Abstract Art

When I was a kid in a small town we had the same art teacher for the first eight years.  There were five elementary schools and Mr. Cooper would travel to all five schools and try to teach us art.  I just recently learned that he also taught art in the same way in elementary schools in the surrounding small towns.  When I went to junior high school I was surprised to see him in the 7th and 8th grade teaching in an old art deco building on the high school campus (my high school was grades 7-12).

The format in his classes was generally the same.  He would spend the first 10-15 minutes talking about art - usually a specific artist or groups of artists, or a technique.  A couple of times a year he would bring in a large orthographic projector that would allow him to project pictures from art books onto a movie screen.   He would typically turn us loose for the last 45 minutes using a specific technique.  During that time he would walk around and make comments on what we were doing and make suggestions on how to improve our art.  Mr. Cooper was very serious and talked with us in a serious manner even though we were kids.  He was serious about art.

The most memorable sessions for me involved finger painting.  That day we would all get a blank piece of white paper.  Mr. Cooper would walk around and place a dollop of thinned wheat paste onto the paper and tell us to spread it around.  He would them come around and place red, blue, green, and yellow powdered paint on the corners of the paper - several tablespoons of each.  For a class of 20-30 kids it takes a while to set all of that up.  Before he could get back up in front of the class, 90% of the kids were already smearing the paint around and 98% of them had smeared it all together.  The standard mix resulted in a lavender clay colored product.  When that happens you are limited to geometry - whatever lines or shapes you could put into the surface.  The few people who keep their colors separate - had many options based on the primary color options and combinations of those colors.  I have never thought about it before but this is a science intersection of sorts - more degrees of freedom or combinations from the basic step of not mixing all of your paint together.

I was one of the people who never mixed the colors together.  I liked the boundaries between bright colors and the areas of pure bright colors.  I liked the non geometric shapes stretched across the paper through numerous color zones.  There was something very satisfying about creating a painting from this simple technique.  At the same time, we were presented with art work by the masters.  We saw plenty of meticulous realistic art from the masters of several eras.  Even then it seemed like many had an abstract quality.  I can remember liking Edward Hopper's work at first sight.  This Andrew Wyeth image had the same effect.  Over the past 40 years, I have studied art where I could find it but I always gravitate to the abstract.  If I have a choice it is typically color field artists like Hans Hoffman, but any abstract artist will do.  I used to tell myself that I would start painting again in my spare time, but practicing medicine these days is not conducive to spare time or doing anything creative during it.  My wife and I do have time to appreciate local abstract artists and purchase some of our favorite pieces like the work of Steve Capiz below (click to enlarge):

    
The artist in this case has been painting abstracts for 50 years and he is still going strong.  He is currently painting very large canvasses on the order of 6-10 feet high and wide.  The last time I was in his gallery there were probably 40 - 50 paintings on sale and I honed in on exactly two of them including the one above.  If you walk into my house you will find the above 36" x 36" painting to the right of the entrance and as you look across the room to the left there is a 48" x 48" abstract above a fireplace in your line of sight.  If you look down the stairwell there is a large print - Morris Louis #2703.  There are four other paintings by Steve Capiz throughout the house.

The reaction to abstract art is always interesting.  When I post some of the art on my Facebook page, friends often comment on what the painting looks like.  It seems like a projective test.  My wife takes the interior design approach.  The colors of the painting need to "pull together" the colors in the room.  Our painter wears a T-shirt that says: "Don't buy art to match the furniture."  He encourages my wife to listen to me when it comes to abstract art.  But I am really not aware of why I love abstract art and why I can discriminate enough to select 2/50 paintings from my favorite artist.  Did it have something to do with my fingerpainting experience?  Or is my brain set up to fingerpaint in a certain way and be attracted to abstract art?  My life experience has certainly been broadened by art.  I have no idea how it has affected my thinking.  Some of those details are known for musical performance.  Learning to play the cello and clarinet has probably led to some enduring changes in my brain plasticity.

Experiments aside - I am glad I met Mr. Cooper when I was a kid.  It has been my experience that you never know enough at the time to optimize your experience with good teachers.  That is as true for art as it was for neuroanatomy.

George Dawson, MD, DFAPA

Accountability - The Last Refuge of a Scoundrel

On April 7, 1775, Samuel Johnson said:  "Patriotism is the last refuge of a scoundrel."  His biographer had to clarify that Dr. Johnson was not talking about love of country but "pretend patriotism which so many have made a cloak for self interest".  We see the rhetorical application in American elections where politicians spend more time on discussions of their military records rather than issues relevant to any kind of plan that they have for the nation or solving any real problems.  Nunberg makes the observation that that the term can also mean an irrational bias favoring one's country and that Americans have applied the term indiscriminately at times. He also points out that it can be a word designed to put people on the defensive.  

If I had to pick a word in the medical field that has similar uses - it would be "accountability".  There has probably been no single word more responsible for facilitating managed care and recent government intrusions into the practice of medicine.  If you think about the premise of physicians being "accountable" to politicians and businesses - it is absurd on the face of it.  Taking a professional who has been trained to be accountable to an individual patient and who operates in a professional environment that specifies behavior toward that person and telling them that they are now going to be monitored by businesses with a goal of maximizing profits or politicians with numerous conflicts of interest and a clear interest in getting re-elected - is an ongoing disaster.  So  how has it happened?  I would suggest that most of it has to do with rhetoric.

Before I point out the medical applications of the accountability rhetoric let me say that I don't consider this to be specifically applied to medicine.  Accountability rhetoric is broadly applied by any person or group seeking some kind of political advantage.  An obvious example is education and teaching.  Politicians everywhere get a lot of mileage out of the idea that they are going to hold teachers accountable usually through standardized test scores.  It has become a pat answer to taxpayers concerns about the money being spent on education and low graduation rates.  In some states, the test scores are marched out every year and used to rank schools and teachers.  Never mind the fact that the school system that produces the top international performance scores does not work that way.  In Finland, a professional teaching culture is by far and away the most significant factor in their academic excellence.  In the book written about this the teachers say they would not tolerate the kinds of intrusions that are common in the United States.  These intrusions are all based on accountability rhetoric.  

In preparing for this post, I searched my e-mails from the past three years and found 1800 e-mails containing the word accountability.  Most of those hits were due to the Health Insurance Portability and Accountability Act (HIPAA).  If you read the long title of this act it was clearly doomed out of the box.  The major impetus for the PPACA (Obamacare) was health insurance portability suggesting that HIPPA was already a failure.  That did not deter legislators from including a Privacy Rule under HIPAA to supposedly crack down on privacy violations.  My read of the bill is that is actually broadens the use of anyone's medical information among all "covered entities" affiliated with your health plan.  In the meantime,  the Privacy Rule was so threatening that it almost immediately made it more difficult for the doctors doing the work to get access to data.  Was it necessary for physicians?  Absolutely not - physicians are trained in medical privacy and all broad breaches of medical privacy have been due to either hacking or business people losing computers with significant amounts of data.  Make no mistake about it - politicians will be there to make the most accountable people accountable and greatly decrease their efficiency.   A great example of the title of this post.

I have recently posted a number of examples of accountability rhetoric being used for political leverage against physicians.   It can be used by medical boards, advocacy organizations, state agencies, federal agencies, and specialty boards in addition to politicians.  I am going to focus on a single example and that is Medicare.  All of the information that follows is public and can be accessed through the Medicare link on the American Psychiatric Association's web site.  I picked it up on my Facebook feed but it disappeared and I had to call APA staff to figure out where it went.  I am very familiar with the history of Medicare quality initiatives because I was one of their quality reviewers for inpatient hospitalizations in Minnesota and Wisconsin in the late 1980s and 1990s.  If you look for inpatient psychiatry measures you will find that many of them (polypharmacy, multiple drugs from the same class, discharge planning) are unchanged from that era, despite the fact that the review organization was disbanded because it did not find enough quality or utilization problems to justify its ongoing existence.

The APA points out that Medicare now has a fee scale that takes into account "quality of care measures instead of just paying a standard fee for every procedure (CPT) code".  They have a Physician Quality Reporting System (PQRS) that requires psychiatrists to report on one measure in order to avoid a 1.5% penalty.  For 2013 that report has to be made on one Medicare patient.  This is described as an "incentive" to report on quality performance measures and of course a "penalty" for those who fail to report.   A managed care company would call it a "holdback" in that it is technically work that has been done, but the no cost way to turn it into an "incentive" is just to take it from the people doing the work and make it seem like they are rewarded with it later.

The document goes on to document "measures identified as pertinent to psychiatrists (along with their designated codes)".  If you are a psychiatrist read through these reporting measures and marvel at the morass of initial codes that I am sure are going to grow as this administrative nightmare continues.  The further problem is that Medicare/CMS clearly has the goal of comparing physicians and holding them accountable based on the fantasy that these measures actually mean something in clinical practice or even the world.  And if this list of measures is not enough, there are also 50+ page guidelines online like: "The American Medical Association-convened Physician Consortium for Performance Improvement - Adult Major Depressive Disorder Performance Measurement Set" that describes an additional set of performance measures.  The AMA is involved and if you click the link 2013 PQRS Quality Measures you can search on Major Depressive Disorder and find the following links.  You can download the 50+ page document from the top link.

Most people realize that physicians currently have some of the highest burnout rates of any group of professionals.  Those burnout rates are directly related to micromanagement even before we get to the level I just described in the above paragraphs.  The paradox that every physician is aware of is that these reportable measures are not valid objective markers and they are being promoted by bureaucrats who not only have no accountability but in the case of the mental health system of care are some of the same people who destroyed it in the first place.  Don't forget that Congress skewed insurance coverage of mental illness and addictions so badly that Senators Wellstone and Domenici had to write legislation in an attempt to correct that.  At this time the final form of their legislation is still pending.

So accountability has become the last refuge of scoundrels.  Be very skeptical of any politician or bureaucrat waving that flag.  It has little to do with reality and more to do with promoting their own self interests while creating a tremendous and unnecessary burden for the doctors they regulate.

George Dawson, MD, DFAPA

Nunberg G.  Going Nucular: language, politics, and culture in confrontational times.  Cambridge: MA Perseus Books Group, 2004.

For a complete analysis of political doublespeak as applied to medicine see:

Robert W. Geist:  Hot Air Index: Political/Commercial Double-speak Lexicon for Medicine

Sleeping Cleans Your Brain

Why we need sleep and what happens during that process is an area of great interest for both the basic and clinical neurosciences. I recall listening to a lecture by Giulio Tononi at the 75th Anniversary of the University of Wisconsin's Department of Psychiatry on a theory of how synapses were processed during sleep in order to renew the brain's learning capacity for the next day.

I encountered a fascinating paper in this week's Science magazine on a possible sleep function that I have never seen described before - flushing toxins out of the brain.  The lead author hails from the Division of Glial Disease and Therapeutics, Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical School.  That probably says a lot about the focus of the paper and that is the movement of interstitial fluid (ISF) as it circulates through the interstitial spaces around neurons and removes toxic waste products including β-amyloid (Aβ)  Since the brain lacks a lymphatic system convective exchange between CSF and ISF controls this turnover.  One author named the system the glymphatic system since the system is dependent on astrocytic aquaporin-4 (APQ-4) channels for establishing the  convective movement of ISF and this is homologous to peripheral lymphatic movement and removal of toxic byproducts from peripheral tissue by the lymphatic system.  The authors also note that the observation that (Aβ)  protein has been observed to be at a higher concentration in the daytime as opposed to during sleep.  To explain this one hypothesis was that production was greater in the daytime.  They tested the alternate hypothesis that glymphatic clearance is greater at night.

The basic experiment for the paper involved teaching mice to sleep on a two-photon microscope.  That allows imaging of dye moving through living tissue.  The researcher would inject mice with  green dye at sleep onset and red dye upon awakening.  They could determine that during sleep a much higher volume or CSF flowed through the brain.  They also injected labelled (Aβ)  protein and showed that the brain of a sleeping mouse cleared these proteins twice as fast.  The art below shows the experiment and the 60% increase in channels carrying CSF during sleep.  I would encourage anyone interested to read the original in color as Science has outstanding graphics.  To download my original PowerPoint slide use this link.

The authors went on to demonstrate that the increase in interstitial space was a sleep related phenomenon because it could be induced by natural sleep and anesthesia but not circadian rhythm.  In looking for a mechanism they postulated that adrenergic mechanisms associated with arousal like locus ceruleus derived noradrenergic signaling was involved.  They demonstrated that adrenergic antagonists could induce the expected increase in tracer influx and interstitial volume so that it was similar to what was seen in the sleep state. 

Implications for psychiatry?  To some extent, those of us interested in neuroscience and not forgetting what we learned in PChem will always be interested in article at the interface between the biochemical and the biophysical.  Despite having this elegant system coupled with our arousal state and metabolic state none of this information was around during the recent Decade of the Brain.  The authors discuss the sensitivity of neurons to various toxic products and proteins and the implications for neurodegenerative diseases.  I can start with insomnia and build from there.  People with addictions can have sustained insomnia and associated impairment in cognition the next day.  Delirium also affects the sleep-wake cycle and some experts have suggested that two different types of delirium can be distinguished based on EEG spectra.  The obvious questions are is the insomnia associated with these states literally toxic to the patient by restricting ISF clearance?    Another key correlate mentioned by the authors is the decrease in ISF with age.  Does that account for the predisposition to delirium and protracted delirium as people age?  And finally what about the toxicity of medication?  We are used to receptor based explanations of why certain medications have sustained or unexpected toxicity.  How much of that is due to a collapsed ISF and restricted clearance to the CSF?

Brain energetics is also an interesting question specifically the AQP-4 channels.  Most psychiatrists are familiar with the renal aquaporin channels when considering renal water metabolism.  The fact that you have these channels on astrocytes and that removing them reduces (Aβ)  clearance by 65% is fascinating and seems like another potential intervention point for brain disease.  What needs to happen to keep these AQP-4 channels healthy and what happens when they are not? 

There are many more questions that come to mind based on the mechanism these authors have elucidated.  I hope that papers like these are translated into both clinical research and our thinking about newer and more innovative ways to think about whole brain function and think about all of the mechanisms instead of just the usual receptors.

George Dawson, MD, DFAPA

Xie L, Kang H, Xu Q, Chen MJ, Liao Y, Thiyagarajan M, O'Donnell J, Christensen DJ, Nicholson C, Iliff JJ, Takano T, Deane R, Nedergaard M. Sleep drives metabolite clearance from the adult brain. Science. 2013 Oct 18;342(6156):373-7. doi: 10.1126/science.1241224. PubMed PMID: 24136970

Footnote:  I decided to update (12/13/2013) this post by adding this interesting piece of news.  According to Altmetric, this paper received the 4th highest rating of online interest in scientific papers.  For the Top 100 papers click on the link.

Stigltiz Commentary and The Implications for the Politics of Psychiatry

Nobel prize winning economist Joseph Stiglitz came out with a recent commentary of the economic recovery and why things are not a rosy as they seem.  He points out that many of the structural problems with the economy including predatory lending and credit, abuses by the credit card industry and abuses by the credit reporting industry are still in place.  In addition there are inadequate capital reserves and no real limits on the kind of low risk speculation by certain parts of the financial services industry - the basic problem that started everything 5 years ago.  I have been posting in political forums for the past 15 years that the American economy at times seems to be based on a fantasy rather than the way a real economy should work.

We have taken an alleged retirement system (401K, 403B) and turned it into a windfall for the financial services industry.  Instead of an actual retirement system, we find that the average American is not able to put away nearly enough to retire and in the process ends up paying significant fees to financial services companies.  In return for these fees they receive the standard boilerplate about no guarantee against losses and frequently have very poor investment choices since they are determined by their employer.  At the same time, low risk retirement vehicles like money market funds are paying negligible amount of interest.  Rather than being a reliable retirement system this is essentially another tax on the American people to fund the financial services industry.  Retirees are left with the option of accumulating cash only or putting their retirement funds at significant risk all of the time in order to accumulate enough capital to retire.

We are in the process of starting a huge health care mandate know as the PPACA or more popularly as Obamacare.  It will create a large influx of capital into the healthcare system based on coverage mandates.  The American health care system is currently the most expensive system of health care in the world.  The standard model used by the federal and state government has been to use managed care companies as intermediaries to contain costs.  There should be no doubt that model is a near total failure.  Recent data for example suggest that a couple nearing retirement should have an additional quarter of a million dollars saved for health care expenses during retirement beyond the cost of Medicare.  The health care system in this country can be viewed as a second tax on the American people.

How do Americans end up with two additional taxes being levied on them in addition to the usual income, Medicare, Social Security, sales, and property taxes?  How does it happen when we have a supposed radical element of one of the major parties working on fiscal responsibility?  I think it comes down to one American institution and that is the US Senate.  The Senate is full of aging, wealthy politicians who have worked for years to develop a power base in Washington and keep it.  They are completely out of touch with what the American people need and pass laws that will largely benefit the businesses that they are heavily lobbied by.  In some cases, they wrote the laws to invent the industry.  The disconnect of this group from the public was evident during the recent stand off to shut down the government and nearly default on our creditors.  In other words they risked the world economy to make a point instead of fairly representing what the average American wanted at that time.

How does all of this apply to the politics of psychiatry?  I can illustrate by looking at a few seminal events that apply to all front line psychiatrists and how their professional organization - the American Psychiatric Association (APA) responded:

1.  Managed care and the disproportionate rationing of psychiatric services:  Apart from Harold Eist, MD and a recent lawsuit against a managed care company there has generally been silence on this issue.  Some literature was generated regarding how to work with meager rationed resources but nothing about how to fight back as managed care became a government institution.  The APA's support of collaborative care means we have come full circle and the APA is explicitly backing a managed care model that involves treating patients without actually seeing them.

2.  The response to accusations of conflicts of interest related to the pharmaceutical industry:  There was a well known initiative against some prominent psychiatrists, the motivations for that initiative are still unknown.  It is well known that many academics in many university departments have contracting arrangements with industries in order to supplement their salaries.  It is well know that some professions charged with determining industry standards insist on industry representation in meetings where those standards are written.  It is known that many professional organizations got more support from the pharmaceutical industry than the APA.  The response to the attack from a Senator was to basically acknowledge that his attack was accurate and proceed with an appeasement approach that allowed critics of psychiatry to use this as additional rhetoric against the profession and any psychiatrist with a contracting arrangement.

3.  The Maintenance of Certification (MOC) issue:  This issue was forced by the American Board of Medical Specialties (ABMS) based on limited research.  The APA immediately aligned themselves with the ABMS despite considerable complaints and a petition by the membership.

The three examples given about are some of the main political issues for psychiatry, particularly the average working psychiatrist and the APA.  To say that the interests of most psychiatrists are not represented by the APA is a massive understatement.   Like the U.S. Senate, the APA seems almost totally disconnected from the people it is there to represent.  I have heard many reasons over the years about how the actual structure of the APA is the problem.  But nobody seems to want to remedy that problem.  I attended a seminar at one point where an APA official explained the MOC issue and how it would actually create a financial burden for the American Board of Psychiatry and Neurology (ABNP), despite the obvious fee generation to take a commercially monitored and administered test.  If it really is that burdensome -  why do it in the first place?  The initial rationale was that the public demanded it.  It seems that there is now solicitation for public support.  Who would not support an initiative to improve the competency of doctors - even if there is absolutely no evidence that a multiple choice exam with a high pass rate does that?

I think it is highly likely that the political structure of the APA is very similar to the political structure of the Senate.  While there is no lobbying there are ideas and affiliations based on those ideas.  Any political structure that is so far removed from what its constituents want it driven by cluelessness, conflicts of interest, or a divine mandate.  It is only logical to conclude that like the Senate, the issue is conflicts of interest.  In the 21st century, patriotism is no longer the last refuge of a scoundrel - accountability is.  The APA would do well not to follow the Senate on that course.

George Dawson, MD, DFAPA

Joseph Stiglitz.  5 Years In Limbo.  Project Syndicate, October 27, 2013.

Cravings

"Unlike most of our crowd, I did not get over my craving for liquor much during the first two and one-half years of abstinence.  It was almost always with me......"  Doctor Bob's Nightmare.  Alcoholics Anonymous, Fourth Edition, New York City, 2001, p 181.

Craving to use drugs and alcohol is a common problem.  As Doctor Bob points out in the above quote, craving is rare for alcoholics beyond the acute detoxification phase, but protracted for many other drugs depending on the class of addictive compound and the pharmacological properties of the specific drug.   Apart from the biological determined heterogeneity of response to addictive compounds there are also the subjective aspects.  In order strive for more objectivity, modern psychiatry has established diagnostic criteria for disorders of interest.  These disorders are grouped in categories to seem uniform.  Depending on the criteria of interest there is a broad range of subjective experience and description when describing common problem like anxiety and depression.  Some people don't know the difference between them.  Others have a mixture of both.  Some people are anxious all of the time independent of their surroundings.  Others get depressed or panic only in certain situations.  The interpretation of what a person considers to be a craving is as diverse.

Craving for an addictive drug or alcohol comes in many forms.  It can be a perception of a physical property of the actual compound itself such as the taste, odor, appearance or consistency.  It can be physical acts associated with its use and a common example there is a feeling that cigarette smokers get when they feel like they need to do something with their hands after they stop smoking.  It can be cue induced like being offered a drug or being in a place where previous drug transactions occurred.  It can be recall of the first intense and protracted euphoric experience of using the drug even though that has long passed related to tolerance.  The overwhelming affect associated with craving is anxiety and fear because of the sign on an impending withdrawal or relapse.  The negative reinforcement that keeps addictions going after the initial states of positive reinforcement due to the euphorigenic effects of the drug is avoiding withdrawal.  Craving may be a signal that acute withdrawal is imminent or that there is a state of chronic withdrawal.

Craving has had an uncertain place in the field of addiction and the diagnosis of addictive states, largely because of the broad range of experiences associated with craving.  This diagrammatic summary shows that various groups have considered the definition to be too vague.  In other cases there was no consensus that craving was a universal enough phenomenon to be considered a diagnostic criterion.  That changed this spring when the DSM-5 added craving and eliminated legal consequences of drug and alcohol use as a diagnostic criterion.  Medications used to eliminate cravings probably led to that consideration, but people with cravings are more likely to relapse and have significant distress during recovery.

The addition of cravings to the DSM-5 opens up a whole new area of focus during encounters with people who have addictions.  Prior to this change the two major texts on addiction devoted about 3-4 pages to craving phenomena.  Addiction psychiatrists and addictionologists may have already been focused on this area, but I think that overall it makes ongoing assessments more dynamic because it is an intervention point for physicians and there are a number of medical and non-medical interventions that are possible.  Omar Manejwala, MD reviews the options in his very readable book entitled Craving.  This book is interesting because it gives a number of practical tips on how to counter cravings based on the substance involved as well as the importance of psychosocial interventions like 12-step recovery and how that might work.  Addiction science has probably been at the cutting edge of neurobiology for at least the past decade and with this focus there is often the implicit understanding that we are searching for some medication that will be an immediate solution to craving.  In some cases we have that medication, but I always emphasize that cravings at some point disappear and that there are non medication approaches to addressing them.

George Dawson, MD, DFAPA

Manejwala O.  Craving: Why We Can't Seem To Get Enough.  Hazelden, Center City, MN, 2013.

Definitions:

Neuropsychopharmacology The Fifth Generation of Progress (2002):  Craving is a powerful, "must-have" pull that causes addicted people to risk and sometimes lose, their relationships, families, money, possessions, jobs and even their lives. (p.1575)

No - I Don't Have Generalized Anxiety Disorder

I was reading a copy of JAMA the other day and a story written by a transplant surgeon Jeremy M. Blumberg, MD.  It was an excellent description of surgical training to the point of autonomy and then the nagging uncertainty of whether the surgery you have trained for years to do will go well.  Will you avoid mistakes?  He describes his first transplant as an attending:

"This operating room was new to me; the nurses were friendly but foreign.  The instruments were familiar, but somehow felt different - was there just a barely palpable increase in tension in the muscles of my hand causing this effect?  The patient's blood vessels were hard, thickened from years of dialysis and diabetes.  She bled more than usual when we reperfused the kidney.  It felt as if every last molecule of epinephrine had rushed out of my glands and nerves, squeezing my blood vessels and taunting my intestines to detonate...."  (p. 1676)

I hear you brother.  I thought that level of anxiety over the balance between doing the impossible and not doing harm might fade away over the years but it has not.  In psychiatry a lot of it depends on the level of complexity that your patients have.  It can be an acute situation but more often than not - it is a problem throughout the day that you take home with you.  Additional medical conditions, non psychiatric medications, polypharmacy, and difficult to treat disorders all compound the problem.  I have designed a hierarchy to illustrate what I mean.  It turns out that when I think about it, the acute problems seen by psychiatrists are not at the top.  The problems at the top are typically problems where there is no good guidance, where you are on your own, left with biologically determined probabilities and you need to come up with your best estimate of what will happen given current circumstances.  The problems encompass both psychiatry and the medicine associated with psychiatry.

Let me provide an example of both.  In the case of the psychiatric problem the usual scenario is a case of impaired judgment.  Is the person at risk for death or self injury?  Are they able to cooperate with the assessment and treatment plan.  Do they seem changed to the point that you can no longer accept their responses as being accurate?  Are you treating them for acute and chronic suicidal ideation and behavior?  Any acute care psychiatrist ends up assessing thousands of the situations across the course of their career.  It is often much more complex than an acute assessment.  Many of these scenarios unfold in the context of ongoing psychotherapy and in order for the patient to be able to improve some risk is taken.  In other cases there are calls to warn people and in extreme cases - calls to the police to check on a person who might be in trouble.  I have not seen it studied but the stress of these situations for the psychiatrist involved is well known.   Overthinking the situation in order to avoid the unexpected call that one of your patients has suicided or killed someone is common.  In my conversations with medical students over the years, one of the main deterrents to psychiatric residency is the worry about suicide prediction.

The medical situations are as complex and they frequently have no clear solution.  A common scenario is that the person has a severe mental illness and they develop a problem that leads to to rethinking the medication they are taking.  A common scenario is a person on maintenance therapy who suddenly develops a renal or hepatic problem necessitating a change in therapy.  The best example is bipolar disorder and lithium therapy.  Lithium remains the drug of choice for many people with bipolar disorder and it can be highly effective.  When I first started to practice it was common to see people who had repeated institutionalizations for bipolar disorder suddenly stabilized on lithium.  Their functional capacity was restored and they were able to return to work and establish families.  In those early days, the issue of lithium nephrotoxicity was not clearly observed.  There was a major study of people on lithium maintenance for decades that showed no difference in renal function.  In the last 15-20 years most nephrologists agree that lithium can lead to renal insufficiency and failure in a minority of patients on lithium therapy.  In the case of a person that lithium has been working well for 30 years, there is no guarantee that anything else will work as good.  That translates to no hospitalizations in a long time to frequent hospitalizations every year.  Monitoring that therapy and in some cases following the patient while they are in dialysis or after transplantation is on example of a situation that you can't leave at the office.

In many ways, the stress and anxiety in psychiatric practice is a measure of attempting to predict the unpredictable.  Psychiatry has accurately said that psychiatrists can't predict future behavior or rare events to explain why all suicides and homicides cannot be prevented.  But some sort of probability statement is inherent in all medical practice.  I would estimate it still happens to me about every three weeks.  Something isn't right and I don't have an exact answer.  It becomes an obsession to an extent.  Laying awake in bed.  Getting up to do some additional research but realizing ahead of time that the yield is low.  Realizing that no matter what decision you make - all of the outcomes are probably going to be suboptimal.  You always get to the point where you  can feel the adrenaline molecules rushing and your heart pounding.  You know you are tense and starting to break into a light sweat.  You readjust yourself in bed and realize your back and shoulders are as tight as a frozen hydraulic jack.  You might actually check your pulse and blood pressure and find that  they are elevated.  It goes on like this until something happens and the intellectual crisis abates.  Sometimes that takes a while - at one point months and a beta blocker to break up the stress induced tachycardia and hypertension.

No I don't have generalized anxiety disorder - I am a doctor trying to deal with the uncertainties of being human.

George Dawson, MD, DFAPA

APA Continues to Hype Managed Care

This YouTube video is fresh off my Facebook feed this morning from the APA.  It features American Psychiatric Association (APA) President Jeffrey Lieberman, MD discussing the advantages of a so-called collaborative care model that brings psychiatrists into primary care clinics.  I have critiqued this approach in the past and will continue to do so because it is basically managed care taken to its logical conclusion.  As opposed to Dr. Lieberman's conclusion, the logical conclusion here is to simply take psychiatrists out of the picture all together.

A prototypical example of what I am talking about is the Diamond Project in Minnesota.  It is an initiative by a consortium of managed care companies to use on of these models to monitor and treat depression in primary care clinics in the state of Minnesota.  In this model, patients are screened and monitored using the PHQ-9 a rating scale for depressive symptoms.  Their progress is monitored by a care manager and if there is insufficient progress as evidence by those rating scales, a psychiatrist is consulted about medication doses and other potential interventions.  The model is described in this Wall Street Journal article.  As is very typical of articles praising this approach it talks about the "shortage" of psychiatrists and how it will require adjustments.  In the article for example, the author points out that there would no longer be "one-to-one"  relationships.  There are two major problems with this approach that seem to never be not considered.

The first is the standard of care.  There are numerous definitions but the one most physicians would accept is care within a certain community that is the agreed upon standard provided by the same physician peers.  In this case care provided by all psychiatrists for a specific condition like depression.  There are professional guidelines for the care of depression and in the case of primary care guidelines for care provided by both family physicians and internal medicine specialists.  One of the tenants of this care is that physicians generally base treatment of an assessment that they have done and documented.  The only exception to that is an acceptable surrogate like a colleague in the same group covering a physician's patients when they are not available.  That colleague generally has access to the documented assessment and plan to base decisions on.  This is the central feature of all treatment provided by physicians and is also the basis for continuity of care.  As such it also forms the basis of disciplinary action by state medical boards and malpractice claims for misdiagnosis and maltreatment.  An example of disciplinary action based on this standard of care is inappropriate prescribing with no documented assessment or plan - a fairly common practice in the 1980s.

In all of my professional life, the standard of care has been my first and foremost consideration.  It is basically a statement of accountability to a specific patient and that is what physicians are trained to be.  Curiously it is not explicit in ethics literature and difficult to find in many state statutes regulating medical practice.  That may be due to the entry of managed care and the introduction of business ethics rather than medical ethics.  It also may be due in part to an old community mental health center practice of hiring psychiatrists essentially to refill prescriptions rather than assess patients.  This is addressed from a malpractice perspective by Gutheil and Appelbaum in their discussion of malpractice considerations and how they changed with the advent of managed care:

"Managed care is one omnipresent constraint.  Patients and clinicians must work together to fashion an appropriate treatment plan to take into account available resources and given the contingencies faced by the patient.  If that plan-properly implemented-fails to prevent harm to the patient, the clinician should not face liability as a result." (p 164).

They go on to explain how ERISA - the Employee Retirement Income Security Act of 1974 indemnifies managed care companies and their reviewers from the same liability that individual physicians have.  They cannot be sued for negligence and the resulting harm.  So managed care can take risks without concern about penalties as opposed to physicians who are obliged to discuss risks with the patient.  Managed care organizations can also implement broad programs like depression screening and treatment without a physician assessment and consider that their standard of care.

The second problem with the so-called collaborative care approach is that there is no evidence that it is effective on a large scale.  I pointed out this criticism by a group of co-authors including one of the most frequently cited epidemiologists in the medical literature.  That group has the common concern that a rating scale is a substitute for an actual diagnosis and everything that involves and given the recent FDA warning on citalopram.

Both of these concerns bring up an old word that nobody uses anymore - quality.  It is customary today to use a blizzard of  euphemisms instead.  Words like "behavioral health", "managed care", accountable care organizations", "evidence-based", "cost-effective" and now "collaborative care".  According to Orwell, the success of such political jargon and euphemism requires

"an uncritical or even unthinking audience.  A 'reduced state of consciousness' as he put it, was 'favorable to political conformity'." (3 p. 124)

Dr. Lieberman uses a lot of that language in his video.  The critics of psychiatry in the business community do the same.  There appears to be a widespread uncritical acceptance of these euphemisms by politicians, businesses and even professional organizations.

An actual individualized psychiatric diagnosis and quality psychiatric care gets lost in that translation.


George Dawson, MD, DFAPA

1.  Beck M.  Getting mental health care at the doctor's office.  Wall Street Journal September 24, 2013.

2.  Gutheil TG, Appelbaum PS.  Clinical Handbook Of Psychiatry And The Law. 3rd edition. Philadelphia: Lippincott Williams & Wilkens.  2000, p 164.

3.  Nunberg G.  Going Nucular: language, politics, and culture in confrontational times.  Cambridge: Perseus Books Group, MA 2004.

4.  American Psychiatric Association Principles of Medical Ethics with Annotations Espcially Applicable to Psychiatry.  2009 version.