How Should APA Guidelines Work?

The guidelines of the American Psychiatric Association (APA) are an interesting story in how guidelines are important if used correctly by professional organizations.  The whole idea behind a profession is that the practitioners in that area have special expertise and that the expertise is standardized to some degree.  Standardization is useful in the case of physicians to assure the safety of the practitioners and so that people have some idea of what to expect in terms of safe and effective care.  Over a decade ago the APA began producing guidelines for practice in various areas of the field.  I thought it was an exciting development.  The guidelines were initially sent along with the monthly copy of the Journal of the American Psychiatric Association.  All of the guidelines are available publicly on this web site, but hardly anyone knows about them.  I make this statement because one of the many red herrings that the critics of psychiatry use is that psychiatry has no standards of care.  They seem quite shocked to find that these guidelines exist and address their complaints directly.  

I was asked to critique one of the existing guidelines and suggest how these guidelines could be used more effectively.   In looking at the guidelines web site, it is apparent that some of the guidelines have not been updated in quite a while.  Publication dates range from 2000 - 2010.  Given the pace of clinical research 5 years might be somewhat acceptable, but 10 - 15 is probably not.  Another issue that the APA needs to grapple with is the diagnostic manual versus treatment approaches.  There is widespread confusion about whether or not the DSM-5 is a guidebook for treatment as opposed to a guidebook for diagnoses.  The APA actually two approaches to treatment guidance - the guidelines themselves and a text entitled Treatment of Psychiatric Disorders (TPD).  TPD is currently in its 4th edition and it has gone from a series of two volume detailed text to a more basic single volume text.  That text was published in 2007.  Some of the chapters in the previous editions provide some of the most detailed information on the pathophysiology and treatment of certain disorders that could be found anywhere.  At that level of analysis, the APA has gone from providing outstanding information on the pathophysiology and treatment of psychiatric disorders to a relative vacuum over the past 10 years.

For the purpose of a more detailed analysis I will consider the Practice Guidelines on Substance Use Disorders and the associated Quick Reference Guide and Guideline Watch - a 2007 update of the original 2006 guideline.  I looked at the Guideline Watch first because it should reflect the latest literature reviews and treatment guidelines.  The document reviews medication assisted treatment of tobacco and alcohol use disorders with varenicline, naltrexone and acamprosate.  The document was a good summary of the literature at the time but it needs a serious update.  Since then there have been more extensive studies of the genetics, combination therapies, re-analysis of existing studies and side effects of naltrexone, acamprosate, and varenicline including use in specific psychiatric populations.  In at least one case, the current literature supports a course of action that is exactly the opposite of what is recommended in this document.  That course of action is: " Given its high potency and partial agonist activity at central nicotinic acetylcholine receptors, varenicline should not be combined with alternate nicotine replacement therapies."  An inspection of the references for varenicline notes that additional research has been done in this area and should be discussed.      

The Quick Reference Guide contains extensive tables from the original guideline so I will go directly to that document.  At first glance it looks like a significant document more than 200 pages long.  But about 177 of the 276 pages of the document are relevant text.   The rest are references and polls of various expert groups on what they consider necessary for a guideline.  Looking at the Table of Contents, the first thing that is apparent is that only a subset of substance use disorders is being considered.  Although it is likely that nicotine, alcohol, marijuana, cocaine and opioids represent the majority of abused substances psychiatrists treating addiction see a broader array of compounds being abused.  The full gamut of abused compounds should probably be addressed in the guideline whether or not there is a consensus about treatment methods or not.  The safety of users and treatment setting considerations will still need to be considered as well as the need for further assessments.  A good example would be Hallucinogen Persisting Perceptual Disorder and what might be the best assessment and treatment.  If the guidelines are supposed to apply to clinical practice then patterns encountered in clinical practice need to be addressed.  If the APA does not address them - governments and managed care companies will, most frequently to the detriment of patients.

The guideline uses the following conventions for the treatment recommendations.  They are conventions frequently see in professional guidelines:

[I] Recommended with substantial clinical confidence.
[II] Recommended with moderate clinical confidence.
[III] May be recommended on the basis of individual circumstances.

The introductory section does not suggest who the guidelines are written for.   This is a critical aspect of the document.  There is an implication that it is for psychiatrists based on the statement about a comprehensive psychiatric evaluation but I think that needs to be more explicit.  It is not uncommon for managed care companies to send letters that deny care to psychiatrists.  The letter often contains a list of guidelines that an insurance company reviewer used to deny the care.  The APA needs to be explicit that these guidelines are intended for use by the psychiatrist who has personally assessed and is treating the patient and not by an insurance company employee or contractor who is sitting in an office reading through paperwork.  Somewhere along the line professional organizations seem to have lost track of the concept that only direct assessment and treatment of the patient was considered the correct way to do things.  Putting it in all guidelines is a critical first step.

The next thing I would change in terms of guidelines is breaking out the treatment setting recommendations into separate sections in table form.  For example the Hospitalization guidelines are copied into the Supplementary section of this post.  They are all very appropriate and I doubt that there are any reasonable clinicians that would have a problem with them.   The problem is that these services are rationed to the point that it is difficult for any reasonable clinician to implement them.  By that I mean that a psychiatrist cannot get a patient meeting these criteria into an inpatient detox or treatment setting based on these criteria.  As an example, consider the patient who says they are drinking 1 liter to 1.75 liters of vodka per day for 6 months.  They describe uncomplicated symptoms of alcohol withdrawal (shakes, sweats, hangover symptoms and drinking in the morning to suppress these symptoms).  I think the person in this vignette meets criteria 2 for hospitalization and detox at least.  A significant number of patients presenting to emergency departments with this pattern of findings are not hospitalized.  Many are sent out with a supply of benzodiazepines to detoxify themselves.  Many are sent to county detox facilities where there is no medical coverage or so-called social detoxification settings.  None of these non-hospitalization options are realistic approaches to the problem.  Giving a person with an alcohol use disorder a bottle of benzodiazepines for home detox ignores the uncontrolled use and cross addiction aspects of the primary disorder.  It is highly likely that person will ingest the benzodiazepines all at once or use them to treat the morning withdrawal symptoms of the disorder.  Social detoxification is an equally suboptimal approach.  It depends on probabilities.  It is more likely that the person transferred to that setting will leave due to the adverse environment and go back to drinking or undergo withdrawal and not experience delirium tremens or withdrawal seizures.  Over the past 30 years, the managed care industry has refused to consider admissions in practically all of these situations often whether there was psychiatric comorbidity or not resulting in the rationing of care at the initial assessment in the Emergency Department.  There must be an awareness that clinical guidelines don't operate in a vacuum.  Having a guideline in place that nobody can use is not the best approach to providing quality care.   Managed care companies can deny inpatient care on practically any of the 7 inpatient criteria simply by saying that they do not exist.    

On the treatment side there are inconsistencies noted in the recommendations and editing problems.  For example, there are 49 references to "12-step" and 2 references to 12 steps.  One of the first statement one encounters is:  "The efficacy of treatment is related to the amount of psychosocial treatment received. The 12-step programs, hypnosis, and inpatient therapy have not been proven effective."  That characterization of 12-step recovery is inconsistent with just about every other reference in the document.  Where it is suggested it is footnoted with a "I" designation or "substantial clinical confidence."

Rather than critique other sections based on data that was not available at the time that this guideline was posted, I thought I would end with a comment on the process and general philosophy of professional guidelines.  Right at the top of this guideline is a section entitled "Statement of Intent".  The crux of that argument is contained in the paragraph (p. 5):

 "The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed
or to serve as a standard of medical care. Standards of medical care are determined on
the basis of all clinical data available for an individual patient and are subject to change as scientific
knowledge and technology advance and practice patterns evolve. These parameters of
practice should be considered guidelines only. Adherence to them will not ensure a successful
outcome for every individual, nor should they be interpreted as including all proper methods
of care or excluding other acceptable methods of care aimed at the same results........"

I don't really agree with that approach.  The concerns about saying that these are standards of care is a medico-legal one and I have rarely found that to be a sufficient basis to practice medicine.  An example would be litigation against a psychiatrist for not following the stated standards of care in a malpractice suit.  This may seem protective of psychiatrists for varying practice styles but it also has the more insidious effect of basically allowing any standard of care to apply.  A walk down the street to a different hospital results in an admission for medical detoxification when the first hospital discharges the patient with a prescription of lorazepam and a promise to follow up with their primary care MD.  The resulting business incentive practice creep results in a complete lack of detoxification and a lack of any standards of medical care.  The default standard is whatever businesses decide to pay for.  My observation is that results in an unacceptable level of medical care.  And further:

"The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment
options available....." 

I agree with the statement but let's face it,  the judgment of the psychiatrist frequently has very little to do with the judgment of the psychiatrist or what options are ultimately considered in the working alliance with the patient.  Practically all inpatient and residential care these days is dictated by managed care companies and insurance companies irrespective of what a psychiatrist would recommend or a patient would accept.  These are standards of care that are forced on psychiatrists and patients rather than the prospective quality based standards.

Stepping back from that fact medical standards play a peripheral role to what businesses want and that unacceptable standard has been present to one degree to another for the past 30 years, I don't think a new approach in guidelines is too much to ask for.  I don't think it is too much to ask that APA guidelines be up to date, internally consistent, inclusive, actually apply as a standard of care as opposed to using business standards as the default, and be used to advocate for the best possible treatment settings for psychiatrists and their patients.  There are a number of specific methods that can be used and I will discuss them when the draft version of the latest  Practice Guidelines for the Psychiatric Evaluation of Adults comes out this year.


George Dawson, MD, DFAPA


References:

Work Group On Substance Use Disorder.  Practice Guideline For TheTreatment of Patients WithSubstance Use Disorders,  Second Edition.  American Psychiatric Association.  This practice guideline was approved in December 2005 and published in August 2006.


Supplementary 1:   These are the hospitalization guidelines from the APA Substance Use Disorders Guideline.

"Hospitalization is appropriate for patients who 

1) have a substance overdose who cannot be safely treated in an outpatient or emergency department setting

2) are at risk for severe or medically complicated withdrawal syndromes (e.g., history of delirium tremens, documented history of very heavy alcohol use and high tolerance); 

3) have co-occurring general medical conditions that make ambulatory detoxification unsafe; 

4) have a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient); 

5) have a level of psychiatric comorbidity that would markedly impair their ability to participate in, adhere to, or benefit from treatment or have a co-occurring disorder that by itself would require hospital level care (e.g., depression with suicidal thoughts, acute psychosis); 

6) manifest substance use or other behaviors that constitute an acute danger to themselves or others; 

or 

7) have not responded to or were unable to adhere to less intensive treatment efforts and have a substance use disorder(s) that endangers others or poses an ongoing threat to their physical and mental health [I]."      (p.  11).

2015 and......

I was going to try to post about alcohol consumption prior to New years Eve, but am still working on that post.  Instead, I found myself reacting to a post on LinkedIn entitled "10 Warning Signs That Your Psychiatrist Is Not A Good Fit" by Amanda Itzkoff, MD.  Look for it on LinkedIN if you are a member and see what you think.  I found it fairly stark and negative.  I found myself immediately typing up my own top ten list on how you know you have found a competent psychiatrist.  That may not fit the usual blogger message that critical statements that apply to only a few is the only reason for commentary.  One of my reasons for writing this blog is that the tremendous number of colleagues who I personally know are all very competent and the list is a composite of what anyone would find walking in to talk with any one of them.  That list follows.

I had thought about posting a list of what I plan to continue to do here in the coming year but decided that was unnecessary.  You can certainly go to any number of blogs to find out what is wrong with psychiatry or psychiatrists.  Much of it is hyperbole.  I hope that you will find what I write here is a realistic antidote to those other sites.

    Top Ten Signs Your Psychiatrist Is Competent

1.  You are understood.

Your psychiatrist makes it very clear to you that he/she understands the problem and all of the mitigating factors by formulating the problem and treatment plan, restating it to you, and giving you useful advice.  That also includes discussing the relationship that you have with the psychiatrist and any concerns that you have about it.  That is one aspect of seeing a psychiatrist that differs from seeing other physicians.  You should be comfortable bringing up any concerns and clarifying any potential misunderstandings.  Your psychiatrist should also be able to answer the basic question about whether you have any diagnosis or problem that requires treatment.  Your psychiatrist should be focused on a discussion of your problems and your best interest should be the focus of treatment.

2.  Your psychiatrist is an expert.

Your psychiatrist has technical expertise in the field and is comfortable discussing new treatments and innovation in the field ranging from psychotherapy to brain science.  That includes an awareness of the current limitations of treatment.

3.  Your psychiatrist knows medicine.

During the initial assessment and beyond, your psychiatrist pays close attention to any other medical problems that you have and how the treatment he/she prescribes might affect those conditions.  That includes being able to diagnose new medical conditions that can lead to psychiatric presentations and ordering the appropriate tests to follow potential complications of any new treatments or how new treatments might impact existing conditions.  That includes a willingness and an ability to talk with the other generalists and specialists providing your medical care.

4.  Your psychiatrist takes enough time.

The assessment and treatment of complicated problems takes time.  Many psychiatrists are in clinics where there are allowed only brief periods of time (10 to 20 minutes) for assessment and treatment.  Many people are satisfied with that amount of time, but if you are not - a different treatment setting may offer more time.  That can be discussed with the current psychiatrist and a referral to psychiatrists practicing in different settings can be obtained.

5.  If medications are involved your psychiatrist thoroughly explains the risks, benefits, and limitations of treatment.

Like most areas of medicine, medical treatments have their limitations.  That includes medications that are not completely effective in alleviating symptoms, side effects, and occasional very serious side effects.  Your psychiatrist should be able to help you negotiate that area and provide you with more detailed information for further study on request.  You should believe that your psychiatrist is taking any concern you have about side effects very seriously.  The discussion of side effects is as important as a discussion of potential therapeutic effects.  Any informed discussion of medical treatment should also include a discussion of non-medical approaches.  Many people are surprised to learn than non-medical approaches are more effective than medications in the treatment of several severe mental health problems.

6.  Your psychiatrist knows about addiction.

A significant number of people being treated by psychiatrists have problems with addiction.  Addiction can cause psychiatric problems and complicate the care of psychiatric problems.  Even if your psychiatrist is not an addiction specialist, he/she should be able to advise you in how to get well and not increase the risk for relapse if you are sober.  Your psychiatrist should also be able to advise you in approaches to your problems if you are not sober.  Chronic pain is also an associated problem and your psychiatrist should be able to make an assessment of your chronic pain problem and how it affects associated mental health and addiction problems.   

7.  Your psychiatrist is able to tell you about things that you do not want to hear.

That can cover a broad range of topics from your expectations about medication and psychotherapy, to unrealistic expectations, to boundary problems involving what appear to be straightforward problems like filling out a disability form.  One example would be concerns about a diagnosis of Attention Deficit-Hyperactivity Disorder (ADHD).  A lot of adults seek treatment for this problem and in many cases they are also expecting an approach that leads to enhanced cognition.  A consulting psychiatrist should be able to say that they do not have ADHD and that stimulant medications are not currently indicated for cognitive enhancement.  

8.   Your psychiatrist is concerned about your safety.

One of the characteristics of some mental health problems is that the safety of the person involved is compromised.   Psychiatrists are trained to make these assessments and determine a plan to address the problem.  Many psychiatric disorders result in impaired insight and judgment that is restored once the primary problem is treated.  It is often useful to have a discussion about that in advance.  Some states have a psychiatric advanced directive that is useful to direct your care in the event of an acute episode of illness that affects your judgment.  We live in a litigious society and physicians are often accused of “covering” themselves by making very conservative decisions.  These decisions are most likely driven more by safety concerns than malpractice concerns.  

9.   Your psychiatrist is willing to talk with your family.

You should be certain that your confidentiality is protected at all times per an explicit agreement with your psychiatrist.  That agreement should include emergency contingencies and advise you about the statutes in your state that affect confidentiality.  You should also expect that when you want your psychiatrist to talk with your family that he/she will do that.  For certain aspects of treatment planning such as discharge planning from hospitals and gathering diagnostic information, discussions with family are critical.

10.   Your psychiatrist is mindful of your financial concerns.

Mental health services are the most rationed services in medical care in the US.  That typically results in more out-of-pocket costs for people receiving psychiatric care than other types of medical or surgical care.  Your psychiatrist should be able to discuss the cost aspects of all forms of care.  That includes medication costs and also the cost of ongoing psychotherapy. Cost effective alternatives for both psychotherapy and medical assessment and treatment should be as easily discussed as any other aspect of treatment.  Your psychiatrist is often placed in an impossible situation by the insurance industry.  The insurance industry often makes it seem like your psychiatrist is responsible for decisions that are really the result of insurance industry rationing.  Any concerns you have about the financial basis for decisions should be clarified with your psychiatrist.

Happy New Year!

George Dawson, MD, DFAPA

How to Improve the Accuracy of Psychiatric Diagnoses - My Take

Allen Frances, MD has just blogged his ideas about how to improve the accuracy of psychiatric diagnoses.  His ideas basically come down to "be extremely alert to severe mental disorders and extremely cautious and patient before diagnosing mild ones."  He suggests a posture of "watchful waiting" of mild conditions to avoid attributing a treatment effect to a medication when in fact it is a placebo response.  He suggests erring on the side of underdiagnosis rather than over diagnosis.  I suppose that is all well and good but I have a few ideas on my own:

1.  Be a physician first - anyone coming for an evaluation needs to be assessed from a triage perspective.  Most American Psychiatric Association (APA) guidelines emphasize the need to assess the psychiatric parameters of acuity such as suicidal ideation and aggressive ideation and the risk of those behaviors, but there is very little medical guidance.   Psychiatrists need to be able to rapidly recognize both acute medical illness and medical illness that is causing the psychiatric presentation. They need to be able to rapidly assess medical problems that may interfere with the treatment of the psychiatric disorder.  The best way to have those  skills is to have adequate exposure to the full range of medical problems that can be encountered, especially from a pattern matching and pattern completion perspective.  That occurs only from treating many people with variations on the problem.  That starts in Medical School where every prospective psychiatrist should be focused on those experiences.

2.  Interpret your own studies - that means actually taking a look at actual brain scans, ECGs, lab tests, and other reports relevant to the care of your patients.  Psychiatrists need to be actively involved in the medical aspects of the care their patients, especially when they know more about the problems than the other physicians on the scene.  A few examples would be in the area of drug interactions, movement disorders, toxic syndromes like neuroleptic malignant syndrome and serotonin syndrome, the evaluation of delirium, electrocardiogram effects of psychiatric medications, and drug intoxication and withdrawal syndromes.

3.  Communicate well with the patient and their family.  Psychiatrists are trained and observed extensively in interviewing techniques.  They should understand the limits of specific interview situations and they should have well developed therapeutic neutrality that other physicians do not necessarily have.  In that environment they should be able to have the most productive dialogue with the patient and their family.  Psychiatrists should be experts in a diagnostic process that includes information from multiple sources.  Psychiatrists are also schooled in the concept of a therapeutic alliance and the implications of that orientation in treatment.

4.  Recognize the importance of psychotherapy.  Many diagnostic sessions require that psychotherapeutic interventions to be woven into that interview to support the patient, alleviate acute anxiety and to allow for a more thorough diagnosis.  Careful approaches to the diagnosis and treatment of patients requires recognition of the fact that some people will not tolerate any medications and psychotherapy may be the only available modality.  I do not hesitate to tell patients after an assessment that psychotherapy may be the best approach to the problem as well as discuss non medical approaches that have documented efficacy.

5.  Perform an actual psychiatric diagnosis.  This task is critical in the training of psychiatrists there is a lack of understanding about what making a diagnosis actually means.  Contrary practically everything that you read in the media, checking off criteria in the DSM 5 is not a psychiatric diagnosis.  Rating scales are also not psychiatric diagnoses and they are not quantitative measures.  It is very common these days for a psychiatrist to see a patient who carries 4 or 5 misdiagnoses like Bipolar Disorder/Major Depression + Attention Deficit-Hyperactivity Disorder + Intermittent Explosive Disorder + Asperger's Syndrome.  These folks are frequently on medications that are supposed to address the various disorders and they may not have ANY of the disorders.  In some cases they may not require medical treatment.  There are many people out there making complicated psychiatric diagnoses and initiating treatment in a 20 minute visit who are not qualified to make these diagnoses.  The other line of demarcation is the impact that a disorder has on the patient.  People who are functioning well in all spheres of their lives, by DSM definition - do not have a psychiatric disorder.  Many people are relieved to hear that they do not have a diagnosis or if they have had a diagnosis in the past that they no longer require treatment.

That diagnosis should be more comprehensive than a list of diagnoses.  There should be a formulation that describes the phenomenology and potential etiologies of the current disorder(s).  A narrative that makes sense to the psychiatrist and the patient.  At the end of my diagnostic session with the patient, I will frequently state it out loud in order to let the person know what I am thinking and get their feedback on my formulation.  I think that there is inherent flexibility in these formulations because the psychological etiologies can still vary based on the model that seems most applicable or the model that the psychiatrist prefers to use.  As an example it could be psychodynamic, behavioral, interpersonal, or existential.  It may employ a more recent model like one based on third generation behavior therapy or be a more supportive model focused on bolstering the patient's defenses.  The formulation is part history but also a discussion of etiologies (biological, social, psychological), dynamics, and defensive patterns.  The formulation can provide convergent validation for the diagnoses.  It provides both a pathway to understand the patient and guide psychological interventions.  The bulk of the material for this assessment occurs in parallel with the discussion of symptoms.

6.  Know the literature on borderland syndromes.  There is a significant overlap between medical conditions that are fairly non-specific in terms of diagnosis and treatment response like chronic fatigue syndrome, fibromyalgia, and chronic pain.  There are a significant number of people who present to medical and surgical clinics with symptoms and they never receive a diagnosis or an explanation for those  symptoms.  Familiarity with these syndromes will greatly assist in the diagnosis and treatment of these individuals if they are referred for psychiatric evaluation.  Specific knowledge of these conditions will allow the psychiatrist to consider an effective approach and effective patient education.

7.  Don't compromise your process because of extraneous variables.  The largest extraneous variable these days is the intrusion of business into the practice of medicine.  Psychiatrists may find that they are subject to limitations that do not apply to other physicians.  As an example, I have been told (by a managed care company reviewer) that psychiatrists don't diagnose or treat delirium when I was the only physician capable of making the diagnosis.   If you assess the patient and believe they need further diagnostic procedures or a medication trial that may be diagnostic do not give in to a case manager or pharmacy benefit manager who refuses to authorize what you need.  Make sure you communicate what you think the best possible care is to the patient rather than what the business people think.  Don't confuse medical quality with what a managed care company is calling "value".  They are probably unrelated.

8.    In the case of children, the best diagnostic approach looks at the family process both initially and in an ongoing manner.  The family should see the psychiatrist as someone who is not only an interested observer, but someone who can offer good advice right from the start of the process and recognize that symptoms in the identified patient can be a product of family dynamics.

9.    Take enough time.  The only valid way to make a diagnosis is to see the patient and interact with them in such a way that they feel understood.  Anything that takes away from that process can negatively impact on the flow of information and the task of providing that person with the best possible diagnosis and treatment plan.  The patient in this situation should not have the same experience they would have in primary care clinic discussing their depression or anxiety symptoms and the most obvious difference should be the total time spent talking with the patient.

10.   Review your findings thoroughly with the patient and family members if they are involved.  The process of psychiatric diagnosis differs from typical medical or surgical evaluations because of the sheer amount of data involved.   As an example, it might typically involve a sleep history similar to what might be obtained in a sleep lab with an additional 200 data points to look at the major diagnostic categories.  Even at that point there may be constraints on the data in terms of accuracy or detail that require corroboration of active debate.

11.  Know your diagnostic thought process - there a number of biases in the diagnostic process that have been written about in the literature on diagnostic decision making and in some journal features like the excellent series in the New England Journal of Medicine.  If you know the heuristics involved you can prevent diagnostic errors.

12.  Consult with your colleagues - consultation with colleagues serves a couple of useful purposes.  No matter how industrious you are it is impossible to see every possible presentation of every possible illness.  When you discuss patient presentations with colleagues who are also treating patients you are in effect extending your own pattern matching capability to include what your colleagues have seen and treated.   In many cases your colleagues have diagnostic and treatment experience with very low volume illnesses that are ordinarily seen a few times in the course of a career.

These are a few ideas I wanted to post today and there are a lot more.  Many of them seem like common sense, but the diagnostic approach to mental illness as practiced in most medical settings these days is anything but common sense.  You cannot get a comprehensive evaluation and diagnosis in ten minutes and you cannot really be walking out of a clinic with multiple prescriptions for medications that are supposed to work for that diagnosis in ten minutes.    

George Dawson, MD, DFAPA

Suggested Changes to Psychiatric Residency Programs

I received an e-mail two weeks ago that asked for my suggestions on immediately reforming residency programs for psychiatry.  I had the experience of completing my residency in two different university based programs.  My residency occurred at the height of the controversy between the self described biological psychiatrists and the psychotherapists and psychoanalysts.  Although I have never seen it written about there was open animosity between the groups at times.  A biological psychiatrist back in the day might make a statement like: "I don't do talk therapy".  A psychotherapy oriented psychiatrist might refer to the biological types as "Dial twisters" referring to an approach that suggested excessive biological reductionism.  Apparently neither group had read Kandel's seminal article in the New England Journal of Medicine four years earlier and how plasticity can be affected by talking, medications, and of course other experiences.

Several years ago, I attended an anniversary of the University of Wisconsin Department of Psychiatry, the program I eventually completed my residency at.  Thomas Insel, MD was one of the invited speakers.   He outlined a revolutionary approach to educating psychiatry residents that involved a joint 2 year neuroscience internship with residents from neurology and neurosurgery.  He did not provide any details.  When I sent him a follow up e-mail two years later, he said it would probably not happen on his watch.  I can easily build on that theme.  I think that a two year program focused on basic and clinical neuroscience remains a good approach.  The current approach to getting the relevant information is haphazard at best.  It depends on lectures in neuroscience being interspersed with clinical rotations of varying quality and to a large extent it depends on the faculty.  How many faculty are there and how many of them are expected to produce managed care style billings or "productivity" rather than high quality teaching.

A comprehensive and integrated approach that will teach state of the art neuroscience and provide the relevant training in neurology and medicine is possible.  There are many obvious areas for improvement.  Residents often spend their time on clinical rotations of minimal relevance for psychiatrists.  I can recall learning ICU medicine and needing to familiarize myself with various tasks (Swan-Ganz catheters, central lines, ventilator settings, dopamine drips, balloon pumps) that I would never use again.  I needed to be seeing hundreds of people with heart disease, arrhythmias, hypertension, diabetes, other endocrine disorders and neurological disorders.  I saw many of those people when they were hospitalized, but seeing these folks in ambulatory care settings designed to enhance the learning experience for a psychiatrist would provide a better experience.   The process should probably start earlier in the fourth year of medical school.  Prospective psychiatrists should be focused on electives in neurology, medicine, and neurosurgery rather than psychiatry.

The teaching of psychiatry needs to address the practical concerns about diagnosis and treatment but also philosophical concerns.  Residents need to be familiar with the antipsychiatry philosophy and the existing literature that refutes it.  Residents need to know about the issue of the validity and reliability of psychiatric diagnoses and how that is established.  There is actually a rich history of how that came about but it could easily be summarized in one seminar.  One of the features that I was interested in when I was interviewing for residency positions was whether or not the program supplied a reading list.  There were surprisingly few that did.  This subject area would be a good example of required reading that is necessary to bring any prospective resident up to speed.

A good model to illustrate the difference between a neuroscience based approach as opposed to a symptoms based approach is American Society of Addiction Medicine (ASAM) definition of addiction on their web site.  Unlike the DSM collection of symptoms designed to pick a group of statistical outliers,  the ASAM definition correlates known addictive behaviors with brain substrates or systems.  Both of the standard texts in the field by Lowinson and Ruiz and the ASAM text by Ries, Feillin, Miller, and Saitz are chock full of neuroscience as it applies to addiction.  When I teach those lectures, I generally am talking about how medications work in addiction at that level but also how psychological and social factors work at the level of neurobiology.  I have not seen the DSM5 at this time, but I do think that it is time to move past defining every possible substance of abuse and associated syndrome and incorporating neuroscience.  Especially when the neuroscience in this case has been around for 50 years.   Residency programs need to teach that level of detail.

Psychiatrists need to maintain superior communication skills relative to other physicians and that means getting a good basic experience in interviewing and psychotherapy techniques.  At the same time - the psychiatrist of the future needs to be able to order and interpret tests including ECGs and MRI scans.  That wide skill base taxes every faculty except the very largest academic departments.  In the Internet age, there is really no reason that every residency program should not have access to the same standardized PowerPoints, lectures, and didactic material.  The ASCP Model Psychopharmacology Program is an excellent example of what is possible.  I would go a step beyond that and say that there should be a culture within organized psychiatry so that every psychiatrist should have access to the same material.  Establishing a culture where everyone (trainees and practicing psychiatrists alike) is up to speed and competent across the broad array of topics that psychiatrists need to be familiar with is a proven approach that is rarely used in medical education.

Psychiatry also needs to be focused on old school quality.  Not the kind of quality that depends on a customer satisfaction survey.  The issues of diagnostic assessment and appropriate prescribing at at the top of the list.  How do we make sure that every person consulting with a psychiatrist gets a high quality evaluation and treatment plan and not a plan dictated by a managed care company?  The University of Wisconsin has a paradigm for networking with all physicians in their collaborative Memory Clinics program.  I see no reason why that could not be extended to different diagnostic groups across the state.  The focus would be on quality assessment and to prevent outliers in terms of treatment.  It could be open to any psychiatrist who wanted to join and it could have additional benefits of providing university resources like online access to the medical library to clinicians in the field.

An interested, excited, and technically competent psychiatrist is the ultimate goal of residency and it should continue throughout the career of a psychiatrist.  That can only happen with a focus on professionalism at all levels.  My definition of professionalism does not include managing costs so that  a managed care organization can make more money.  Psychiatrists need to forget about being cost effective and get back to defining and providing the best possible care.   

George Dawson, MD. DFAPA