A Garage Door Lesson

I learned a valuable lesson from a garage door today that I thought I would pass along to some posters who think they know something about psychiatry and psychiatrists.....

I came home early this afternoon and hit my garage door remote, like I had done thousands of times in the past.  This time the door went up and seemed to hesitate and drop back about 2 inches, then it went all the way up.  I stepped out and noticed a bolt laying on the floor.  I picked it up and it was a 5/8 x 1 1/2 inch self-tapping bolt.  Looking around, I noticed that it has fallen out of the plate that fastens the garage door to the door itself.  The plate was bent and there was only one bolt left holding the door.  I grabbed a socket wrench and a ladder and headed up to where the door was suspended to fix it - about 5 or 6 feet off the floor.  It was immediately evident that the plate was bent at such an angle that I could not gain any purchase in the door with the free end of the bolt - or it was stripped.  Without thinking, I thought I would pull the emergency door release hanging just to my right to give me just enough slack to fasten the bolt.

In an instant, the arm assembly jerked my left hand very hard toward the door opening as the door crashed from fully open to fully closed in a less than a second.  I was propelled about ten feet through the air landing on the floor at the base of the door with some serious neck strain and a few sprains but otherwise, none the worse for wear.  I was somewhat stunned by all of this.  When I looked up I noticed the coil spring over the left side of the double garage door was snapped in half.  Directly in front of me was a warning that I had read many times before:

The universal "Don't turn your own wrench" sign.  I apparently ignored some pretty basic information that any professional garage door mechanic would not have.  It resulted in me getting knocked around pretty good and putting me at serious risk for a head injury, a spinal injury or death.  A few data points and I ignored them.  I also knew that garage doors were dangerous.  Just a few years ago, my brother showed me a healed scar across his palm that resulted when he attempted to repair a snapped garage door spring.  But where in all of this is the lesson for the inappropriate criticism of psychiatrists?

I should probably define at least part of what I consider inappropriate criticism and what a poster here has touched on as important dynamic.  On the sites where it is common for psychiatrists to post or sites that claim some legitimacy in the area of criticism, there are also some thoroughly hostile and malignant posts that are at the minimum inappropriate and at their worst pathological.  I have received a few directly here last week, but have decided that posts such as these will not appear on this blog.  I am aware that some people think that anyone should be allowed to criticize psychiatrists in any manner.  They are wrong.  People suggesting that I should "burn in the hottest part of hell" of course would be one example, but there are many more.

The garage door incident is instructive for at least some of them.  I recently saw a number of anonymous posts saying that psychiatrists can "just say anything" and that psychiatric credibility could be "shredded" in forensic settings.  Interspersing those arguments among supposedly legitimate critics takes the level of their arguments way down.  If these types of posts were always the case, it would be very easy to ignore a thread inhabited by barbarians.  I could certainly come up with a neat little definition of the barbarians but what is the point?   A related question is why those sites feel compelled to include this posts?  I don't think that is a passive or well thought out decision.  Once the discussion has headed into abusive, threatening, or irrational territory and it remains in fair play - that says a lot about the intent of the administrator.  At the very minimum, the intent is no longer a reasonable discussion.  Granted that it is often difficult to determine what is reasonable, given the overall tenor of the site.  For example, if I wrote a book bashing all psychiatrists and was promoting it on a site, why wouldn't I include every possible irrational post as evidence that I am correct?

It is much more instructive to look at the garage door example and what it implies for the basic argument that there is no such thing as mental illness and the closely related arguments - psychiatrists are not needed for the diagnosis and treatment of mental illness or that they have simply made up mental illness so that they can all be rich and drive expensive cars (another e-mail from one of the fans).  The garage door is a simple scenario with three critical points of information that any experienced person could observe - arm plate screw missing, arm plate bent, and left main garage door coiled spring snapped in half.  As an additional historical point I should add that in my experience these springs snap about every 15 years and this one was only 5 years old.   I observed 2/3 of the points thought I could make the repair and nearly had a catastrophic result.

In the case of a psychiatrist seeing a new patient, there are hundreds of relevant points that all have to be acquired and examined in the initial evaluation.  The total number of critical points is unknown, but to use just the example of a basic instrument for the assessment of suicide potential they number in at least the 20-30 range.  This assumes that the patient is able to respond appropriately to the questions.  There are at least another 20 or 30 points when it comes to the prescription of medications and coming up with a treatment plan.  As any affected family member can attest, severe mental illness or addiction is at least as serious as a crashing garage door that knocks you off a ladder.  It leads to trying to shake off the acute effects and prevent any long term harm.  In that event many people are seen and treated successfully by psychiatrists.  As I have posted here before, we are the people who are trained to see significant problems and the psychiatrists I know do a good job.

In practically all of the irrational criticism of psychiatry, none of these information points are covered.  People seem quite content to tar and feather psychiatrists with whatever seems fashionable at the time.  So this lesson is really one about the information content not typically being covered and how missing even a small point in any information set can be potentially problematic, and in my analogy, not just in terms of my own safety but the liability issue if anyone had been working with me.

I know that this lesson may be a stretch for some and in that case consider this a public service announcement for not trying to fix your own garage door.  Do not try it at home like I did.  Leave it to the professionals.

Oh - and I am not sorry to disappoint those who would have just as soon seen another psychiatrist bite the dust.

As far as I know - I am OK.



George Dawson,  MD, DFAPA

Interviewing 101

Interviewing seminars are a big part of the first year of psychiatric training.  I am not sure how it goes these days, but I can recall having to record interviews and being critiqued by the instructor and all of my peers in seminars.  I can remember not always agreeing with the critiques.  Every psychiatrist goes on to develop their own interview style around the basics.  Just about every interview is unique because it also depends on the person you are talking with.  The flow of information in the interview has always been fascinating to me.  At times you can cover all of the essential elements in 30 minutes.  At other time you can talk for 90 minutes and end up with 25% of the information.  Facilitating and directing that flow of information is one of the key elements of interviewing.  Against that backdrop I found this commentary on an interview of Robert Downey, Jr. somewhat interesting.  It seems surprisingly linear.  It reminded me of some of my media interview experiences where the predominate advice seemed to be: "No dead air.  Either I am talking over you or you are talking over me.  Got it?".  This clip has been widely broadcast for the past several days.  In it, the interview takes a bad turn and Downey politely gets up and walks out.  The discussion near the end of this brief clip suggests that there were probably just a few minutes left.







In the critique of this interview, Kathleen Kelley Reardon focuses on what is described as the human chemistry between the participants and how that potentially involves features like attractiveness, mood, timing and other features.  Reardon speculates that Downey may not have been up for the interview and the transition to personal questions may have been premature. She sees it as an excellent case study in what can go wrong with interviews.  I think that there are some good examples of what might go wrong but there are also some unknowns.  From my vantage point as a psychiatrist I have a few other observations and I have never had to worry about the tone of the interview, but then again I am never working on an interview as an infomercial.

1.  The introduction is very important, but we may have missed it.  Even though this is supposed to be the entire interview, it begins with Downey speaking.  This is an old Oral Boards style point - if you don't introduce yourself and set the context of the interview - come back and try it again next year because you have just failed the exam this year.  The interviewer could have saved himself a lot of problems by discussing the interview context ahead of time and setting ground rules for what the actor is or is not willing to discuss.  You don't have time to discover that in an 8 minute interview.

2.  Too many people in the room is never a good thing.  Because I am teacher, I still have people observing my interviews for teaching purposes and I never like it.  I have to be completely focused on the other person and how they are affecting me.  I did not see Downey as distracted or disinterested; I saw him look to his advisor several times until it got to the point he was overtly looking for advice.  I saw him make a clear announcement at one point: "Are we promoting a movie?" where he was clearly dissatisfied in the direction things were headed and that comment was directed to other people in the room.  The best way to maintain focus is to make sure that there are only two people in the room.

3.  What is the purpose of the interview?  There has to be a focus on that point and the interviewer needs to be aware of it.  In a psychiatric or medical interview the overriding agenda is that there is a mutual focus on a problem that needs to be solved for the patient.  Everything is as confidential as possible.  I heard a prominent psychiatrist and researcher say at a psychotherapy conference that some of the primary goals are: "Be nice to the patient and say something useful to them."  In a celebrity interview there are really dual agendas - publicity for both the interviewee and the interviewer.  Being a celebrity interviewer can lead to celebrity status on its own.  The interviewer is probably aware of how they want to come across to the viewers.  Where do they want to be along the famously provocative to famously uncontroversial spectrum?  Do they aspire to be a celebrity interviewer?  How focused are they on entertainment versus journalism?  I personally cannot think of a greater intrusion into the interview process.

4.  Contrary to the author's point, I don't think that the reporter (Krishnan Guru-Murthy) had a problem with transitioning or failing to read the cues of Downey. He seemed anxious to me. Downey came across as authoritative when talking about American cultural influences but then somewhat oppositional and defensive when talking about a past opinion that he gave during an embarrassing period in his life. He was aggressive when commenting on the interviewer's motor behavior and suggesting that he was running out of time to ask (what was probably going to be) a controversial question.  This would have been an entirely different interview if the focus had been maintained on superhero culture and the actors theories of where the film fits into that genre. He had a pretty good interpretation of some of the Stan Lee origins in Vietnam era America.  Just the time line of those developments and the further implications for the film would have filled the time.

5.  Sometimes the person being interviewed drops a gift at your feet and you have to go with it. As an example, if I am interviewing a person who has been incarcerated I rarely go directly after that information.  I can probably get the historical details elsewhere and it is a threat to the interview process.  I don't want the interviewee to develop the "cop transference" and start to experience it as a police interrogation.  And I usually have an hour compared to this less than 10 minutes session.  The  interviewer needs to be aware of the fact that he is not doing psychoanalysis and that all of those Barbara Walters interviews where there was a key emotional disclosure occurred after hours of interviewing and heavy editing.  In this case Downey talks about how he portrays the character and how his interpretation of the character had changed over time.  That leaves him talking to a small part of the audience for this interview - the people interested in art and acting but that would have ended a lot better.

6.  As I watched the interview, I had the question about whether there were any journalistic biases operating.  It becomes clear that Guru-Murthy wants Downey to answer questions that have nothing to do with the movie and were from a very difficult time in the actor's career.  It is clear that the reporter's anxiety level is building as he tries to force those questions.  And, it is clear that he is trying to force them into the smallest possible window in this interview - the final minutes.  It was anxiety provoking for me to watch that section of the interview.

7.  There is often a lot of focus on the process aspects of the interview.  It seems that the emphasis on the communication aspects of the interview are very linear - pick up this cue and make this intervention.  Interviews (at least the way I see them) are non-linear,  There are a lot of parallel processes going on and interviewers tend to elicit much different information based on their biases and techniques.   There may be times where I slow the interview way down to get at specifics and at other times I am looking for global markers and whether they are present or not.  

8.  Based on my past experience,  I also had to wonder if the gotcha dynamic was operative.  I have been called in for media interviews where the reporter has some preconceived notion of how the world works.  A good example is the fallacy that the Christmas Holiday season is the peak time of the year for suicides.  After I had spent some time explaining to the reporter over the phone that this is really not true, during the interview I was pummeled with comments and anecdotes about how people naturally get depressed and kill themselves more often during Christmas.  This has happened to me more than once and it is a good reason to avoid reporters.

The way this interview ended seemed quite civil to me.  It is not surprising to me that the media is making a big deal of it in spite of the fact that really catastrophic interview endings tend to occur with people who are accusatory, demanding, threatening and/or aggressive.  In an interview with an actor that is not likely to happen.

Despite all of our focus on interviewing in psychiatry, we seem to be loathe to look into the science of it all.  For the past 30 years we have been operating under the illusion that in order to make a DSM diagnosis, all it takes is getting the answers to the right questions.  Those questions were typically structured interviews using DSM or the precursor RDC criteria.  It gave way to the Diagnostic Interview Schedule (DIS) for early epidemiological work followed by the Schedule for Affective Disorders and Schizophrenia (SADS).  This work seems to have led to brief diagnostic checklists based on  the DSM criteria.   I read an article in the Journal of Clinical Psychiatry once that suggested if all of the clinicians in a clinic used the SADS as their diagnostic interview they would have better outcomes.  The idea that a structured interview or checklist elicits better or more useful information than an experienced psychiatrist interviewing the patient is another great fallacy in the field.  I would actually put that at the top of the list and rate it higher than needing a head to head comparison of antipsychotics based on time to discontinuation or whatever the Cochrane Collaboration has to say about "limitations of methodology / need more study" for practically any drug trial.  The evidence that I am right is replicated tens of thousands of times every day by psychiatrists out there doing the same work.  If you interview the same patient twice it is very unlikely that they will give  you the same history.  I have a standard flashcard that lists about 100 medications of all classes and they will not consistently endorse the same medications on this list.  We interview people about their subjective experience and that experience is always plastic.  That is much more interesting than storing the encyclopedia on computer chips.

In some cases we might put a metric like test-retest reliability on an interview metric or the global result of a structured interview.  Given that we are measuring something that reflects the functioning of a highly plastic organ, I don't know why we would expect reliability to be high.

That brings me back to this interview.  Our interview technology is a holdover from the 1950s.  We have evolved subtle modifications over the years but currently we are constrained to a small fraction of the conscious state and we do not know how to optimize the flow of relevant information.  This is a major limitation.  There have been some theorists who have looked at mapping diagrams of the interview process but none have gained any widespread acceptance.

The only good news for psychiatrists now is that we are not operating at the level of reporters.


George Dawson, MD, DFAPA

No Information From The EHR - An Ongoing Problem

Like most physicians - I like the concept of an electronic health record (EHR).  It is just that the real EHR as it exists is a far cry from the concept.  The proponents of the current EHR,  especially those who want it mandated by legislative activity continue to brag about the savings and all of the benefits.  Any physician looking for information or an ability to enter and move information without ending up in a click fest of mouse clicks knows the reality.  Any physician looking for a note that reflects an intelligent conversation between a physician and a patient is also left wanting.  Reading the electronic or printed out version of the EHR usually results in very choppy documentation.  Lists that are the result of not very intelligent coding by EHR IT engineers, notes produced strictly to meet billing and coding bullet points, and notes produced because they could be rapidly compiled with features like smart text.

All of this can be a nightmare for a compulsive physician like myself who wants to use all of the relevant information in patient care.  My career has been treating patients with complex medical conditions who are also on complicated combinations of medications.  Many have known heart disease and take combination of medication that can adversely affect their cardiovascular status and interact with psychiatric medications that I prescribe.  All of that needs to be considered.  Since ziprasidone (Geodon) hit the market in 2001, psychiatrists have been preoccupied with the QTc interval.  The QTc interval is the electrical interval that corresponds to the contraction and relaxation of the left ventricle.  In cases where this interval is too long it predisposes the patient to ventricular arrhythmias some of which are potentially fatal.   The FDA had a warning on ziprasidone about the potential for QTc prolongation and subsequently came out with warnings about citalopram.  In the course of clinical practice, many psychiatrists had already encountered this issue with older antipsychotic medications and tricyclic antidepressants.  The FDA makes these pronouncements but gives physicians no guidance on what to do about the clinical situations.  I have a practice of looking at ECGs and any Cardiology evaluations that have been done.  That is the only way the QTc interval can be determined and even then there are various factors that can affect it.

Rather than order an ECG, I will ask whether they have already been done and get the patients consent to have them faxed to me.  That result is frequently disappointing, especially in the case of the EHR.  I will often get a series of cryptic sheets, that look like a sparsely populated medical record.  There are often no coherent notes from physicians or if they are there, they do not contain standard information that I am looking for.  I have never seen an ECG tracing contained in these stack of records.  The best I can hope for is a brief note that lists an impression like "NSR - no acute changes."  An added bonus would be an actual description of the critical intervals.  For the tracing at the top of this page it would say:  "PR interval - 164 ms; QRS duration - 100 ms; QT/QTc - 434/415 ms."  That is really all of the information I need to know.  But the most important issue with the EHR is that all of this visual information is usually lost, unless I submit a second or third request and it usually has to say "send me the ECG tracing."  The medium that purports to provide a lot of information to physicians and put it at their fingertips is a bottleneck.  By the time I see the information I need to see, it is not necessary.  I have moved on and not recommended a treatment that I could have recommended if the ECG was normal.  That practice has been reinforced by getting an ECG after the fact and realizing that not only was there a prolonged QTc interval, and it was read that way by a Cardiologist but reported as "normal" in the EHR.

I will be the first to admit that there is minimal evidence that my tight QTc surveillance has saved any lives.  But my threshold is really to prevent any complications.  I am not treating acute heart conditions.  I am trying to make sure that I don't cause any by the medications that I prescribe, by ignoring a critical drug interaction, or by not recognizing the significance of a patients physical illness and how it needs to direct the therapy that I prescribe.

That doesn't end at ECGs.  I would throw in imaging studies (CT and MRI), EEGs, and even routine labs.  If the EHR is supposed to convey the maximum information why wouldn't all of the visual information of an episode of care be included?  Why can't all of the brain imaging studies be sent along as a disk or e-mailed to me?  Why do I have to read a 200 page fax and try to reconstruct all of the lab results  in a coherent manner that are spread randomly across those pages so that I know what happened in the hospital?

The EHR as it currently exists is a tremendous burden to physicians.  It takes far too long to enter data and quality notes about care are rare.  If you happen to lack online access to the program where the record is constructed, good like trying to piece together the information that you need for clinical decision-making.  Politicians are good with ideas, but none of them seems to be aware of the real problems that exist in these systems.  Despite that lack of knowledge they continue to insist on the wide implementation of these systems and that is really a tax on physicians that is being used to subsidize the development of EHRs and fund this industry.

Hopefully that will pay off someday, but the current problems have been there for at least a decade and there are no signs that they will be going away soon..



George Dawson, MD, DFAPA  

Medical Knowledge Goes A Long Way - Or Does it?

"Exacerbation of both COPD and asthma, which are basically defined and diagnosed by clinical symptoms, is associated with a rapid decline in lung function and increased mortality." - Frontiers in Microbiology October 1, 2013.

For starters this is a lengthy and somewhat obsessive look at a personal episode of illness and the implications it has for some of the common threads on this blog ( overidealization of general medicine, dislike of psychiatry, inaccurate comparisons of psychiatry to the rest of medicine, wild criticism of psychiatry, etc.).  So if you are not into that - this would be a good place to stop and move on...........

I have been off work 9 out of the past 10 days with an upper respiratory infection leading to an exacerbation of asthma.  At least that is one theory.  I first noticed it when I stepped off my ergometer trainer about 2 weeks ago and noticed that I did not seem to be able to take a deep breath and I was wheezing mildly.  I saw an Internist the next day who did a history and examination and got a chest x-ray and an electrocardiogram - both of which were normal.  She decided to double the dose of a corticosteroid inhaler that I was using and told me to increase double the dose of the albuterol inhaler I was using.  She said she would not add oral prednisone at this point.  When I got home I realized that my corticosteroid inhaler was empty and I needed a new one.  The office was contacted and sent a prescription for the previous dose rather than the new dose.  When I called and asked them to read the documentation, the note mentioned an even higher dose that was not possible with the inhaler I was using.  The inhaler cost $187 for one month so I figured it was easier just to start using it rather than wait for them to sort of all of the communication problems, especially because the physician was not available for another several days and I was still wheezing.

Two days passed and my breathing seemed slightly better so I went into work.  By mid afternoon the inability to take in a deep breath came back and I went to an Urgent Care clinic through my health plan right after work.   The new doctor repeated the history, physical, and chest x-ray (again negative).  He prescribed a more intensive course of therapy with a 12 day prednisone taper starting at 60 mg/day and a nebulizer machine with ampules of 2.5 mg albuterol.  He told me to keep taking both inhalers and add both of these.  When I got home I took the prednisone and assembled and used the nebulizer.

I will digress to say that I am a firm believer in the absolute need to control blood pressure and pulse.  I measure my blood pressure and pulse four times a day or more depending on the circumstances.  White coat hypertension probably happens but how many people know what their blood pressure is once they get back home?  I know from personal experience that a hostile work environment can drive both your pulse and blood pressure through the roof not just for days but for weeks to months.  The only time I am comfortable being hypertensive is when I am exercising because it it physiological, I have been monitored doing it by sports physiologists and they were happy with it, and I know there is a compensatory post exercise response that controls BP and pulse in the long run.  I take what most physicians agree is a homeopathic amount of antihypertensive but my BP is never greater than the CDC recommended cut off blood pressure of 120/80.  It is usually 10 points less.   That belief comes from seeing many people over the years who had decades of untreated hypertension that either they or their physician seemed to attribute to something else.  Psychiatrists are occasionally in the situation of treating patients with extremely high  blood pressures like greater than 200 systolic and 120 diastolic who refuse treatment.  They are usually being seen by psychiatrists because of the need to get a court order for them to be treated and that often takes several weeks, putting the patient at risk all the while.  I have seen the full spectrum of blood pressure related problems and there is only one logical conclusion that blood pressure needs to be well controlled.

I am also a student of respiratory viruses and a veteran of two different avian influenza task forces.  The task force experience left me quite pessimistic about our ability to fight off any actual pandemic for a reason that is quite striking - the denial that there is an airborne route of infection.  Everyone on the task force was focused on hand washing and controlling fomites and there was very little focus on what was needed to contain airborne infections, probably because we learned that capacity would be overwhelmed on the first day of the pandemic.  At that point we are basically in a slightly better position than we were in the influenza epidemic of 1918.  At one point they showed us a couple of plastic covered pallets of Tamiflu in a government warehouse somewhere.  I stopped attending when they started to talk about where the dead bodies would be stored.

But my interest is also in the area of common everyday respiratory viruses.  When you are working in a hospital with 1970s era ventilation systems (contain the air to save heat) you witness the staff around you and yourself and the patients get ill in mini-epidemics 3 - 4 times a year.  All with the same symptoms of varying severity.  Some will end up on antibiotics and some will end up on Medrol dose packs or both.  It happens whether you wash your hands or not.  At some point I started to e-mail the Minnesota Department of Health and inquire about the respiratory surveillance of flu and flu like illness.  At some point they got tired of my email and put it all online.  The bottom panels show (with a lag time) the likely viral culprits based on various identification methods.  Rhinovirus and adenovirus are among the usual suspects.  Reading my copy of Gorbach, Bartlett and Blacklow confirms the syndromes.These are the kinds of trends I would see every year.  I consulted with a top expert in airborne viruses in building.  He had done the first studies to confirm that viruses can be sampled in the airflow of buildings and that they are typically airborne viruses.  For two years, I studied the airflow and filtering characteristics of buildings and how older ventilation systems might be modifiable to reduce the risk of respiratory infect by airborne viruses.  I looked at the specific air flow characteristics of the building I worked in.  I surveyed the employees on each unit showing a high clustering of upper respiratory infections and and flu like illnesses.   During that entire time I got numerous respiratory infections with no exacerbations of asthma, but according to the following graphic - it was just a matter of time (click to enlarge):

            

After the initial nebulizer treatment my systolic and diastolic blood pressure was up about 30% and I was feeling somewhat agitated and anxious.  I had only had one nebulizer treatment in my life and it was about 20 years ago.  I looked at the doses and found the inhaler contained 180 mcg of albuterol compared to the 2.5 mg in the nebulizer with greater bioavailability.  In other words the nebulizer delivered 14 times the dose and I was told to use it up to 6 times a day.  I slept about 2 hours that night.

The next day I ran a drug interaction search on my revised list of medications and several potential drug interactions were noted - a couple of them significant.  I logged into my health plan and sent my personal Internist a note with several question on the interactions with drugs and my existing medical morbidities.  He called me up concerned that I might have the flu, but I had just seen him and been referred for an extensive immunology evaluation for the flu shot and got it.  I told him about my experience with the nebulizer and he chuckled:  "In the ER they might give you this very 1 - 2 hours but of course you are hooked up to a monitor and they are checking your blood every hour."  At this point I have not had a single blood test.  He suggested that I try a new inhaler - levalbuterol and the equivalent nebulizers.  They were supposed to have fewer side effects.  I spaced the treatments out exactly 8 hours and five minutes after the third treatment my heart rate shot up to 140 beats per minute and a blood pressure of 147/103.  I took some medication that I knew would bring it down in about 45 minutes, but also prepared to call 911 if it continued to climb.  Gradually over the course of 30 minutes my blood pressure and pulse recovered.

So what can be concluded by my latest foray into the healthcare system?

1.  Medical knowledge may not lead to any improvements.  As far as I can tell nobody is very receptive to the idea that respiratory viruses exist and that while hand washing is helpful it will not necessarily protect you against some of the worst viruses.  The unreceptive parties occur at all administrative levels and seem content with watching employees get recurrent viral infections and use their paid time off.  Is that a form of cost shifting?

2.  Syndromal diagnoses are alive and well in medicine and not just psychiatry.  I have talked with 4 physicians during this week long bout of illness and none of them have a clear diagnosis other than an exacerbation of asthma.  The asthma we are talking about is not a specific type or subtype that may have implications for treatment - but the good old heterogeneous type.  As heterogeneous as just about every known psychiatric diagnosis.  The first physician thought the likely cause was dry winter air.  By the time I had seen the second physician I had some additional symptoms to suggest a URI.  Only my personal physician seemed concerned that I may have influenza and called me back a second day to make sure that I had not developed a fever.  I had vital signs determined, peak flow meters, oxygen saturations, 2 chest x-rays and an electrocardiogram.  None of the tests was a biological test for asthma or whether there was an underlying infectious agent.  None of the tests were positive or could quantitate my illness.  Recall that a typical argument rolled out about psychiatric diagnoses is that there is no specific test and that they are all syndromes.  I learned that clinics in my health care system no longer do the rapid test for influenza because it is not considered to be accurate.  In all cases I was being treated based on a syndrome and nothing else.

3.  Could a more specific diagnosis be worthwhile?  Most certainly since there is some evidence that rhinovirus is a common cause of asthma exacerbations and may also be a cause for asthma in childhood.  There is also evidence that rhinovirus can replicate its RNA in the lower respiratory tract for up to 16 days post infection.  It was only recently discovered that rhinovirus inhabits the lower respiratory tract and can replicate there.  The biological test that was done for influenza is no longer used because it was inaccurate, would that be useful to know?  I have a previous post here about asthma endophenotypes.  Is there an endophenotype for rhinovirus induced asthma?  Is it caused by epigenetic mechanisms?  These are all parallel questions that psychiatric researchers are working on right now with most major psychiatric disorders.

4.  Cost shifting to the patient is paramount from several sources.  I purchased 3 - $200 inhalers in 3 days that were not covered by my insurer.  The first one was an error because it would have covered 2 weeks of treatment and it did not match the documentation in the original note.  In all three cases the pharmacists warned me about the high cost of the inhaler, but when I asked them if there was a generic substitution they said there was none.  The current albuterol inhaler also has no generic apparently because it is the only environmentally friendly one.  That is the difference between a $50 copay and a $4 copay.  There is also an angle from the perspective of ethical purism and pharmaceutical manufacturers.  Is this a case to be made for samples?  Should a patient try a sample of the inhaler in their doctor's office to make  sure they can tolerate it and know the price before going to the pharmacy?  That way there would be an assurance that the patient could tolerate and afford a very expensive medication.  I currently have $400 of inhalers that will be used twice and are otherwise worthless to me.  The other scenario that is difficult to contemplate is a person being forced to drive away from the pharmacy without a medication due to the surprise cost or copay.

5.  There was minimal discussion of side effects and contingencies but scripting was noted.  Scripting is a public relations initiative where health care personnel are trained to ask questions that the patient may be asked about in a satisfaction survey.  For example at the end of the visit the physician says: "Do you have any additional questions for me today?"  A week later you get a survey to rate the physician on whether or not he asked that question.  In the meantime no warnings about prednisone or what to do if I got hypertension or tachycardia from the albuterol.  I was told that I might expect some palpitations and that might be expected because "there was more medicine in there than from the inhaler".  The levoalbuterol was supposed to solve the problem but it resulted in significant tachycardia and I later learned it was pulled from a hospital formulary because it did not "work as advertised".  That is the optical isomer did not protect against side effects like tachycardia.

6.  Pattern matching is implicit and probably carries the day.  I have previously written about the importance of pattern matching in medical diagnosis and it was probably a significant factor in all of my physician encounters.  They looked at me and could tell I was not acutely ill - I did not need to go to a hospital.  There are various ways of phrasing it but that conclusion was uniform.  The pattern matching also probably drives a lot of the questions that flowed from the patterns of asthma exacerbation in their previous patient encounters.

7.  Complex medical diagnoses are a process.  On this blog I have pointed out why a checklist screening is generally an inadequate approach.  There is probably no better example than logging in to your health care system's triage software and realizing that your problem is not listed among the choices.  In this case information changed over time from asthma due cold air to asthma due to a viral exacerbation.  The treatment was also significantly and expensively changed along the way.

8.  Asthma and related conditions are a huge public health problem.  The prevalence of asthma is about 10% in developing countries and it accounts for 1 of every 250 deaths worldwide.  Only 1 in 7 people with asthma have it well controlled.  Public health interventions seem like a last resort.  Trying to get people interested in the true nature of airborne viruses and how to prevent these cyclical infections is practically impossible as far as I can tell.  I have corresponded with the head of the Cochrane Collaboration section on Physical interventions to interrupt or reduce the spread of respiratory viruses who cautioned me that no one knows how URIs spread or how many of the interventions work!  Even World Health Organization (WHO) initiatives seems to leave out the all important aspect of building design and airflow.  There seems to be a distinct medical bias when it comes to respiratory infections.  The only potentially useful and very cost effective public health interventions that I may have availed myself of are the pneumococcal vaccine polyvalent (Pneumovax) vaccine and the influenza vaccine.

A related issue is how much epigenetics comes into play, specifically epigenetic modifications that occur to environmental exposure of let's say - rhinovirus.  Is it possible that exposure to rhinovirus causes more long term health problems for kids than exposure to cigarette smoke?  If that is even possible, why aren't we doing more about it?

9. The elegant hypothetical molecular mechanisms of disease don't translate well to clinical medicine in the case of asthma any more than they do with mental illnesses.  Skeptics and critics of psychiatry (most of whom seem to know nothing about molecular biology) frequently use this rhetoric without understanding how little these mechanisms apply in other major diseases.  Cytokine signalling alone has been described as "having such staggering complexity that the long term behavior of system is essentially unpredictable."  Brain complexity is far greater.  The use of prednisone to shut down inflammation is more of a shotgun approach to shutting down inflammation rather than anything to do with disease specificity.  Given the fact that endophenotypes are not actually diagnosed at this point and viral infections often are associated with acute onset of asthma, it would seem that there is not a lot of diagnostic specificity beside the syndromes.  There is also the question of the time course of improvement.  People have ideas about how quickly medication prescribed by a psychiatrist should take to work.  Very few of those ideas are accurate.  On the other hand here I am on day 16 of treatment for asthma and I am still ill.  Aren't real treatments that are based on elegant biological mechanisms supposed to work faster than that?

In the end I am reminded that psychiatry is no different than the rest of medicine that deals with complex heterogenous conditions.  Diagnoses are imprecise, there is a focus on patterns, there are very few pathognomonic or gold standard tests, and the management of side effects of medications is as important as treating the underlying problem - at least in non acute situations.  Information transfer between the patient and physician is imperfect and nobody seems to be working on ways to optimize it.  If anything the critical time domain is being restricted by businesses and governments.  Those same businesses and governments seem completely disinterested in non medical approaches to reducing disease burden like building design.  There are plenty of false positives and the best assurance you can get is from a single physician who knows you the best.  Despite all of the medical care I have received these past two weeks, I think about all of the decisions I had to make on my own and ask myself: "How do people with no medical training decide what to do in this situation and how do they know what information is relevant?"

It must be mind boggling.

Despite all of the technology and medical knowledge a lot of the information transfer still comes down to what happens between the patient and the doctor.  There has to be enough time for that  to happen.  It has to be meaningful and the patient should know what to do if problems occur.

That is true for doctors of all specialties.

George Dawson, MD, DFAPA

Supplementary Information 1:  The supplementary material here is a graphical primer on allergic asthma and how exacerbations of asthma may occur.  Rather than an airborne allergen a respiratory virus triggers the cascade of events that leads to the flare up (top figure).  That fact is still only recently being elucidated.  For example, rhinovirus is a common initiator and it has only recently been demonstrated that rhinovirus replicates in the lower respiratory tract and that rhinovirus RNA can be present for as long as 16 days.  As indicated by the tables that follow, cytokine signalling in asthma is complex.  The authors show here it may involve up to 22 separate cytokines.  Corticosteroids like prednisone and prednisolone inhibit gene expression via transcription factor NFκB to decrease the activity of cytokines.  They also reduce the activity of nitric oxide, prostaglandins, leukotrienes, and adhesion molecules by similar effects on on synthesis and decrease lymphocyte activity.

Supplementary Information 2:  I have a post available that looks at the early addition of prednisone, but there is a lot of additional information.  The following table is the actual course of treatment that I received from four different physicians (color coded) over the course of two weeks.  It is posted here for discussion purposes only and should not in any way be construed as medical advice.  The disclaimer for this blog applies in that nothing here is for the purpose of medical treatment or advice.