They Don't Even Know What They Are Seeing.......

I was walking back from a meeting with a psychiatric colleague the other day.  There was the usual grousing about the practice environment and miscommunication and she made the following observation about why physicians and psychiatrists don't get the information they need.  She pointed out that in many cases the nonphysician  observers: "Don't even know what they are seeing."  If you are counting on people for observational data and that is true - that is a setup up for suboptimal care at the minimum and a catastrophe at the worst.

Take the case of a very basic measurement - blood pressure and pulse.  Anyone taking those measurements should be aware of the guidelines and whether or not the patient has a baseline abnormality, condition that can affect either, or medication effect that leads to changes in the vital signs.  They should also be aware of the limitations of measurement.  All of the automatic blood pressure machines in the world will not be able to assess and treat the patient unless the operators know what the numbers mean.  They also need to know that one of the problems with single operator and strictly machine operated approaches is that arrhythmias are problematic even if the blood pressure is fine.  There have been situations where I had to put together a continuing education course on blood pressure and pulse and the correct assessment of both.  That was a long time before the recent article on common mistakes made by medical students in these measurements.

If measurements that are considered routine and done hundreds of times a day are problematic what about observations that occur on the other end of the spectrum.  A common health care myth today is: "If I have a checklist and check off all of the boxes on that list that will lead me to some kind of diagnosis."   That is probably a minimization of the myth.  In the case of psychiatry, the myth is more: "If I convert a standard psychiatric assessment into a form (or a checklist) - the ultimate product of going through that list will basically be a psychiatric evaluation and diagnosis."  Systems of care who use this approach can deny these myths as much as they want but I see this happening every day. Organized psychiatry and the DSM approach to diagnostic criteria is partially responsible, although the manual does say that it can't be used by anybody.  It doesn't say who specifically should use it and it does not suggest (like Kendler) that it is an indexing approach.

Looking at the graphic at the top of the page illustrates why a form or a checklist does not suffice.  The observer/psychiatrist in the drawing is doing more than asking the subject a series of yes or no questions.  The psychiatrist is looking for patterns in symptoms (medical and psychiatric), what is happening in relationships with the person (including the relationship to the psychiatrist), and the person's conscious state - specifically whether there has been a departure from baseline.  There is often a balance between historical detail, phenomenology, the person's ability to describe what has happened and a plausible scenario based on probability estimates from the psychiatrist's previous experience.  Any psychiatrist who has been trained in many presentations of complex psychiatric illness is more likely to see those patterns than somebody who has not been.

To illustrate some of these concepts I will describe several cases that are all what non-psychiatrists (nonphysicians and other physicians) called hysteria. Hysteria is an old word that dies hard.  The DSM equivalent is histrionic personality disorder.  The generic use of the term suggests a person who is overly emotional, dramatic and attention seeking but there are 8 diagnostic criteria that are unchanged between DSM-IV and DSM-5.  Many clinicians opt for the term Cluster B - a DSM-IV originated term that grouped personality disorders in groups according to some common diagnostic features.  The Cluster B group included individuals that often appear dramatic, emotional, or erratic.  Those personality disorder diagnoses include antisocial, histrionic, narcissistic, and borderline.

The rule-in criteria (significant impact on life circumstances and onset when you expect a personality disorder to occur) and the rule-out criteria (not due to another mental or physical disorder) are predictable for any causal reader of a DSM and could be included on any checklist or form.  How does all of that play out?  Well here are a few examples:

Hysterical patient #1:   A 30 year old woman presents for a therapy intake.  She is mumbling and laughing.  The therapist describes her as "odd and having an odd affect."  She alludes to some suicidal behavior in the past but is smiling and joking about it.  The therapist has the impression that she is manipulative and overly dramatic.  He contacts the clinic psychiatrist and says that she is histrionic but he is concerned about her suicide potential.  The psychiatrist sees her that day and makes a diagnosis of bipolar disorder-mixed type with psychotic features.  The patient is eventually stabilized on lithium and an atypical antipsychotic.

Hysterical patient #2:  A 25 year old woman is being treated on a general medicine ward for dehydration from a respiratory infection.  She suddenly gets tearful and agitated.  Family members visiting have to physically restrain her when when she tries to get out of bed.  She starts to make very loud high pitched vocalizations.  A psychiatrist is called to go in to assess hysteria and possibly sedate the patient.  The psychiatrist sees an agitated young woman who is not able to respond coherently to any examination questions.  Brief neurological examination suggests increased intracranial pressure is the problem and the patient requires immediate transfer to a neurological intensive care unit. 

Hysterical patient #3:  A 58 year old man is referred acutely from a therapist for acute panic attacks and "probable Cluster B" personality traits.  He has recently retired due to osteoarthritis of the knees.  He had no earlier history of panic attacks but the therapist thought that he was overly dramatic at the initial session 2 days earlier when he was unable to relax and breathe normally with behavioral techniques that are usually effective.  The psychiatrist gets a history of the patient needing to abort an exercise stress test two weeks earlier due to the arthritis and having  a prolonged period of immobility at home due to sore knees. During that time he developed acute shortness of breath.  The episodes of anxiety that he described were secondary to shortness of breath and not panic attacks.  The psychiatrist sends the patient to the emergency department where an acute pulmonary embolism is diagnosed and he is admitted to the ICU.     

These are just a few examples restricted to one collection of psychiatric symptoms that illustrates what my colleague was referring to.  The value of psychiatric training goes far beyond what is in the DSM and what checklists and templates can be extracted from it.  I have never really met a psychiatrist who was focused on the DSM probably because it is implicitly evident to us that it is an index more than a diagnostic manual. We are focused on what is not in the DSM and as far as I know that is not well documented in many places.  Those are the patterns associated with clinical practice and that should have been gleaned along the way with medical training.  The DSM doesn't tell you how a pulmonary embolism presents. It is possible that you night have never seen one. But in medical training I can guarantee that it was discussed somewhere along the line in the differential diagnosis of dyspnea.  I can guarantee that one of those attendings discussed the phenomenon of the healthy young adult immobilized by air travel who gets off at their destination and suddenly has an acute pulmonary embolism. All of those features and urgencies should be in a physicians conscious state when they are seeing the whole patient and not some DSM/checklist version of a patient.

This brief post also illustrates the biasing effects of language.  What  does "Cluster B" really mean?  Aren't people who are acutely medically (or psychiatrically) ill dramatic, emotional, or erratic?  Hysteria is an extremely biasing term that over the centuries has been applied selectively to women rather than men.   The examples above illustrate that point.  If you are seeing the world through DSM language and that is your only lens - you are by definition not seeing the whole patient.  The list of possible errors in that landscape is very large.

There are a number of constraints that will get  in the way of a trained psychiatrist trying to see the whole patient.  Inadequate time is one, but time frames vary significantly.  Diagnosing a life threatening medical problem upon seeing a patient may take a matter of minutes and is clearly the most important diagnosis.  Seeing a long series of new patients briefly to prescribe treatment will necessarily mean that certain features in the above diagram will be missed.  So-called measurement based care depending on a large number of checklists to "quantitate" affects or other psychiatric states makes the same mistake.  Collaborative care where a psychiatrist looks at these rating scales and recommends treatments makes the same mistake.

The best assurance that the critical aspects of care will not be missed is to be sitting across the room from someone who has been taught all of the critical aspects of care.  That process is complex and as far as I know has never been adequately described.  A first approximation is whether that person knows what they are seeing and how to respond.

George Dawson, MD, DFAPA     

Anecdotes Are Not Evidence And Other "Evidence-Based" Fairy Tales

A lot depends on the kind of anecdote that you are talking about.  When we talk about anecdotes in medicine that generally means a case or a series of cases.  In the era of "evidence based medicine" this is considered to be weak or non-existent evidence.  Even 30 years ago when I was rounding with a group of medicine or surgery residents: "That's anecdotal..." became a popular part of roundsmanship as a way to put down someone basing their opinion on a case or series of cases.  At the time, series of cases were still acceptable for publications in many mainstream medical journals.  Since then there has been and inexorable march toward evidence-based medicine and that evidence is invariably clinical trials or meta-analyses of clinical trials.  In some cases the meta-analyses can be interpreted in a number of ways including interpretations that are opposed to the interpretation of the author.  It is easy to do if a biologically heterogeneous condition is being studied.

There has been some literature supporting the anecdotal but it is fairly thin.   Aronson and Hauben considered the issue of drug safety.  They made the point that isolated adverse drug reactions are rarely studied at a larger epidemiological level following the initial observation.  They argued that they could establish criteria for a definitive adverse event based on a single observation.  In the case of the adverse drug event they said the following criteria could be considered "definitive":  extracellular or intracellular deposition of the drug, a specific anatomic location or pattern of injury, physiological dysfunction or direct tissue damage, or infection as a result of an infective agent due to contamination (1).  They provide specific examples using drugs and conclude: "anecdotes can, under the right circumstances, be of high quality and can serve as powerful evidence.  In some cases other evidence may be more useful than a randomized clinical trial.  And combining randomized trials with observational studies, or with observational studies and case series, can sometimes yield information that is not in clinical trials alone."  This is essentially the basis for post marketing surveillance by the Food and Drug Administration (FDA).  In that case, monitoring adverse events on a population wide basis, increases the likelihood of finding rare but serious adverse events compared with the the original trial.

Enkin and Jadad had a paper that also considered anecdotal evidence as opposed to formal research (2).   They briefly review the value of informal observation and the associated heuristics, but also point out that these same observations and heuristics can lead some people to adhere to irrational beliefs.  The values of formal research is a check on this process when patterns emerge at a larger scale.  Several experts have applied Bayesian analysis to single case results, to illustrate how pre-existing data can be applied to single cases analyses with a high degree of success.  Pauker and Kopelman (3) looked at a case of hypertension and when to consider a search for secondary causes - in this case pheochromocytoma.  They made the interesting observation that:

"Because the probability of pheochromocytoma in a patient with poorly controlled hypertension who

does not have weight loss, paroxysms of sweating, or palpitations is not precisely known, the clinician often makes an intuitive estimate.  But the heuristics (rules of thumb) we use to judge the likelihood of diseases such as pheochromocytoma may well produce a substantial overestimate, because of the salient features of the tumor, its therapeutic importance, and the intellectual attraction of making the diagnosis."   

They take the reader through a complex presentation of hypertension and likelihood ratios used to analyze it and conclude:

"Hoofbeats usually signal the presence of horses, but the judicious application of Bayes' rule can help prevent clinicians from being trampled by a stampeding herd that occasionally includes a zebra."

In other words, by using Bayes rule,  you won't subject patients with common conditions to excessive (and risky) testing in order to not miss an uncommon condition and you won't miss the uncommon condition.  Looking at the data that supports or refutes that condition will make it clear, if you have an idea about the larger probabilities.

How does all of this apply to psychiatry?  Consider a few vignettes:

Case 1:  A psychiatric consultant is asked to assess a patient by a medicine team.  The patient is a 42 year old man who just underwent cardiac angiography.  The angiogram was negative for coronary artery disease and no intervention was necessary.  Shortly afterwards the patient becomes acutely agitated and the intern notices that bipolar disorder is listed in the electronic health record.  He calls the consultant and suggests an urgent consult and possible transfer to psychiatry for treatment of an acute manic episode.  The consultant arrives to find a man sitting up in bed, appearing very angry and tearful and shaking his head from side to side.

Case 2:  A 62 year old woman is seen in an outpatient clinic for treatment resistant depression.  She has been depressed for 20 years and had had a significant number of medication changes before being referred to a psychiatric clinic.  All of the medications were prescribed by her primary care physician.  She gives the history that she gets an annual physical exam done each year and they have all been negative.  Except for fatigue and some lightheadedness, her review of systems is all negative.  She is taking lisinopril for hypertension, but has no history of cardiac disease.  She has had electrocardiograms (ECGs) in the past but no other cardiac testing.  The psychiatrist discusses the possibility of a tricyclic antidepressant.

Case 3:  An inpatient psychiatrist has just admitted a 46 year old woman who is concerned about the FBI.  She has been working and functioning at a high level until about a month ago when she started to notice red automobiles coming past her cul de sac at a regular frequency.  She remembered getting into an argument at work about American military interventions in the Middle East.  She made it very clear that she did not support this policy.  She started to make the connection between the red automobiles and the argument at work.  She concluded that an employee must have "turned her in" to the federal authorities.  These vehicles were probably the FBI or Homeland Security.  She noticed clicking noises on her iPhone and knew it had been cloned.  She stopped going into work and sat in the dark with the lights out.  She reasoned it would be easier to spot somebody breaking into her home by the trail of light they would leave.   There is absolutely no evidence of a mood disorder, substance use disorder, or family history of psychiatric problems.  She agrees to testing and all brain imaging and laboratory studies are normal.  She agrees to a trial of low dose antipsychotic medication, but does not tolerate 3 different medications at low doses.

These are just a very few examples of the types of clinical problems that psychiatrists encounter on a daily basis that require some level of analysis and intervention.  A psychiatrist over the course of a career is encountering 20 or 30 of these scenarios a day and ends up making tens of thousands of these decisions.  What is the "evidence basis" of these decisions?  There really is nothing beyond anecdotes with the availability of various strengths of confirmation.  What kinds of evidence would the evidence based crowd like to see?  In Case 1, a study that looked at behavioral disturbances after cardiac catheterization would be necessary, although Bayes would suggest the likelihood of that occurring would be very low.  In Case 2, a large trial of treatment approaches to 62 year old women with depression and fatigue would be useful.  I suppose another trial of what kinds of laboratory testing might be necessary although much of the literature suggests that fatigue is very nonspecific.  In most cases where patients are being seen in primary care - fatigue and depression are indistinguishable.  Extensive testing, even for newer inflammatory markers yields very little.  Further on the negative side,  evidence-based authorities suggest that a routine physical examination and screening tests really adds nothing to disease prevention or long term well being.  Case 3 is more interesting.  Here we have a case of paranoid psychosis that cannot be treated due to the patient experiencing intolerable side effects to the usual medication.  Every practicing psychiatrist knows that a significant number of people can't take entire classes of medications.  Here we clearly need a clinical trial of 40 year old women with paranoid psychoses who could not tolerate low dose antipsychotic medication.

By now my point should be obvious.  None of the suggested trials exist and they never will.  It is very difficult to match specific patients and their problems to clinical trials.  Some of the clinical occurrences are so rare (agitation after angiography for example) that it is very doubtful that enough subjects could be recruited and enrolled in a timely manner.  And there is the expense.  There are very few sources that would fund such a study and these days, very few practice environments or clinical researchers that would be interested in the work.  Practice environments these days are practically all managed care environments where physician employees spend much of their time administrative work, the company views clinical data as proprietary, and research is frequently focused on advertising and marketing rather than answering useful clinical questions.

That brings us to the larger story of what the "evidence" is?  The anecdotes that everyone seems to complain about are really the foundation of clinical methods.  Training in medicine is required to experience these anecdotes as patterns to be recognized and classified for future work.  They are much more than defective heuristics.  How does that work?  Consider case #1.  The psychiatric consultant in this case sees an agitated and tearful man who appears to be in distress.  The medicine team sees a diagnosis of bipolar disorder and concludes the patient is having an acute episode of mood disturbance.  The consultant quickly determines the fact that the changes are acute and rejects the medical team's hypothesis that this is acute mania.  After about 5 questions he realizes that the patient is unable to answer, pulls a pen out of his pocket, and asks the patient to name of the pen.  When he is not able to do this, he performs a neurological exam and determines the patient has right arm weakness and hyperreflexia.  An MRI scan confirms the area of an embolic stroke and the patient is transferred to neurology rather than psychiatry.  The entire diagnostic process is based on the past anecdotal experience of diagnosing and treating neurological patients as a medical student, intern, and throughout his career.  Not to labor the point (too much) - it is not based on a clinical trial or a Cochrane review.                

The idea that the practice of medicine comes down to a collection of clinical trials that that are broken down according to a proprietary boilerplate and generally conclude that the quality of most studies is low and therefore there is not much to draw conclusions on is absurd.  Trusting meta-analyses for answers is equally problematic.  You might hope for some prior probability estimates for Bayesian analysis.  But you will find very little in the endless debate (4) about whether or not antidepressants work or they are dangerous.  You will find nothing when these studies are in the hands of journalists who are not schooled in how to practice medicine and know nothing about treating biologically heterogeneous populations and unique individuals.  No matter how many times the evidence based crowd tells you that you are treating the herd - a physician knows that if they treat the herd - it is one person at a time.  They also know that screening the herd can lead to more problems than solutions.

Treating the herd would not allow you to make a diagnosis of complete heart block and immediate referral to Cardiology for pacemaker placement (Case 2) or psychotherapy with no medications at all and eventual recovery (Case 3).  If you accept the results of many clinical trials or their interpretation by journalists - you might conclude that your chances of recovery from a complex disorder are not better than chance.  There is nothing further from the truth.

That is why most of us practice medicine.



George Dawson, MD, DLFAPA


References:

1:   Aronson JK, Hauben M. Anecdotes that provide definitive evidence. BMJ. 2006 Dec 16;333(7581):1267-9. Review. PubMed PMID: 17170419; PubMed Central PMCID: PMC1702478.

2:  Enkin MW, Jadad AR. Using anecdotal information in evidence-based health care:  heresy or necessity? Ann Oncol. 1998 Sep;9(9):963-6. Review. PubMed PMID: 9818068.

3:  Pauker SG, Kopelman RI. Interpreting hoofbeats: can Bayes help clear the haze? N Engl J Med. 1992 Oct 1;327(14):1009-13. PubMed PMID: 1298225.

4:  Scott Alexander.  SSRIS: MUCH MORE THAN YOU WANTED TO KNOW.  Slate Star Codex posted on July 7, 2014.

Attribution:

Photo at the top is Copyright Gudkov Andrey and downloaded from Shutterstock per their Standard License Agreement on 2/3/2016.

Physicians Replaced By Computers - Lessons From A Roomba

My Memorial Day project was purchasing a Roomba and getting it up and running.  I am a big believer that robots will make all of our lives easier at some point and decided now is the time to start walking the walk.  For those not familiar with the Roomba, it is designed as a robotic vacuum cleaner.  Once you have set up the rooms and programmed it, it is basically supposed to vacuum your floors automatically and then park itself in a docking station for charging.  The machine itself is about a 14 inch diameter disk that rises to a height of about 3 1/2 inches off the floor.  It is a light 8.4 pounds.  It is able to accommodate sharp angles with a secondary brush that spins on an arm that extends from under the main disk.  This combination of the main disk spinning and the extended spinning brush cleans the corners of a room.  I purchased the latest model, a Roomba 880 after consulting with friends and relatives who had earlier models.

One of the considerations in buying the Roomba was whether it would help turn my home into an even cleaner environment than it currently is.  That is a tough act.  One of my friends who is a physician gave his opinion that my home is "museum-like".  My office is probably the only problematic room with stacks of books and journals piled everywhere.  Disarray certainly but minimal dust.   My entire first level is hardwood flooring that is typically vacuumed with a built in system.  To its credit the Roomba contains all of the debris in the machine until it is emptied and all of the exhausted air is HEPA filtered to avoid exhausting any dust particles.  The main cleaning mechanism consists of two debris extractors that are rubberized bars that spin at a high rate of speed across the floor surface to capture dust, hair and larger particles.  But the most interesting aspect of the Roomba was going to be its observed behavior.  It has two modes when vacuuming.  It can start in a spot and spin increasing circles in an outward direction until gets to about a 3 foot diameter and then it spirals back in to the center spot.  In the more typical mode it heads to the room perimeter and then "automatically calculates the room size and cleaning time."  The most valuable tip in the manual was to take measures to restrict it to one room at a time and it comes with two Virtual Wall^®Lighthouse^TM devices that allow for easy demarcation of the work area.

The most fascinating aspect of getting started with the Roomba was going to be setting it up and watching how it went about the task of vacuuming.  I did some very minor room preparation, charged it up, and turned it loose.  As expected it headed straight for a wall and then attempted to establish the perimeter.  I remembered this as standard rodent behavior.  If you have ever confronted a mouse in an open area of your floor, their first move is to dash to the baseboards and run parallel to them to escape.  That strategy works well in the wild because the maneuver is associated with more cover and makes them less susceptible to predators.  It works much less well when confronted by a human who knows that it is their first move.  And yes, scientists have bred mice that do not exhibit this behavior.  My guess is that they would not fare well if they made it outside the lab.  The Roomba's behavior is less rigid than a typical mouse with some exceptions.  In the hour and 20 minutes it took to vacuum the adjacent kitchen and great room - it circled a kitchen island perfectly at least 10 times, but at the wall perimeters it was much less predictable.  At times the Roomba would peel off and take off across the room in a single pass or rarely return and continue along the original wall.  Sometimes it would head off the wall at a 45 degree angle and at other times 90 degrees.  There were never the usual adjacent passes that a human would make using a standard vacuum cleaner.

According to the literature,  the Roomba is supposed to "crisscross" the room in order to clean the floor.   I placed two small pieces of popcorn in the middle of a large section for flooring to use as markers of cleaning efficiency.  In the course of an hour, the Roomba passed these markers many times, sometimes very closely without vacuuming them up.  During that time it was very difficult to detect how much crisscrossing had occurred since mouse-like it spent the majority of the time in the periphery, bumping and spinning around walls and furniture.  It eventually did break free from the walls and set off on a 45 degree path picking up one popcorn fragment at about the one hour mark and the other at about one hour and ten minutes.  The old adage about pictures is true and I happened across this 30 minute time lapse photo of the Roomba working a room (with permission from the SIGNALTHEORIST web site).  It correlates well with my description of the actual paths.

As I surveyed the job afterwards, the floor was definitely clean and the warning light on the machine was saying that the dustbin was full.  When emptied, it contained an impressive amount of debris and dust relative to what seemed visible to the naked eye.  Another win for the robots?  Well, not really.  It is an interesting tool that I will continue to use and study, but in comparison with humans it is not efficient and at this point certainly not autonomous.  Despite all of the guidance in the manual the Roomba can still encounter unpredictable surfaces and get itself into trouble.  In my case it was the pedestal of a recliner.  The wood at the edge was about 3/4 of an inch high.  For some reason, the machine did not recognize it as an obstacle and continued to run up the base and get hung up.  A loud spoken error message would sound advising the human in the room to pick it up and start it in a new place.   The other concern is efficiency.  It spent far too much time in the perimeter and a low percentage of time covering the main floor areas.  That was tremendously inefficient.  It took at least 5 times longer to vacuum the main rooms than I would have if I was pushing a vacuum cleaner.  Even though it allows me to do other things, it says something about current state of available and affordable domestic robots.  They can't match the performance of humans on a fairly basic task.  This is an important concept.

Before any of the futurists out there jump on me for being a Luddite, let me disclose a few details.  I am a member of the IEEE and have been for the past 18 years.  I am currently a member of the IEEE Robotics and Automation Society.  I am not an electrical engineer and I have not designed or built any robots, but hope to start doing this when I retire from psychiatry.  I consider myself to be an expert in the human brain and the advantages it confers on humans over other animals and machines.  The Roomba is a basic case in point.  It cannot sense and adapt to novel conditions quickly enough to match a human doing the same task.  Even more striking is that although it is designed to vacuum homes and I have a fairly typical home with a better than average floor surface, it still encounters situations that exceed its response capacity.  In those situations it needs a human assist.  What is it about the human brain that leads to that kind of an advantage?  First and foremost, it is a rate of pattern matching and pattern completion capacity that allows us to recognize vacuuming problems, anticipate them and correct them by developing novel solutions even before the problem leads to a stop in action.  Some of this happens when a human goes around the room to set it up for the first time for the Roomba.  That human has made some assessment of the machines capacities and limitations and is problem solving for the machine before it is turned on.

Observing the limitation of the Roomba leads me to a point where I can address both the idea of computers replacing doctors and how that fits into the common anti-physician narrative in this country.  Is there a connection between the two?  My experience tells me that there is.  For nearly 30 years there has been a constant stream of antiphysician rhetoric.  The sources have been expected.  One of them is the key opinion leaders (KOLs) of the managed care industry.  I can recall reading one of the the first books written by one of them, a non-physician who was widely acclaimed as being an expert in managed care.  His early theory was that the high cost of health care was due to the decisions that physicians make.  But in the middle of the book he wrote what he thought of physician salaries and only grudgingly acknowledged that they should probably be paid a good wage due to their education.   I have posted here many times my experience at a managed care conference in the 1990s.  The speakers at that conference were very clear that the explicit agenda of their industry was to replace all of the specialists with primary care physicians.  The examples given were orthopedic surgeons and psychiatrists.  When a psychiatrist in the crowd pointed out the shortcomings of that philosophy - he was called a "whiner" by a Governor who was an anointed KOL in the industry.  Then the KOLs from the financial services industry started weighing in.  You could find glimpses of it while reading the investment literature.  People who were investors with no particular degree started saying that some day, physicians would get what they deserve - with the implication being that whatever that was - it was not good.  Any physician has experienced this prejudice.  The comments about how physicians are "expensive" as a rationalization for working them to death by not hiring any additional help.  Replacing physicians with computers seems like a logical extension of this rhetoric.  Googling this topic returns a number of provocative articles written from a point of view that is generally consistent with who the author is.

I know that some of those authors know the difference between a robot or a computer and a doctor, but it is also clear that some do not.  They certainly don't seem to understand that the real processing power of a human diagnostician's brain is in the area of pattern matching.  In order to duplicate that property with current technology, takes a massive computer and it is one of the reasons why my new $700 Roomba, although well designed - can easily be beaten by a human with a standard vacuum cleaner.  But the human advantage goes far beyond that.  Human diagnosticians do far more than match simple patterns.  They are able to complete fragments of patterns and anticipate what the whole pattern should be.  For example, is it likely that a depressed person is in this current state as the result of an inherited form of depression, their current state of detox from an opioid and/or benzodiazepine, current stressors or interpersonal conflicts, brain trauma, an undiagnosed medical condition, childhood adversity, psychological trauma as an adult, or defects in reasoning at either the emotional or cognitive levels.  Then there is the matter of acquiring all of the data to make the determinations.  Patterns upon patterns of data.  The Roomba-like approach would be to give the person a checklist of depressive symptoms and pretend that is all that needs to be known.  Checklists are already being administered by a computer and may be administered by robots someday.  

Yet it takes the pattern recognition, and several layers of it, as well as human experience dependent learning in order to make a real medical or psychiatric diagnosis.
        

George Dawson, MD, DFAPA






Supplementary 1:  The graphic at the top of this post is a photo that I shot of the inside of the box that my Roomba came in.

Supplementary 2:  I don't want to give the false impression that I do a lot of vacuuming.  My wife does practically all of it, but I am trying to do more especially if there is a high tech twist to it.  Some of the first robotics I hope to work on will be human controlled arms and hands designed to do yard work and move heavy objects around in the house.  I can't believe this is an area that has been ignored.

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.