Eye Clinic Follow Up

I went back in today for a one week follow up of laser surgery for a retinal tear.  An acute problem always brings some issues into focus so I thought I would continue on about some comparisons of psychiatry with modern medical technology as well as some of the differences that cast some advantage to psychiatrists.   As usual there are always political implications.  I have the added advantage of showing the retinal scans from today, courtesy of the clinic.  As most patients know, experience with getting results like this from clinics is highly variable.  Most of that confusion is a direct result of the Privacy Rule that started under the Clinton administration and ended under the Bush administration.  It is complicated by CFR42, a federal regulation that directly impacts the release of sensitive data and the way it can be released.  after the recent modification to make it clearer and easier to get date, one of the clinics I go to will no longer e-mail me graphical data.  That is the outcome I expected when special interest attorneys get involved in health care law.

The visit itself went very well.  The clinic demonstrated the same efficiency.  The retinal exam included scans of both eyes by physical examination of only the affected eye.  The scribe was in the room and she picked up an error in the original note and corrected it.  The conclusion was no change in retinal opacities  (blood in the vitreous) - but well sealed off laser site with resolving retinal edema.  In the manner of most proceduralists that I have encountered, it was time for questions.  No spontaneous advice.  I carefully outlined the physical activities that I am involved in and was advised that I could resume with nor restrictions.  I had stopped taking 81 mg of aspirin a day on my own initiative and was advised that I could resume that.  The only additional information was follow up in 6 weeks and call if problems.

That call if problems is always a tricky proposition.  With the retinal opacities from the original tear the large amoeba-like blob over about 1/3 of my visual field was still there, but over the course of the day it comes and goes.  At times there are about 20-30 very small black dots floating around in that eye.  Given what I know about brain adaptation to let's say prism viewing, I wondered if my brain was adapting to the retinal opacities and only showing me the clear visual field.  There were times when it seemed worse, but I concluded that unless it was consistently worse, I should probably not call the clinic.  I arrived at that conclusion on my own. but confirmed  it with the retinal specialist between now and the next appointment.

I also thought about the time it takes me to coach patients about how to self monitor and also warn them about rare side effects.  I can spend 10-20 minutes on serotonin syndrome,  neuroleptic malignant syndrome, prolonged QTc interval, drug induced liver disease, priapism, metabolic syndrome, and diabetes mellitus.  And that is after we have discussed progress and medication side effects.  When I thought about the complication rates quoted to me for retinal/vitreous detachments and tears and the success rate of laser surgery - I am telling people about many potential complications that are a thousand to ten thousand times less likely to occur.

That is the range I am living in.  I am not complaining about it.  I think it is much more reasonable to have informed patients who understand that taking a medication is not a walk in the park or a miracle cure.  I am concerned that despite my detailed explanations and accompanying literature many people do still not understand it or just ignore it.  On the other hand I have had people with known problems like cardiac problems come back and recite everything I told them about potential cardiac problems and what to watch for.  The side effect that bothers most people is the potential for weight gain, but most of them can be assured that there is a strategy to deal with that problem.  If a medication is effective, people will want to take it even if there are potential problems with it including weight gain and ECG abnormalities.

The measurement technology used in ophthalmology is interesting.  The human retina is unique enough to allow it to be used for biometric identification.  No two retinas are identical and technically even though retinal tears have similar characteristics they are all in a unique biological landscape.

Technology clearly differentiates ophthalmology from psychiatry.  We remain stuck in the 1960s with an obsessive narrative that classifies but probably does not diagnose.  Depending on who you read, phenomenology is there to some degree.  Ophthalmologists done't really need to depend on objective descriptions of symptoms - they can see what the problem it.  I just read an article on a consensus treatment guideline  for depression that adds absolutely nothing to the field beyond what a psychiatrist has learned in residency training in the past 15 years.   At the end of the day we have no retinal scan that we can hand a patient and say: "This is your problem and this is what we did to fix it in about 1 hour."

And that is what we need.



George Dawson, MD, DFAPA


Supplementary:

I could not fit this into the body of the post anywhere but age-related retinal and vitreous diseases seem like a major oversight in medical education to me.  I studied geriatric psychiatry and geriatric medicine and the major focus was on age related causes of blindness that were essentially chronic illnesses.  As far as I can tell age-related acute retinal and vitreous problems are a major epidemic and every physicians should know how to diagnose them and how fast they need to be triaged and referred (fast).


                    

  

Ophthalmology versus Psychiatry Part 2.

Spoiler Alert: Ophthalmology always wins!

I was driving home last Friday night and for several minutes it seemed like there was a bug in my right eye.  I did the upper lid over lower lid trick a couple of times and that didn't work so I pulled over and tried to rinse it out with artificial tears.  No change at all with that maneuver and then I started to see familiar floaters and small black dots in my visual field but only on the right.  I had the exact same symptoms a year ago that led to a diagnosis of a vitreous detachment with no retinal problems.  Later that night I started to see flashing halos in the upper right visual field.  I got in to see an optometrist through my health plan and was referred immediately to a vitreous and retinal specialist today.  At a about 2PM today, I had a laser surgery procedure to fix a small retinal tear in the periphery of my right retina.

The specialist explained pathophysiology, the rationale and the expected success rate.  There is age-dependent liquefaction of the vitreous humor and in that process it can pull away from the retina.  That process can be benign like it was for me a year ago or it can lead to a "traction-event" on the retina and cause a tear.  The main reason for the laser surgery is to spot weld the tear by forming a photcoagulation scar where the laser hits and prevent a more extensive tear that could require open surgery of the eye and the risk of infection and further vision loss.  The decision for the laser surgery was an easy one, especially because I have known many people who required variations of the open surgery.  I sat in an ophthalmology exam chair with my head in a fixed position.  This video illustrates the exact procedure that I underwent today.  The laser light was green and at the end of the procedure I was completely blind in the eye for about 10 minutes and then transitioned to a violet vision and then back to normal.  This phenomenon is cause by saturation of the photoreceptors by laser light.  The procedure I underwent was much faster with repeated pulses of the laser.  If I had to estimate, I would say about 150-200 pulses of light were used.  The specialist kept me posted: "30% done.... 50% done, etc)" and also coached me on how I was doing focused on the extreme limits of my visual field.    

I had some observations about ophthalmology and orthopedic surgery last year and this year is no different.  First, I am amazed at how many of these vitreous retina specialists exist across the country.  Given my previous estimate of the total number of ophthalmologists and the numbers of people that they treat,  the distribution must be very good across the country.  Their services are certainly in demand.  Retinal and vitreous disease is clearly an age related problem.  There were 15 people in the waiting area and there was one person younger than me.  Most were considerably older and many were there to get injections to slow the progression of macular degeneration.

I am no stranger to ophthalmologists.  When I was in the 8th grade I shot myself in the eye with a BB gun and have had appointments every year to follow up on that injury.  That has also allowed me to follow the way that ophthalmologists practice.  Back in the 1960 to 1980s they did everything.  They started out with visual acuity tests, then visual fields, the intracranial pressure by tonometry and eventually the slit lamp approach.  They did the entire refraction and tried to get the visual acuity as good as possible. They proceeded to the slit lamp exam and at some point started doing retinal exams using hand held lenses and lens in conjunction with the slit lamp.  If an ophthalmologist was really flying and had a patient who was able to  cooperate - it might be possible to get all of this done in 20-25 minutes.

Things have changed drastically since that time.  I was roomed by a medical assistant who recorded the history and  took my vital signs.  In Room 2, I saw another medical assistant who took additional history, cursory social and family history (only eye diseases and diabetes in parents and siblings) and a cursory review of systems (have you had a heart attack or stroke? do you have chest pain today?).  She did visual acuity, visual fields by confrontation, and ocular motility and recorded it in the chart.  She did a slit lamp exam.  She measured intraocular pressure by some kind of digital hand held tonometer that I had never seen before.  She got my eyeglass prescription off the new lenses and did not need to do a refraction.  In Room 3, I was introduced to a scribe who told me that she would be taking notes for the specialist.  She set up twin displays with the EHR spread across.  The specialist walked in and performed indirect ophthalmoscopy by both slit lamp and standing hand held lenses.  He told me that I had a retinal tear and we discussed the surgery.  The scribe reminded him how it needed to be worded in the chart and how she was going to record it.  I electronically signed the consent form.  In Room 4, I saw a person who only did retinal scans with a blue light.  Finally in Room 5, the laser procedure was done.

This was a significant display of efficiency in terms of division of labor with a sole focus on problems related to the eye.  The social history is not that important in this case - they were only interested in marital status, offspring, and occupation.  They were not really interested in a review of systems other than a more detailed review of ocular symptoms - including my history of the BB gun injury.  They efficiently proceeded to laser my torn retina (at about the 45 minutes mark) and if the quoted statistics were correct - greatly reduce the likelihood or a major retinal tear and the need to open surgery or in the very worst case partial or complete blindness.      

Unfortunately in psychiatry we have nothing like this.  I am still doing what I have done for the past 30 years - an obsessive 240 plus point interview that included a detailed history.  My medical history, review of systems, social and family histories are all comprehensive and customized for the situation.  If I want vital signs or some examination - I have to do it myself.  In some clinics I can get checklists - but despite all of the hype about collaborative care or measurement based psychiatry those rating scales are a poor excuse for detailed questions about the problem.  The people who believe they are actually using quantitative metrics to measure care with these scales are fooling themselves.  In order to make up for the stunning lack of efficiency in psychiatric practice we have the workarounds of more and more prescribers - all asking their own questions and making their own diagnoses or we have the collaborative care psychiatrist advising primary care physicians on how to treat their patients based on rating scale scores or the questions of those physicians.

The other limiting factor is the lack of value assigned to the psychiatric evaluation.  I have not seen the bill for laser eye surgery - but I can speculate that it will be many times what I am paid for a comprehensive evaluation in roughly the same period of time that it took to diagnose and repair my retinal tear.  With the division of labor, the ophthalmologist was seeing 7-8 times as many patients in an hour than I can see.

To me that is both the most positive aspect of clinical psychiatry, but also its downfall.  Psychiatry is too complicated to commoditize.  Don't get me wrong - it happens all of the time.  Very few psychiatrists who are not in private practice have the luxury of talking with people for an hour.  That makes patient experiences highly variable.  We have to find a model that takes us out of the 1970s but also provides more clear cut results.  Ophthalmology has clearly been able to do that.  Science and treatment in medicine is better with precise measurement.  There is nothing about rating scales that I would call precise.

With my retina and vitreous problems I have come to another conclusion.  Training in Geriatric Psychiatry is designed to increase sensitivity to ageism and and biases against the elderly.  I have had plenty of that training.  Now that I am technically a geriatric person myself, I can speak with authority -  aging is an inescapable disease.  I hope someday there is a better solution.

But that is a topic for another post.



George Dawson, MD, DFAPA        





















  

Ophthalmology Styled Practice As A Goal For Psychiatry (And The Rest Of Medicine)

Over the years whenever I have thought of an ideal way to practice medicine ophthalmology comes to mind.  I remember a good friend of mine telling me shortly before he became an ophthalmologist that the speciality seemed to have the ideal mix of medical and surgical interventions and they were mostly effective.  He also had the great observation that no matter what field of medicine you specialize in - the information in that field will generally be contained in two or three large volume texts.  The information always expands to that amount with specialization.   My friend was a very bright guy.

Like most specialties, I have had my fair share of personal contact with them starting with a BB gun injury in the 8th grade.  That's right - just like in the movie - I almost shot my eye out.  And just like in the movie, my father told me shortly before the accident: "Be careful with that BB gun - you will shoot your eye out!"  Within minutes, I was standing there in disbelief.  A BB had ricocheted off a steel lamp cover in our basement and instantaneously hit me in the left eye.  Within minutes I looked in the mirror and was more shocked to discover that my iris color had been replaced with blood inside the anterior chamber of the eye.  The family doctor was called and advised my parents not to bring me to their office or the emergency room, but to see the new ophthalmologist in town.  He was the only physician in town who could assess and treat this injury.  I spent a week in the hospital with both eyes covered and eventually recovered with a traumatic cataract in the lens of my left eye.  Every ophthalmologist since has said the same thing: "You are lucky that cataract is just off your visual axis and it does not affect your vision."  Even more interesting, the last ophthalmologist I saw wanted to know about my experience of seeing with a traumatic cataract just off my visual axis.  In what ways did it seem different than the other eye.  After many questions he finally said: "I am just trying to find out what it is like for you to have this cataract."  An ophthalmologist interested in my conscious state of vision?

These are some useful lessons from ophthalmology:

1.  Precise assessments based on clear markers:

There is still room for interpretation.  No two retinas are alike.  As another example, an eye doctor told me recently that prominent retinal arteries may put you at risk for glaucoma.  I saw a second eye doctor 2 weeks later who agreed that I may be in the subgroup of people with prominent retinal arteries but that does not put me at higher risk for glaucoma.  In 50 years of annual eye exams my intraocular pressures have always been normal.  I have also used the eye exam in lectures on diagnostic accuracy looking at the issue of the diagnostic accuracy of direct ophthalmoscopy versus indirect ophthalmoscopy, basically ophthalmologists versus everyone else.  The ophthalmologists win by a wide margin when it comes to detecting retinal pathology.  The odds that a primary care physician can detect these changes with direct ophthalmoscopy as a screening exam are no greater than chance.   In the days when I did a lot of direct physical examinations of patients,  I was convinced that most physicians either did a poor job of using an ophthalmoscope or were just focusing on major landmarks.  They also seemed to ignore the general clinical status of the patient.  I recall an agitated, hypertensive, young stroke patient and clear hemorrhages in the retina.  I diagnosed the retinal hemorrhages and nobody else did, but they could confirm when I told them where to look.  Like all of medicine the subjective factor is there, even in what appear to be objective assessments, but ophthalmology seems to have some of the greatest potential accuracy and reproducibility.

2.  Interventions that are fast, safe and effective:

About 8 years ago I was interviewing a patient and looked down at the wood grain of the table. It started to swirl and move in one visual field.  I was part of a big multidisciplinary clinic at the time.  The information flow among the specialists was the best I have ever seen it.  I called the ophthalmology clinic spoke with an ophthalmologist.  After about 30 seconds of symptoms he said: "You have a retinal migraine.  We can get you in this afternoon, but I doubt there is much else."  I went with that advice and have had no similar problems since.  A few years ago a family member called me on a Saturday morning and said he had sudden onset of veiled vision and floaters.  He lives in a town of about 50,000 people.  He was able to see a retinal specialist and get laser surgery on his torn retina in a matter of hours.  I have had three other relatives with retinal surgery - all very successful.  In my case about one month ago, I had a sudden onset of eye aching, massive floaters, and large bright halos surrounding the entire visual field of my left eye.  I was triaged to ophthalmology in a few hours and diagnosed with an acute vitreous detachment with a plan to observe for any retinal damage in two weeks.

3.  Interventions that clearly enhance quality of life:

Saving someone's vision needs to be at the top of anyone's list when it comes to quality of life.  Surgical specialties are generally a very active intervention by physician with very good outcomes and some complications.  From what I have seen the complication rates of eye procedures are very low and in some cases the advertised procedures being done are in excess of 10,000 - 100,000.  In many cases there is an expectation that you will be seeing the doctor 2 or 3 times and that the chances of a good outcome that will improve your life are very high.

4.  A clear path to getting well:

The majority of patients seeing ophthalmologists, don't have to do much to get well.  Recognize the problem, discuss the treatment plan and risks/benefits of the surgical procedure and make the follow up appointments.  In the case of medical treatment - use the required eye drops, visual aids, diet, and protective equipment and participate in the monitoring plan.  In the patients I see with eye problems I know that many of them do not follow up.  I routinely ask about a personal history of eye trauma, visual problems, glaucoma, and macular degeneration.  In some cases I call their ophthalmologist directly about whether the medication I am about to prescribe would affect their treatment.  But generally an optimal path to care with a good outcome is outlined form most ophthalmology patients and the burden of adherence is relatively low.

Contrast that with a patient walking into a psychiatric clinic.  By that I mean a patient who gets a direct appointment with a psychiatrist.  There is no precision in the assessment.  There is a diagnostic manual that gives the appearance of precision, but it is fairly worthless unless the physician knows how to get at it and that generally involves having seen many patients with the problem.  It also involves concluding that many DSM-5 categories are so nonspecific or unrealistic that it makes no sense to make the diagnosis.  With a diagnostic manual that imprecise, markers are sorely needed and I am optimistic that we are on the verge of some.  I am optimistic that with the correct markers we will be able to define categories and clearly define treatment paradigms on those categories, but I don't expect that to resemble a DSM or an RDoC for that matter.  The burden of adherence is much higher.  Polypharmacy and keeping all of those medications straight is certainly as big a problem in primary care and the medical specialties.  Nobody else wants to see people back on an hourly basis for weeks, months, and years.

One of the fastest and safest interventions in psychiatry is electroconvulsive therapy.  In many parts of the country it is unavailable.  The FDA has some continuous program afoot to "reclassify" it.  This is the second iteration of that program since I responded to the first one years ago.  The only logical conclusion is that this is some kind of political maneuver being played out in a regulatory context.  My understanding is that reclassification would mean new sets of clinical trials to get FDA approval for devices.  It should not be surprising that very few places offer it, and thousands of patients go through endless clinical trials of antidepressants with no remission of their symptoms.  TMS (transcranial magnetic stimulation) and VNS (vagal nerve stimulation) seem far less impressive in treatment resistant populations.  Just last week a colleague also pointed out that there are probably thousands of patients who might benefit from ketamine infusions and that seems to be another procedure in limbo pending FDA considerations.  Without FDA approval, health insurers will deem a treatment experiment and not pay for it.  That is when treatment usually grinds to a halt.

Quality of life considerations should be high on any psychiatrists agenda since we learned that we treat conditions that are listed in the Top 10 of the World Health Organizations list of disabling conditions.  Unless we get robust treatment responses, quality of life is not likely to improve.  There are vast numbers of patients who are disabled and maintained on medications.  They clearly need more than the medication but the only service offered by their health plan is a series of brief visits with a psychiatrist or a prescriber, generally focused on polypharmacy.  There is no attempt at cognitive or vocational rehabilitation.  Those services are available to stroke patients but not psychiatric patients.

The path to getting well and recovering from a mental illness or addiction is often not clear.  The message has been oversimplified to "Take your medications as prescribed."  The same patient may hear "Don't do drugs or alcohol." but typically only after a problem has been identified for a while.  The average person with an addiction (according to survey literature) does not disclose that to a physician.  Most people after an acute episode of a mood disorder or psychosis - don't know where to start.  They don't know what happened to them and they don't know how to prevent it from happening again.  They may hear that they need "therapy" or "counseling" and realize that after 5 or 6 sessions, they don't like the therapist or the sessions aren't going anywhere.  What is left at that point?  Go back and see the prescriber in 15 minute lots about medications that seem to hardly have an effect or a seemingly endless series of medication trials?        

Instead of parsing words in somewhat meaningful categories we need to pick up the pace.  In my experience the people who are willing to see psychiatrists for a long period of time for pharmacotherapy, psychotherapy or both are in the minority.  It is clear that many psychiatrists end up seeing patients three or four times a year in what appears to be interminable treatment.  All the while the patients have varying degrees of disability and problematic quality of life.

All of this care is delivered by 19,216 ophthalmologists who are addressing an impressive array of eye diseases and injuries.  As previously noted there are 49,070 psychiatrists also addressing a lot of illness and disease.  Just like my previous argument about orthopedic surgeons, I have never heard of any shortage of ophthalmologists.

Ophthalmology teaches us that there is a much better way and we should be designing those paths of care instead of the giving it over to the business people and politicians.  A critical question on the idea of a shortage of psychiatrists is how much of that is due to the inefficiencies suggested above including interference from politicians and business organizations.



George Dawson, MD, DFAPA