The Drive To Do Good Work When No One Is Looking

Himmelstein and Woolhandler have hit it out of the park again.  This time in a seemingly modest letter to the editor in the weeks JAMA.  Although their main point was the perversity of pay-for-performance incentives in the final paragraph they make this observation:

"We fear that pay-for-performance incentives will undermine the mindset required for good physician practice (ie, the drive to do good work even when no one is looking)." (p.304)

This is a quote that everyone should pay attention to because the so-called financial incentives that have been with us for years are highly problematic and have not contributed a thing to the quality of medical practice.  The first consideration is whether or not what Himmelstein and Woolhandler say is true?  It has  clear validity.  Physicians are trained to do the right thing in terms of individual patient care.  That involves dedication and adhering to professional standards like continuity of care.  Physicians as a group are driven people.  They will work past the point of exhaustion especially f they feel that they need to follow up a certain problem for a certain patient.  Many primary care physicians are working 24/7 in order to keep up on paperwork, labs, prescriptions, and test results.  It is not possible to "call it a night" if there is a critical lab value that needs to be evaluated or a patient that needs to be informed.  There are plenty of decisions in medicine that have a high inherent degree of uncertainty and that can lead to sleepless nights searching for an answer.  The electronic health record (EHR) has increased that burden.  I have colleagues that tell me that every morning when they walk into clinic they may have as many as 200 lab results waiting for them in the EHR.  If they do not have assistance with triage, they have to personally view these results and do something about them.  They may also have to respond to direct e-mails if they are affiliated with a plan that allows patients to directly e-mail their physician.  That is before they begin seeing a full schedule of patients and seeing urgent problems that day.  Responsibility to the patient is what drives this process not trivial financial rewards and penalties based on illogical outcome measures.

Why all of the confusion?  I think the problem can be analyzed at several levels.  At the antiphysician level there are obvious forces in play that want to coopt the professionalism of physicians and make it seem like without a business and government bureaucracy that physicians would be out of control.  In other words the public needs the government and big business to control physicians.  This was the essential rhetoric that led to the managed care era in the first place.  Physicians were greedy, did too many procedures for financial gain, and needed to be managed by a large and expensive business administration.  The managed care theory completely ignores two basic facts.  The most obvious fact is that three decades of managed care has not controlled health care inflation or increased health care access as promised.  That is compounded by the fact that many of these companies currently own all of the means of production including the doctors, hospitals, labs, and MRI scanners.  But nobody has accused them of being greedy.  The second fact is that independent review of the problem from the 1990s showed that the political theory that physicians were engaged in massive overutilization was so inaccurate that they closed the government review program down.  How often does a government program get shut down?

The assault on the professionalism of physicians reached new heights in the 1990s when the federal government under the Clinton administration decided that fraud conducted by physicians was also a major driver of health care inflation.  Armed with billing codes and guns, it was an era where FBI agents were trained to enter offices, get the records and determine of the documentation matched the billing code.  There were several high profile cases where the Department of Justice decided that "fraud" had occurred.  The fraud they were referring to in one of the landmark cases was attending physicians not writing an extensive enough note in addition to whatever note the resident physician wrote.  That led to about two decades of excessive and unnecessary documentation.  Right up until the point that the federal government could grant this power to managed care companies and give them the power to deny payment and demand reimbursement back based on their interpretation of whether the documentation supported the service provided.

Throughout all of this heavy handed political intervention physicians have continued to do the right thing and maintain their professionalism but the rhetoric has taken a heavy toll.  It is not unusual for a person to enter a health facility owned by a managed care company and see some credos from the physician code of conduct plastered on the walls in an elevator.  When that happens the company is generally sending a clear message: "It is only because of us that medical professionals behave in a professional manner."  Nothing is farther from the truth.  There is no carrot or stick that keeps a neurosurgery residents on call in a hospital every day and night for a year at a time.  There is no carrot or stick that keeps psychiatrists treating aggressive patients who continually threaten and may try to assault them.  There is no carrot or stick that keeps physicians going to the point of exhaustion and to the point that they realize that they are clearly spending much more time caring for other people than their own families.  A typical response from people with those scenarios is either: "You don't have to do that." or "You don't have to work that hard."  Physicians currently waste 20-30% of their time on bureaucratic nonsense dreamt up by people who themselves do not provide direct patient care.  In the time left they are expected to see more patients and do more documentation than physicians have ever had to do at any point in history.

I don't mean to suggest that there are not people in all walks of life who do the right thing at work.  As I am typing this I recall my father describing one of his coworkers sometime back in the 1960s.  My father was a railroad engineer.  He drove locomotives of both the diesel and steam variety.  The railroad world in those days was a parallel universe that I would occasionally get a glimpse of.  Massive buildings smelling of diesel fuel storing massive, loud, pulsating diesel locomotives.  They just let them run 24 hours a day.  My father and a group of his railroad colleagues were rebuilding the porch on our house one day and they were all talking very positively about a car knocker who worked for the same railroad.  A car knocker is a rail car repairman.  They keep trains rolling.  All of my father's co workers and my father all praised this person because at work he always seemed to do the right thing.  The quality that they seemed to admire the most was that he would always attend to part of the task even when he lacked a certain skill that required him to pass part of the job on.  That was apparently a rare trait and that was my first observation of the quality of doing good work and how it was widely admired on its own merit.  No financial reward or employee of the week parking spot.  Just the mostly hidden admiration of your coworkers.

To me the most perverse aspect of physician "incentives" is that they are already earned by physicians.  In the managed care world, groups of physicians are subjected to a "holdback" of anywhere from 5-15% of their gross billing.  The idea is that unless the entire department makes the productivity expectation (an arbitrary number set by an administrator) the money is lost.  If the financial target is made money "awarded" was already earned.  There are no bonuses only penalties.  A lot of the incentives for reporting various measurements or complying with the next bureaucratic hoop are in the 1-2% range.  That is important only for the bean counters described in the letter.  Make no mistake about it - they will exert whatever pressure they can on physicians to "make" that 1 or 2%.  And make no mistake about it - twenty years that bean counter job would not have existed.

And there still would have been physicians in hospitals all night long trying to do the right thing and not caring who knows about it.

George Dawson, MD, DFAPA

Himmelstein DU, Woolhandler S. Physician payment incentives to improve care quality. JAMA. 2014 Jan 15;311(3):304. doi: 10.1001/jama.2013.284475. PubMed PMID: 24430325.

Additional Clinical Note 1:  Some health care settings have really taken the incentive programs to an absurd level.  Mandatory pep rallys for the employees, employee of the week or month awards and the expectation that everyone generates a huge amount of false enthusiasm for these rewards.  At the same time the confidential 360 degree performance review is the latest tool that administrators can use against physicians.  In this exercise a panel of anonymous multidisciplinary coworkers rate physicians on a number of non-medical standards (like how well they support corporate standards).  The performance review is basically a combination of subjective impressions that have very little to do with the physicians medical competence.  It is all part of the corporate beauty contest that is passed off as medical quality.  Most managed care companies seem to not know the meaning of the word.

Additional Clinical Note 2:  Governments and managed care companies are never at a loss for measuring things that are completely irrelevant to the provision of quality medical care.  The best example is patient satisfaction surveys.  If you are ever handed one as you leave the hospital or clinic the first question to ask yourself is whether the questions seem familiar.  If they do it is because your were scripted.  That means that the person you just talked with covered a number of bullet points corresponding to your survey.  It is designed to maximize the score on that satisfaction survey.  These results are often linked with incentives.  But nobody ever talks about the fact that you could have received the best care in the world and may not been able to complete a survey when you left the hospital.   

A Better Way To Manage - Lessons From the Coach

I ran across a basic article on Phil Jackson the other day in the AARP newsletter.  Like most people unfamiliar with his story I get the occasional stories about him that describe him as a guru.  I can see the movie now with novices climbing to the top of some mountain in the Himalaya's only to find him seated in an wooden temple, speaking the basic truths about NBA coaching in a way that only he is capable of.  He is a legendary basketball coach.  The AARP newsletter was brief but it contained huge advice.  In it we learn that he is the son of two clergy and spirituality naturally guides his decision making.  When people think about spirituality they frequently equate that with religion and react to it on that basis.  They miss the point that spirituality can be the essence of a person.  It can be a connection with a process greater than one's self and have nothing to do with religion.  One of my colleagues John MacDougall captures this well in his definition of spirituality as:  "the quality or nature of our relationships in three dimensions - relationships with our Higher Power, with ourselves and with other people."

The other Phil Jackson observation from the article that impressed me was the notion that he used nonauthoritarian methods to empower his players and these methods came directly from a spiritual direction that allowed him to be true to himself.  He talked about knowing that "things of a higher calling could unite groups of men."

"I've learned that the most effective way to forge a winning team is to call on the players need to connect with something larger than themselves......  It requires the individuals involved to surrender their self interest for the greater good so that the whole adds up to more than the sum of its parts."  -  Phil Jackson in Sacred Hoops (p. 5)

Contrast that with typical managed care or business strategies that leave the people out of the equation.  The best way to look at that contrast is by looking at some team situations I have been in the past.  I wrote about my Renal Medicine team in the past.  It was my last rotation in medical school and I walked off that service at about 8 PM on the last day before graduation.  The whole raison d'etre of that team was the two goals of excellent medical care and education.  The approach to both goals was intensive.  Even as a medical student, I felt like a critical part of the team.  My job was to go out into the large medical complex on the grounds of the Milwaukee County Medical Center and do consults.  On the last day, the two residents I was working with approached me and said: "Look George, we know this is your big day but we are getting killed.  Can you do these consults?"  Of course I did.  The only meaning that my action had at the time was the I was a part of this team and I wanted to share the workload.  After we completed rounds that night at about 9 PM, those same residents joked about how I was a super medical student and some of the jokes were quite funny.  But that rotation (with a few others) was one of the most meaningful educational experiences of my life.  To this day, I miss working with that team.  It was a spiritual experience!

Teams on inpatient psychiatric units can be a different story in part because they are influenced by the typical silo style management of big hospitals.  The managers are ego rather than team driven.  There are separate nursing and physician structures.  Some of the team members may be in separate unions.  There are multiple disciplines that can be split be numerous administrative hierarchies.  It is always easy for administrators to try to play one discipline against the next.  Institutional attitudes can affect psychiatric teams at multiple levels.  At various times I have been in teams where one or more members were being influenced by administrators to the detriment of the team.  That almost always translates to suboptimal patient care.  The administrative message to teams can be fairly extreme.  At one point I can recall being told that we were no longer doing team meetings.  Productivity measured as individual physician-patient contacts was more important.  At that time we had already been told that our documentation was supposed to include a blurb about observations made in the team meeting or it would not "meet criteria" for the correct billing code.  At other times we were plagued by observers - bureaucrats, consultants, or business types who clearly did not know anything about the work or at least the work we were doing.  Many were hired guns brought in by our own administration as the "next big idea" or an attempt to manipulate the team in some way.  In the most extreme situation, a representative of the administration was sitting in team meetings and telling us what to do.  I say extreme because the administrator had never assessed any of the patients and did not know them.  They also did not have the expertise to make a diagnosis or treatment plan.  All of their decisions were strictly financial.  They needed us to carry them out to provide the legitimacy of having licensed professionals names in the charts, especially on the discharge orders.

All of those last scenarios are at the extreme other end of the spectrum from Phil Jackson's approach.  My guess is that Phil Jackson would not have been able to keep Kobe Bryant in LA when he wanted to be traded with just financial incentives and a business approach.  It took a spiritual one.  He had to feel like he was part of a larger process.  That is the spiritual atmosphere that needs to be created on treatment teams.  You won't get to that by expecting physicians or nurses or social workers or occupational therapists to be mini-administrators focused on "cost effectiveness".  In fact, it is exactly the wrong approach.

The correct spiritual ground for a team is unity, appropriate concern for other team members, common goals and positive affect associated with being on that team.  Team members need to  to have a uniform neutral and spiritual approach to the people they are trying to help.  One of John MacDougall's suggested approach to improve spirituality is:  "try treating every human being that you meet as if he or she were a beloved child of a Higher Power."  It has nothing to do with being a bean counter and in fact if the bean counters can't support the development and maintenance of teams - it is time for everybody to walk away and start over.

Phil Jackson's elaboration of a non-authoritarian spiritual approach to managing people on teams is just another important way that the government and the managed care world miss the boat and end up providing the worst possible management of health care workers, especially mental health care workers.  Micromanagement and a general cluelessness about managing knowledge workers is another.  We don't have a shortage of worker productivity or a shortage of workers - we have grossly mismanaged workers and some of the worst managers in the world.

George Dawson, MD, DFAPA

John A. MacDougall.  Being Sober and Becoming Happy.  CreateSpace Independent Publishing Platform, 2013. p. 40.

Phil Jackson and Hugh Delehanty.  Sacred Hoops.  Spiritual Lessons of  a Hardwood Warrior.  Hyperion, New York, 1995.

Latest Bad Ideas From the FDA - Zohydro and Adasuve

Like them or not the FDA is the critical agency in terms of pharmaceutical regulation and the politics of pharmaceuticals.  It is easy to confuse the politics of drugs with pharmaceutical science.  Clear examples include special interest groups lobbying the FDA and members of Congress for rapid access to medications that have not been approved for specific indications.  Some of those medications have significant side effects and very low therapeutic efficacy.  At the same time, the FDA is criticized for approving medications that add nothing to the existing pharmacopeia or that have marginal evidence for efficacy.  If you view medications as tools that need to be applied in various on and off label ways by practicing physicians, that is by definition a lower threshold for regulatory approval than the standard that a medication must be very effective and very safe.  It turns out that there are very few medications with that profile.  Some problems and inconsistencies are more glaring than others.

I was surprised to get a recent warning letter from the FDA on an inhaled preparation of loxapine called Adasuve.  Loxapine is an antipsychotic drug of medium potency.  Back in the late 1980s we had a drug trial of loxapine versus haloperidol on one of the inpatient units I was running at the time.  It was a fairly effective drug for acute symptoms of psychosis and was less potent than haloperidol so it has fewer neurological side effects.  It never seemed like a very popular medication with psychiatrists.  There was some recurrent interest around the issue of first and second generation antipsychotics with some authors suggesting that it had a receptor profile that was more similar to second generation or atypical antipsychotics.  During the initial period when it was approved and marketed under the brand name Loxitane it was available in both oral and injectable forms.

I could only locate one study at PubMed on the Adasuve in the current medical literature searching on the brand name.  There were 20 studies at clinicaltrials.gov web site but unfortunately no results were posted.  Some of them appear to be very interesting including one that looks at the QTc interval effects of inhaled loxapine.  A review of the Adasuve web site shows that bronchospasm is a black box warning and that there is a Risk Evaluation and Mitigation Strategy (REMS) to assess prior to prescribing and monitoring the patient after each administered dose. It looks like it can only be given in a registered health care facility by personnel who can assess and manage any pulmonary complications.  Although the pulmonary conditions that contraindicate use seem fairly straightforward (asthma, COPD, any pulmonary diagnosis associated with bronchospasm) the actual diagnoses are probably more complex due to a number of factors including smoking status, body weight, and the complexity of the underlying pulmonary syndromes.  Staff administering this medication should assess the patient for pulmonary problems at every episode and not depend on historical diagnoses.

From a philosophical standpoint, there needs to be an active debate about new patents or patent extensions on medications that are currently generic drugs like loxapine.  During the time it was primarily used it certainly did not demonstrate any superior efficacy or side effect profile relative to other typical or atypical antipsychotics.  Loxapine is metabolized to amoxapine, an FDA approved antidepressant that has been used on a limited basis in psychiatric practice and is generally not considered a first or second line antidepressant.  The metabolic relationship led some authors to speculate that the combination may be effective in psychotic depression but that application was never realized.   So in this case we have a drug with limited applications that has been repackaged in a riskier dosage form.  That seems like several steps in the wrong direction.    The details about the pharmacokinetics are available in the package insert.  Looking at this data, the main advantage appears to be the short time is takes to reach maximum plasma concentration (1-2 minutes).  A useful study here would have looked at a subgroup of patients taking parenteral loxapine and similar pharmacokinetic measures.  In the study I alluded to from the 1980s loxapine was compared directly to haloperidol for acute agitation in schizophrenia or bipolar disorder. 

With this medication released into practice, if I was still working on an acute inpatient unit I would be very skeptical of using this medication for acute agitation.  Use is limited to a single dose in a 24 hour period.  The people who need this medication are generally medically complex, may still have street drugs in their system, are generally cigarette smokers and their pulmonary and in many cases their cardiac status may be unknown.  If the initial dose is not effective, the question becomes - now what?   Patient preference may be an issue since some patients request a fast acting medication but they do not want parenteral injections.  Patients with an addiction history may have used drugs by insufflation, inhalation, and intravenous injection and that may be a factor in their decision making.  All other factors considered there have been studies of patient preference for specific medications to treat acute agitation and of the antipsychotic class of medications only olanzapine is highly rated.  Besides the degree of acceptance, post marketing surveillance will be important in terms of medication side effects.  The current approval was based on pooled data from three studies looking at a total of 259 patients getting the active medication and 263 patient receiving placebo.  That is not many doses of this medication.

Zohydro probably requires less discussion.  Zohydro is advertised as the only acetaminophen free, extended release form of hydrocodone available in the United States.  It is available in dosage forms ranging from 10 mg to  50 mg intended as a twice-a-day dose schedule.  Zohydro comes with the following black box warning:

The interesting part of this approval process was that the scientific advisory panel, for the FDA voted overwhelmingly against approving this medication, but it was approved anyway.  We are currently in the midst of an opioid epidemic based on a number of metrics including emergency department visits for complications, deaths from accidental overdose, per capita consumption of opioids relative to the rest of the world, and the increasing number of people addicted to opioids.  We are also entering a period of increased policing of physicians by numerous agencies for opioid prescribing practices.  There is fairly good evidence that the "opioid epidemic" started with a pain treatment initiative suggesting that physicians were not treating pain aggressively enough.  The pendulum has swung to the point where there will be clear blame for at least some physicians who are using opioids to treat chronic pain. 

There are a couple of additional problems with the FDA approved package insert for Zohydro.  The first is the Indication or reason the FDA approved this drug in the first place.  The indication for Zohydro is: ".....the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment for which alternative treatment options are inadequate."  That is a shockingly inadequate description of a pain syndrome.  In keeping with a medication as a tool model for regulatory approval this is acceptable.  But any physician prescribing this medication should have a more specific pain diagnosis that specifically addresses the chronicity of the pain and why this might be an acceptable approach. 

The second problem on my first read through of the package insert is the following graphic of the efficacy of this medication.  It plots the results of an study of Zohydro versus placebo in 510 subjects who were already on chronic opioid therapy for chronic back pain. 

I think that these examples highlight the fact that the FDA does not seem to have any guiding philosophy when it comes to some new drug approvals of repackaged generics other a Darwinian free market approach.  Since the original drug passed the safety and efficacy standards why wouldn't the repackaged generic?  Physicians should demand a more specific regulatory approach.  At the minimum there needs to be clearer evidence of an advance in pharmacotherapy in terms of increased efficacy or a better side effect profile.  Repackaging generic drugs without that kind of guidance and obvious risks seems like a mistake to me.   There also needs to be a better approach to chronic pain and drugs that are clearly addictive and a more uniform methodology for measuring efficacy.  Most studies looking at opioid use in chronic pain show modest pain relief at best.  In clinical practice, the relief is generally on the order of what is expected with non-opioids on population wide comparisons.  There should be an easy way to operationalize that knowledge and instruct pharmaceutical manufacturers on the appropriate design of clinical trials to answer these questions.  There is also the issue of conflict of interest and the need for complete disclosure of who is advocating for the use of the medications in question.

From an addiction standpoint, hydrocodone and acetaminophen compounds are some of the most frequently diverted and abused compounds.  It is not uncommon to get a history of people taking amounts that are the equivalent of chronic overdoses with the acetaminophen component.  Many if not most of the people with this addiction are aware of the risks of the acetaminophen component but when the chronic phase of the addiction develops they will continue to use it and ignore that danger.   Patient preferences can be a factor in the decision to prescribe an opioid.  Hydrocodone combination medications are in high demand on the street indicating to me that is is a preferred product to many addicts.  The package insert contains remarkably little useful practical information on abuse, dependence, and addiction.   We are told that there is a REMS strategy and that the FDA is requiring manufacturers of newly approved long acting opioids to conduct long term follow up studies to look at the "serious risks of long term use."

I think it would be a lot easier if FDA regulators just looked at the current data on the CDC web site about the addiction risk of opioids and answer the question: "Why would Zohydro be any different?"

George Dawson, MD, DFAPA


FDA.  Adasuve Full Prescribing Information. (Click on appropriate link).

European Medicines Agency.  Adasuve EPAR (European Public Assessment Report).

Additional Clinical Note 1:  On 1/14/2014 the FDA issued a recommendation that health professionals stop using combination products that contain more than 325 mg acetaminophen.  That same page has a link to a letter that will be sent to manufacturers that these dose strengths be withdrawn over the next three years.  Based on their rationale (no increased efficacy with acetaminophen and risk for hepatotoxicity), I don't know why 325 mg acetaminophen is the magic number.  The addiction experience with combination products suggest that people will routinely use potentially toxic doses as part of their addiction, even when they know that there is a potential problem with the amount of acetaminophen.  This new rule may increase increase the amount of opioids prescribed.

It Is Cold Outside

I was driving into work this AM. I drive a six year old Toyota Van. The thermometer on my rearview mirror hovered between - 20 and -21 Fahrenheit, but every bank I passed said -24. Before I left home this morning I added a layer of polyester, packed additional headgear, and wore my Sorel boots. This is serious weather even if you are born and raised here and you need to be prepared for the worst. Standing outside for even a few minutes without adequate cover can result in frostbite or worse. The Governor of Minnesota closed down all of the schools today to prevent frostbite injuries and so far there have been no arguments with that decision.  The drive home at night was slightly warmer at -16 degrees.  The sky was so clear it was like being in outer space.  I had to stop for gas and the driver's side door froze open.  I had to hold it shut for about 6 miles until it thawed to the point I could slam it.

Apart from the pragmatics of winter survival, the cold weather also triggers a lot of associative memories - starting with my Sorels. I got these boots originally in 1971 in order to do a Limnology experiment on Lake Superior.

A friend of mine helped me and we went out onto the ice for a about 5 hours and pumped about 200 gallons of lake water through a plankton net to look at the winter plankton population. It was about -5 degrees that day. A few years earlier he had a case of frostbite after walking about 10 blocks to school wearing nothing but a pea coat.  Like a lot of people in the northern US and Canada, I have found that these boots absolutely protect your feet in subzero weather.

I lived in Duluth, Minnesota for a while and can recall trying to speedskate when it was -10 to -15 degrees. At that temperature, a skate blade cannot compress and liquefy the ice enough to support much glide so the skating motion and its mechanics are seriously disrupted. I was wearing two layers of polyester, a layer of Lycra, and a layer of fiber.  Unlike Sorels - speedskates even with neoprene boot covers don't protect much against the cold.  When I got home I had to lay on top of a radiator under a blanket for 30 minutes in order to warm up. The coldest I have ever been in the winter usually happens after falling through the ice. I can recall walking across a creek and just getting ready to step up onto the far bank when I fell through the ice up to my chest in icy water. The sensation that occurs when that happens is incredible. Your breathing stops for a while followed by rapid gasping as you struggle to get out of the water. That is followed by the desperate run home. In my case it was only about 7 blocks and by the time I got there my clothes were frozen solid.  A friend of mine was skating on Lake Superior and fell through the ice catching himself only by his fingertips. He ran home about the same distance but he had been totally submerged.

My more recent memories are about how the cold has been a factor in my role as a psychiatrist. Most psychiatrists in the Midwest have first-hand experience with the complications of cold weather. We have seen people with frostbite injuries both on burn units and after they have been transferred. We know many of the people who are caught in the endless inpatient unit -> emergency department -> homeless cycle that seems like a permanent artifact of our managed care inpatient and county mental health systems. We have seen the human interest stories that tend to run in the papers when the potentially lethal cold weather hits and the temporary concern about whether or not there are enough shelter beds.

Weather this cold does not allow you to make a lot of mistakes. Sometimes all it takes is the idea that you can run out to the trash can without putting on a jacket and finding that you have locked yourself out of the house. People with memory problems and disorientation can wander off and get lost. People with drinking problems can pass out or just take too long to get home. All it takes is a decision that keeps you out in the subzero weather for minutes too long and you can be in serious trouble.

Potentially lethal cold weather is also an integral part of treatment decisions. You can't really watch people coming in to appointments wearing summer clothing in this weather without doing an assessment for cold weather safety. It becomes part of the discharge decision making. Exactly how stable is the person's housing and how likely are they to keep themselves safe? Can they walk 10 blocks from the hospital to their apartment wearing a sweat suit, basketball shoes, and no hat?  Should they be discharged to the street, even if they want to be?  Should they be discharged if a managed care reviewer says that they should be discharged?  We are generally talking about people who have chronic problems with insight and judgment.  What about people with suicidal ideation? What about the person with chronic drug problems who has a history of drug induced blackouts and waking up on park benches?  What about the person with Alzheimer’s disease who does not have 24 hour supervision?   

How do you make an unbiased decision in that context?  I can say that you don’t.  You don’t because as a psychiatrist you are aware of all of the adverse outcomes.  The continuum of severe frostbite injuries to the hypothermic who could not be resuscitated to those who were found frozen to death.  You don’t want to see that happen to anyone.  You don’t care if somebody wants to call that paternalistic.  You don’t really care if it costs a managed care company or (more likely) a hospital a few bucks.  You have been there yourself and you know you cannot take any chances in subzero weather.  It’s not about a fear of being sued, it’s about concern for a fellow human being.

There are implications for the imminent dangerousness standard that is commonly applied to involuntary holds.  I have argued with enough county attorneys over the years to understand that the standard itself is purely subjective and arbitrary.  No matter how it appears on paper you will hear ten different interpretations from 10 different county attorneys.  There are a few states where a gravely disabled standard applies.  That standard states that a person may have problematic judgment to the point that it potentially impacts their ability to secure adequate food, medical care, or housing.  That standard probably generally applies in these situations, but if you happen to be in a state where there is no statute or the county courts ignore it for convenience or financial reasons it may not be available for use.  

Those are the kinds of things I think about when it gets this cold.  I do get the occasional lighthearted thoughts – making sure I recall the thermodynamic equations that show my car battery dependent on temperature and telling myself that I am going to call Columbia and ask them if they make some type of expedition wear that is warmer than my current Titanium coat.  But mostly – I hope the most vulnerable among us get the help they need and nobody gets injured or killed.  Hopefully someday people will think about the fact that some people have a hard time protecting themselves - irrespective of the air temperature.

George Dawson, MD, DFAPA

Andy Rathbun.  Regions Hospital Sees "Record-Breaking" Number of Frostbite Cases.  St. Paul Pioneer Press.  January 6, 2013.

From the article:

"Most of the people that come in with severe frostbite are "in some way compromised," he said. A small number are physically or mentally disabled, but a majority are people who have consumed too much alcohol or were abusing drugs and didn't realize how cold it was outside, Edmonson said."
             

What Is Really Going On At The Minnesota Security Hospital?

The Minneapolis StarTribune posted a recent story about the Minnesota Security Hospital (MSH) on December 27, 2013 that was updated today.  The article raises concerns about patient treatment and safety at this facility both for patients and staff.  It should be read by everyone with an interest in how state mental hospitals function.  It is of particular interest to Minnesota residents who may have a relative being treated at this facility but also anyone concerned about the image of the state and how it treats residents with severe mental illnesses.  From a policy standpoint it should be an issue of great importance for both local psychiatric societies and the American Psychiatric Association (APA).

Let me preface my remarks by saying that I have no inside knowledge of what is occurring at the MSH beyond what I read in the papers.   The first concern is about the information base for the article and who is interpreting that information.  That is contained in the fourth paragraph of the article at the very end of that paragraph:

"Nearly two years after the hospital's professional psychiatric staff departed in a mass resignation, the state still has not hired a full complement of psychiatrists, documents show.  Basic medical record-keeping has been neglected, employees have been placed in danger and patients have been discharged with inadequate safeguards, according to internal memos, federal records, and agency files reviewed by the Star Tribune."

The problem here is that there is nobody at the Star Tribune who is an expert in the treatment of patients with severe mental illness and aggression.  The second problem is that there is a significant conflict of interest anytime a journalist has access to clinical material with a potential sensational interpretation.  From my experience journalists will make that interpretation out of ignorance or for the purpose of enhancing the dramatic impact of the story.  In this article the names of two patients are disclosed.  Journalists are not confidentiality bound to not disclose the names of patients and there may be some public documents with the names of these patients.  My experience with journalists has been that they want to talk to actual patients with real names, and really do not understand the problems with that.  There are always many potential weaknesses when considering a journalistic source.

There is a precedent for the review of confidential hospital records by expert unbiased reviewers and that was the Medicare Peer Review Organizations (PRO) system.  In that process, physicians who were experts in the field in question were rigorously screened for conflicts of interest.  As an example, they could not have any affiliation however peripheral with the hospital or clinic being reviewed.  The compensation for reviewing the records was trivial and you could not make a living at it.  Reviewers were expected to be practicing medicine full time and not be an administrator.  As a reviewer, I reviewed tens of thousands of pages of hospital records - many from state hospitals for both quality problems and utilization problems.  A newspaper reporter looking at a patchwork of records, memos, and files from multiple sources is hardly an adequate standard to draw any conclusions.  A reporter can make it seem like the hospital is a "bad" place for restraining people or in this case failing to restrain a person.

A potentially rich source of information is the hospital's former medical director - Dr. Jennifer Service.  She has one quote in the article about how the MSH is "broken", but it provides no details.  My speculation is that there is nobody who had a better front row seat to what happened than Dr. Service and possibly the previous medical director.  In the treatment of severe mental illness and aggression the medical director or clinical director has a critical role in making sure that there are no administrative factors that adversely affect the treatment team or their ability to provide care and a safe environment.  A common mistake is that administration believes it can effect change and they do not pay close enough attention to the impact on the clinicians providing care.  When treating aggressive people any environmental change like that can result in increasing aggression and chaos in the treatment environment.  The Legislative Auditor's Report suggests several areas where the therapeutic neutrality of the environment and staff cohesion were problematic.  During 23 years of conducting team meetings, my experience was that psychiatrists are an integral part of the team and should be the team member most experienced in team dynamics, countertransference, and approaches to violence prevention.  There is no indication that occurred on teams at the MSH and in fact, participation is described as marginal.

There are other potential conflicts of interest here that potentially bias the story.  Minnesota Department of Human Services apparently administers the place.  In this case Commissioner Anne Barry talks about the goal of increasing the likelihood of discharge by making community living environments more available.  Since DHS also administers all of those environments in the state it should be a relatively easy task.  Why is it not being done?  Are there people who realistically cannot be discharged without recreating a hospital environment for them in the community?  In the cases where that has happened have there been more adverse outcomes?  Are those environments more humane than the hospital environment where the patient was initially?  The Deputy Commissioner talks about accountability, but DHS seems like one of the most opaque state agencies out there.  Lately they seem to have moved into the area of micromanagement of the treatment providers especially around the issue of aggressive behavior.  Are the administrators of DHS responsible for the failed programs at the MSH?  Commissioner Barry talks about a more "therapeutic environment".  Is she qualified to determine what that is?  And finally the Legislative Auditor's Report alludes to a report by previous consultants.  Who were these consultants and where is that report?

Another good illustration of how conflicts of interest potentially bias the StarTribune article was the issue of accusations of maltreatment by professional staff.   The first is an allegation that a psychiatrist "committed maltreatment" by threatening an uncooperative patient with electroconvulsive treatment.  DHS investigators concluded that this happened but their finding was overturned by the DHS Inspector General.  The State Ombudsman for Mental Health and Developmental Disabilities apparently believed it happened and made a request for the DHS Commissioner to reconsider the finding.  The Inspector referred the matter to the Board of Medical Practice.  In the second case, 2 nurses were accused of maltreatment.  From the way the article is written it appears to be related to the incident where the patient was "slamming his head repeatedly into a concrete wall" and they were unable to get an order to physically restrain the patient.  The nurses were fined and reported to the nursing board.  Based on the incidents of maltreatment and another incident where a patient did not receive timely assessment for a stroke the DHS Commissioner extended the hospital's probation through 2014.  There are many problems with employees paying the price for chaos in the system.  Administrators often do not recognize the professional obligations of the staff.  I have personally seen quality psychiatric staff paralyzed by indecision that was brought about by administrative mandate or personnel problems.  The other problem here is that DHS appears to be the administrator, investigator and judicial process rolled into one.  We have a number of political appointees (DHS, Ombudsman, Board of Medical Practice) charged with deciding the professional fate of a physician who seems to be practicing in the worst of possible scenarios.  It should not be too surprising that MSH is unable to recruit and hire psychiatric staff.

The Legislative Auditor's Report is probably a better source of information than the newspaper report, but it has the same lack of input from experts.  It is useful from the perspective of bureaucratic information on the details that can be counted like the number of psychiatric contacts, number of hours of therapeutic contact, number of staff injuries for a certain period of time, etc.  One of the areas that is most interesting to me as a psychiatrist is the frequency of patient contact by psychiatrists.  The report gives an example of a recent census of 321 patients.  It provides an exhibit showing that from a policy standpoint the suggested frequencies of contact are monthly, quarterly, or semi-annually.  These frequencies are interestingly lower than the frequency of contact in some 19th century German asylums.  I can recall that Binswanger made a point of seeing all 200 patients in his asylum every week.  The report said that of the 321 patients in the study 45% had been seen in the previous month, an additional 24% 1-2 months earlier, 17% 2-3 months before and 4% greater than 3 months before.  Going from a full complement of eight psychiatrists to a total of two psychiatrists and 1 nurse practitioner is an obvious problem in terms of contact.  Actual contact with psychiatrist is an insufficient metric for treating patients and other quality measures need to be developed.  

If the article and the Legislative Auditor's report are even partially accurate with regard to facts, the glaring problem here appears to be that there is nobody in charge who knows how to run a hospital that treats people with severe mental illness and problems with aggression.  It is probably more correct to say that at this point we have not been presented with any positive evidence that there is a person in charge with the necessary qualifications.  The information presented in the StarTribune article does not suggest a clash of cultures.  There is no psychiatric hospital culture that I am aware of where there is confusion about whether or not a patient should be allowed to injure themselves.  The second problem is that this hospital needs psychiatrists who are trained to treat severe mental illness and aggression.  They do not need to be forensic psychiatrists, but they do need expertise in treatment of severe mental illness.  Forensic psychiatrists are basically needed to perform specific evaluations of criminal responsibility but the priority here is described as patient and staff safety.  The people needed in this situation currently work in a number of acute care and community settings.  They are very comfortable with the treatment of major psychiatric disorders and the associated medical comorbidity.  It is safe to say that they enjoy working with these problems and talking with the people who have them.  They are also sensitive to the needs of their co-workers and can establish the necessary environment of mutual trust and neutrality needed to succeed.

There may not be anyone around who remembers that Minnesota has solved a similar problem in the past.  The year was 1990 and there were significant problems staffing the major state hospital in the system - Anoka Metro Regional Treatment Center.  At that time, a Medical Director who was recently out of training was hired and he hired several colleagues from the same generation.  They were all enthusiastic and interested in providing quality care.  The state offered them competitive salaries.  Within a very short period of time a cohesive staff developed and they became a favored training site for medical students.  Treatment at the state hospital improved dramatically and several of the psychiatrists in that cohort went on to become leaders in the state in the provision of psychiatric services to patients with severe mental illness.

That still seems like a good idea today.


George Dawson, MD, DFAPA

Paul Mcenroe.  Minnesota Security Hospital: Staff In Crisis Spreads Turmoil.  StarTribune, December 27, 2013.

Office of the Legislative Auditor.  Evaluation Report: State-Operated Human Services.  February 2013.

Additional Clinical Note 1:  Looking back over my post it is clear that I do not answer the question that is the title.  Like most people I am speculating based on an imperfect data set.  The main difference is that I am also speculating as an expert based on what needs to happen to provide the safest scientifically based treatment for people who are mentally ill, aggressive, and may have failed most if not all of the available treatments.  I also recall that some past state hospital problems were resolved that has not been brought up in the discussion so far.

The Real Conflicts of Interest in Medicine and Psychiatry Today

I noticed some confusion around the GSK article that was recently posted.  I decided to start the New Year examining conflicts of interest (COI) in medicine and psychiatry because they are widespread.  These COI are much more widespread than the press or politicians have stated.  That is because there are more players than physicians involved and these other players are hardly ever mentioned. You would never realize that by reading the papers largely because COI is always described as a problem with physicians.  Nothing could be further from the truth.

My goal is to outline as many as possible and hopefully readers here will be able to fill in any that I might have missed.  Because I am just one guy working in his spare time, it will not be an encyclopedic listing but it will be more comprehensive than you will find anywhere in the press or possibly the existing medical literature.  It will also be more comprehensive than the typical political analysis that usually suggests that the only relevant conflicts of interest have to do with physicians making money or prescribing drugs in exchange for certain rewards.  As you will see, these may be some of the least important conflicts of interest.

A good starting point is this diagram I made that looks at all of the important conflicts of interest that impinge on physicians.  The diagram is not exhaustive. (click to enlarge)

Not all of the links are drawn and there are many smaller entities involved that have not been graphed. As you can see I have 13 major areas here that directly impact on physicians.  It is important to keep in mind the main goal or interest is the practice of medicine.  It flows from an ethical relationship with a physician.  That relationship is defined as the physician acting toward the patient in a way that is only in the best interest of the patient in exchange for a professional fee.  The modern relationship makes an important distinction in that the physician needs to be practicing scientific medicine.  The American Psychiatric Association (APA) has a policy statement with some useful definitions.  The APA defines the primary interest as "the highest level of evidence based practice, ethically based and scientifically valid research, and quality continuing education for the benefit of patients, the profession and society."  They define secondary or personal interests such as personal, financial, or professional that:  "may inhibit, distract, or unduly influence their (physicians) judgment or behavior in a manner that detracts from or subordinates the primary interest of patients and may be perceived by some as undermining public trust."  Six examples of situations that may require vigilance to prevent conflict of interest issues are given and 5 of 6 can be seen as derivative of physician relationships with the pharmaceutical industry.

The Institute of Medicine (IOM) definition of conflict of interest is: "a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest."  Note that the IOM makes no distinction about conflict of interest versus the appearance of conflict of interest.  It turns out that the appearance of conflict of interest is the common standard that is used to indict the medical profession.  The classic example that is typically given in the media is the influence of pharmaceutical representatives on physician prescribing behavior.  The recent GSK disclosure confirms that that pharmaceutical representatives were paid based on the number of product prescriptions that the physicians they visited actually wrote.  The idea is that promotional items of widely variable value (pens to pizza to golf outings to trips) and free samples led to increased prescriptions.  Free samples provided to clinics was probably also a major factor and became a mainstay for many patients with limited or no mental health benefits.  Typical press coverage suggests that the results of this type of conflict of interest are widespread and certain, but I would suggest that the great majority of physicians including many of those who were paid consultants by the pharmaceutical industry were not laboring under any conflict of interest.

Consider for a moment the conflicts of interest (COI) listed across the top of the diagram starting on the left with Managed Care COI.  I have reviewed those conflicts of interest in great detail in previous posts.  As an example consider the conflicts of interest in this post on how physician employees are managed by managed care companies.  In all cases, there is a direct conflict of interest between physicians interest and the interest of the company and its managers.  In every situation that I am aware of the physicians lose.  That is typically viewed as a plus by the business managers running the company because it allows them to do whatever they want to do in terms of closing clinics and programs, firing physicians, firing support staff, coming up with business based performance metrics that are divorced from clinical reality, and denying care when they want to.  When the conflict is framed as entitled doctors being managed for the first time in order to be fiscally responsible - apart from the obvious rhetoric the real impact on patients is lost.   That has included the rationing of psychiatric services, the destruction of inpatient psychiatry services, the elimination of psychotherapy services, and the wholesale shifting of care for people with the severest forms of mental illness to deficient state operated services and correctional facilities.

Managed Care COI is almost always transacted by an army of intermediaries.  There are so-called physician reviewers or utilization reviewers who look at records from a distance and second guess physicians actually treating the patient.  They can say that they don't think a patient needs a particular service such as hospitalization and the patient is invariably discharged.  These days many hospitals owned by managed care companies employ non-physician case managers who function the same as utilization reviewers and tell physicians when to discharge patients from the hospital.  This review process represents what I consider to be the largest conflict of interest affecting the decision making process in medicine and it is the least transparent.  You are not likely to hear about it until you or a family member are hospitalized and you are told that it is "time to go" based on an insurance company decision.  You can see from the diagram that this COI is enmeshed with federal and state governments, think tanks, and some of the other managed care rationing tactics - Pharmaceutical Benefit Manager COI and Insurance Company COI.  All of these bureaucracies can produce insurmountable obstacles to physicians trying to care for patients by denying diagnostic and treatment modalities and denying appropriate settings for care.

Staying on the Managed Care COI for a moment what do some of the other relationships imply?  A full description of those relationships would require several books to explain.  This all started about 30 years ago as a concerted anti-physician movement.  Several political forces had an interest in making the argument that the reason for the high cost of American medicine was that physicians were greedy and they did too many procedures.  The federal government set up a complex subjective billing and coding system to slow down physicians.  It was a mechanism that could be used to investigate and prosecute anyone who seemed to be billing too much.  They initially enforced these totally subjective rules with the FBI.  At some point in the late 1990s, they allowed managed care organizations to internalize this process and control over physicians using this mechanism was handed off to managed care.  Today it allows a managed care companies to look at the documentation of patient care, decide that the notes don't meet criteria for a certain bill, and retrospectively demand payment for reimbursed services based on the number of other people seen for that problem.  The relationship between managed care companies and governments allows them to reimburse whatever they want for a service and demand back as much as they want.  No other professionals have private industry and governments stacked against them in this manner.  It is a motivating force for psychiatrists to not accept government backed insurance at a higher rate than other physicians.

Managed Care COI also means that it is practically impossible for a physician to appeal a decision by a managed care company.  The appeal is to another doctor who is employed by that company.  Any attempt to go outside of the company to a state insurance board is usually not productive.  State insurance boards are after all generally run by political appointees who are insurance industry insiders.  There are no neutral parties who are free of conflict of interest who can decide an appeal of an insurance company decision.

Practically all of the major entities represented on this chart operate in a similar manner to the managed care and insurance company conflicts of interest.  They are business entities who have woven themselves deeply into the political system at all levels and they can generally do what they want to do in terms of running the US Health Care system.  In most cases they treat physicians with impunity and tolerate professional groups only so far as they can co-opt some of their ideas and make it seem like they have an interest in quality care.  They have also used their influence to introduce cost-effectiveness rhetoric into places where it makes no sense.  That is especially true for psychiatric services where many have simply been shut down because they were not "cost-effective" enough.    

Some of the other entities on the diagram are more subtle.  Journalistic COI has a few sources.  Certainly journalists have no interest in patient care or treatment standards.  They do have an interest in selling stories and in some cases books.  They have an interest in influencing people.  Many of the stories I have commented on this blog over the past year were clearly rhetorical.  Many were also the product of ignorance.  Psychiatry is the only field in medicine, where non-experts don't hesitate to put their opinion in the New York Times and the New York Times doesn't hesitate to print it.  One of the most read posts on this blog in the past year was about a Washington Post article that I critiqued for many of these reasons.

Professional Organization COI is also an interesting one.  Consider the APA represents roughly 40,000 psychiatrists but only about 40% are actual members.  When the American Board of Medical Specialties decided that they would introduce a new and onerous procedure to certify physicians in an ongoing manner instead of for life, the APA clearly sided with the ABMS despite widespread dissatisfaction by the membership.  The conflict of interest considerations here are considerable and heavily financial.  There is no scientific evidence that the proposed ABMS recertification process is a valid approach.  There is certainly no evidence that a less onerous approach that would be less stressful to physicians would not achieve the goal of ongoing professional education and public safety.

The next time you read a story in the press about wealthy physicians being paid off to prescribe unnecessary medications or to perform unnecessary surgeries, pull up the COI diagram and print it out.  The truth is that physicians are caught in a web of conflict of interest.  Those conflicts of interest are generally set up to ration services to patients; ration or deny reimbursement to physicians; maximize the profits of middlemen (MCOs, HMOs, PBMs, Insurance companies); make politicians, think tanks, journalists and critics look good; and distribute a large chunk of the health care dollar to people who are not involved in providing the services.  The impact is the greatest by far in the area of psychiatric services but at some level it affects all of medicine.  The impact on physicians is also significant.  All of the pressures on physicians as a result of these conflicts of interest widen dissatisfaction with the field and increase burnout.  Both of those factors can potentially impact physician availability and intellectual resources necessary for optimal performance.  So if your physician looks burned out - he or she may well be.  It is probably directly related to doing an additional 2 or 3 hours of work every day to satisfy the requirements of all of these extraneous conflicts of interest.  Of course that is all generally unreimbursed time.  How would most workers react to putting in a full day and then an additional 2 - 3 hours off the clock to satisfy the requirements of some outside company?  It is like working for free for another company.

That is the real cost of conflict of interest and one of the reasons that health care premiums are essentially another tax on all Americans.

Happy New Year!

George Dawson, MD, DFAPA

Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22942/ 

Pills Don't Save Lives - Psychiatrists Do

I am paraphrasing David Healy from a previous post and I am doing it here to emphasize - it's all about the side effects.  Healy's comment serves as a counterpoint to a highly successful multi-decade advertising campaign by pharmaceutical companies.  It began with the first National Depression Screening Day in 1991.  The emphasis  was on identifying and treating depression with antidepressants.  There was no real discussion of antidepressant side effects or the general problem of side effects with most medications.  Since then antidepressant treatment has been conceptualized as comprehensive treatment wrapped up in a pill or capsule.  That bias continues today as various political forces have shifted depression screening from an annual event to primary care clinics.  Some health care organizations and states consider depression screening and serial ratings of depression to be quality markers of health care services despite the fact that there are definite problems with that idea.  Unless there is a highly specific screening test any screening procedure has the potential to expose more people to the side effects of treatment.  There is no highly specific screening test for depression.

A second factor in considering side effects is the physician's role.  Doctors are trained to identify and treat conditions with surgery or medications.  Psychiatrists have additional training in psychotherapy. When you are in your training, the emphasis in on making the correct diagnosis and selecting the medication that will be the most useful.  Even though medical training is long, the longest you might follow any patient might be for a couple of years.  In medical practice you have the ability to see people for decades rather than months or years and how their medical treatment changes over those years.  You also observe first hand the long term toxicity of many medications when you might have only been exposed to that on a theoretical basis during training.  As a practicing physician you are expected to help people deal with the fact that they have side effects and the medications they are using may not be that useful.  In fact, in many cases they may not be beneficial or may be causing more harm than good.

All of that experience with side effects leads clinicians to develop new practices that they were never trained to do.  Very early in my career, I had the experience of treating a person who had been on an antidepressant for about 6 years.  She had headaches and depression and like many people with chronic depression she was in a stressful situation that she could not remove herself from.  She had chronic depression in the context of a chronic stressor that was not going away.  At some point her headaches resolved and her depression improved.  We decided to taper her off the antidepressant.  She came in 2 weeks later and said: "I feel much better.  All of the years that I was taking that medication I didn't realize it, but I felt like I had the flu.  That has now cleared up."  That early experience led me to modify the ways that I discuss medications with people.

I generally tell people that I don't expect anyone to "get used to" a medication.  I often tell them that people may get used to feeling ill rather than develop a tolerance to medication side effects.  I tell them that if they are experiencing any side effects at all to let me know about it and we will decide what to do about it at that time.  I let them know the range of experiences with medications and what they might expect.  As an example, I might say that "60-80% of people might take this medication and not notice that they are taking anything, but 5-10% of people might not tolerate it at all."  I let them know about all of the FDA contraindications, in some cases I review it with them many times.  I discuss the common side effects and usually provide them with the MedlinePlus handout on the medication.  I think it is more comprehensive than most handouts and it gives the FDA black box warnings (in a red box) on the front of every handout.  I talk with them about rare but potentially serious side effects like drug induced liver disease and arrhythmias and what to look for.  In the case of atypical antipsychotics, I discuss movement disorders and metabolic effects.  I demonstrate what the movements of tardive dyskinesia may look like.  I let people know if the medications they are taking are potentially addictive.  I the case of lithium, I let people know about the unique toxicities and the safest possible way they can take it.  In the case of antidepressants, I let people know that they may be difficult to stop due to discontinuation symptoms.

My side effect discussions with people have taught me valuable lessons.  There are people who are placebo responders and nocebo responders.  The nocebo responders develop problems taking any medication, even medications that are generally well tolerated at low doses.  Some of them are aware of the problem and decline any discussion of side effects.  They might say they don't want the MedlinePlus handout because: "If I read about any side effects I will probably get them."  They would rather be surprised.  Whenever I encounter that attitude, I respect their wishes but advise them to contact me if they have any side effects.  I also recall my Forensic Psychiatry lectures during residency.  The instructor advised us that we "could be sued" if our side effect discussions prevented a patient from taking a useful medication and there was an adverse outcome as a result.  I have realized over the years that basing your decisions on whether you could be sued is generally a bad idea because you can be sued for just about anything.  I think that people need to hear about what really happens with psychiatric medications and consider myself to be a good source of information.

I have also found that there is a hearty group of people who decide on their own that they will try to tolerate side effects and not let me know about it despite our discussion.  When I see them in the follow up appointment they will say: "Well you know doc, I had a pretty good headache the first three days on the medications, but I decided to keep taking it to see if it would go away and sure enough on day 4 the headache was gone."  They tell me that even though I advised them to not tolerate side effects and to call me if they had any side effects.  These patients are almost always men with a history of avoiding doctors and not taking care of themselves.  I guess their experience confirms that some people develop a tolerance to side effects but why would you want to?  I was at a large conference on the treatment of anxiety disorders and listened to a renowned psychopharmacologist talk about his technique for treating anxiety disorders with SSRI and SNRI type antidepressants.  His approach was to keep titrating the medication "to the point of toxicity" and then back off to the lower dose.  My experience has taught me that the best approach in non acute situations is to use the lowest possible dose.  That is usually the dose recommended for anxiety disorders and titrate it to the exact point where the symptoms are in remission.  I am never  compelled to increase a medication by a multiple based on the pill size or a drug level based on the aggregate experience of a cohort of people in a drug trial.

I obsess about the hypothetical.  Physicians in practice are aware of trends in the medications that are prescribed and psychiatry is no exception.  Drug interactions have been an area of focus in psychiatry since it was first learned that fluoxetine could inhibit the hepatic metabolism of tricyclic antidepressants and that could lead to antidepressant toxicity.  I treat people who are often on a mind boggling combination of medications for their chronic illnesses and psychiatric disorders.  I routinely run those lists through one or more computerized drug interaction software packages.  The software is inconsistent and I often have to look up the case report or study that suggest a specific interaction or problem.  I have to make the decision to accept or reject what the software is telling me.  The QTc interval or the interval on the electrocardiogram that corresponds with the total time of ventricular contraction and relaxation has been a major concern since the approval of ziprasidone.  It has been complicated lately by the FDA concern that citalopram may prolong the QTc interval in some people to a significant extent.  I screen people with electrocardiograms if it appears that their clinical status or total medication burden may lead to prolongation of the QTc interval.          

In some cases a concern for the hypothetical requires some inductive reasoning.  Current textbooks, literature, and standard prescribing references create the illusion at times that everything is known about a medication, it is just a matter of finding it.  There are plenty of examples where that is not true or where there is a lot of uncertainty about when a medication can be safely and effectively prescribed.  To illustrate, consider a hypothetical situation of patient with bipolar disorder who may benefit from taking lithium.  For a time during my residency training the renal toxicity of lithium was openly debated.  Nephrologists at the time certainly believed it was nephrotoxic but there were large series of patients who were described with minimal signs of renal toxicity.  Clinical practice treating patients with severe bipolar disorder has lead me into situations where I have treated patients on, during and after dialysis and kidney transplantation.  The estimation of glomerular filtration rate (GFR) by 24 hour urine collections was also problematic.  That has been greatly improved by the practice of using calculated GFRs.   I have no doubt at all that taking lithium for a period of time can lead to renal failure in a portion of patients taking it.  Anyone prescribing lithium needs to be aware of this fact and take all measures necessary to minimize episodes of lithium toxicity and exposure to other nephrotoxins.  In some cases like NSAIDs, the toxins are well known.  In other cases like tenofovir, the interactions are not known and in fact you can scan an entire FDA approved package insert and might find no references to lithium.   Making that decision may take hours or a weekend of study to figure out the best course of action.

I hope that I have made the case for psychiatric medications needing a careful analysis of side effects before they can be initiated and continued.  The decision to take medications is a serious one.  In 29 years of practice I have not met a single person who told me that they liked to take medications.  The decision to take medications often comes down to having tried everything else and realizing that a major change is necessary to get back to where you want to be.  A recent reply to my previous blog post described medications as "tools" rather than a panacea and I think that until perfectly safe and effective medications are invented that is true.  Healy's point is that the advertising notion of "Take an antidepressant and get better" is false.  Psychiatrists are trained to help you navigate the complicated process of recovery from depression and side effects and the potential for side effects is generally the most complicated aspect.

George Dawson, MD, DFAPA


Additional Clinical Note 1:  Another blogger sent me an e-mail earlier this week asking me to send a list of psychiatrists who I thought were competent to taper people off of SSRI/SNRI type antidepressants.  The intention of the e-mail was to have a ready list of people who could help people with that particular problem.  I think that all psychiatric residents should be taught about medication discontinuation effects and how to resolve them, but apparently that is not the experience of some people who end up taking these medications.  As an instructor in a psychopharmacology course, I can verify that the residents I taught were all aware of this problem and how to deal with it.  They also had the very good back up reference of the ASCP psychopharmacology course PowerPoints and lecture materials on this problem.  I realize that this blog is not widely read, but I would appreciate any posts from instructors or professors about the issue of side effect recognition and treatment in general and SSRI discontinuation symptoms in particular and the approach to teaching these topics in your program.  I would also appreciate hearing your thoughts on this problem about SSRI/SNRI discontinuation symptoms and the variable experiences of people trying to get the problem diagnosed and treated.

Additional Clinical Note 2:  The processes that I am describing in the above post take time.  In many cases the equivalent amount of time required to do psychotherapy and longer.  I do have people telling me that their physicians (all types) seem to be poised over a prescription pad.  They tell me nobody has ever informed them of the risks or potential side effects of a medication.  I don't think the problem has been investigated and it would be difficult to do.  The idea that "medication management" in psychiatry, internal medicine or any other field is a brief uncomplicated encounter that takes little thinking on the part of a physician is largely an invention of business interests seeking to reimburse physicians at the lowest possible rate.  If you are a consumer of medical services, consider my approach in the above post and ask yourself if you have had the discussions that I describe.