The Insurrection

This has been an historic week in the United States. On January 6, 2021, President Donald Trump and several of his supporters incited a large group to attack and invade the Capitol Building as Congress was in the process of certifying the electoral college vote – the last official but routine step for Joe Biden to become the duly elected President of the United States.  During the riot, Capitol police were assaulted and one of them was killed. A rioter was shot and killed.  Three people died of medical emergencies due to poor access at the scene. There were scores of people injured, many serious.

Police and the National Guard eventually regained control and Congress was able to reconvene and certify the electoral college vote.  The challenges to the votes in several states were overwhelmingly rejected.  The President had also suggested that the Vice President Mike Pence could decide to not accept the votes and nullify the election, but the Vice President was very explicit about his Constitutional duties and knew that was outside of his scope of power. He kept the process going and brought it to appropriate closure declaring that Biden-Harris were the winners.

The aftermath of this event has produced a little certainty but not much.  As I write this late on a Saturday night, all that we know for sure is that Joe Biden is the certified winner of the election and that he will be inaugurated on January 20^th.  President Trump’s supporters from the recertification debacle are in disarray.  Press reports quote them as lashing out at the expected fall out from their efforts and the insurrection at the Capitol. At least one has lost a book deal and in other cases constituents are calling for their resignation.  Since the official vote was preceded by the insurrection and violence, some of the people who were expected to object to the certifications from specific states did not. Other Republicans were outspoken against the process from the outset since it was clear that the President had repeatedly lied about the election being stolen and there was no factual basis for any objections. Republicans adopting those positions were subjected to derision and threats from Republicans who supported Trump.

On the night of the insurrection, there were rumors that Trump’s cabinet may be considering invoking the 25^th Amendment and removing the President from power based on his incapacity to do the job. Inciting an insurrection against the government and Constitution that he was sworn to uphold would seem like a sure way to get anyone fired.  The other logical question is, if a person can make such a drastic error in judgment – does it imply that they will continue to make further drastic errors?  In other words is their judgment compromised even beyond the crisis they have created?  I am not talking about a diagnosis of mental illness. I am an adherent of the Goldwater Rule and don’t believe that psychiatrists should speculate about the mental health of a public figure without doing a thorough personal assessment and then disclosing the result of that assessment only with the consent of that individual.

That does not mean that professional organizations should abdicate their roles in advocating for science, social justice and correcting disparities related issues, and most of all advocating for a practice environment that allows physicians to provide high quality health care to our patients who need it the most. Health care professional organizations have not done a very good job on these issues largely because they have been completely ineffective against the business takeover of health care. 

With the recent events the American Psychiatric Association came out with a statement on January 7, 2021 entitled: APA Statement on Yesterday’s Violence in Washington.  It seemed to be overly reactive to me and it carried the usual generic conclusions – if you are having problems see someone. It would have more authority if there had been statements at every stage of the President’s escalating rhetoric.  Where was the APA for example when the President attacked science, the CDC and its scientists, and Dr. Fauci?  Where was the APA when the President attacked Black Lives Matter and showed support for white supremacists? Where was the APA when the President trivialized the COVID-19 epidemic, politicized the treatment and endangered lives, and spread misinformation about the origins of the virus and how it spreads. There is no authority when you sweep in at the very end when conditions are dire and seek to correct what you did not comment on in the previous 10 months. Real time commentary on political action that is detrimental to the social fabric of the country is necessary from professional organizations, especially one whose members assess the impact of that social fabric on every patient they see.

But there is more blame to go around – especially when it comes to social media companies.  Facebook, Twitter, and Google all seem to be very confused about how they are used for propaganda purposes. Misinformation is a euphemism for propaganda these days and there has never been a more powerful amplifier of propaganda than American social media. To be clear, propaganda is an intentional lie that is repeated over and over again until a certain segment believes it to be true and starts to react emotionally to it. This behavior was clearly visible from people at the Trump rally and people who invaded the Capitol building. People clearly agitated about the election being “stolen”, socialists taking over, the country turning to socialism, personal freedoms being impinged upon.  Image after image of people in the media who were obvious Trump supporters who were agitated about what are essentially non-issues. The clearest non-issue was the election being stolen.  Trump himself keeps repeating this despite the clear facts that the elections are much more well run that when Al Gore was defeated by hanging cardboard chads in the 2000 election that was decided by a Supreme Court decision and a 271 to 267 electoral college vote. In fact, the score card about election fraud shows that there is a complete lack of evidence of significant “fraud” or stolen elections.  The major social media players finally came around and banned Trump and his accounts, but even as I type this he is vowing to get more media access and continue his divisive propaganda campaign.

In the big picture, the Trump propaganda is much more than a curiosity at this point.  In addition to the insurrection at the Capitol, Trump followers have threatened violence against the families of both Democrat and Republican elected officials largely as a way to support Trump.  These coercive tactics have no place in a functional democracy and at the individual level should be considered terroristic threats by local police. The insurrection has provided a blueprint for both foreign and domestic enemies of the United States who seek to disrupt the functions of our government and the security of our citizens. The disruptive effect that the Trump administration has had on our military, intelligence community, allies and leadership role in the world adds greatly to the insecurity of the republic. President Trump and his administration should be considered a case study of incompetent leadership and suggest pathways to competency that future leaders should be assessed by.

I started to write this with some suggestions about what needs to happen over the next 10 days to get the country back on track and correct some of the current glaring deficits:

1:  President Trump: the people on the ground specifically his Cabinet and leaders in Congress need to make an assessment acutely about whether he lacks the current capacity to function in his role as President. The insurrection is strong evidence.  His lack of commentary of a major Russian government hack that has been occurring for months (the extent of which is not currently known) is another.  There is speculation that some of his cabinet members are contemplating this but there have been resignations and temporary appointments.  There is a question about how fragmented the Cabinet is and whether that would hinder the process.  Members of Congress are apparently considering impeachment, but that is a long process.  There are platitudes about how impeachment would not “heal the divisiveness” that are more than a little ironic considering the people making these statements. I have heard that two impeachments of any President rules out any future candidacy and if that is true – it is a very good reason for proceeding with impeachment.

There are still some mental health professionals out there who think a psychiatric emergency is a better response. I routinely did psychiatric emergencies for 22 years and I can say without a doubt that there is no court judge that I know of who would detain President Trump on an emergency basis for hearing or schedule a hearing for guardianship or conservatorship on the basis of a mental illness. Media reports are full armchair diagnoses of narcissistic personality disorder or malignant narcissism (not an actual diagnosis) and even if these diagnoses were accurate – they are not diagnoses that result in court action.  Those diagnoses are typically statutorily defined severe mental illness.  The legal criteria in the 25th Amendment is much clearer: unable to discharge the powers and duties of his office. The only problem is that it is interpreted by lawyers and politicians and not everyone will agree with that interpretation.

Another feature of the legal versus psychiatric intervention is that the decisions can be made right now, by people who have been working with the President in some cases for 4 years.  That constitutes a larger amount of information and a much shorter timeline for action than is possible in any psychiatric scenario. 

2:  The security issue:  The Capitol and any place there are elected officials doing the work of the US Government needs to be very secure. That means there needs to be an adequate force and clear rules of engagement.  Right now there are people threatening the inauguration process and there must be very thorough plans to prevent that from happening.  The FBI is apparently trying to identify as many people as possible from the original insurrection and the message is out there that they will be prosecuted.

The larger security issue is starting to counteract the propaganda about stolen elections, fake pandemics, fake news, and freedom being under attack. I am confident that clearer messaging from the White House and members of Congress will be useful as well as integration back into the international community.

3:  The potential for Civil War:  Not my idea.  About 3-4 months ago I was contacted by people who knew that I was a bit of a survivalist.  Their concerns ranged from civil unrest disrupting the food and power supply as well as access to medical treatment to outright armed conflict between warring factions  Their specific questions were about what they should acquire now to protect themselves and their family if the Trump induced negative reverberations through society continue and worsen.  I am not a historian and wonder if an attempted coup by an autocrat who refuses to accept or even acknowledge 200 years of democracy qualifies as a civil war?  The autocracies in my lifetime including Hitler, Stalin, Mussolini, Pol Pot and many others extending right up to modern times do not seem to be the products of civil war.  Many occurred as the result of internal political turmoil often fomented by propaganda.  Many of these propaganda techniques were codified by the Nazis such as the Big Lie propaganda technique.  

The transition from ordered to disordered society is never clear. No American anticipated the rise of a disruptive autocrat and the impact that he could have on ordinary citizens.  In many ways it reminds me of Robert J. Lifton's interviews in The Nazi Doctors and how the transition to state sanctioned medical killing occurred during the Holocaust.  On page 13 he quotes a French speaking eastern European physician on whether what happened can be understood from a psychology viewpoint:

"The professor would like to understand what is not understandable. We ourselves who were there, and who have always asked ourselves the question and will ask it to the end of our lives , we will never understand it because it cannot be understood."    

I think there may be some insights from the anthropology of warfare.  Keeley gathered anthropological evidence of ancient conflicts between tribes, towns, and eventually cities.  He concluded that there were no peaceful primitive people. The settlement of disputes between neighboring tribes or city states have always been violent with a significant toll on the losing population.  That theme is obviously extended to current times where there is an uneasy peace based on nuclear deterrence but a quarter million people lose their lives each year due to small arms fire.  Peace does not seem to be the interest of many nations even though there are clear cut advantages.  The human propensity for violent dispute resolution is not reassuring in a heavily armed nation and an angry faction who show up on government property holding assault rifles.  Interestingly one of the features of society that Keeley considered protective against war was an active trading and economic relationship with rivals.  That is another area where President Trump has not done well. 

4:  The propaganda at the individual level:  Many people ask me why so many people buy into obvious propaganda like the stolen election lie.  It turns out this recipe for influencing large groups of people politically has been around for decades.  The general message is to keep repeating the lie and at some point people start to emotionally react to it and that reinforces it.  From a neuroscience perspective there have been some imaging studies that claim to be able to detect Democrats from Republicans but I question those results.  Some suggest the problem is a lack of critical thinking, but I know a lot of professionals who have accepted Trump’s stolen election lie as a fact and their critical reasoning capabilities in all other areas seem to be intact.  One of my colleagues proposed an evolutionary social theory that seems to have some plausibility – as humans we are socialized to follow charismatic leaders whether they are right or wrong.  There seems to be a lot of historical data to back that up.

I would suggest a complementary hypothesis and that is the emotional inputs for day-today decision making.  Some time ago on this blog I discussed some of the groundbreaking work of Antoine Bechara, MD, PhD and his work on why emotional input is critical for human decision making. He demonstrated that without it – subjects with normal intelligence is unable to function.  We also know that an excess of emotion can adversely affect decision making and lead to errors both acutely and on an ongoing basis.

Propaganda has both a cognitive component (the lie) and a strong associated emotional component.  Supporters of the stolen election lie are clearly angry about getting a raw deal, about their rights being impinged up, about needing to take the law into their own hands, about someone treating them (or their candidate) unfairly, the list is quite lengthy but the emotion is always anger.

I don’t claim to know how to reverse that process.  I did take a course in how to deprogram cult members at one point and the main intervention was to get them away from the people influencing them.  Removing the continuous inaccurate social media messaging may be useful in that regard. An improvement in the general tone of the media may also be helpful.  Since the insurrection, the mainstream media seems a lot more willing to make determinations of what is accurate and what is a lie.  One lesson appears to be that even if the propaganda lie is labeled as misinformation that is probably not enough.  It will still be altered in a positive way and propagated for propaganda use.  Propaganda needs to be eliminated when there is obvious overwhelming evidence against it.

There also have to be organizations that are willing to step up and make a stand for accuracy to correct political misinformation.  Both Science and Nature the major general scientific publications have been doing that on an increasing basis.

And finally, there is the appeal to the individual. In some of my earlier writing on this blog about firearm violence I suggested that people self-monitor for violent or aggressive thinking and seek out help if they noticed this. My thoughts related this insurrection are no different.  Nobody should be thinking that American elections are rigged or that they need to take the country back from someone.  We all know how this democracy works and it has been working well for 200+ years.  It works well because of the concept of peaceful transfer of power and the associated traditions. In other words, it is about what is good for the country and its people and not an individual official.  The President is the President for all of the people and not half of the people and he or she serves at the will of the majority.

Let that sink in……

 

 George Dawson, MD, DFAPA

Supplementary 1:  A poster on Twitter pointed out the rationale for the suspension of Trump's account.  The rationale is listed in this blog post.  Pay particular attention to the last 5 bullet points, especially bullet point 5:

"Plans for future armed protests have already begun proliferating on and off-Twitter, including a proposed secondary attack on the US Capitol and state capitol buildings on January 17, 2021."

I am hoping that there will be more than a few hundred National Guard troops present at the Inauguration and that Governors take these threats seriously, especially in states where gun advocates have succeeded in getting laws passed to carry firearms on state government property. I would suggest going as far as a temporary order to suspend firearms in proximity to the state capitols in addition to an adequate show of force to deter further antigovernment activity. 

Supplementary 2:  For anyone confused about what happened at the Capitol building it comes down to this:

References:

1:  Lawrence H. Keeley.  War Before Civilization. Oxford University Press, New York 1996.

2:  Robert Jay Lifton.  The Nazi Doctors. Basic Books, New York 1986: p 13.

Image Credit:  This is an image from the Capitol Building on Jan 6, 2021 from Shutterstock per their standard agreement.

Anti-ECT Rhetoric ........

There is probably no clearer example of the pernicious effect of rhetoric in psychiatry than what has happened with electroconvulsive therapy or ECT.  ECT has a demonstrated therapeutic and life saving effect for decades and yet it is a flashpoint for antipsychiatry groups.  I had the experience of being attacked for pointing this out and the people attacking me posted references from a book that was published in 1980 and it was debunked at the time of publication in a book report in the New England Journal of Medicine.  Ignoring what the facts are - often for decades is one of the rhetorical techniques. Interestingly that technique was pointed out in the book report.

There is no doubt that ECT is a very safe and effective treatment. The onset of action is also much faster than can be expected from medications of psychotherapy. But the most important aspect of the ECT recommendation is way it is recommended by clinical psychiatrists.  It is not recommended for everyone just because it is highly effective.  Clinical psychiatrists recommend ECT for treatment resistant depression. By definition, that means various treatment modalities have been tried and found to be ineffective.   That may have included many antidepressant trials. It is often forgotten these days that psychiatrists are seeing patients who have been treated for decades with antidepressants.  I often see people who have been taking the same antidepressant with dose modifications for 10-15 years or people who have been taking 5-9 different antidepressants over the same period of time.  Those antidepressants have been prescribed by various non-psychiatrists.  The majority of these patients have also seen psychotherapists and list the acronyms (CBT, DBT, IPT, ACT, REBT, etc) and specifics about the therapy. They are also clear that they were not helped by psychotherapy.

The process of being stuck in that situation by itself can lead to increasing hopelessness associated with the thought: "Am I always going to be depressed? Is there anything that can be done to get rid of this depression. Would it be better for myself and anyone else if I was just dead rather than hanging on like this?" In the case of more dangerous forms of depression, delusional thinking presents a greater level of danger in the form of suicide attempts and completions.  One of the ironies of depression is that the public perceives it as a minor condition that is easily treated.  That ignores the fact that most people that die from suicide are depressed.  Severe depression is a lethal condition and not a minor one. Ignoring severe depression and not treating it is an option only by denying that it exists.

A second group of people who need ECT as a life saving treatment are people with catatonia.  Catatonia is a potentially lethal condition that develops in association with other severe mental conditions - especially mood disorders.  Malignant or delirious catatonia had an extremely high mortality rate (80%) prior to use of ECT.  Death from catatonia typically occurred from severe food and water refusal, agitation leading to congestive heart failure, injuries from severe agitation, and in some cases autonomic dysregulation often seen as elevated body temperature with no evidence of infection.  This group of patients is hospitalized and cannot function outside of a hospital setting. Even inside a hospital they need very intensive monitoring to protect them from injury.  The fastest way to treat these patients, keep them safe, and help them to get out of the hospital is ECT.  In fact, it may be the only consistently effective therapy.   

People with severe medical problems who cannot tolerate antidepressant or antipsychotic medical constitute another group who can benefit immensely from ECT.  In many cases these patients are disabled by depression and do not appear to be recovering form their associated medical illness.  They may be in a coronary care unit and taking in inadequate amounts of food and fluids due to depression.  At the same time they may not be able to take medications due to an acute cardiac condition.   They can generally be safely treated with ECT.

A final important group of people are those with experience with ECT.  They typically have a form of disabling depression, know that most of the usual medications either do not work or cause unacceptable side effects.  They are also typically very functional people and know that they need to get back to work as soon as possible.  They request elective ECT for treatment.

Why should anyone want to deny ECT to people in the above groups when it is safe and effective?  Here is some of the rhetoric evident in any Internet discussion. 


1.  I don't like it and will never accept it!

You don't have to.  First it is only indicated for a limited number of severe conditions like treatment resistant depression, depression, catatonia, treatment refractory mania, psychosis, and high suicide risk. If you don't have any of those conditions no psychiatrist is going to recommend it to you.  But further - even if you have the conditions a psychiatrist may not recommend it because it is not available in the area.  Political rhetoric may have driven it out.  Other less effective treatments like ketamine infusions and transcranial magnetic stimulation (rTMS) may be recommended instead.

The second issue is informed consent.  You can decide you don't want it. Story over at that point.  I have no interest in talking anyone into it.  My job is to provide the latest information and the patient decides and consents or does not consent. 

2.  ECT causes brain damage!

Irrelevant based on the informed consent issue outlined above unless you are trying to make a political argument.  But more striking is the body of evidence that has accumulated that there is no evidence at all that ECT alters brain anatomy or leads to neuropathological changes. Denial or lack of scholarship are the most likely explanations of this problem.  Given the ease with which medical information can be accessed these days and the fact that many people making these arguments use antiquated and disproved data while ignoring the contradictory positive data - denial or intentional distortion of the data are the only obvious motives.

3.  There are important political and ethical considerations!  

Are there really?  Not when you look at the severity of the problem. Considering psychiatric illness and disease on par with other physical illnesses is difficult if you have never seen what happens on an acute care psychiatric setting where the most serious problems in psychiatry are treated.  In the current American healthcare system these patients are often committed and in some cases transferred to state hospitals if they do not get well.  In some cases, states have found it easier to close hospitals so that these extremely ill people are sent back to their families, to jail, or to the streets.  I routinely see patients who have had a severe psychiatric illness and were ill and unstable for decades.  In many cases they are chronically ill and never regain stability because of neglect or inability to treat them. All of those years of suffering and in many cases death could have been avoided with proper treatment early in the course. In many cases the proper treatment was ECT.

How does that compare with the rest of medicine? It does not. People with life threatening and/or disabling conditions are allowed access to high risk treatment options. A few examples can illustrate this point.  Cancer is a good example.  Chemotherapy agents are high risk medications that can lead to serious and in some cases lethal side effects. Giving informed consent for treatment with chemotherapy requires agreeing to accept the risk of congestive heart failure and many other serious and potential lethal side effects from those agents. The explosion of immunotherapy agents for autoimmune disorders provides similar risk.  Even more importantly, every patient consenting to the treatment are considered to be competent consentors.  In other words they are  considered able to understand the information, make rational decisions about it, and provide consent on that rational basis.  Patients consenting to ECT may not be competent cosentors based on vulnerability laws in states.  Consent is not considered to be competent necessarily based on status (on an inpatient psychiatric unit or outpatient clinic) or by specific statutes about diagnoses or recent behavior.  Those same rules do not apply to people giving consent for high risk medical or surgical treatments.  Keep in mind that ECT is portrayed as a high risk procedure - but in reality it is not.

4.  What about involuntary treatment with ECT?   

Some states have statutes that allow courts to decide on whether or not people who are civilly committed and have high risk psychiatric illness.  That is typically based on a hearing with opposing attorneys and a judge.  Unique state statutes provide the standards that must be met in those hearings.  The court typically hires examiners (psychologists, psychiatrists) to testify about diagnosis and recommendations.  Since ECT is a medical procedure psychiatrists may be required to examine the patient and testify about the recommendation.  These hearing may also be used because the patient is not competent to consent, but clinical competency is not a formal legal decision until it has been made by a court.  In these cases the state has an interest in preventing death and disability of its citizens. 

I have thought a long time about getting rid of involuntary treatment with ECT but how would that work?  The psychiatrist would be in a position that would be difficult to defend from a clinical standpoint.  Anyone with a severe disorder not responding to standard treatment needs to hear about ECT as an option.  Their treating psychiatrist needs to make sure that happens and that the discussion is documented as well as the patient's response. If involuntary treatment was not an option for severely ill people who were unable to consent, they would basically be maintained in a chronically disabled, high risk, or worsening course of illness. I don't think that is a decision that a psychiatrist can make because it is essentially one with a dubious basis.  At that level court intervention makes sense.

5.  What can be done to address ECT side effects if I get them?

First, like all medical procedures make sure the ECT is provided by an expert, working with an anesthesiologist who is used to providing general anesthesia for ECT.  Second, that expert needs to assess the results and side effects of those treatments on a treatment to treatment basis.  Modifications in techniques and side effect prevention need to occur on a regular basis if side effects are there.  In the case of voluntary ECT and significant side effects, stopping the treatment at any time is an option for the patient. In the case of involuntary treatment or substituted consent by a court involved family members or the patient can advocate for the same discontinuation.  The attending psychiatrist can also initiate discontinuing the treatment at any time based on side effects.

The perplexing issue is the number of people who write about numerous ECT side effects and that they have had a course of many treatments.  I ask myself, how does that happen?  Have they been told that they will get used to side effects?  Were the side effects ignored?  What happened?  Why didn't they just decide to stop? In those cases, the first step should always be to discuss the issues with the attending psychiatrist and psychiatrist performing the ECT.  If that is not effective, every state in the United States has multiple forums for investigation.  In the state of Minnesota, there is an Ombudsman for Mental Health and the Board of Medical Practice. Both of these agencies will exhaustively investigate any complaint brought to their attention. People are encouraged to complain about physicians and a national watchdog agency monitors how many complaints are made in each state and holds states with low complaint rates in a negative light.

More problematic is the political approach to ECT and how it has affected policy and has the potential to decrease the availability of this modality for very ill patients.  A recent editorial review pointed out how the process in the UK was factored into NICE guidelines that were restrictive and that those guidelines may adversely affect ECT practice in the US (1).  The restrictive nature of the NICE guidelines was apparently based in part on a flawed study suggesting more dissatisfaction and memory loss than expected.  A re-analysis of that data (3) describes the nature of those flaws that include in part:

"Two other studies selected individuals from user/advocacy groups generally biased against ECT and were probably overlapping. The significance of memory problems was not mentioned in any of the studies."

It is interesting that it took 9 years to reassess the original data and come to that conclusion and in the meantime it apparently was enough to alter ECT policy in the UK.

No other medical specialty allows political biases to affect practice standards, especially when it compromises the care of severely and potentially fatally ill patients. 

There is no reason why psychiatry should either.
 

George Dawson, MD, DFAPA 


 References:

1: McDonald WM, Weiner RD, Fochtmann LJ, McCall WV. The FDA and ECT. J ECT. 2016 Jun;32(2):75-7. doi: 10.1097/YCT.0000000000000326. PubMed PMID: 27191123

2: Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients' perspectives on electroconvulsive therapy: systematic review. BMJ. 2003 Jun 21;326(7403):1363. Review. PubMed PMID: 12816822.

3: Bergsholm P. Patients' perspectives on electroconvulsive therapy: a reevaluation of the review by Rose et al on memory loss after electroconvulsive therapy. J ECT. 2012 Mar;28(1):27-30. doi: 10.1097/YCT.0b013e31822d796c. Review. PubMed PMID: 22343578.

4:  FDA (Proposed Rule for reclassifying ECT devices):  Neurological Devices; Reclassification of Electroconvulsive Therapy Devices Intended for Use in Treating Severe Major Depressive Episode in Patients 18 Years of Age and Older Who Are Treatment Resistant or Require a Rapid Response; Effective Date of Requirement for Premarket Approval for Electroconvulsive Therapy for Certain Specified Intended Uses AGENCY: Food and Drug Administration, HHS. ACTION: Proposed order.

 https://www.gpo.gov/fdsys/pkg/FR-2015-12-29/pdf/2015-32592.pdf

5:  Electroconvulsive Therapy (ECT) Devices for Class II Intended Uses Draft Guidance for Industry, Clinicians and Food and Drug Administration Staff.  

https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM478942.pdf

One Small Step For Physician Autonomy

Physicians have been oppressed in the United States for the past 30 years - nearly the entire length of my career. That is not rhetoric. It is a fact. The oppression has occurred at the level of federal and state governments and eventually the businesses that those governments actually support.  A lot of it is documented on this blog and I am not going to repeat it here.  The most recent twist on that oppression has been in the form of maintenance of certification (MOC) actively promoted by the American Board of Medical Specialties (ABMS).  All medical specialty organizations in the United States are members of the ABMS and are forced to abide by its rules.  Some specialty organizations  started their own MOC that did not involve ABMS procedures and they were told they had to all go through the same process.  That process involves testing and intrusive measures into a physicians practice.  It is a major departure away from life-long learning that physicians aspire to and use to shape their individual practices.

The move to MOC was initiated by ABMS on their own and well before there was any debate of the evidence.  As an example, I was board certified by the American Board of Psychiatry and Neurology (ABPN) in 1988.  There was no time limitation on the original certifications until 1990.  I was certified Added Qualification in Geriatric Psychiatry in 1991; but that certification was time limited 1991-2001.  I was re-certified in Geriatric Psychiatry ten years later and that certificate states Recertified 2000-2010.  I was also certified Added Qualifications in Addiction Psychiatry 1993-2003.

Somewhere around the time I was due for certification for Addiction psychiatry, I asked myself: "Why are you doing this?" It costs a thousand dollars to take the test.  The test did not confer any special status, privileges, or salary.  It did not change any study habits at all.  I was still attending quality CME courses, reading the literature, and incorporating it into my practice. I was teaching and that is always associated with needing to know a lot more about current debates in the field as well as the representative scientific literature.  Even though I have never failed one of these board exams, there is a ritual of needing to take time off and study material that may not be immediately relevant to your practice - medical and psychiatric trivia that is an essential part of standardized test gamesmanship.  So I decided no - I am a professional. I am at the top of my game and all indications are that things are going well.  Even if they weren't, a thousand dollar board exam or even MOC procedure is not remedial.  It does not provide any feedback. It is essentially a prep school exercise of jumping thorough another hoop.  You either make it or you don't.  At that time there had been 7 hoops* and that was enough.  I stopped the process at that point. 

My guess is that a lot of other physicians saw the light the same way that I did.  My further speculation is that the ABMS reacted by increasing their leverage first by not issuing lifelong original certifications like they gave me back in 1988 and then making those re-certifications as onerous as possible.  I am not being dramatic when I use the term onerous.  I thought about getting back into the current MOC stream about a decade ago at an APA convention and talked with the ABPN representative at their booth. At the time, he literally could not tell me what I had to do to resume the endless cycle of paying fees and taking tests only that there was even more to do than that.  Not an inspiration to get back into the process.

Since then the ABMS has become much more strident about the MOC process.  They were playing the odds.  Physicians and their professional organizations are generally politically clueless and ineffective.  The best evidence of that is their inability to prevent managed care advocates in both government and business from taking over the field and dramatically decreasing the quality care.  They made arguments about how it was necessary to maintain quality and knowledge in a field.  How does that happen by taking a trivial pursuit style exam with no feedback and a very high pass rate?  How does that happen by basically doing patient satisfaction surveys on my patients - a procedure that is rapidly falling into disrepute in clinical settings. 

In the interest of brevity, I am not going to point out all  of the logical errors or overt conflict-of-interest in the ABMS arguments.  There are many bloggers out there who have done outstanding job of that including Cardiologist Westby G. Fisher, MD, FACC and Psychiatrist Jim Amos, MD.  In the literature the standard bearer against the MOC process has been Cardiologist Paul Tierstein, MD who was instrumental in founding the alternate board certification process through the National Board of Physicians and Surgeons (NBPAS). 

My conclusion after wading through all of the politics for that past decade was to get re-certified though NBPAS for several reasons including:

1.  Meaningfulness -  the existential equivalent of that word meaninglessness has been with me since I read Yalom's classic book Existential Psychotherapy in 1982. Yalom referred to it as the fourth ultimate existential concern - right after death, freedom and isolation.  Becoming a practicing physician is an exercise in delayed gratification.  As an intern and a resident the term "busy work" is used to designate tasks that have to be done but don't seem to advance true knowledge or understanding. It is really not clear what your professional life is going to be like until you are in the field interacting with colleagues and patients and practicing medicine.  Physicians as a group are overachievers, overwork, and compulsively question themselves about their decisions.  They are not work averse at all.  One of the motivators to expend this kind of energy is doing meaningful work.  Dr. Tierstein emphasizes this on the last slide in his lecture.  MOC is busy work and its meaning is arbitrarily defined by outsiders. 

2.  It reflects the original ABMS process - we certify you to go out in the world, practice medicine, and keep up with the theoretical and clinical aspects on your own as a professional.  Working with very bright colleagues providing excellent care for 30 years validates that approach.

3.  It certifies my ongoing work - I hope it is apparent from this blog that I am not a casual reader of the psychiatric literature.  I study it at several levels. I have two rooms in my home that are covered from ceiling to floor with medical and psychiatric literature.  I correspond with interested colleagues around the world.  I attend conferences.  I am working on current research.  I teach. I consider all of this life-long scholarship.  At one point the ABPN suggested they were going to put an asterisk (*) next to the names of lifetime certificate holders unless they participated in MOC.  To me that is an insult to my current work and professionalism. It's like designating me as some kind of steroid user.

4.  The NBPAS certifies continuing medical education credits (CME) - my state medical board asks me to report the total number every three years.  There is a suggestion that they will audit all of my certificates, but in 30 years that has never happened.  NBPAS does not certify you until you meet their CME requirement and send them all of the certificates via their web site.  They have an excellent website that can accept uploads of at least 10 of these documents at a time.  So here is a powerful reason for every state medical board to use NBPAS certification.  It immediately means that CME requirements are met very 2 years and they are certified.     

5.  It reflects what I do in my clinical work - sub-specialization in any field is always controversial.  Does there need to be another division in the field?  Is there enough evidence that it is far enough away from what everyone else is doing to be a separate body of knowledge?  After 30 years of work - I say no.  I still see geriatric patients, patients with general psychiatric disorders, patients with addictions, and patients with medical problems every day.  It's not like I can go to a magical clinic somewhere and just see a patient who only has one problem affecting their brain.  To do a good job, you have to continue to know it all.  It is hard work and there are often not a lot of clear answers, but that's why it is called practice and that's why we love medicine.

6.  It is tremendously cost effective considering what gets certified - the financial incentives for the MOC movement are huge and funded by physicians.  Stepping out of the MOC loop makes a clear statement.

7.  It is view consistent with my political philosophy -   I am from blue collar roots and was socialized to suspect the motives of politicians, businessmen, and even union organizers.  Very little of my experience as an adult seems to counter that perspective.  I see health care being run by the same mechanisms as the financial services industry and not for the benefit of physicians or their patients.  NBPAS certification is an antidote to the ABMS Big Brother approach.  In Dr. Tierstein's video he points out why it is no accident that healthcare companies insist that any physician working for them have MOC.  It is all part of the conflict-of-interest driven ruling class approach to business and regulation that we should expect.

That is why I got the NBPAS certificate.  I understand that there are early career physicians locked into some HMO who are told they need to be in the MOC cycle or they will lose their privileges and job (further evidence BTW of what MOC really is).  I can't understand younger physicians who don't recognize splitting when they see it.  I have read their opinions about how some think they know more than older physicians and how they are more tech savvy and how they are not averse to managed care manipulations.  I will just say that being an expert takes more than writing a smart phone app or thinking that you know every thing in the field after passing the initial board exams.  The true innovators and experts that I know have been doing what they innovated for the past 20-30 years.

The bottom line for this post is irrespective of where you are in medicine, if you ignore the politics you do so at your own peril.

Currently MOC is at the top of that list. 


George Dawson, MD, DFAPA




References:

1: Teirstein P, Topol EJ. Maintenance of Certification Programs and the Interstate Medical Licensure Compact--Reply. JAMA. 2015 Sep 1;314(9):952. doi: 10.1001/jama.2015.8912. PubMed PMID: 26325571.

2: Teirstein PS, Topol EJ. The role of maintenance of certification programs in governance and professionalism. JAMA. 2015 May 12;313(18):1809-10. doi: 10.1001/jama.2015.3576. PubMed PMID: 25965219; PubMed Central PMCID: PMC4751049. 

3: Teirstein PS. Boarded to death--why maintenance of certification is bad for doctors and patients. N Engl J Med. 2015 Jan 8;372(2):106-8. doi: 10.1056/NEJMp1407422. PubMed PMID: 25564895.

Supplementary:

*  The 7 hoops included part 1, 2, an 3 of the National Board Exams to qualify for a medical license and the subsequent 4 certifications and recertifications by the ABPN.  After thinking about this there were actually 8 hoops because there were actually 2 ABPN ceritifying examinations for psychiatry.  Part One was a written exam on psychiatry and neurology including imaging questions.  Part Two was an Oral Board exam that consisted of two parts.  One half of the day was an examination based on an observation of a videotaped interview. The other half of the day was an examination based on your observed interview of the patient.  Part Two had a higher failure rate probably due to a high degree of subjectivity.  I knew people who failed it more than once. So that is really a total of 8 tests altogether.


         

Why There Are No Bipartisan Solutions To Exorbitant Healthcare Costs In The USA

I happened to see Face The Nation yesterday.  Governors John Kasich and John Hickenlooper were on, talking about their attempted bipartisan solution to health care reform.  Their basic idea is that they and their staffers should be able to compromise and come up with a better proposal and possibly model cooperation for all of the uncompromising members of Congress.  Things did not look very well after the opening question by host John Dickerson:

"And we have seen in Washington both sides say they don't want to give up much of anything.  Give me your sense of what Republicans should back down on and what Democrats should back down on just as a preliminary good-faith effort to show that people are, on the health care question, committed to maybe working together."

I took out the key statement for both responses and included them in the above graphic.

The statements are very telling in terms of political rhetoric disguised as political philosophy.  Kasich seems to believe that there is a free market at work.  Hickenlooper seems to be more focused on the insurance principle of adverse selection - in this case the buyers of insurance with health problems are more likely to buy health insurance than younger healthy people without health concerns.  That leads to a concentration of buyers who increase the risk for the insurance company paying out and in the worst case a loss for the company.  Translation - the Democrats should give up on the idea of mandatory health insurance and the Republicans should give up on the idea of repealing mandatory health insurance.   That is quite a compromise.

An ethical framework is probably a better one to start from.  As I argued in a recent post - if your ethical priority from a political perspective is to allow people to have a choice - then give them choices when it comes to health care.  No choice is not an ethical option.  If your ethical priority is the value of human life - then universal access is necessary.  If the ethical priority is making sure that the resources being used by people who need health care services is finite and needs stewardship - then by all means make the entire system more cost effective for society at a whole.

All of the suggested ethical approaches cannot occur when the level of financial conflict of interest is large like it is in Congress.  Members of the US Senate get on the average $438,000 in donations from the Health care sector (PACs and individual contributions in the 2015-2016 election cycle).  That is a powerful incentive to keep making arguments about free markets and insurance markets that do not make any sense.  They make even less sense when it is clear that these same politicians are being lobbied to maintain the status quo - even though it is the most expensive and most inefficient health care system in the world.  The following graphic on the accumulation of administrators relative to the increase in physicians is just one illustration of that point.

Personal Communication David Himmelstein with his permission - July 2017.

So the next time you hear about the need for compromise and results from Congress, keep this scenario from Face The Nation in mind. Unless you have a reasonable assessment of what the problems really are, there is no starting point for compromise or consensus building. Policy makers in Washington are so far removed from an accurate assessment of the problem bad policy after bad policy is the logical outcome.


In discussing the problem with them a fair question is why the United States is incapable of coming up with effective health care at a reasonable price when all health care is currently rationed by for-profit companies.

It does not take single payer to get a better result, but it does take a government that is for the people rather than big health care business.



George Dawson, MD, DFAPA


References:

1: Face The Nation Transcript from August 6, 2017: Guests included Tom Cotton, John Kasich, John Hickenlooper, Jeh Johnson, Susan Page, Reihan Salam, Jennifer Jacobs and Jamelle Bouie. (Accessed on August 6, 2017).

Abortion, Women's Mental Health, and Politics...

Let me preface this post by saying that I am not a member of a political party and I do not endorse any political views about abortion.  The only interest that I have in abortion is what women tell me about it in the context of a psychiatric evaluation and treatment.  I also do not want to see women's mental health become a surrogate end point for the political debate on abortion.  In the state where I practice the Minnesota Department of Health mails a report on the number of abortions in the state with a number of warnings about the legal requirements of reporting abortions (p 51-57 of this report) despite that fact that 99+% of all physicians and 100% of psychiatrists do not perform abortions.  I bristle when I get that politically motivated report each year.

I am writing this post to examine whether or not any objective research on the mental health effects of abortion can be done.  This examination was precipitated by a post on a forum of the Time story "Abortion Doesn’t Negatively Affect Women’s Mental Health: Study".  Whenever I see an article like that I think of two things - the life experiences that women have told me over the years and where abortion fits in.   I also try to think about how I would do a study of this issue.  What would constitute mental health?  Most large studies don't depend on interviews anymore and that typically means a checklist or some sort of psychometric instrument.  There are typically cutoff scores and comparisons of cutoff scores between the research subjects and a control group.  Correlations are made with come psychiatric diagnosis or psychological construct to determine mental health.  With that kind of technology the underlying assumption is that these are good measures of mental health and that it covers all of the possibilities.  Human consciousness covers a lot of ground and there are generally subtle problems that don't get covered by these gross measures.

The study in question (1) is based on telephone interviews semiannually over a period of 5 years of a cohort of women selected for having an abortion, having a first trimester abortion, being turned away from access to an abortion and giving birth and being turned away from access to abortion and not giving birth.  In their results section, the authors plot the results of 11 interviews, but they point out that the subjects participated in an average of 8 over the 5 year period.  The women who received an abortion presented within 2 weeks of the clinics gestational limit for abortions (N=452).  Women with pregnancies up to 3 weeks past the gestational limit were turned away.  The turnaway group either gave birth (N=161) or had an abortion or miscarried (N=70) as possible outcomes.  Based on those outcomes they were identified as the turnaway-birth and turnaway-no-birth groups.   The first trimester group (N=273) was included to study whether or not the psychological outcomes differed if a woman had an abortion early or late during the pregnancy.

The test metrics were all Likert scales.  The depression and anxiety ratings came from the Brief Symptom Inventory (BSI) a 53 item rating scale of various psychological symptoms.  There are grouped ratings for 9 different symptom constellations including anxiety and depression.  All subjects are asked to rate their level of distress due to a symptom on a severity score ranging from 0 (not at all) to 4 (extremely).  For anxiety and depression their are 6 items each and subjects were identified as a "case" of anxiety or depression if their aggregate score were 9 of the total possible score of 24.  

Life satisfaction was determined by one item from the Satisfaction with Life Scale: "I am satisfied with my life."  One item was also included for self esteem.  Both were rated on a 5 - point scale from 1 (not at all) to 5 (extremely high life satisfaction/self esteem).

Using these variables, the trends were best illustrated in graphics of depressive cases versus time and depressive symptoms versus time (figure 1 above) and similar graphics for anxiety, self esteem, and life satisfaction.  The general trend was for less anxiety and depression slightly higher self esteem and life satisfaction over the 5 year course of the study.  I think analysis of the latter two elements was limited by the the single items 5 point scale and a regression toward the midpoint of the rating.  There is the usual extensive statistical analysis of what I would see as fairly limited data.  The turnaway groups and the near limit group generally had more depressive and anxiety symptoms and cases and lower self esteem and life satisfaction that the first trimester abortion group.  Their statistical analysis is consistent with those observations.

The authors conclude:  "Our findings add to the body of evidence rejecting the notion that abortion increases women’s risk of experiencing adverse psychological outcomes. Women who had an abortion demonstrated more positive outcomes initially compared with women who were denied an abortion."  In their secondary analysis they show that a history of previous mental health problems or psychological trauma correlated with adverse outcomes and may have worse outcomes if they are denied an abortion.  They discuss the importance of individualized care and recognizing the response to an abortion or in this case denial of abortion.  One trend that I did not see any specific comments on was the turnaway-no-birth group and the fact that it seemed to have the best outcome at 5 years in terms of depressive symptoms/syndromes and higher self esteem and life satisfaction.  In their overall conclusion the authors believe that their study shows that there is no necessity for laws warning women about the adverse psychological consequences of abortion and that being denied an abortion is potentially more detrimental.  

In their own discussion of the limitations of the study, loss of subjects over time was significant - 43% over 5 years.  They discuss the methods they used to limit bias due to loss (potentially of subjects with mental illnesses).  They discuss their alteration of the BSI and point out that it is really a screening instrument so that the identified cases in their study would require additional screening for an actual diagnosis of an anxiety disorder or depressive disorder.  

I had several thoughts when I read this study.  Women don't generally come in to psychiatrists and say they are depressed or anxious as the result of an abortion or a denied abortion.  That might be different in psychiatric clinics that specialize in women's health issues.  They often don't discuss the issue at all in the initial diagnostic evaluation.  They disclose these details along with other sensitive issues after a relationship has been established with a psychiatrist.  In that context there can be discussions about thoughts, images,  and feeling states related to abortion into other forms of psychopathology.  An example would be intense guilt, rumination, and self criticism about the abortion during an episode of depression.  When any person gets depressed it is a common experience to scan past personal history for stressful events from the past that lead to the same emotion.  There can be daydreams and fantasies of what the child would have been like.  There can be brief episodes of depression or anxiety related to self criticism, doubt, shame, or interpersonal conflict about having had an abortion.  Many of these thoughts can occur at a future date when the history of an abortion can take on new meaning such as a new committed relationship.   Any life event that impacts person's conscious state and causes them distress is significant to me, whether it is picked up by rating scales or not.  I would see these reactions as being part of normal emotional life rather than anything pathological.

Equating the mental health of women to a DSM diagnosis  or psychometric construct is a mistake.  The DSM is a product of looking at the 5% of people who are outliers and trying to characterize their problems with with categories or continua.  That approach removes human consciousness from the equation and that should no longer be acceptable to psychiatry or anyone interested in the conscious life of real people.  An event with as much potential meaning as abortion can never be adequately characterized as a psychiatric diagnosis or a psychometric scale.  The reactions are too diverse and nuanced.  Suggesting that abortions or the lack of abortions does or does not affect women is more of a political statement than a statement that takes into account the most important aspect of the human psyche - the unique conscious state of every person.  That conscious state is unique because what happens over the course of your lifetime matters and some events matter more than others.

My conclusion from practice is that abortion is one of many events that has the potential to significantly impact the conscious state of a woman.  That should be the consideration in the case of contraception, pregnancy prevention, and abortion and not whether or not it causes mental illness or symptoms.  A woman's unique conscious state should also be considered in the case of unplanned pregnancies and why that decision is much more complex than a list of social variables or whether or not contraception is used.  A more appropriate focus on conscious state rather than mental illness or symptoms would yield a more realistic idea about the effect of life events like abortion.  That result will be anything but simple and that is why simplistic political solutions or response to those solutions do not apply here.

I have a secondary conclusion about the place of politics in both the research and clinical care of women.  It has no place at  all.

It is as obvious as an annual vaguely threatening letter about abortion reporting to a psychiatrist from the state government.  When politicians practice medicine nothing good happens, but this letter goes way beyond that.


George Dawson, MD, DFAPA


References:

1:  Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women's Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study. JAMA Psychiatry. 2016 Dec 14. doi: 10.1001/jamapsychiatry.2016.3478. [Epub ahead of print] PubMed PMID: 27973641.

Attributions:

1:  Graphic at the top is from Reference 1 with permission from the American Medical Association - Order Number 4024950066424

2:  Thanks  to Pearson Assessments for sending me a sample copy of the Brief Symptom Inventory.  www.pearsonassessments.com

The Problem With EHR Software - A Clear Example

The above example is as clear as it gets in terms of illustrating the problem with electronic health record (EHR) software and associated hype and government mandates.  The idea that we need an EHR is a given, and I am not arguing that point.  I am arguing that the current software is inefficient, on par in many ways with software I was using on my PC in the 1990s, high maintenance, and a tremendous burden to any physician who has to use it.  It is also vastly overpriced with no end to that overpricing in sight - largely due to a monopoly of manufacturers and the use of a licensing model for the software.  And like practically every process in medicine these days, the implementation and actual use of EHRs is a highly politicized process that is far removed from the people who have to use it every day.

In the above example, I am tasked with a basic titration of gabapentin according to a recent research protocol (1).  All of the doses used are generic 300 mg capsules of gabapentin for the purpose of simplification.  The dose is titrated over 3 days to 300 mg TID (three times a day) or 600 mg TID.  People reading this may have picked up prescriptions with instructions typed out on the label about how to increase the dose to a therapeutic level.  In settings where a particular medication is used repeatedly and across a large patient population, the rate of titration and capsule side may need to be varied but the concept is the same.  

The question is how do I get this information to the pharmacy so that the medication can be dispensed to the patient in the most effective manner.  In the "old days" of paper records or the early hybrid models where  all of the orders and medications were entered into a text based computerized record, I would enter the orders onto a paper order sheet.  From there the pharmacist would either write up a parallel record for what the pharmacy needed to do or enter it into computerized pharmacy software.  An MAR (medication administration record) would be used by nursing staff to record the administration and time of administration of every medication.  There was a set of checks and balances because every dose of medication was checked at some point by a physician, a nurse, and a pharmacist.  In the 1980s and 1990s, clinical pharmacists would often have close relationships with the inpatient nursing and medical staff.  Those relationships were instrumental when it came to dosage changes, using novel medications, and making sure that all of the medication was given as scheduled.  The entire chain of events in the case of a low dose gabapentin prescription would start with a very simple handwritten order like the one below:

That is all written in my notoriously bad handwriting but I think it is perfectly legible.  I wrote it to show in two places that the capsules used here were all 300 mg and how they can be increased over three days.  More importantly, I turned on a stopwatch just as I started to write this order and it took me 1 minute and 50 seconds.

Compare a recent effort using an EHR.  The scratching in red at the top of this post is basically a worksheet on how to enter the medication without making a mistake.  The overall titration is the same (except the starting dose is 300 mg three times a day), but there are large differences.  In this case the physician is responsible for entering the medication into the pharmacy record and MAR at the same time.  The convenience with which that can be done is software dependent.  With the available software there are only two possibilities - add a new line of gabapentin doses to the HS, AM and Noon doses respectively over three days or rewrite the adjacent blocks of gabapentin doses and ultimately the 600 mg TID dose.  The difference is that the first procedure involved three steps and the second procedure four steps.  Each step also involves writing in the "Comments" section on each order to make sure that there is no confusion and that multiple doses of gabapentin do not end up being given over the course of the day.  For example in the red diagram for the single gabapentin 300 mg dose at the bottom of the column on the 28th I might enter:  "This is a single gabapentin 300 mg dose in the AM on 7/28/2016.  It is a one time dose".  Using any standard EHR will generate four or five separate orders for these simple titrations.  My first time through using the top method took me 30 minutes and at the end I had broken into a cold sweats.  I had to double check all of the text orders against my sketch (boxes and U-shaped checks) and the MAR.  I ended up calling the pharmacist and giving him a verbal version of my sketch as a back up.   The second method took me a total of 15 minutes.

This very basic example illustrates some huge problems with the EHR:

1.  Fewer people have hands on the medication orders - There may of may not be an immediate double check by the pharmacist.  Nursing staff are no longer entering the MAR and double checking how it looks.  The entire task and all of the associated time has been shifted to the physician.  When this happened, clinical pharmacists also disappeared from the floors.  The hype was that we have a newer and safer systems.  It should be apparent from my example that more can go wrong with the EHR titration than more traditional methods, even if there is a clinical pharmacist at the other end reading and approving hundreds of these order entries.

2.  More and more time is added to the physician - The EHR is a classic example of how numerous jobs including billing and coding, transcribing, and now data entry that used to be done by a pharmacist has been added to the physician's burden over the years.  It is as if physicians have unlimited time for all of these additional tasks.  The time constraint has to increase the likelihood of errors in the EHR.  If you have 5 or 10 minutes between patients and have to add even a mildly complicated order - it can easily take up twice that amount of time.  Administrators view this as a plus, because other jobs can be eliminated and physicians never get paid for administrative time.  By now it should be apparent that the enterprise wide EHR is such a financial burden on organizations that jobs need to be eliminated to pay for it - often many more jobs than the physician workload has assumed.

3.  The software itself has 20th century sophistication but without the report writing capabilities or data analysis - anyone who used spreadsheet or database software in the 1990s is used to the intensive data entry approach used in the modern EHR.  Should an extremely expensive, federally mandated piece of software be this clunky to use?  Should it take me 5-10 times as long to enter an order with this software as it did by writing it down on a piece of paper?  Should the final report of a hospitalization be a phone book sized incoherent document with very little information density?  I don't think that any of these constraints should apply.  I did not include the time it takes in direct conversations with a pharmacist to clarify what was entered in the EHR.  Every home computing environment these days is at least partially object/icon based to minimize typing where possible.  In the case of medication entry, the obvious solution would allow the physician to point and click medications on the MAR with no typing.  Select the medication and dose and enter it directly into the MAR with a few mouse clicks.  That would easily beat my time for writing it out and it would be more accurate than either of the approaches that I wrote about here.

I can only speculate about all of the business and political incentives in place that has resulted in the current EHR environment.  A lot of them have been clearly documented on the Health Care Renewal blog by searching EHR.   That search will also reveal a number of safety concerns and the inescapable political factors that currently exist in a healthcare environment that routinely ignores the concerns of physicians in favor of those with no medical expertise.    



George Dawson, MD, DFAPA      


Reference:

1:  Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Internal Med. Published online November 4, 2013. doi: 10.1001/jamainternmed.2013.11950.

2:  Brett Boese.  Mayo Clinic tries to avoid physician burnout.  Rochester Post-Bulletin.  July 29, 2016.  Link. 

Timely article on Mayo Clinic concerns about burnout and the EHR.  The Mayo Clinic is currently in the process of conversion to Epic EHR and will "go live" on various dates between the summer of 2017 and fall of 2018.  Tait Shanafelt was interviewed about a study he co-authored on the EHR showing the clerical burden led to decreased job satisfaction and burnout.  Responding to a number of strategies to reduce physicians clerical burden his conclusion was: "The specific strategy probably used likely matters less than recognizing that physicians should not be doing this and finding a practical way to have this task completed by support staff."

3:   Shanafelt TD, Dyrbye LN, Sinsky C, Hasan O, Satele D, Sloan J, West CP.  Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48. doi: 10.1016/j.mayocp.2016.05.007. Epub 2016 Jun 27. PubMed PMID: 27313121.

4:  Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP.Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015 Dec;90(12):1600-13. doi: 10.1016/j.mayocp.2015.08.023. Erratum in: Mayo Clin Proc. 2016 Feb;91(2):276. PubMed PMID: 26653297.

The Demise of the "5th Vital Sign"

The American Medical Association came out two days ago and said that they were dropping the pain as the fifth vital sign movement because it encouraged opioid overprescribing.  Even more interesting is that I did not get the news from the AMA (I am a 30 year member) but from the Pain News Network.  The only stories that I could Google the next day was about the AMA defending its position against attacks from pain societies and organizations who want to maintain what I would describe as a liberal approach to opioid prescribing as the best way to approach pain.  My term liberal is meant to connote a political position with no basis in science and the lack of science started in 1998 with the pain as a 5th vital sign approach.  In 1996, the President of the American Pain Society declared pain as the Fifth Vital Sign.  In the year 2000, the Joint Commission (then JCAHO) launched a pain initiative that described the 10 point pain scale as a "quantitative approach to pain."

I don't know if quantitative analysis is still a prerequisite for medical school, but this is a reason why it still should be.  In quantitative analysis, the task is to measure chemical concentrations accurately and reproducibly.  To use a quote from my old analytical chemistry text (1): "Qualitative analysis is concerned with what is present, quantitative analysis with how much is present."  The ability to do this is often a major part of the grade for that course.  Since the chemical composition in the samples are known - they should be determinable with precision.  In some cases, a lack of accuracy can reflect problems with the analytical technique if there are widespread variations in the results.  This is a true quantitative approach.  Asking a person to rate their pain on a 10-point scale is not.  Pain is a subjective experience influenced by a number of variables including whether the pain is acute or chronic, emotional state, the presence of an addiction, and personal biology affecting pain perception.  It is not a quantitative assessment.  It is as obvious as asking someone where they are on the 10-point  scale and being told they are a "14".  There are a lot of potential messages with that statement, but none of them involve an accurate measurement of pain.  A quantitative scale has no implicit meaning - it is supposed to be a known measurable quantity no matter what.

From a medical perspective, there is also no better example of the adverse consequences of widespread screening for a problem.  Chronic pain varies with age and other demographic factors.  Epidemiological surveys show widely variable numbers of people with chronic pain, but some suggest an average is about 25% of the population and 10% of the population with pain that has some secondary disability.  While there are no good ways to estimate the optimal amount of opioid needed to treat pain in a population, current data suggests that the US is the largest consumer of prescription opioid drugs in the world.  For example, the US has 5% of the world's population and Americans use 55% of the world's supply morphine and 37% of the world supply of fentanyl.  By contrast 80% of the world population uses 9.9% of the morphine and 19.7% of the world's fentanyl.    The United States is clearly at the top in terms of opioid consumption.

Clinical trials have also shown that opioids are moderately effective for some forms of chronic pain and no more effective than non-opioid medications.  The screening approach to chronic pain is clearly associated with overexposure to opioids, widespread availability of illicit sources of opioids, and an epidemic of overdose deaths.  The idea that rapid assessments can be made with rapid qualitative screening by anyone also eliminated pain specialists as gatekeepers in the decisions about who would receive treatment with opioids for chronic noncancer pain.

In the opening days since the AMA statement, it appears that political forces are lining up to maintain the status quo.  The idea that the AMA has to defend their position seems like pure rhetoric to me.  How about the American Pain Society defending the original statement in the context of everything that has happened since?  Despite defensive statements about how opioid prescribing was increasing before the position was adopted - the hard data suggests that it was associated with a major inflection point in opioid consumption in the USA.

The policy debate on this simple statement has far reaching effects for health policy in the United States.  At every level in today's health care system there are groups of managers/administrators who have set themselves up to monitor various measurements and hold somebody accountable.  I doubt that they know the difference between quantitative or qualitative measurements any more than the people who proposed that a subjective pain scale was somehow a quantitative measure.

I doubt that any one of them ever took a class in Quantitative Analytical Chemistry.



George Dawson, MD, DFAPA



References:

1:  James S. Fritz and George H. Schenk.  Quantitative Analytical Chemistry. Second Edition.  Copyright 1969 by Allyn and Bacon, Boston, p 3.



Attribution:

Pain scale graphic downloaded from Shutterstock per their standard license on June 29. 2016.

Executive Order: No Psychiatrists On Governor's Task Force On Mental Health

I received an e-mail two days ago from the current President of the Minnesota Psychiatric Society on the formation of a Governor's Task Force On Mental Health.  That e-mail commented that no psychiatrists were considered for the Task Force, but that psychiatrists could apply as concerned citizens and were encouraged to do so.  I have done this in the past and been ignored so I was not eager to repeat that again.

The public mental health system in Minnesota has been seriously mismanaged and ignored for the past 30 years or about as long as I have been a psychiatrist in this state.  During that time, I have witnessed a long string of bureaucrats with no specific experience trying to manage a state hospital system or more likely trying to shut it down.  Those efforts were seriously compromised by some of the same legislators who decided to develop a system of civil commitment for sex offenders because they thought it would be easier to detain them on a dangerousness standard than the usual legal criteria.  Let's forget about the commitment standard that suggests the person should have a treatable illness.  The efforts to shut down the state hospital system were also compromised by the fact that the system really started to backfire when the number of available beds in Minnesota dropped to the lowest number in the US.  At that point there was always a large pool of unstable patients circulating between the emergency department, brief inpatient stays where not much happened, and the street.  During that time significant housing resources for both adults and children with significant psychiatric problems was shut down.

The icing on the cake from the State Legislature was their myopic approach to the problem of the mentally ill being incarcerated.  They "solved" the problem by coming up with a rule that any county jail inmate could be transferred to Anoka Metro Regional Treatment Center (AMRTC) within 48 hours.  AMRTC was supposed to the the remaining flagship public psychiatric hospital for patients with no forensic problems, that is they had not committed a violent crime due to mental illness.  This was a predictable double whammy, sending violent inmates to a hospital setting and short circuiting long waiting lists of patients waiting to get to AMRTC as a result of commitments at community hospitals.  This has led to a record number of assaults on staff working at AMRTC, at a time when nurse manager staff critical in managing aggression had been downsized.

Community mental health centers (CMHCS) have certainly not fared any better.  At some point the decision was made that they could be treated like managed care clinics.  In other words they would be funded by staff "productivity" and practice medication rather than psychotherapy focused services.  Even then, reimbursement from traditional funding sources was so poor or so entangled in unnecessary paperwork that the funding was inadequate to keep the doors open.  Some CMHCs have just gone out of business and advised their patients to see primary care physicians or distant mental health clinics.  People generally do not drive long distances to be seen, at least not for very long.  It is hard enough to drive across town, much less several hours for an appointment.

Looking at the goals of the Mental Health Task force and who the Governor wants on it - it is clear that this is a serious committee with a serious mandate to develop a continuum of care and the supporting infrastructure with funding sources.  The political and managerial members of the Task Force are carefully specified.   Why then would representatives of the same failed agencies from the past be appointed to serve on it?  Why are there no psychiatrists or psychiatric nurses - linchpins of what can be loosely described as this system of care?  Why are there no psychiatric social workers - the people with the most experience in dealing with the glaring lack of resources?  These are the people who know what the problems are, how they can be solved, and what they have to put up with every time a state politician or bureaucrat makes another bad decision.  And yet none of these groups are specified Task Force members.

The implicit question is how many times these state government driven processes need to fail before there is a rational process?  One of the associated questions I dealt with as the President of the Minnesota Psychiatric Society is why professional organizations in the state always seem to fall silent about these processes every time they occur.  There are psychiatrists employed in these systems that may not want to hear any criticism from their professional organization about the overall processes, and that is something I have never really understood.  There are certainly plenty of professionals who avoid contact with these systems entirely.  It is one thing to have to try to function very day at work in an environment where doing the work is impossible due to financial and bureaucratic constraints.  It should be fairly obvious that is not a personal criticism of any employee in that system.   It is well past the time when the professional organizations represented in these systems get involved and tell whatever Task Force coming down the pike what is necessary to provide quality care to people with severe mental illnesses.

Until that time comes, I encourage every psychiatrist in the state to use my standard answer about why the mentally ill in this state get rationed and inadequate treatment:

"This decisions in this state are made by people who know considerably less about it than I do."

That is just the way we do business in the USA right now.  At some point the American people were sold the idea that managers with no particular skill other than declaring themselves to be managers were what we needed to solve problems.  Being a politician or a manager seems to trump just about every technical skill, but in this case the resulting problems have been more than a little glaring.  Knowing how to treat the severe mental illnesses that are seen in state hospitals and CMHCs requires more than an MBA or JD.  You have to be well trained and know what you are doing.

This Task Force seems to be a collection of what has come to be called stakeholders and it is more than a little ironic that this group never seems to include the people who show up each day to do the work. 


George Dawson, MD, DLFAPA


Reference:

Here is the original Executive Order - dated April 27, 2016.


Supplementary 1:

A rich source of political rhetoric that is frequently used against professionals by managers is: "Let's see you come up with a solution."  They never really step aside and let the professionals manage.  They are just trying to shut them up.  Well here are a few ideas for starters that I will put up right now against any Task Force product.  And I am the only stakeholder writing this blog:

Minnesota State Hospitals Need To Be Managed to Minimize Aggression - link

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 Years Of Rationing - link

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression - link

Public Sector Mental Health Continues to Be Squeezed Out Of Business - link