A Gun In The Snow

A colleague of mine was out for a walk today.  It is a brisk winter day in Minnesota.  There is about 6 - 8 inches of snow cover.  He was walking across the street and found this handgun laying there.

He took a picture of the gun and called the police to pick it up.  They were there in 20 minutes.

My views on violence and gun violence are fairly well known. My recent position has been that arguing with gun advocates and the pro-gun lobby in Congress is futile.  But when I saw this posted on Facebook with the accompanying story I couldn't help but think: "Guns are so common they are falling on the ground like wallets."  Only a fool believes that this level of gun availability does not result in death and injury of all kinds including accidents, suicides, and homicides.  Only a fool believes that with this level of gun availability it is possible to prevent guns from ending up in the hands of people who are not competent to use them.  I live in a state that passed a concealed carry law that  is basically the right to carry a concealed firearm.  It passed a few years ago by tacking it on to unrelated legislation.  The gun and holster look like a common one that is sold to those who complete a brief concealed carry course.  The main argument of the concealed carry contingent was that they were supermen of sorts.  There was literally nothing that would compromise their judgment if they were carrying a handgun.  Since then there have been a number of incidents involving concealed carry owners showing that in fact problems happen.  In the most notable incident a concealed carry owner opened fire on an undercover police officer.  I think it is safe to assume that there are probably at least as many lapses of judgment involving concealed weapons as there are driving automobiles.  The main difference is that people spend more time driving.  The reporting of these incidents is not transparent and that is typical of much gun legislation.

On a worldwide basis, small arms fire is a leading cause of death and disability.  I had the opportunity to see how some of that was transacted when I lived in Africa for two years.  In travelling as little as 100 miles there were frequent roadblocks at times.  The intent of the roadblocks was not clear but each roadblock was manned by police or paramilitary personnel and everybody was heavily armed.  The American friend that I most frequently traveled with told me about a time he got out of his car to ask if there was a problem.  One of the police officers pushed the barrel of a machine gun into his chest and prodded him back to his car.  He previously served in a country where a fellow volunteer accidentally drove through a police checkpoint because there was nobody around.  It appeared to be abandoned.  He made it a short distance before he was shot through the head by soldiers out of sight up on a hill.

In the US, besides the obvious problems with the legal availability of firearms there is also the issue of the black market and stolen firearms.  Since 1994 an average of 232,000 firearms are stolen every year and 80% of those are not recovered.  Stolen guns account for 10-15% of the guns used in crimes.  The majority of guns used in crimes are purchased by proxy or so-called straw purchase sales including other tactics like diversion of guns to criminals by licensed gun dealers.  There are several common sense changes that can occur in firearm policy that might make a difference in the sheer number of firearms in the general population and their availability to criminals.

This week marked another school shooting.  It marked the anniversary of the Sandy Hook Elementary School shootings.  In practically every school shooting easy access to firearms is a major part of the problem.  There are clear models for what happens to firearm deaths when some restrictions are placed on their access.  Fareed Zakaria has a new feature Global Lessons on Guns on his Sunday news program GPS.  Last Sunday he reviewed gun policies in Japan.  Getting a license to have a firearm in Japan is very difficult.  The authorities need advance information on where it will be stored and they need a detailed floor plan of the residence where it will be stored.  In a country of 130 million people there were a total of 4 firearm homicides last year.  By contrast, in the United States with a current census of 317 million people, there were 31,672 firearm related deaths (see Table 1-1 and 1-2).  The example from Japan is also interesting because it looks at the issue of violent video games.  They are played at a higher rate in Japan than the U.S. and it obviously had no impact in the context of extremely limited gun availability.

Even though I think there are better approaches for psychiatry to focus on than strictly gun policy and confrontations with a pro-gun lobby we need a basic level of awareness that current gun laws in the US are probably not what the Framers of the Constitution intended.  I think they would be as shocked as anyone if they found a gun in the street.  They would be equally shocked to find out that 7 times as many Americans die every year as a result of firearms than died in the Revolutionary War.  (see Table 1)

George Dawson, MD, DFAPA

The Spine In Psychiatric Practice

I am not talking about the spine as a metaphor, I am talking about the real spine.  I am also not going to discuss some alternate therapies affecting the spine, I am going to refer to it only in the context of actual medical practice.  Maybe it was my interest in chronic pain and neurosurgery that led me to the observations, but many years ago I started to notice the high number of patients who were seeing me and had associated spine problems either associated with their psychiatric disorder or making it worse. As far as I can tell, this problem is really not well addressed in the psychiatric literature.

The spectrum of spinal disorder presentations varied from undiagnosed, to incorrectly diagnosed, to diagnosed and treated many times.  There is also the issue of how normal imaging studies vary greatly with age and eventually produce radiology reports that sound pathological but do not necessarily explain the observed pain or disability.  The usual psychiatric diagnoses included depression, anxiety, insomnia, and chronic pain.  The correct diagnoses were most often only possible by a detailed discussion of the problem.  In many cases the patients I was seeing had never actually seen a physician for back pain.  Let me illustrate with a couple of examples (none of these vignettes represent actual patients).

Patient A is a 35 year old woman being seen for depression.  She is in a stressful work situation because she is expected to be physically vigorous and move many 40 pound boxes of paper per day, but she is limited by neck pain and muscle atrophy in the left arm.  She injured her neck at a different job 5 years earlier lifting a heavy piece of equipment down from a shelf.  She felt immediate neck pain and over the next several weeks had muscle twitching in her left arm.  She did not have health insurance from her employer and was never assessed for the injury.  She has had daily pain since the injury and on days where she has more physical activity, she has more pain and more depression.  She is interested in treating the depression.

Patient B is a 50 year old man being seen for depression and insomnia.  He has a 5 year history of taking zolpidem for insomnia.  He is referred by his primary care physician because he has had to increase the dose of zolpidem to 20 mg/day because of worsening insomnia.  The patient gives a history of no longer being able to sleep on his right side because he has neck pain with radiation to the shoulder that resolves when he changes his sleeping position.  He has seen the Silenor and Lunesta commercials and is interested in changing his sleep medication.

Patient C is a 60 year old woman with a history of multiple upper and lower back procedures including fusions, discectomies, and foraminotomies.  She has also had surgical complications including infections and a cerebrospinal fluid leak.  She is taking oxycodone 40 mg QID with addition 5-10 mg prn doses of oxycodone.  She is also taking lorazepam 1 mg TID for anxiety and drinks wine on a daily basis.  She is referred for treatment of depression and chronic pain.

These three descriptions of patients highlight a number of problems unique to psychiatric practice.  Psychiatrists often see people with degenerative or traumatic changes to their spine that have never been assessed by a physician.  We also see patients who have had intensive surgical treatment and who have been treated in pain clinics for a long time before anyone thought to refer them to a psychiatrist.  In both cases an antidepressant seems to be a proxy for a psychiatric evaluation or an interview that seeks to determine if the spinal problem is a cause of depression, insomnia, or anxiety.  That type of evaluation is fairly straightforward but it does require time and the ability to do a medical and neurological review of systems and recognize common patterns of spinal syndromes.  The risks are minimal and the potential rewards are great for the patient.  I have had people ask me why I was asking them so many "medical" questions or report that their primary care physician wanted to know the same thing.   But I have also had people tell me that they were glad to know that they really had chronic pain from a fixable spinal problem rather than chronic insomnia and a need to take sleep medication forever.

This issue also highlights the issue of a physical exam in psychiatric practice.  When is it necessary and in what context can it be done?  In my first job I recall asking the clinic administrator whether she would provide a room and basic equipment for a physical exam.  She said that she would but in the three years I worked there it never happened.  If there is no adequate place to examine a patient I don't think an examination should be done.  There is also the question of the emotional relationship with the patient.  Many people seeing psychiatrists consider them to be their primary physician and have had many intense discussions with them over the years.  Psychiatrists should be aware of this emotional context and the meaning of any physical touch that occurs in that context and keep the assessment at the verbal level.  Referral to a physician who you know does a thorough neurological and spine exam is indicated for most cases, but in many cases you are seeing people referred from these physicians and it has already been done.  What about imaging studies?  My rule of thumb is to do them only if the patient has been physically examined.  I have physically examined people only in acute care settings and ordered imaging studies (CT and MRI) in that context.

On the positive side a lot can be done within the constraints outlined above, first and foremost is a detailed evaluation of the problem.  How is it that insomnia from neck pain can be treated for years as primary insomnia without any attention being paid to the cervical spine pain as being the likely source of that insomnia?  The only explanation I can come up with is a cursory evaluation of the pain.  Borrowing a page from Engel any psychiatric evaluation of a person with depression or anxiety, insomnia, and pain needs to be as comprehensive as possible.  The evolution of those problems since childhood and the relationship to physical and psychological trauma as well as other major life events needs to be detailed.  Assessing the patient for any possible addictions is another requirement.  A description of the pain and associated neurological symptoms is critical.  I like to review old records, imaging reports and the images themselves if possible.  There are a few of the highlights of what is necessary to come up with a psychiatric plan of care for people with spinal problems.  In many cases, a psychiatrist is the only person addressing their pain, even though they have a known diagnosis of degenerative disk disease and chronic back pain.  It is very useful to have referral patterns and treatment plans established to be able to offer treatment of the pain or associated spinal problem in addition to addressing the identified psychiatric syndrome.

The ability to help this group of patients also has training implications.  You don't learn about the spine, neurosurgery or neurology doing psychiatry rotations in medical school.  I was fortunate enough to have intensive exposure to these areas and to excellent clinicians.  I was also fortunate to work in a multispecialty clinic for 23 years where I had the benefit of discussing these cases with specialists from all fields.  I was also able to walk down to Radiology and discuss films with an excellent neuroradiologist.  The training suggested by Insel with a clinical neuroscience in psychiatry, neurology, and neurosurgery would enhance the evaluation of these problems. 

It pays to focus on both the central and peripheral nervous system when indicated.

George Dawson, MD, DFAPA

MCAT Hyperbole

The Medical Education issue of JAMA came out today with two articles discussing the new and improved Medical College Admission Test (MCAT).  I read both articles and they reminded me of the new and improved MCAT that I took back in the day when I applied to medical school.  I think that we were about two years into the new and improved version then.  I could not tell the difference between physicians selected on the basis of the old version, the new version or no versions of the MCAT.  I am sure that many of the professors that I identified with had never taken an MCAT.  Many were not trained in the United States.  Good doctors are good doctors and the idea that a multiple choice test will pick them seems about as likely as making accurate diagnoses of depression using a multiple choice questionnaire.

At the time I took the exam, there were all sorts of ideas about how you could select a "good" doctor.  They were in a trend where science was being deemphasized.  Somebody had the idea that you had to be "well rounded" with a liberal arts education.  Pure science majors might be frowned upon.  As a Biology/Chemistry major - did I stand a chance?  They had just phased out the General Knowledge section of the MCAT.  The rumor was it discriminated against students born and raised in rural areas with no access to museums, art, and theater.  As a Jack Pine Savage (I like the loose definition of a native from the natural range of Pinus banksiana) - I probably dodged a bullet there.  Critical thinking was emphasized.  It always is in these tests.  I took the GRE and they said the same thing.  It seemed like the critical phase of the admissions process was the interview.  I was interviewed by a Cardiologist who wanted to know if I was "aggressive" enough.  I did not know what he meant and stammered for quite a while.  Then he learned I was in the Peace Corps and said: "Anyone sitting in the bush for two years is aggressive enough for me."  He gave me a favorable rating.

The new MCAT promises to pick doctors of the future better.  It is described as being the product of a survey of 2700 shareholders.  It is supposed to be designed to test the competencies suggested in two reports - The Scientific Foundations for Future Physicians and Behavioral and Social Science Foundations for Future Physicians.  In the current JAMA article one of the authors defines 4 signals that the new MCAT sends for the future of medicine as summarized in the Table below (per reference 2):

Signals Sent by the MCAT Revision
1.	Focus on foundational competencies required of future physicians rather than specific undergrad courses.
2.	Candidates must be able to learn and think like scientists.
3.	Behavior interacts with biology.
4.	Critical thinking will be emphasized with a balanced testing between natural sciences and social/behavioral sciences.

None of these ideas seems revolutionary to me.  Looking at the second signal:  "Candidates must be able to learn and think like scientists."  I can think of no better way to do that than take a senior level chemistry or physics course from an interesting professor.  For me it was Physical Chemistry, the dreaded course of Chem majors.  You either were or you were not a Chem major based on whether or not you passed PChem.  It was the most mentally strenuous course I have ever taken and there certainly were no medical school courses that came close.  I can still recall studying thermodynamics and learning how Maxwell and Gibbs thought about things.  Our professor even digressed to talk about how long it took Linus Pauling to learn thermodynamics.  I still have thermodynamics swirling in the background whenever I see crystals dissolving in a solution, whenever I have to bring my car battery in the house to warm it up, and whenever I am thinking about complicated pharmacodynamic interactions.  Keep in mind that at the time I took the MCAT, science majors were out of favor.  The thinking at the time was that you would develop critical thinking from a liberal arts education with only the core science course (general chemistry, organic chemistry, quantitative analysis, and physics) being specified.  Unless you are Gauss, I think that generally involves some level of advanced training beyond what are generally the rote courses.

What actually happened to the cohort of physicians trained under the previous iterations of MCAT?  I am thoroughly biased by my undergrad training and always like to hear about other undergrad chem majors.  In the department where I previously worked there were two and they are excellent psychiatrists.  There are chem majors in every medical and surgical speciality and they are excellent physicians even if they did not have the same amount of humanities courses.  At the same time I have encountered excellent physicians from practically every undergraduate major ranging from music performance to applied mathematics.  The only logical conclusion is that the undergraduate medical education system can turn any reasonably bright group of people into physicians irrespective of their undergraduate majors or MCAT results.  It seems to me that some of these documents emphasize the MCAT as the limiting factor when there is no evidence to suggest that is true.  How can it be considered a signal when the signals are the same ones that have been important since formal education of physicians began?

The real area where physicians are produced is in medical school and if you want physicians to think like scientists that is also the logical place where it happens.  Recalling my biochemistry course in medical school - there was practically no memorization.  We had a seminar group (in addition to lectures) where ten of us were expected to discuss state-of-the-art biochemistry experiments at the time and on an ongoing basis.  Volumes of these papers were assigned - each emphasizing a specific concept.  We had to know the experimental methods and the limitations.  We were also expected to have a subscription to the New England Journal of Medicine and discuss any relevant research there.  The exams were essays about these experiments and methods.  They were 7 points apiece and you had to get a 6 or a 7 on each exam to pass.  There was an undercurrent of dissatisfaction by many with the typical complaint being that we would go into the board exams at a disadvantage because we were not memorizing metabolic pathways. 

During the clinical years, the formative process was seeing and identifying with professors who were excellent clinicians and scholars.  They did not have to be scientists in the Kandel sense of the word, but they needed to be scholarly, well-read, and experts in their field.  For me the most engaging process was being on a team with one or two of these folks, senior residents and me as the medical student. That dynamic learning environment was absolutely the best way to acquire the skills, attitudes, and knowledge base requires to be a physician.

So where does that leave me with regard to the messages of the main article and the opinion piece?  I think the science aspect of the MCAT is overemphasized but not for the reason that Cohen suggests in the editorial.  I have always believed that physicians should think like scientists and we are ethically obliged to provide scientifically based treatment.  The problem is that physicians are currently practicing in an unscientific environment.  Any scientist would be appalled at the number of pseudoscientific guidelines and quality markers that physicians have to adhere to.  They range from the purely financially based to management decisions negating any critical analysis that a physician may come up with.  The wringing of science out of medicine is a direct result of the political theory that funding private businesses to ration health care is an effective way to reduce health care inflation and it certainly is not.  I don't think it is honest to build medicine up as an intellectual endeavor when physicians will be routinely second guessed by administrators who often have only business training.  We need to tell the people who are truly interested in science to go into science and engineering and avoid medicine.  And if that is really true why are we interested in physicians thinking like scientists at all?   

Cohen's editorial has two issues that I would like to comment on.  The first has to do with what he describes as "skills previous generations of physicians had scant use for" among them "how to use resources parsimoniously".  As a member of the medical specialty that has been viciously rationed over the past three decades to the point where there are marginal resources to treat the most ill patients, I say it is time to get rid of the "cost effectiveness" argument.  It has been the battle cry of the managed care industry and you only have to look as far as your nearest emergency department to see the result.  Pricing is the largest single economic problem in American medicine and the best way to address it is to get the prices on par with other efficient health care systems (like Japan) and to suggest that managed care companies owning the means of production (MRI scanners, cardiology clinics, hospitals, etc) is a massive conflict of interest resulting in prices that are much higher than they are anywhere else in the world.

The second issue is Cohen's multidisciplinary team concept.  His view is that physicians need to "demonstrate antihierarchical teamwork".  His ideal team of the future eschews individual accountability and ability to function as a leader but also as an equally valuable member.  Like most other areas of medicine, psychiatric expertise and experience in this area is ignored.  I had a multidisciplinary team that met on a daily basis for 23 years.  We met during a time when the dark forces within managed care were telling us we didn't need to meet and we met during a time when they wanted us to meet so that they could put case managers on the team and tell us what to do.  Apart from the expected negative influences of managed care, teams depend on a number of practical issues including the number of full time employees and who is present when patients are admitted, discharged, and when their family members show up.  In those 23 years there were no other team members present for the time that I was present and I viewed it as my job to communicate what happened to everyone else.  The other practical matter and a significant cost factor that Cohen may wish to compensate for by parsimonious use of resources is defensive medicine and all that entails.

In conclusion,  I don't have a favorable view of either of these articles for the previously stated reasons.  The  best way to assure that future physicians have what it takes is to make sure that they have a practice environment that is intellectually and professionally stimulating.  Can you really expect that medicine can continue to attract high quality candidates from all undergraduate majors if the practice environment remains stagnant or deteriorates further?  You can't expect to have people thinking like scientists when they are managed like production workers by people with no knowledge of medicine or science.  At the very best, you will end up with highly frustrated overtrained professionals or at the worst a much wider range of skills than currently exists in the field.  By that I mean the spread of applicant qualifications will increase and the brightest people will go to any school that can get them placed outside of the current managed care environment as the health care system evolves into two tiers of care.

When that day comes, the nature of and scores on the MCAT will be meaningless.

George Dawson, MD, DFAPA

1: Cohen JJ. Will changes in the MCAT and USMLE ensure that future physicians have what it takes? JAMA. 2013 Dec 4;310(21):2253-4. doi: 10.1001/jama.2013.283389. PubMed PMID: 24302085.

2: Kirch DG, Mitchell K, Ast C. The new 2015 MCAT: testing competencies. JAMA.  2013 Dec 4;310(21):2243-4. doi: 10.1001/jama.2013.282093. PubMed PMID: 24302080.

My First Flu Shot

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

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

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

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

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

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

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

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

George Dawson, MD, DFAPA

The Selling of Medical Marijuana

I have been thinking about how to approach this topic for a while.  My experience is not the experience of most people because as a psychiatrist I am seeing some of the worst possible outcomes.  That usually involves psychotic symptoms, depression, severe anxiety and panic, paranoia or some combination of all of these symptoms.  I have seen a much larger group of people who stopped on their own, usually after getting paranoid or experiencing a panic attack.  A lot of people cannot stop smoking even when they have a clear medical problem.  In some cases they are using marijuana or some cannabinoid product for a specific medical problem despite the fact that they are not getting relief and I would not expect them to.  These folks are typically heavy smokers (blunts, spliffs, vaporizers) but like all pharmacologically active compounds the dose response curve is highly variable.  

The  epidemiology of major symptoms caused by cannabis use has become a lot clearer in the past 10 years.  Thirty years ago there was an isolated study showing that army conscripts who were marijuana smokers were more likely to develop schizophrenia.  There was also a prominent researcher at the time suggesting that populations where there were high levels of cannabis use did not have higher rates of psychosis.  But those populations did not have high quality epidemiological data.  The latest studies show significant increases in the likelihood of schizophrenia and mood disorders.  I think that this probably happens in a minority of people and probably those consuming the most THC.  There is a lot of discussion about the differences in THC content of marijuana in the 1970s relative to what it is now, but not much reliable data to back that up.  Since THC is a pharmacologically active molecule with known pharmacokinetic properties it is always a question of dose as well as potency.  Multiple doses will eventually get you to the same levels of fewer doses of a more potent product.  he need to avoid positive urine toxicologies for THC also drives the market in synthetic cannabinoids, since the word on the street is that taking these drugs does not result in a positive toxicology screen and jeopardize employment.

A recent public opinion poll shows (click  to enlarge).  The recent trend to legalize comes in the context of an increasing trend about using marijuana and other controlled substances for legitimate medical purposes and media portrayals of marijuana as a source of employment, entertainment, and alternative medicine.

There is not the same level of skepticism about marijuana as there is about psychiatric medications.  In that case, the drugs are approved as safe and efficacious by regulatory bodies.  There is no evidence that they cause problems at anywhere near the level of marijuana and yet the latter is generally given a bye in the media.  Incredibly, many states get around the legalization of a scheduled drug by making it a "medically necessary" substance.  In spite of the fact that cannabis has been around for over 850 years and tens of thousands newer medications were invented and used successfully, the myth that cannabinoids are necessary as a medication has been promulgated in an apparent effort to increase the legalization of this substance.  The Obama administration has taken a public stand on the medical marijuana issue saying that the state statutes stand, but that they will engage in a selective prosecution that targets organized and violent crime, especially if that crime involves children or increased access to firearms.

I think that medical marijuana is generally a concept that has little to do with medicine and more to do with the legalization of marijuana.  It would become much more obvious if there were exposes in the press about how prescriptions for medical marijuana actually work.  What has to be said in the interview to get the prescriptions and what are the incentives of these prescribers?  We have had a fairly constant barrage of criticism of psychiatrists prescribing non-addicting drugs to patients for legitimate FDA approved indications that are in aggregate safer than cannabinoids.  Where are the questions about an industry that is selling a potentially addictive drug that has no clear medical indication and the potential conflict of interest of the prescribers?  I certainly have no problem continuing to advise all my patients with, anxiety, mood, addictive, and psychotic disorders that they need to not use marijuana at all, despite the fact that they are getting advice that marijuana is good for anxiety, depression, and insomnia.  I also have no problem telling anyone who might want a medical marijuana prescription that medical marijuana is a political term that has nothing to do with the practice of medicine and as such - I am not a "prescriber".

The other physician dimension to this issue is overprescribing.  The current epidemic of prescription opioid use and resulting accidental overdose deaths is a good example.  Unlike marijuana, the opioids have clear indications for use and contraindications.  In aggregate, marijuana probably has a wider safety margin, but the prescribing dynamic is similar to opioids and antibiotics.  The physician is confronted with a highly motivated patient who wants to leave the office with a prescription and physicians have have varying levels of motivation and skill to deny a wanted but unnecessary prescription.

I have no problem with any state declaring marijuana or any cannabinoids legal for its residents to line up and purchase.  Although marijuana promoters always give the message that it is safer than alcohol, it has the same general parameters  of use and no real medical indication.  I do have a problem with involving medicine in an experiment to legitimize it for just about anything.  I also think that physicians should know better.  We ran similar experiments for drugs with clear medical indications like opioids in the past century and they did not turn out well.

George Dawson, MD, DFAPA

American Society of Addiction Medicine (ASAM):  ASAM Medical Marijuana Task Force White Paper.

Joseph Lee, MD on Marijuana Legalization and the Impact on Children and Adolescents.

Dr. Oz addendum:

An example about the type of information the public gets from the media can't get any better than this Dr. Oz episode "Is Weed Addictive?" on December 4, 2913.  The full details are not really provided at this time.  I saw a debate and one of the participants was Pamela Riggs, MD who provided standard information on the addictive properties of marijuana.

Dr. Oz posts additional comments on his blog and seems to confuse the issues of addiction, legalization, and medical use.  After talking how it is going to be widely available he concludes:

"As the trend towards legalizing this drug continues, we need to be aware of its risks and teach our children its proper place, which is in the pharmacy, not in the kitchen cabinet and certainly not in the school locker."

So it will be more widely legalized as a pharmaceutical that people will use that way?

I will post additional details of this broadcast as they become available.

Lessons From Google on How To Manage Physicians

This month's Harvard Business Review has an interesting article on managing technical professionals entitled:  "How Google Sold Its Engineers on Management."  One of the secondary goals of this blog is to point out how people who manage physicians are not only technically inept but in many cases openly hostile to the physicians they manage.  That is largely because the entire system is based on artificial productivity measures and practically all of the management is focused on how to get more artificial productivity out of physicians.  A classic example of this kind of management focuses on how many deeply discounted patient visits are seen per day.  Other tasks like chart checks, telephone calls, paperwork of various kinds, and the tremendous burden of managing the electronic health record and all that involves are not counted as productivity of any sort.  Physicians are basically expected to do all of that plus teaching and lecturing on their own time.  In one system where I worked you were given points for being a good citizen and eligible for some trivial reimbursement if it was apparent that you were doing more than cranking out RVUs (the standardized measure of productivity).

This whole system of management is archaic in that it is a system that was set up to manage production workers and not knowledge workers with technical expertise.  Physician managers seem oblivious to the fact that the product of their organization rests solely in the expertise of their doctors.  A healthcare organization will only be that good and it is in the interest of that organization to retain and develop the careers of the best physicians they can find.  That is not the prevailing way that employed physicians are managed.  In fact, physicians are micromanaged and their decisions are routinely second guessed.  In the worst case scenario, if the physician disagrees with the financially based decisions of their managers they can be fired or politically scapegoated for not being a team player.  Some physicians may be subjected to several of these confrontations per day often over trivial cost savings.  In psychiatry for example, the arguments often arise over length of stay considerations where there is a set reimbursement for a hospital stay and the manager wants the person out sooner so the hospital can make more money.  The patient care goals of the physician based on their technical expertise and the financial goals of the case manager are discrepant.  That conflict is compounded by the fact that the managers do not have the professional credentials or the accountability of the physicians they are literally ordering around.
    
How do they do it at Google?  I consider engineers and doctors to be equivalent professions.  They  both require years of study and ongoing study.  They both have professional codes of conduct.  If there is any management on the technical side, engineers and physicians both want those people to have the best technical qualifications.  In that context the HBR article was interesting.  At one point Google wanted to try a completely "flat management system" with no managers.  Many of the engineers thought that it might recreate an academic environment similar to graduate school and produce a similar level of excitement and creativity.  That model resulted in upper management being flooded with human resources issues.  They eventually developed a system of managers with few layers designed to reduce micromanagement.  The example given was that some of the managers have up to 30 engineers reporting to them.  According to the engineer interviewed for the article: "There is only so much you can meddle with when you have 30 people on your team, so you have to focus on creating the best environment for engineers to make things happen."  This is a foreign concept in managed care.  Not only are physicians micromanaged but their work environment if frequently manipulated by various managers to decrease both their productivity and work-life balance.  It is a set up for burnout and suboptimal intellectual performance.

The following table is a good example of the differences between how Google manages their engineers to remain a state of the art engineering company with an emphasis on technical expertise.  There are very few medical organizations that have a similar focus.  The ones that do are usually criticized by managed care companies and dropped from their networks for being "too expensive."  As a physician ask yourself which environment you would prefer to work in.  Imagine working on the most exciting and intellectually stimulating team you have ever worked on in your training compared with where you currently work.  As a patient, the question is no less significant.  Do you want a physician who is excited about practicing medicine, who is intellectually stimulated, and not burned out or do you want a physician as they are currently managed?

Google Managers	Physician Managers
Micromanagement is prevented	Micromanagement is the rule of the day
Work environment is optimized for engineering work	Work environment is optimized for managers
Respect for technical expertise and problem solving rather than title and formal authority.	Strictly chain of command often flows from people with no technical expertise.
Good manager empowers the team.	Good manager empowers themselves and their boss.
Helps with career development.	At the minimum does not care about career development and at the worst may try to actively interfere with professional career.
Has technical skills to help and advise the team.	Has no technical skills and often has no medical degree or license.
Productive and results oriented.	Productivity is measured in adjusting physician productivity units

I used to work in a clinic that was analogous to Google in that we were: "A clinic built by physicians for physicians."  Our mission was to provide care to all people irrespective of their ability to pay.  We did not have a lot of resources, but we were good at our mission.  The collegial atmosphere was excellent and we did not make a lot of money.  It was an incredible learning environment where psychiatrists routinely interacted with colleagues from all specialties.  It was acquired by a managed care company and was managed less and less like Google.  Today all of its management parameters rest fully on the right side of the table.

The best management for knowledge workers is known.  Why don't we see it applied to physicians?

And yes, that is a rhetorical question.

George Dawson, MD, DFAPA

Fantasy Foundation For The Preservation of Psychiatry

Psychiatry is on the ropes.  The content of this blog illustrates the prevalent biases against the field that all eventually trickle down to less resources to work with and managed care companies rationing those meager resources in order to make money.  One of my favorite fantasies lately is to think about what I would do to save psychiatry if I ran a foundation with significant resources.  I have thought about it long enough and hard enough to come up with a number of guideposts:

1.  Save the teachers - probably the most beleaguered people in the field these days are the teachers of psychiatrists.  There are a lot of bloggers out there complaining about the "ivory tower" academics who just don't know how life is on the front lines.  The usual gripe is that they make too much money or are in some kind of shady consulting deal.  How dare they dictate to the rest of us how to practice?  That has not been my experience, and I have probably taught as much to medical students and residents as the next guy.  I see people trying to make a living and teach at the same time.  I see people needing to meet absurd "productivity" expectations and teach at the same time.  Teaching in generally is not counted as "productivity" in a managed care environment.  I see people who give up their ability to type up more patient notes at noon so that they can give a lecture to mostly disinterested medical students or fatigued residents.  They end up typing those notes at night on what is supposed to be their own time.

When I ask myself what would help them the most it comes like a flash - free high quality graphics for PowerPoints.  I have a parallel blog with some ideas, but there is nothing like great graphics that are free to use and save your faculty hours of sleep trying to come up with their own and not violate somebody's copyright.  You would think that professional organizations, like the American Psychiatric Association (APA) would support this idea.  Like everybody else, they produce downloadable PowerPoint slides for their major journals.  If you read the small print, you are supposed to go to the CopyRight Clearance Center and pay a fee.  I paid a fee of $45 for a lecture to a class of 12 and $85 to lecture a class of 42.  That was to project the slide and include it in my PowerPoint for the day.  I currently give about 32 lectures a year.  Considering the reimbursement I get for the lecture, it is not a commercial presentation, and I have been paying lots of money to the APA for about 30 years - you would think I could get a break.  As the head a a great foundation, I would purchase the rights to several good resources like Blumenthal's Neuroanatomy Through Clinical Cases or Atlas' MRI of the Brain and Spine and make them freely available to any instructors of psychiatrists.

2.  Free neuroscience conferences - there need to be much better basic science courses to bring clinical psychiatrists up to speed on the latest neuroscience and how it applies to the field.  Typical conferences are centered around some clinical activity that most of us are doing anyway.  Do we really need to hear more about something that we are doing everyday?  Something that we know everything about including the usual limitations?  Why not expand back into a consciousness based discipline looking at innovative ways to conceptualize problems and solutions.  Neuroscience is critical to that and there are several very articulate voices in the area.  I would plan a conference every years that was free to psychiatrists for 2 - 4 days of neuroscience.  There is a lot of neuroscience out there and I would ask some of the top journals like Nature, Science, Neuron, Biological Psychiatry, and Molecular Psychiatry to submit a program of Neuroscience for psychiatrists.  I would award the grant competitively to the best submitted program.

3.  Free computerized psychotherapy and an affiliated institute of psychotherapy using computers - I previously posted about John Griest's work in computerized psychotherapy and its effectiveness.  The whole point of the post was to emphasize a significant source of non-medication based treatment that is essentially not limited by manpower requirements.  There are several groups who have implemented this already, but to my knowledge none of them are major U.S. health care organizations or managed acre companies.  The commonest managed care approach is to give everyone a non specific depression rating scale, call that a quality marker, and then put as many people on antidepressants as soon as possible.  There is enough IT available that a foundation could take the lead in this area, develop the programs, and accept referrals from psychiatrists across the country for specific types of computerized psychotherapy.   

4.  Free clinical workgroups -  I have posted on the University of Wisconsin Memory Clinics collaborative clinical network across the state that focuses on maintaining a high level of expertise in all of the cooperating clinics for the diagnosis and treatment of Alzheimer's Disease and other dementias.  There is no reason that model cannot be extended to Depression, Bipolar Disorder, Post Traumatic Stress Disorder, or Attention Deficit Hyperactivity Disorder.  When people talk about collaborative care, they are usually talking about a managed care model that marginalizes psychiatrists.  A recent post suggested that some of the promoters of the managed care model have challenged naysayers to come up with an alternative.  I am a naysayer to anything that resembles managed care and the UW model is definitely a competing model that emphasizes psychiatrists at the top of their game in diagnosing and treating mental disorders.  That would be my priority over a managed care model that is so watered down, you don't even need a psychiatrist on the premises.

5.  An independent certification process - The American Board of Medical Specialties (ABMS) has a chokehold on all board certification processes with the exception of the American Board of Addiction Medicine (ABAM).  ABAM has their own certification and recertification process.  The current controversy involves the recertification process and whether it should be a standard blind exam with no learning aspects and a review of patients in a physicians practice or not.  I have posted some details about this to show how highly politicized it has become.  There is really no good evidence that recertification beyond the usual CME requirements is needed.  Although the American Board of Psychiatry and Neurology (ABPN) and the APA has gone along with ABMS ideas, most members find the process onerous and not conducive to learning, especially when they are in a labor intensive work environment that allows little time for study.  Any professional organization should be innovative enough to come up with an ideal process that would keep members up to speed professionally while not intruding on their limited time.  My foundation would develop a recertification system based on the APA's Focus journal an develop a process that would allow members to study on their own time and recertify by taking the Focus examinations.  It should eventually be possible to incorporate modules from the ongoing neuroscience seminars and what is learned in the computerized psychotherapy lab as study modules.

Using these innovations and hopefully more, my foundation would seek to improve the technical expertise of all psychiatrists, highlighting what is possible for the future and bring every clinician out of the current misery of political overegulation and managed care overproduction.  The whole idea that we currently have a professional organization and a specialty board that are not protective of psychiatrists is one thing.  The idea that they are actually doing things that are counterproductive to the ongoing professional education of psychiatrists and increasing burnout by creating a more stressfull practice environment is another.

My fantasy foundation would hope to reverse those trends.

George Dawson, MD, DFAPA