"Good News - Your Care Today Was Free"

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

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

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

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

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

Dear George,

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

We're sorry we couldn't help you this time, but please keep us in mind the next time you're feeling ill. Thanks for choosing us.


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

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

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

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

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

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

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

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

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

You already know what I have to say about that.

George Dawson, MD, DFAPA

The Issue With Patient Management Problems

So-called patient management problems have been building up on us over the past 30 years.  I first encountered them in the old Scientific American Medicine Text.  They are currently used for CME and more importantly, Maintenance of Certification.  To nonphysicans reading this they are basically hypothetical patient encounters that claim to be able to rate your responses to fragments of the entire patient story in such a way that it is a legitimate measure of your clinical acumen.  I am skeptical of that claim at best and hope to illustrate why.

Consider a recent patient management problem for psychiatrists in the most recent issue of Focus, the continuing education journal of the American Psychiatric Association (APA).  I like Focus and consider it to be a first rate source of the usual didactic continuing medical education (CME) materials.  Read the article, recognize the concepts and take the CME test.  This edition emphasized the recognition and appropriate treatment of Bipolar II Disorder and it provided an excellent summary of recent clinical trials and treatment recommendations. The patient management problem was similarly focused.  It began with a brief descriptions of a young women with depression, low energy, and hypersomnia.  It listed some of her past treatment experience and then listed for the consideration of the reader, several possible points in the differential diagnosis including depression and bipolar disorder, but also hypersomnia-NOS, obstructive sleep apnea, disorder and a substance abuse problem.  I may not be the typical psychiatrist but after a few bits of information, I would not be speculating on a substance abuse problem and would not know what to make of a hypersomnia-NOS differential diagnosis.  I would also  not be building a tree structure of parallel differential diagnoses in my mind.  Like most experts, I have found that the best way to proceed is to move form one clump of data to the next and not go through and exhaustive checklist or series of parallel considerations.  The other property of expert diagnosticians is their pattern matching ability.  Pattern matching consists of rapid recognition of diagnostic features based on past experience and matching them to those cases, treatments and outcomes.  Pattern matching also leads to rapid rule outs based on incongruous features, like an allegedly manic patient with aphasia rather than a formal thought disorder.

 If I see a pattern that looks like it may be bipolar disorder, the feature that I immediately hone in on is whether or not the patient has ever had a manic episode.  That is true whether they tell me that they have a diagnosis of bipolar disorder or not.  I am looking for a plausible description of a manic episode and the less cued that description the better.  I have seen evaluations that in some cases say: "The patient does not meet criteria for bipolar disorder."  I don't really care whether the specific DSM-5 criteria are asked or not or whether the patient has read them.  I need to hear a pretty good description of a manic episode, before I start asking them about specific details.  I should have enough interview skills to get at that description.  The description of that manic episode should also meet actual time criteria for mania.  Not one hour or four hours but at least 4 days of a clear disturbance in mood.  I recall reading a paper by Angst, one of Europe's foremost authorities on bipolar disorder when he proposed that time criteria based on close follow up of his research patients and I have been using it ever since.  In my experience practically all substance induced episodes of hypomania never meet the time criteria for a hypomanic episode.  There is also the research observation that many depressed patient have brief episodes of hypomania, but do not meet criteria for bipolar disorder.  I am really focused on this cluster of data.

On the patient management problem, I would not get full credit for my thinking because I am only concerned about hypersomnia when I proceed to that clump of sleep related data and I am only concerned about substance use problems when I proceed to that clump of data.  The patient management problem seems more like a standardized reading comprehension test with the added element that you have to guess what the author is thinking.

The differential diagnosis points are carried forward until additional history rules them out and only bipolar II depression remains.  At that point the treatment options are considered, three for major depression (an antidepressant that had been previously tried, an antidepressant combination, electroconvulsive therapy, and quetiapine) and one for bipolar II depression.  The whole point of the previous review is that existing evidence points to the need to avoid antidepressants in acute treatment and that the existing relatively weak data favors quetiapine.  The patient in this case is described as a slender stylishly dressed young woman.  What is the likelihood that she is going to want to take a medication that increases her appetite and weight?  What happens when that point comes up in the informed consent discussion?

The real issue is that you don't really need a physician who can pass a reading comprehension test.  By the time a person gets to medical school they have passed many reading comprehension tests.  You want a physician who has been trained to see thousands of patients in their particular specialty so they have a honed pattern matching and pattern completion capability.  You also want a physician who is an expert diagnostician and who thinks like an expert.  Experts do not read paragraphs of data and develop parallel tree structures in their mind for further analysis.  Experts do not approach vague descriptions in a diagnostic manual and act like they are anchor points for differential diagnoses.  Most of all experts do not engage in "guess what I am thinking" scenarios when they are trying to come up with diagnoses.  Their thinking is their own and they know whether it is adequately elaborated or not.

This patient management program also introduced "measurement based care".  Ratings from the Inventory of Depressive Symptomatology (IDS) were 31 or moderately depressed at baseline with improvements to a score of 6 and 4 at follow up.  Having done clinical trials in depression myself,  and having the Hamilton Depression Rating Scores correlated with my global rating score of improvement, I have my doubts about the utility of rating scale scores.  I really doubt their utility when I hear proclamations about how this is some significant advance or more incredibly how it is "malpractice" or not the "standard of care" if you don't give somebody a rating scale and record their number.  In some monitored systems it is even more of a catastrophic if the numbers are not headed in the right direction.  Rating scales of subjective symptoms remain a poor substitute for a detailed examination by an expert and I will continue to hold up the 10 point pain scale as the case in point.  The analysis of the Joint Commission 14 years ago was that this was a "quantitative" approach to pain.  We now know that is not accurate and there is no reason to expect that rating scales are any more of a quantitative approach to depression.

Those are a couple of issues with patient management problems.  The articles also highlight the need for much better pharmacological solutions to bipolar II depression and more research in that area.

George Dawson, MD, DFAPA


Cook IA.  Patient Management Exercise - Psychopharmacology.  Focus Spring 2014, Vol. XII, No. 2: 165-168.

Hsin H, Suppes T.  Psychopharmacology of Bipolar II Depression and Bipolar Depression with Mixed Features.  Focus Spring 2014, Vol. XII, No. 2:  136-145.  

My First Flu Shot

I got my very first flu shot on 12/3/2013.  Up until now I have depended on my coworkers being vaccinated and protecting me against the virus.  Very recently I have had Tamiflu and at the times I have used it thought that it worked very well.  I have asked repeatedly about getting the shot, including the Infectious Disease consultants who promoted the mass immunization of my fellow employees.  Over the years I have asked about 5 of them this question and they all said the same thing: "You can never take this flu vaccine."  My history was: "In 1975 I received two doses of anti-rabies duck embryo vaccine and had two episodes of anaphylaxis".  I was very interested in the new vaccine (Flucelvax) for people with egg allergies and when I asked about it, my primary care doc was initially enthusiastic, but then told me I had to be evaluated by Allergy and Immunology in order to get it.  That lead to a comprehensive evaluation that was nearly three hours long.

After the check in and doing some asthma tests, I met the Allergist.  He was about my age and the first thing I noticed was that he was gathering a history in nearly the same way I do.  It was detailed and comprehensive.  Not just the buzz words but what actually happened right down to what that duck embryo vaccine looked like in the syringe.  It was oily and it had particles in it.  Even in those days I was skeptical of the idea that all Peace Corps volunteers going into a specific country needed to take it.  There were about 50 of us and in the two years of service, I don't recall hearing that anyone was bitten by an animal.  The first time I got it, I broke out in hives and had a rash.  My friends took me down to a local Kenyan hospital where they gave me Polaramine (dexchlorpheniramine) and epinephrine.  When I got the second injection, I got intense abdominal cramping, hives, swelling of the face and lips, wheezing and lightheadedness.  At that  point they gave me Benadryl (diphenhydramine) and epinephrine.  Even though I can recall the antihistamine they were using in Kenya at the time, I can't recall why they gave me the second shot.   The Allergist wanted all of these details and more, like when was the first time anything like this happened.

That was 50 years ago.  The anchor point was the JFK assassination.  The day before his funeral I shot myself in the left eye with a BB gun and developed a hyphema.  I was hospitalized for a week and the hemorrhaging resolved completely.  In the follow up, I was in the ophthalmologist's office next to a fish tank.  My face started to swell of to the point that my eyes were swollen shut and my lips were extended.  I developed hives over much of my body.  I started to wheeze.  They moved me into a different room and talked with my mother who told me later that the diagnosis was "psychosomatic reaction".   Apparently the stress of not losing an eye or my vision was felt to be a more likely etiology than a moldy fish tank.  For the next 10 years or so, I start to wheeze when mowing the lawn.  I would get up in the middle of the night with hives or wheezing and drank Diet Pepsi until it went away and I could go back to sleep.  At some point one of the primary care docs in town gave me an epinephrine based inhaler.   I didn't see my first real allergist until I was about 25, after the Peace Corps and working at my first job cloning evergreen trees.

The skin testing began at that point.  96 patch tests up and down my back, all of them very positive.  I was given a long list of what to avoid and it was basically unavoidable.  I began a long series of immunotherapy injections, but gave up when they did not seem to do anything.  I remembered taking TheoDur the entire time I was in medical school and doing a rotation in Allergy and Immunology.  I gave a presentation about what was known about anaphylaxis at the time and at the end, one of the allergists seriously questioned me about why I was going into psychiatry rather than internal medicine.  During residency, I took my first course of prednisone for a flare up of asthma after a viral infection.  Since then, it has been random episodes of spontaneous anaphylaxis, corticosteroid inhalers and trying to minimize my exposure to them when possible, and using antihistamines and an Epi-Pen when the episodes of anaphylaxis seem particularly bad (that is infrequent).  The Allergist recorded this 50 year history of mostly inadequate treatment.

At the same time, I was marking where I would be in an interview with a person who had lifelong depression and anxiety.  Attempting to reconstruct the episodes of mood disorder and what the symptoms were.  Attempting to correlate it with major life events.  Attempting to determine in retrospect the exact nature of the symptoms and likely etiologies at the time.  Asking myself if the treatments received were appropriate or what it suggested.  Thinking about the resilience or vulnerabilities of the person I was talking with.  It is the same process I use in making diagnoses and treatment plans.  Were there differences?  Of course and the most noticeable were the objective measures for assessing asthma.  I did the usual assessments of FEV1.0 before and after bronchodilators.  There was also a new assessment of alveolar nitric oxide (NO) as a measure of asthma  control.  It would be extremely useful to have tests like that to objectively measure the distress, anxiety, or depression levels of the person sitting in front of me, especially if it involved something as simple as blowing into a tube.

But the most interesting part was that in the end, the Allergist addressed the question about whether I could take an egg cultured influenza vaccine by carefully synthesizing the data and correctly answering the question.  He did not need a test of any sort to answer the question.  He took a meticulous 50 year history of a guy with life-long allergies including asthma and anaphylaxis and correctly concluded that I could be given the shot, even though all of the experts with the same level of training had come to the opposite conclusion.  I got the shot, sat in the clinic for 30 minutes.  The information sheet said that delayed reactions for "up to several hours" could occur.  He told me that would not happen and I went home.  That was almost exactly 24 hours ago.

The lesson here is one that I have seen time and time again in the field of medicine.  The information content in the field is vast.  There may be only a certain physician or specialty capable of answering that question.  There is no better example than me getting a flu shot, but it also happens daily in the people I see who have had psychiatric disorders for the same length of time or less than I have been dealing with allergies and asthma.  No two people with asthma or depression are alike.  Meticulous history taking and pattern matching can get to the correct answer.  Suggestions that we can treat a population of people all in the same way will not.

People are biologically complex and as physicians we should celebrate that.  That also involves getting them to the person who can correctly answer their questions.

George Dawson, MD, DFAPA

Pattern Matching in Psychiatric Diagnosis

I first heard about pattern matching and the importance it has in medical diagnosis over 30 years ago.  A friend of mine who was in medical school at the time told me about one of his professors who was always interested in the Augenblick diagnosis or the diagnosis that  could be arrived at in the blink of an eye.  He gave me examples of several diagnoses that could be either made immediately or within minutes based on a set of features that would lead to immediate associations in the mind of the clinician without an extensive evaluation.

I had many encounters in my medical training with the same phenomenon.  I can recall being on the Infectious Disease consult team and being asked to see a patient with ascites for the possible diagnosis and treatment of spontaneous bacterial peritonitis.  The consultant with an expert in Streptococcal infections and after patiently listening to the resident's presentation he asked what we thought of the rash on the patient's leg.  The patient had lower extremity edema with a slightly erythematous hue and a slight exudate in areas.  What was the diagnosis?  Without skipping a beat the consultant said this was streptococcal cellulitis and suggested sending a sample to the lab for confirmation.  It was subsequently confirmed and treated.  Why was the attending physician able to hone in on and diagnose this rash when it escaped the detection of two Medicine residents and two medical students?  He was an Infectious Disease specialist and that may have biased him in that direction but is there something else?

One of the ways that physicians and probably all classes of diagnosticians arrive at Augenblick diagnoses or efficiently clump and sort through larger amounts of information faster is by pattern matching.  Pattern matching is also the reason why clinical training is necessary to become an adequate diagnostician.  That will not happen with rote learning alone.  It is one thing to read about heart sounds and actually experience them and to have that skill refined by listening to hundreds and thousands of normal hearts and hearts with varying degrees of pathology.  Rashes are classic examples and several studies have documented that the speed and accuracy with which dermatologists can make an accurate diagnosis of a rash is much higher than the average physician.  In pattern matching a recognizable feature of the patient's illness triggers an immediate association with the physicians experiences from the past leading to a facilitated diagnosis.

Probably the best conceptualizations of pattern matching comes from the fields of philosophy and cognitive science.  My favorite author is Andy Clarke and his book Microcognition.  He addresses the issue of biologically relevant cognitive science and the model of parallel distributed processing.  A simplified diagram drawn from this model is shown below:

In this case we have a very practical problem of a patient with known bipolar disorder and a question of whether or not they have had a stroke.  In this case the respective clouds (there are many more) represent collection of features of medical diagnoses that may be relevant to the case.  Unlike a textbook, these features represent a lot of varied information including actual events and nonverbal information like the clinicians past history of diagnosing strokes and caring for people who have had strokes.   Each cloud here can contain hundreds or tens of thousands of these features.  These features are unique aspects of the clinician conscious state and the only way to control for variability between clinicians is to assure that physicians in the same speciality have similar exposure to these experiences in their training.  Even in the ideal situation where all specialists have an identical exposure to the same illness there will be variability based on different levels of ability and other capacities.  An example would be a Medicine resident I worked with whose examination of the heart with a stethoscope predicted the echocardiogram results.  It became kind of a joke on our team at the time that all he had to do was hold his stethoscope in the air in a patient's room and it was as good as an ultrasound.

The basic idea in pattern matching is that the clinician immediately recognizes one of the features they know and that allows for a rapid diagnosis or plan based on that feature.   Looking how that works in the hypothetical case we can look at a few features in the map:

 For the purpose of this discussion consider that our patient B is a 60 year old woman with a 35 year history of known bipolar disorder.  She has known her psychiatrist for years.  One day the husband calls with the concern that the patient seems to have developed a problem with communication.  She seems to be talking in her usual voice but he can't comprehend what she is saying.  She does not appear to be manic or depressed.  The psychiatrist listens to the patient on the phone and concludes that she has a fluent aphasia and recommends that they take her to the emergency department as soon as possible.  Ongoing care requires that the psychiatrist talk with the emergency department physician and hospitalist to make sure that acute stroke is high in their differential diagnosis and eventually go in to the hospital and examine the patient to confirm the diagnosis.

Practically all cases of psychiatric diagnosis require some measure of this pattern matching process with varying degrees of medical acuity.  I would go so far to suggest that it is the most important aspect of the diagnosis.  Keep in mind that the pattern matching also applies to the purely psychiatric part of the diagram.  Despite all of the recent criticism and focus on the DSM 5 the elaboration of pattern matching leads us to several important conclusions:

1.  Psychiatric diagnosis is a much more dynamic process than rote learning from a diagnostic manual.  The average clinician should have many more features of diagnoses than are listed in any manual.

2.  Psychiatric diagnosis requires medical training.  There is no way that our psychiatrist in the example could have made the diagnosis of aphasia and remain involved in the diagnostic process to its conclusion without medical training and previous exposures to these scenarios.

3.  The training implications of these scenarios are not often made explicit.  Every medical student, resident and practicing physician needs to be exposed to a diverse population of patients with problems in their area of expertise in order to develop a pattern matching capability.  They can also benefit by asking attending clinicians about how they made rapid diagnoses, but at that level of training the question is not obvious.

4.  Removing physicians with these capabilities from the diagnostic loop reduces the capability of that loop.  The best example I can continue to think of is the primary care process where the diagnosis and ongoing treatment of depression or anxiety depends on the results of a checklist that the patient completes in less than 5 minutes.  This assumes that there is an entity out there called depression that is based purely on a verbal description and pattern matching is not required.  It actually assumes that there is a population of people with this affliction.  Despite all of the hype about how this is "measurement based care" - I don't think that a single person like that exists.

5.  Pattern matching blurs the line between objective and subjective.  There is often much confusion about this line.  Are there "objective criteria" that can be written in a manual somewhere that captures even the basic essence of diagnosing a stroke in a patient with bipolar disorder?  Is there an "objective" checklist out there somewhere that can capture the problem?  Obviously not.  For some reason people tend to equate "subjective" with "bad" or "unscientific".  In the example given and any similar example, the subjective state with the most experience diagnosing strokes is probably the "best" diagnostician - subjective or not.  An "objective" rating scale doesn't stand a chance.

So consider pattern matching to be an important but unspoken part of the diagnostic process.  For obvious reasons it is more important than diagnostic criteria in a manual.  The most obvious of these reasons is that you really cannot practice medicine without it.

George Dawson, MD, DFAPA

Clark A.  Microcognition.  London, A Bradford Book, 1991.