressive and have severe impairments in judgment or see them as a means to escape or perpetrate violence. Law enforcement officers involved are also not able to maintain a high enough level of vigilance to prevent an unexpected attack. A hospital environment is not generally a very stimulating environment. There may be a significant amount of background noise, but there are not a lot of events that require focused attention - like very low frequency aggressive events.

The best protection against these events are physical barriers to protect people from the aggressive person and maintaining a therapeutic environment with multiple interventions to reduce violence. The barriers include jail cell units where incarcerated patients who need acute medical treatment can be transferred to and entire 18-20 bed units that specialize in treating aggressive men. In the case of open units, staff must be available and out there with the patients to provide therapeutic interactions and also frequent assessments. In this era of the electronic health record, it is common to see people sitting in unit offices charting on computers all day long. That is not an approach that optimizes the therapeutic environment. The units themselves have to be staffed with people who are comfortable dealing with aggression and who know how to address it. The environment has to be secured against contraband weapons and drugs and all material coming into the unit needs to be searched. Metal detectors are also employed to detect any weapons coming into the unit.  I have also witnessed incidents where visitors have become physically aggressive and threatening to staff.  One of the logical flaws of gun advocates is that anyone who is licensed to carry a firearm always acts in a rational manner.  You don't have to be a psychiatrist to see that as an unrealistic statement.

The real problem in visitors carrying weapons into a psychiatric facility is the potential adverse impact on individual patients who are being treated there.  To cite a few examples:

1.  Patients with a history of trauma and in some cases post traumatic stress disorder.   These patients are hypervigilant and scanning the environment for the slightest hint of danger.  What would appear more dangerous than a person walking in with a gun?

2.  Patients who constantly expect to be harmed or killed - paranoid patients.  During inpatient work it is common to have many people with this problem.

3.  Suicidal patients who may have those thoughts under fairly good control until these see a highly lethal method within arms reach.

4.  Aggressive patients who may have been involved with weapons prior to admission and immediately gravitate towards anyone carrying a weapon.

There are more examples, but in our society guns are powerful symbols.  Any powerful symbols tend to be amplified in many predictable and unpredictable directions by psychopathology.   The other unappreciated fact is that there is a psychological environment in any hospital setting.  That environment is the conscious and unconscious product of every staff person, patient and visitor in that facility.  Unless that environment is actively managed for safety and affiliative rather than confrontive interpersonal communications there is the potential for major problems.   Carrying firearms into a psychiatric facility is more than a bad idea.  It is an inexcusable use of a psychiatric facility for political purposes at the cost of a therapeutic environment.

In order to get more details about this legislation and the positions of Texas psychiatric organizations I sent an e-mail to the Texas Psychiatric Federation - a website that lists Texas Society of Psychiatric Physicians, the Texas Academy of Psychiatry, and the Texas Society of Child and Adolescent Psychiatry as the major professional organizations in the state.  I am interested in getting feedback on the positions that these organizations are taking as well as the position of the American Psychiatric Association.  I delayed posting this for a few days but so far have not received a reply.  I will post information in the comments section as it becomes available.

Every psychiatric professional organization and every psychiatrist should know what is wrong with this picture and demand safe and therapeutic hospital environments for our patients.
.


George Dawson, MD, DFAPA


References:

Rick Jervis.  Texas allows guns into state mental health hospitals.  USA Today August 8, 2016.
http://www.usatoday.com/story/news/2016/01/08/texas-open-carry-psychiatric-hospital/78522138/


Attributions:

The graphic at the top is downloaded from Shutterstock via their Standard License Agreement and is copyrighted by Bob Orsillo.

Why Would A Psychiatrist Carry A Gun?

I thought I could resist commenting on this issue, but after seeing what the press did with this issue today - somebody needs to set things right.  What may be going through a psychiatrist's mind as they think about arming themselves?  I don't need to speculate about another psychiatrist.  As I recently posted, I have had to make the decision and in talking it over with colleagues many of them had to make similar decisions.  It is definitely not a linear process.  Here are some of the elements:

1.  Contact with aggressive and violent patients who have severe mental illnesses:  In another recent post - the most familiar scenario is the person with paranoia or a severe personality disorder and who uses the psychological defense of  projection or projective identification.  In the popular vernacular a person who tends to blame other people for their problems, even when there is no realistic connection.  That can happen to psychiatrists because of the unique a aspects of the relationship and nature of treatment, but it can also happen to other physicians, therapists, and counselors.   In many  cases the blame is projected onto anyone who works for the organization or clinic and that puts everyone in danger - including the clerical staff.

2.  A significant substance use disorder:  The usual scenario is the severe psychiatric disorder, aggressive behavior and a substance use problem.  Most intoxicants are disinhibiting and they have the potential for activation, increased paranoia, and increased psychosis with impaired judgment.  They can also lead to aggressive or suicidal behavior that occurs during blackouts.  That not only increases the likelihood of action on a threat but makes any contact with patients in this context very problematic.  That includes crisis intervention centers, emergency departments,  acute inpatient psychiatric facilities, and detox facilities.  It is crucial that all of these settings have adequate staffing and crisis plans to contain both any  aggression that occurs and ways to limit access to people with weapons or people who are out of control.  In some cases patients with acute intoxication need to be rapidly sedated to prevent self injury or injury to staff.

3.  A specific threat against self or family:  Any threat needs to be taken seriously and this is also a training point.  Every mental health professional needs to learn how to address this issue and the first step is to make sure that everyone in the workplace is aware of the threat.  A threat assessment needs to be done and matched with the appropriate plan.  Those plans could range from an immediate call to the police, emergency hospitalization,  civil commitment, and interventions about how the clinic or hospital will interact with that person in the future.

4.  Police involvement:  This is not a debate about gun rights.  Nobody tells you in medical school that homicidal patients are an occupational hazard.  Nobody tells you that if somebody threatens to kill you - you may be on your own.  When you hear about some of these scenarios on television and in the movies one of the themes typically is:  "Well these are just threats.  He/she hasn't actually done anything yet so we can't do anything."  That was a very common attitude from law enforcement 20 years ago.  

Attitude problems can also exist at the court level.  I have testified in hearing about threats where it was suggested that this was an occupational hazard for psychiatrists and therefore less relevant as evidence of criteria for commitment.  Nursing staff are also subjected to these illogical attitudes.  Assaults on nurses are commonly viewed as an occupational hazard and the administrative response is generally that the responsible patient is never prosecuted.  In this era where civil commitment is often watered down to the point that it is completely ineffective, court ordered treatment from a criminal rather than a civil court may be the only available treatment.

A lot of laws have changed in the past two decades and the police should be able to do a lot more at this point.  In recent cases of telephone threats, even very indirect telephone threats, the police will often make a visit to the person making those statements and explain new laws about terroristic threats.  Any mental health professional should not accept the idea that something beyond a threat needs to happen before law enforcement can get involved.  The only action necessary is a threat.  What the police actually do is frequently a determining factor in whether a firearm is acquired.

5.  A secure treatment environment:  There are many aspects to this dimension including access to the physical environment, staffing, and the security arrangements.  Are there security cameras?  Are they actually monitored by security staff.  Is physical access to the environment limited to a few staff?  Most inpatient psychiatric units are locked.  I have been grateful many times that the locked door was more useful for keeping people out rather than preventing patients from leaving.

6.  An awareness that psychiatrists and other staff are killed by aggressive patients:  This happens frequently and it has been going on for a long time.  It tends not to make the papers anymore.  Here is an old New York Times article that was uncharacteristically blunt about the problem.   It described a full spectrum of homicidal aggression toward psychiatrists back in 1983.  That was the same year that I became an intern and I don't remember ever seeing this article.

7.  A functional administration:  Lack of an administrative support that prioritizes the treatment of violence and aggression and an associated systems approach to violence prevention is critical.  The appearance that a single psychiatrist is in a confrontation with a potentially violent and aggressive perpetrator needs to be avoided at all costs.  Staff splitting that encourages patients to act on aggressive wishes toward a staff member need to be avoided at all costs.  This may sound like common sense function, but in my 30 years as a psychiatrist, I have never seen a situation like this handled appropriately by administrators.  In fact, I have seen just the opposite when administrators dislike a staff person and suddenly there are rapid succession of administrative, staff, and patient problems focused on that person.    

It is very likely that the business oriented, "customer friendly" approach to patients that has been promoted by managed care has the potential for making these situations much worse.  It is hard to imagine a worse situation than to find out that a potentially aggressive patient who has threatened you is now being taken seriously by various patient representatives, customer service representatives and ombudsman.  Many of these patients realize that the state medical board is a gold mine in terms of being able to continue the harassment of the object of their aggression.  Multiple complaints against multiple parties can be filed even when it means that egregious threats made by the patient are included in the medical documentation will be sent to the medical board.

8. Dynamic issues:  There are a number of critical issues related to individual and group psychodynamics.  I have heard the term "therapeutic grandiosity" used to describe a situation where a psychiatrist failed to anticipate a dangerous situation and ended up injured or killed.  I think it is far more likely that the psychiatrist involved did not recognize different conscious states of the patient and the fact that one of those conscious states was capable of severe aggression.   Many people seem to be confused about legal definitions or reduced capacity here.  The law believes that a rational act that is internally consistent with a given psychotic state means that the person is responsible for their actions.  Every psychiatrist knows that there are mood disordered and psychotic states that result in decisions that the person would never have made if they did not have a mental illness.  One of those decisions is deciding whether or not to become aggressive toward their psychiatrist.   Making that determination can depend on very subtle findings.   If they are missed and there is an agreement to meet about an issue, especially if it is after hours the clinician may find that they are interacting with an unexpected person.  The structure of a clinic schedule and a crisis plan for that clinic can provide a basic background for not making these mistakes.

On an individual level, it is possible to view a patient's aggression as a personal failing on the part of the psychiatrist.  Many psychiatrists who have been assaulted are full of doubt about what they missed and whether the care being provided was adequate.  It is easy to lose sight of the fact that any physical aggression toward a physician is grossly inappropriate.  In the cases I have been personally aware of most of the psychiatrists were spontaneously assaulted and were not even interacting with the aggressive patient at the time.  In many cases the assaults occurred by patients who did not even know them.

There are also interpersonal dynamics that are disquieting at times.   Other staff speculating on the origins of the assault or threats, acting like the aggressive behavior can be interpreted.  This often occurs with little knowledge of the patient and their unique characteristics.  In some cases assaultive behavior is explained away on psychological grounds and the person who has been assaulted is unsupported  and alienated from the rest of the staff.  In my experience, this is a very dangerous position for the the staff to be in.  In an incredible twist, the aggressor seems to have more support than the victim even when the victim has sustained obvious injuries.   Although it has not been studied, it would not be surprising to find that staff in this position would conclude that they have no support, can expect no help, and need to arm themselves or risk annihilation.

9.  Cultural hate of psychiatrists:  There is no doubt that the haters of psychiatry have some influence here.  It is always easier to perpetrate violence against any minority group that is routinely vilified in the media and seen as a stereotyped monolithic group.  The people involved may have difficulty distinguishing symbolic hate and annihilation from the real thing.

All of these factors come in to play in considering whether or not to arm oneself to ward off a potentially homicidal threat.   From the psychiatrists I have talked with, next decision is the threshold for self defense.  Do you carry a weapon or is the threshold your front door?  Are security cameras and alarm systems enough?  I knew a psychiatrist who carried a rifle with him when he was riding his lawn mower.

The critical factor comes down to the threat assessment and all of the mitigating factors listed above.

For anyone second guessing a psychiatrist in this position, the critical question becomes:  "Where would I allow anyone to kill me?"  Is that thought compelling enough to ignore competing ethical considerations, even though there is nothing in medical ethics about a patient trying to kill their physician?  Is that thought compelling enough to ignore the law in order to protect yourself and your family?  What is your threshold for making those kinds of decisions?

For people interested in stopping this kind of aggression, the points above are all considerations of what can be done to stop it cold - long before there is any gunfire.  At that level of analysis, psychiatrists thinking of carrying guns or walking around with them is really a sign as well as an outcome.  It is a sign that multiple systems in society and medicine are either inconsistent, have failed or been corrupted.  We have these systems in place in some places and they can work.  I have seen every one of them work well at some point and prevent aggression and violence.

Fixing that larger problem should benefit everyone including the involved patients.

George Dawson, MD, DFAPA

A Gun In The Snow

A colleague of mine was out for a walk today.  It is a brisk winter day in Minnesota.  There is about 6 - 8 inches of snow cover.  He was walking across the street and found this handgun laying there.

He took a picture of the gun and called the police to pick it up.  They were there in 20 minutes.

My views on violence and gun violence are fairly well known. My recent position has been that arguing with gun advocates and the pro-gun lobby in Congress is futile.  But when I saw this posted on Facebook with the accompanying story I couldn't help but think: "Guns are so common they are falling on the ground like wallets."  Only a fool believes that this level of gun availability does not result in death and injury of all kinds including accidents, suicides, and homicides.  Only a fool believes that with this level of gun availability it is possible to prevent guns from ending up in the hands of people who are not competent to use them.  I live in a state that passed a concealed carry law that  is basically the right to carry a concealed firearm.  It passed a few years ago by tacking it on to unrelated legislation.  The gun and holster look like a common one that is sold to those who complete a brief concealed carry course.  The main argument of the concealed carry contingent was that they were supermen of sorts.  There was literally nothing that would compromise their judgment if they were carrying a handgun.  Since then there have been a number of incidents involving concealed carry owners showing that in fact problems happen.  In the most notable incident a concealed carry owner opened fire on an undercover police officer.  I think it is safe to assume that there are probably at least as many lapses of judgment involving concealed weapons as there are driving automobiles.  The main difference is that people spend more time driving.  The reporting of these incidents is not transparent and that is typical of much gun legislation.

On a worldwide basis, small arms fire is a leading cause of death and disability.  I had the opportunity to see how some of that was transacted when I lived in Africa for two years.  In travelling as little as 100 miles there were frequent roadblocks at times.  The intent of the roadblocks was not clear but each roadblock was manned by police or paramilitary personnel and everybody was heavily armed.  The American friend that I most frequently traveled with told me about a time he got out of his car to ask if there was a problem.  One of the police officers pushed the barrel of a machine gun into his chest and prodded him back to his car.  He previously served in a country where a fellow volunteer accidentally drove through a police checkpoint because there was nobody around.  It appeared to be abandoned.  He made it a short distance before he was shot through the head by soldiers out of sight up on a hill.

In the US, besides the obvious problems with the legal availability of firearms there is also the issue of the black market and stolen firearms.  Since 1994 an average of 232,000 firearms are stolen every year and 80% of those are not recovered.  Stolen guns account for 10-15% of the guns used in crimes.  The majority of guns used in crimes are purchased by proxy or so-called straw purchase sales including other tactics like diversion of guns to criminals by licensed gun dealers.  There are several common sense changes that can occur in firearm policy that might make a difference in the sheer number of firearms in the general population and their availability to criminals.

This week marked another school shooting.  It marked the anniversary of the Sandy Hook Elementary School shootings.  In practically every school shooting easy access to firearms is a major part of the problem.  There are clear models for what happens to firearm deaths when some restrictions are placed on their access.  Fareed Zakaria has a new feature Global Lessons on Guns on his Sunday news program GPS.  Last Sunday he reviewed gun policies in Japan.  Getting a license to have a firearm in Japan is very difficult.  The authorities need advance information on where it will be stored and they need a detailed floor plan of the residence where it will be stored.  In a country of 130 million people there were a total of 4 firearm homicides last year.  By contrast, in the United States with a current census of 317 million people, there were 31,672 firearm related deaths (see Table 1-1 and 1-2).  The example from Japan is also interesting because it looks at the issue of violent video games.  They are played at a higher rate in Japan than the U.S. and it obviously had no impact in the context of extremely limited gun availability.

Even though I think there are better approaches for psychiatry to focus on than strictly gun policy and confrontations with a pro-gun lobby we need a basic level of awareness that current gun laws in the US are probably not what the Framers of the Constitution intended.  I think they would be as shocked as anyone if they found a gun in the street.  They would be equally shocked to find out that 7 times as many Americans die every year as a result of firearms than died in the Revolutionary War.  (see Table 1)

George Dawson, MD, DFAPA

No applause from me

The APA came out with a press release today in response to President Obama's initiative to reduce gun violence and prevent future mass shootings.  Although the release "applauds" these proposals they seem to be short on the mental health side. From the APA release:

“ We are heartened that the Administration plans to finalize rules governing mental health parity under the 2008 Mental Health Parity and Addiction Equity Act, the Affordable Care Act, and Medicaid. We strongly urge the Administration to close loopholes involving so-called ‘non-quantitative treatment limits’ and to ensure that health plans deliver a full scope of mental health services in order to comply with the law. Such action will best ensure that Americans get the full range of mental health services we believe they are intended to receive under federal law.”

So I guess the APA is applauding the initiative but encouraging the closing of loopholes. Call me a skeptic but 20 years of rationing mental health services and cutting them to the bone through managed care intermediaries and aggregating those managed care intermediaries into accountable care organizations does not bode well for the "full range of mental health services". The APA seems to have the naïve position that you can support managed care tactics and provide increased access to quality mental health services.

The next point in the APA release supports school screening and enhanced mental health services in schools for both violence prevention and to identify children at risk or in need of current mental health services. Those are certainly laudable goals but there is minimal evidence that screening is effective. There is also the problem of a lack of infrastructure.  Twenty years of rationing and restricting access to psychiatric services has resulted in long waiting lists or completely unavailable services. If you talk with a child psychiatrist, they will tell you that the current system is set up to offer medications in place of a more comprehensive approach to psychiatric treatment. At the social services level, residential treatment for children with severe problems is practically nonexistent. As a recent example, I was informed last week of a school social worker who could not get a child assessed for admission to an adolescent psychiatric unit and when that was not possible could not get an appointment to see a psychiatrist in a major metropolitan area. Screening for problems does not make any sense unless there is an infrastructure available to address those problems when they are found.

The final point in the APA release addresses the issue of physicians being able to discuss firearms at home with their patients. This has been a standard intervention for physicians ever since I have been practicing and it is always part of an assessment for suicide and homicide risk. There was a state initiative last year making it illegal for physicians to discuss firearms in the home with their patients. Part of the rationale for that law was that it could result in firearm owners being identified and placed them at theoretical risk for their firearms to be confiscated by the state.  I can say from experience that my discussions with patients about firearm safety and the discussions of other physicians that I have been aware of have been highly productive and have probably saved countless lives. The best example I can think of is talking with a primary care physician who asked me to take a look at a closet full of firearms that he convinced patients to turn into him over the years before he turned them into the police. Those patients were all depressed and suicidal and at high risk for impulsive acts. He would not have been able to make that intervention with a gag law in place preventing those discussions.

What about the President's original release?  It had 84 instances of the word "mental" usually as "mental illness" or "mental health".  As noted above it has received some accolades from the APA and other members of the mental health community. It elicited a strong and poorly thought out response from the NRA  who produced a YouTube video accusing the President of being elitist and a “hypocrite” because his daughters had armed security but he expected that everyone else’s kids would be protected by gun free zones.  The White House responded quickly:

“Most Americans agree that a president’s children should not be used as pawns in a political fight,” said Jay Carney, the White House press secretary. “But to go so far as to make the safety of the president’s children the subject of an attack ad is repugnant and cowardly.”

The full text of the White House 22 page document is located at this link.  It is ambitious and covers a lot of ground in terms of the specific regulation of firearms, school safety, and increasing mental health services. The firearm regulation is most specific in that it closes background check loopholes, bans assault weapons, outlaws armor piercing bullets, and sets the maximum magazine size at 10 cartridges.  Part of this document is a "call to Congress" so it is not clear to me how much can be accomplished by the President's executive orders as opposed to Congressional action.  I am reminded of the NRA President last weekend stating that Congress would never pass a ban on assault weapons.  The Executive Order section of that part of the document lists the following activities:

1.  Addressing unnecessary legal barriers in health laws that prevent some states from making information available about those prohibited from having guns.

2.  Improving incentives for states to share information with the system.

3.  Ensuring federal agencies share relevant information with the system.

4.  Directing the Attorney General to work with other agencies to review our

laws to make sure they are effective at identifying the dangerous or untrustworthy individuals that should not have access to guns.

The school safety initiative seems more nebulous. There is funding for 1000 "school resource officers and school based mental health professionals" and the recommendation to train 5000 additional “social workers, counselors, and psychologists.”   Considering the fact that there are probably close to 100,000 schools, this seems like a drop in the bucket.   Ensuring that each school has an emergency plan for contingencies like mass shootings does not seem to be a novel idea.  Creating safer school climates and reducing bullying has already been initiated in many school districts. There seems to be a clear lack of public health measures in the school that would reduce the likelihood of violent events.

The mental health initiative is equally lacking. In addition to the deficiencies I pointed out initially in this document, there is discussion of providing mental health training to teachers and school staff. There is probably evidence that teachers and school staff may over identify mental illness rather than under identify it.  Is this really a problem and will this level of screening be effective?   The document describes the initiative here as "increasing access" to mental health services. Screening larger numbers of students and identifying them as having potential problems actually creates a bottleneck in the system rather than increasing access.  The suggested mental health interventions in this document fall short in terms of both primary and secondary prevention of mental illness and associated aggressive behavior. Depending on a managed care model that has an established track record of dismantling the mental health infrastructure and providing limited access to poor quality care will do nothing to accommodate increasing referrals other than assure that referred students will be rapidly medicated.

My final analysis of the President’s initiative today is that it may be a starting point.  He is certainly taking the issue seriously and deserves plenty of credit for that.  His support for reopening firearm safety research that was closed by the gun lobby is important. What will become of the firearm regulation is anyone's guess at this point. The school and mental health initiatives are largely symbolic and I would not expect them to have any impact. What is sorely needed is the American Psychiatric Association coming out with standards, quality guidelines, and medical education initiatives to improve the care of people with severe mental illnesses who also happen to be aggressive.  An important piece of those guidelines should include the public health measures that were previously mentioned on this blog and those measures should also play a much larger role in any Executive initiative.

George Dawson, MD, DFAPA

Colorado Mass Shooting Day 2

I have been watching the media coverage of the mass shooting incident today - Interviews of family members, medical personnel and officials.  I saw a trauma surgeon at one of the receiving hospitals describe the current status of patients taken to his hospital.  He described this as a "mass casualty incident".  One reporter said that people don’t want insanity to replace evil as a focus of the prosecution.

In an interview that I think surprised the interviewer, a family member talked about the significant impact on her family.  When asked about how she would "get her head around this" she calmly explained that there are obvious problems when a person can acquire this amount of firearms, ammunition, and explosives in a short period of time.  She went on to add that she works in a school and is also aware of the fact that there are many children with psychological problems who never get adequate help.  She thought a lot of that problem was a lack of adequate financing. 

   

I have not listened to any right wing talk radio today, but from the other side of the aisle the New York Times headline this morning was "Gunman Kills 12 in Colorado, Reviving Gun Debate."  Mayor Bloomberg is quoted: “Maybe it’s time that the two people who want to be president of the United States stand up and tell us what they are going to do about it,” Mr. Bloomberg said during his weekly radio program, “because this is obviously a problem across the country.”

How did the Presidential candidates respond?  They both pulled down the campaign ads and apparently put the attack ads on hold.   From the President today: " And if there’s anything to take away from this tragedy, it’s a reminder that life is fragile.  Our time here is limited and it is precious.  And what matters in the end are not the small and trivial things which often consume our lives.  It’s how we choose to treat one another, and love one another.  It’s what we do on a daily basis to give our lives meaning and to give our lives purpose.  That’s what matters.  That’s why we’re here."   A similar excerpt from Mitt Romney: "There will be justice for those responsible, but that’s another matter for another day. Today is a moment to grieve and to remember, to reach out and to help, to appreciate our blessings in life. Each one of us will hold our kids a little closer, linger a bit longer with a colleague or a neighbor, reach out to a family member or friend. We’ll all spend a little less time thinking about the worries of our day and more time wondering about how to help those who are in need of compassion most."

These are the messages that we usually hear from politicians in response to mass shooting incidents.  At this point these messages are necessary, but the transition from this incident is as important.  After the messages of condolences, shared grief, and imminent justice that is usually all that happens.  Will either candidate respond to Mayor Bloomberg's challenge?  Based on the accumulated history to date it is doubtful.
  
A larger question is whether anything can be done apart from the reduced access to firearms argument.  In other words, is there an approach to directly intervene with people who develop homicidal ideation?  Popular consensus says no, but I think that it is much more likely than the repeal of the Second Amendment.

George Dawson, MD, DFAPA

Barack Obama. Remarks  by the President on the Shootings in Aurora Colorado.  July 20, 2012

Barack Obama.  Weekly Address: Remembering the Victims of the Aurora Colorado Shooting.  July 21, 2012.

Mitt Romney.  Remarks by Mitt Romney on the Shooting in Aurora, Colorado.  NYTimes July 20, 2012. 

Mass shootings - How Many Will Be Tolerated?

I have been asking myself that question repeatedly for the past several decades.  I summarized the problem a couple of months ago in this blog.  In the 12 hour aftermath of the incident in Aurora, Colorado I have already seen the predictable patterns.  Condolences from the President and the First Lady.  Right wing talk radio focused on gun rights and how the liberals will predictably want to restrict access to high capacity firearms.  Those same radio personalities talking about how you can never predict when these events will happen.  They just do and they cannot be prevented. One major network encouraging viewers to tune in for more details on the "Batman Massacre." 

We can expect more of the same over the next days to weeks and I will not expect any new solutions.  Mass shootings are devastating for the families involved.  They are also significant public health problems.  There is a body of knowledge out there that has not been applied to prevent these incidents and these incidents have not been systematically studied.  The principles in the commentary statement listed below still apply.  

It is time to stop acting like this is a problem that cannot be solved.

George Dawson, MD, DFAPA

A Commentary Statement submitted to the StarTribune January 18, 2011 from the Minnesota Psychiatric Society, The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education

Violence and Gunplay - Why Nobody is Informed by the Media Anymore

Mass shootings have been a phenomenon of my lifetime.  I can still clearly remember the University at Texas-Austin shootings that occurred  on August 6, 1966. A single gunman killed 16 people and wounded 32 while holed up on the observation deck of an administrative building until he was shot and killed by the police. I first read about it in Life magazine. All the pictures in those days were black and white. Some of those pictures are available online on sites such as "Top 10 School Massacres.”  I generated this timeline of mass shootings when Google still had that feature in their search engine. 

The problem of course is that the mass shootings never really  stop.  In the USA, the press is so used to them that they seem to have a protocol.  Discuss the tragedy and whether or not the perpetrator was mentally ill, had undiagnosed problems or perhaps risk factors for aggression and violence.  Discuss any heroic deeds. Make the unbelievable statement that the victims were "in the wrong place at the wrong time."  And then move on as soon as possible.  There is never a solution or even a call for finding one.  It is like everyone has resigned themselves to to repetitive cycles of gunfire and death.  It is clear that the press does not want to see it any other way.

When you are practicing psychiatry especially in emergency situations and hospitals, you need to be more practical.  When I took the oral boards exams back in 1988 and subsequently when I was an examiner, one of the key dimensions that the examiners focused on was the assessment of dangerousness.  Failing to explore that could be an exam failing mistake.  Any psychiatric inpatient unit has aggression toward self or others as one of the main reasons for admission to acute care and forensic settings.  With the recent fragmentation and rationing of psychiatric services, many people who would have been treated in hosptials are diverted to jails instead.  That led one author to describe LA County jail as the country's largest psychiatric facility.  

I have introduced the idea of looking for solutions into professional and political forums for over a decade now and it is always met with intense resistance.  Some mental health advocates are threatened by the idea that it will further stigmatize the mentally ill as violent.  Many people consider the problem to be hopeless.  Others see it as the natural product of a heavily armed society and no matter what side you are on that argument - that is where the conversation ends.

In an attempt to reframe the issue so that this impasse could possibly be breached the Minnesota Psychiatric Society partnered with the the Barbara Schneider Foundation and SAVE Minnesota in the wake of a national shooting incident to suggest alternatives.  Rather than speculate about psychiatric disorders or gun control we were focused on solutions that you can read through the link below.

The actual commentary was never published by the editor who apparently stated that there was a conflict of interest because we seemed to be fishing for research dollars.   It appears that the press can only hear the cycle of tragedy, speculation about mental health problems, and the need to move on.  The problem with that is that we continue to move on to another shooting.

George Dawson, MD


A Commentary Statement submitted to the StarTribune January 18, 2011 from the Minnesota Psychiatric Society, The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education