No Information From The EHR - An Ongoing Problem

Like most physicians - I like the concept of an electronic health record (EHR).  It is just that the real EHR as it exists is a far cry from the concept.  The proponents of the current EHR,  especially those who want it mandated by legislative activity continue to brag about the savings and all of the benefits.  Any physician looking for information or an ability to enter and move information without ending up in a click fest of mouse clicks knows the reality.  Any physician looking for a note that reflects an intelligent conversation between a physician and a patient is also left wanting.  Reading the electronic or printed out version of the EHR usually results in very choppy documentation.  Lists that are the result of not very intelligent coding by EHR IT engineers, notes produced strictly to meet billing and coding bullet points, and notes produced because they could be rapidly compiled with features like smart text.

All of this can be a nightmare for a compulsive physician like myself who wants to use all of the relevant information in patient care.  My career has been treating patients with complex medical conditions who are also on complicated combinations of medications.  Many have known heart disease and take combination of medication that can adversely affect their cardiovascular status and interact with psychiatric medications that I prescribe.  All of that needs to be considered.  Since ziprasidone (Geodon) hit the market in 2001, psychiatrists have been preoccupied with the QTc interval.  The QTc interval is the electrical interval that corresponds to the contraction and relaxation of the left ventricle.  In cases where this interval is too long it predisposes the patient to ventricular arrhythmias some of which are potentially fatal.   The FDA had a warning on ziprasidone about the potential for QTc prolongation and subsequently came out with warnings about citalopram.  In the course of clinical practice, many psychiatrists had already encountered this issue with older antipsychotic medications and tricyclic antidepressants.  The FDA makes these pronouncements but gives physicians no guidance on what to do about the clinical situations.  I have a practice of looking at ECGs and any Cardiology evaluations that have been done.  That is the only way the QTc interval can be determined and even then there are various factors that can affect it.

Rather than order an ECG, I will ask whether they have already been done and get the patients consent to have them faxed to me.  That result is frequently disappointing, especially in the case of the EHR.  I will often get a series of cryptic sheets, that look like a sparsely populated medical record.  There are often no coherent notes from physicians or if they are there, they do not contain standard information that I am looking for.  I have never seen an ECG tracing contained in these stack of records.  The best I can hope for is a brief note that lists an impression like "NSR - no acute changes."  An added bonus would be an actual description of the critical intervals.  For the tracing at the top of this page it would say:  "PR interval - 164 ms; QRS duration - 100 ms; QT/QTc - 434/415 ms."  That is really all of the information I need to know.  But the most important issue with the EHR is that all of this visual information is usually lost, unless I submit a second or third request and it usually has to say "send me the ECG tracing."  The medium that purports to provide a lot of information to physicians and put it at their fingertips is a bottleneck.  By the time I see the information I need to see, it is not necessary.  I have moved on and not recommended a treatment that I could have recommended if the ECG was normal.  That practice has been reinforced by getting an ECG after the fact and realizing that not only was there a prolonged QTc interval, and it was read that way by a Cardiologist but reported as "normal" in the EHR.

I will be the first to admit that there is minimal evidence that my tight QTc surveillance has saved any lives.  But my threshold is really to prevent any complications.  I am not treating acute heart conditions.  I am trying to make sure that I don't cause any by the medications that I prescribe, by ignoring a critical drug interaction, or by not recognizing the significance of a patients physical illness and how it needs to direct the therapy that I prescribe.

That doesn't end at ECGs.  I would throw in imaging studies (CT and MRI), EEGs, and even routine labs.  If the EHR is supposed to convey the maximum information why wouldn't all of the visual information of an episode of care be included?  Why can't all of the brain imaging studies be sent along as a disk or e-mailed to me?  Why do I have to read a 200 page fax and try to reconstruct all of the lab results  in a coherent manner that are spread randomly across those pages so that I know what happened in the hospital?

The EHR as it currently exists is a tremendous burden to physicians.  It takes far too long to enter data and quality notes about care are rare.  If you happen to lack online access to the program where the record is constructed, good like trying to piece together the information that you need for clinical decision-making.  Politicians are good with ideas, but none of them seems to be aware of the real problems that exist in these systems.  Despite that lack of knowledge they continue to insist on the wide implementation of these systems and that is really a tax on physicians that is being used to subsidize the development of EHRs and fund this industry.

Hopefully that will pay off someday, but the current problems have been there for at least a decade and there are no signs that they will be going away soon..



George Dawson, MD, DFAPA  

The Luck Of The Ethical Researcher

“My point here is that when discussing an actual case, the ideological wars melt and people from multiple sides of a debate can usually agree. "Clinician trumps Ideology." 

From 1BOM March 30, 2015 post.



Not sure that I follow that line of thinking.  That has not been my experience in psychiatry or any other medical specialty.  There is plenty of ideology and a lack of technology across the board.  There is also the dirty little word that nobody likes to see affiliated with medicine and that is politics.  As far as I can tell a lot of the ethical debates in medicine are all politics. I can point out several on this blog.

There is also the question of uncertainty.  I can recall being a grunt in a new drug protocol that I will not name but I will say it is in a therapeutic class almost never prescribed by psychiatrists.  My job was to do the medical and psychiatric evaluations and assure that the patients were medically fit to continue the protocol.  Part of the weekly screening was an ECG. I looked at this patient’s ECG, determined it had been changed and told the monitor that I was stopping the protocol.  The monitor got very angry at me because the patient was 2/3 of the way through the protocol and would not count as a completed patient.  I referred the patient immediately to a medicine clinic and they agreed the ECG was changed.  The patient was advised to come back for routine follow up care.  They could not comment on the study drug and they did not recommend any acute care. The monitor remained angry, but I stood my ground and the patient was taken out of the study and referred back to medicine.

A week later the patient had a major medical complication and ended up in the ICU. The monitor and the chief investigator both thanked me for taking the patient out of the protocol at that time – one week later.  The monitor apologized for getting irate with me.

So the rub is – am I more “ethical” than the monitor (who was not an MD) or am I just lucky? Uncertainty certainly can make you look like a hero or a zero in a hurry in medicine.  In this case an internist did not have any reason for concern even though the ECG was clearly different. Was the ECG change causally connected to the ICU incident?  Was it casually connected to the study medication?  Or was the decision to stop the protocol more related to my blue-collar anti authoritarian roots?  To this day nobody knows (but as I age I am more inclined to credit the roots).

And what if I had no markers and the person had stayed in the protocol and ended up in the ICU on the study medication?  Certainly the company and the FDA would have investigated the study and me and my methods.  Would I have been vilified as just another researcher working in the interest of a pharmaceutical company?  Would it have been good press for somebody trying to benefit at my expense?  My only thoughts at the time were in the interests of the patient.  But that difference in course could have been career changing for me, despite the fact that my only interest then and in the past 30 years has been patient safety.

Situations like this are easily politicized and there is a very porous boundary between politics and ethics.

George Dawson,  MD, DFAPA

Supplementary 1:  For the whole story go to the 1BOM blog and start reading at the link.

How To Ruin Your Life Without Being Dangerous

Changes in Personality and Decision-Making

The above table is really all that you need to know. You don't need to know anything about psychiatric diagnoses. You don't need to know anything about medications. That is typically how the problem is approached these days. What could have gone wrong? What kind of mental illness could account for what happened to this person? Let's get a panel of experts together, put them all on TV and have them speculate about what type of mental illness the person might have. I have never observed this to be a useful exercise. How could it be? There are just too many conflicts of interest and too much entertainment bias for anything of value to occur. The diagram is meant to illustrate the basic transitions associated with many mental illnesses and how the problems occur. It appears to be very simple and it is even more simple than depicted.

The top two zones - both Dangerousness and Altered State of Consciousness can be combined because Dangerousness has no medical or psychiatric meaning.  It is a legal and/or managed care definition.  From the legal side of things it determines grounds for civil commitment, guardianships and conservatorships. More importantly it determines when courts can dismiss these cases and not spend money on the people brought to their attention.  In the case of managed care companies, they view dangerousness as the only reason that somebody needs to be in a psychiatric hospital.  The diagram illustrates why they are wrong.  Rather than considering this process to be tabular a Venn diagram might be a better way to view things.  I constructed this one looking at some relative contributions of these conscious states.  Keep in mind that the dangerous conscious state here is an artificial legal and insurance company construct and that all of the demarcations here are permeable to indicate that transitions between states commonly occur.  A porous line might be better but I am limited by my software.  The diagram also illustrates that in these transition zones the difference between an altered and even dangerous state may be practically indistinguishable from the baseline state.

The simple 3 row table also describes what families have observed happening since ancient times.  It has only recently been modified to include the role of physicians, medications, insurance companies and local governments.   What do I mean about family observations?  Within the timeline of any family, the generations observe their members starting out as a vigorous young people and going through the expected developmental stages of adulthood.  The trajectory is predictable with some notable exceptions.  Some family members will get sick and die unexpectedly.  Some may get sick or injured and become disabled.  That is as true today as it was a hundred years ago.  It is also the case that the disabilities can be mental problems as well as physical health problems.  They can be something that you are born with or something that you acquire along the way.  Most families have stories about members who experienced some kind of transitional event and they were never the same afterwards.  That transitional event could have been a serious illness, an accident,  an episode of psychological trauma, exposure to combat,  excessive exposure to street drugs or alcohol, changes in interpersonal relationships, or losses of significant people in their life.  There is a consensus in the family.  They all see the person as changed.  That change is sometimes positive, but typically the person seems less well and less capable of handling life's everyday stressors.  The diagram attempts to illustrate what families observe in terms of personality characteristics and decision-making.

In the diagram, the diagnosis is really not the most important consideration.  All diagnoses and all problems for that matter are mediated by a conscious state.  All human beings have a unique conscious state that starts in the morning when we wake up and our feet hit the floor.  We have a stream of ideas and thoughts that occur in familiar ways every day and our behavior patterns and personalities are fairly predictable to our friends and family.   There are very limited discussions of conscious state in any discussion about psychiatric diagnosis or the ways that diagnosis impacts on a person's ability to function.  A further complicating factor is that most of the considerations about problems functioning suggest that there is a linear relationship between the mental illness and the inability to function.  For example, in the case of schizophrenia the diagnostic criteria may be met, but at some point a determination of the person's insight and judgment is made.  Problematic behavior is often taken as proof of a lack of insight.  Anosognosia or a form of neglect has been cited as one of the reasons for impaired insight in schizophrenia.  The actual sequence of events looks something like this:

Baseline -> Symptoms of schizophrenia ->  Diagnosis of schizophrenia ->  Problematic behavior

The real sequence of what happens is far from that linear.  Problems are often noted over a number of years.  Drug use and other behavior problems are often theories that families have before there are more clear cut symptoms allowing the diagnosis.  The concepts of pre-clinical, sub-clinical, and latent syndromes are described by some researchers.  But the main point I am trying to make here is that the pathway is not linear and there are associated changes in the person's conscious state.  There is rarely a sequential pathway to a significant mental illness.  There are starts and stops and often misdiagnosis along the way.  People can pass back and forth between an altered state of consciousness and their baseline mental status for a long time before any psychiatric diagnosis is declared.  

Psychotic depression is often a difficult illness to diagnose and treat.  Consider another common scenario.  An elderly woman walks into her kitchen and discovers her husband pointing a shotgun at himself.   She convinces him to put the gun down and go to see their doctor.  She is completely shocked about the suicidal behavior and did not see it coming.  They have been married for 40 years.   Her husband had no prior history of suicidal behavior or depression.  As they talk with his primary care physician, she corroborates that he seemed to have been sleeping well, but seemed less spontaneous and "happy".  She was shocked to find out that he had lost about 15 pounds.  He is sent to a local hospital where he talks with a psychiatrist and at one point says: "I just could not go on living anymore."  Further questioning leads to a discussion of an event that occurred when he was in high school (over 65 years ago) that he was guilty and embarrassed about.  His worries about the event continued to build until he got to the point that he saw suicide as his only means of relief.  He was too embarrassed to discuss it with his wife.  He had the original suicidal thought over 6 months ago and he observed it "come and go" over time.   This is a good illustration of how delusional guilt can be associated with transitions between baseline and then within the altered states model to one that is potentially dangerous.  It also illustrates how the individual life experience of the person is relevant. 

Manic and hypomanic patients often have transitions in their mood state.  Families members will call and say that the person needs to be in the hospital because they are keeping the whole family up all night and there have been some dangerous confrontations as a result of the sleep deprivation.  The patient can present very calmly and declare that the only problem is their family.  They may not acknowledge that they are spending money excessively, driving recklessly and starting to drink a lot.  Since they do not believe that there are any problems they will refuse crisis care, sleep hygiene advice or medication changes.  They are incapable of recognizing a change in their conscious state that puts their marriage, finances, and health at risk.  With many people this can be a self limited change, but in others it can lead to mania and psychosis or severe depression.  At the critical point where the altered conscious state could be treated, they are unable to process that information and make a decision in their best interest.  They may come back later and tell the psychiatrist who was trying to make an acute assessment that they were really out of it at the time but during the acute episode they were not able to see this reality.

Altered conscious states also occur in outpatient settings.  It is not uncommon to talk with professionals who need a specific medication that is prohibited by their licensing or regulatory body.  These are typically professions that regulators decide can inflict a significant amount of damage if they are compromised in some way by prescription or illicit drugs.  In the case of a person concerned about losing that profession, not reporting the medication or not taking it can happen.  That can occur as both a direct attempt to mislead regulators or as a result of impaired decision making from a substance use or mental disorder.

From what I have seen about the way that mental illness and substance use can alter conscious states, figuring out how to recover baseline conscious state is far from clear.  The first issue is that there is no real focus on the problem.  Psychiatric hospitalizations depend on a handful of yes-no questions about suicide and in some cases homicide.  I was recently told that a psychiatric hospital said that their admission criteria was: "You have to be suicidal and we have to be able to discharge you in less than a week."  That statement is so far from the reality of how mental disorders need to be treated it is stunning.  That statement shows a lack of regard for quality assessment and treatment.   There is no apparent interest in restoring a person to their baseline or even finding out what that baseline was.  On the other hand, I have had active discussions with psychiatrists who were interested and actively talked about these things to their patients each day.  If you are such a psychiatrist, patients will often say that in retrospect their very interested and compulsive psychiatrist missed the fact that they had significant suicidal thinking or that their were probably psychotic in a previous interview.  

The life ruining events discussed in this post and the possible mechanism illustrate that our lives are a complicated web of social interaction.  We make decisions based on that web every day and all day long.  Going into a hospital and being discharged based on whether or not the suicide question is endorsed or whether or not you are aggressive is a very low standard of social behavior and ability to function.  It takes a lot more than that to stay married, stay on the job and perform it safely, stay in the role of spouse and parent, and stay in a stable living situation.  Those are the real goals of assessment and treatment when it comes to recovery rather than ruin. The necessary decision making is linked to a conscious state that may be in a state of flux during an acute episode mental illness.

It is important to recover and recover completely.  Being familiar with baseline conscious state rather than a list of symptoms as being a good measure for this seems like a reasonable approach.  


George Dawson, MD, DFAPA

Death Cults

That may seem like an odd topic for a psychiatry blog but I did not know where to put this.  Earlier this week my wife and I decided to stop watching a popular television show called The Following.  It is basically a fictional show about a death cult that involves a charismatic psychopath who engages other psychopaths to do mass killing.  They typically use knives as murder weapons and kill large numbers of innocent people at public gatherings like book signings in book stores.  In one episode last year, the main psychopath in the show happened across the camp of another death cult run by a different psychopath and it was the expected lethal battle for leadership.  The dramatic tension is created by a group of FBI agents trying to catch and stop the psychopaths and the personal stories in that group.  In the opening show this year, there was a murder scene that was explained to the audience and then implicitly done that was so sadistic and so sick that we decided to shut off the show and never watch it again.

Violence and aggression are always in the background in America.  We take violence and aggression for granted and it seems surprising when they are excluded from entertainment.  What no car chases or shootings?  And it has been there a long time.  I can remember being in East Africa in the 1970s and at that time many of the Africans that I met, had the idea that most Americans carried guns.  That conclusion was from watching American films.  There has always been the debate about whether or not the display of all of this violence affects people.  Like practically all research of this type, I would expect the results to reflect the biases of the researchers.  Typical research would look at a large group  exposed and not exposed to violence in the media and the results are mixed.  Mixed results lead to the status quo, but the status quo has gradually gotten worse.  Television shows commonly have sadistic serial killers as their plot line and in one case a serial killer is the main character and hero.  

According to a 2012 report by the Media Violence Commission (1) major medical (including the American Psychiatric Association) and the major psychological organization in this country support the argument that there is a casual connection between media violence and aggressive behavior.  This report also looks at the biases that may be in place that might obscure that connection.  The authors mentioned the belief that the effects must be immediate and severe is a common bias.  In other words, I see a violent movie and perpetrate a violent act within the next day or two.  Instead over time, exposure may decrease prosocial behaviors.  This report briefly summarizes the literature on possible psychological mechanisms that occur with exposure to violence but the most important  conclusion is:

"One conclusion appears clear-extreme conclusions are to be avoided. Not every viewer or player will be affected noticeably, but from understanding the psychological processes involved, we know that every viewer or player is affected in some way."

Many clinical psychiatrists have talked with people who have perpetrated violence based on some act that was portrayed in the media.  These stories are also described in the media with some regularity.  I think that if there are any factors containing a media effect it is the moral development of most people and that fact that a lot of the violence is hypothetical and it could not be enacted without considerable resources.  Factors that may facilitate violence after exposure would include a developmentally immature brain or a brain that would be more susceptible to the priming effects of violence.  That would include various forms of severe mental illnesses or personality effects like psychopathy or antisocial personality disorder.  In many cases the perpetrators of violence has no idea about how devastating injuries can occur from fictional portrayals where people get up after being hit over the head with a pipe.  They don't realize that in many cases that results in a fatal or disabling brain injury.

The overriding dimension affecting violence that needs to be addressed is at the cultural level.  A critical recent development is the resurgence of the death cult.  The concept of death cult is poorly defined at this time and as far as I know there are no definitive scholars.  They seem to come in two forms.  The first requirement is a cult or an organization with a charismatic leader and followers who are willing to uncritically follow the edicts of the leader.  There have been various studies of the dynamics of these groups and who might be susceptible to becoming a cult member.  Jerrold Post, MD has analyzed the dynamics of charismatic leaders and describes them as "mirror hungry" personalities that require constant admiration, convey a sense of omnipotence and grandeur,  have the appearance of certainty, and rely heavily on splitting as an adaptive psychological defense (2).   Death cults seem to come down to 2 varieties - those predisposed to mass suicide and those that are predisposed to homicide and mass homicide or in some cases genocide.  For the purposes of this post, I am focused on the latter, because they seem to pose the most immediate danger to the most people.

Prototypical homicide focused cults or movements in my lifetime have included the Nazis and Pol Pot.  The concept of "charismatic leader" can probably extend to larger groups of extremists that have been described as being responsible for genocides (3).  Over the past 30 years, we have seen many of these cults or movements commit homicide to various degrees often with loose religious rationalizations.  The killings have become increasingly vicious and sadistic.  The killings have reached a level of intensity that all of the religious justifications no longer seem to apply.  The international solution has been to mobilize against these groups and in some cases, explicitly threaten to kill them.  The media is always complicit with death cult propaganda and the resulting desensitization may have been one of the factors in the escalation.  This is an interesting parallel with television entertainment that seems to be in the same cycle of escalating to the most horrifically sadistic and brutal types of killing and torture.

What is missing in all of this mass exposure to violence and killing is an explanation of the driving forces and a plan for change at a cultural level.  There is a current and shocking increase in antisemitism spreading across Europe, to the point that one author has suggested that it may be time for the Jews to leave Europe (4).  There don't seem to be any pacifists any more.  There is no peace movement like there was in the 1970s.   I have not seen any explanations for this primitive behavior and why it occurs even though many explanations have been around for years.  Here is one from Lifton that has been available since 1986 and it is accessible to any psychiatrist trained in psychodynamics or any good student of English literature:

"Fascist ideology can have particular appeal for the survivor self fighting off disintegration because it holds out, at all levels, a promise of unity, oneness, fusion.  It deals with death anxiety, moreover by glorifying death, even worshiping it.  While one's own death as a warrior is idealized, the self mostly escapes death - achieves the death of death - by killing others.  There can readily follow a vicious circle in which one kills, needs to go on killing to maintain one's cure, and seeks a continuous process of murderous, deathless, therapeutic survival.  One can then reach the state of requiring a sense of perpetual survival through the killing of others in order to re-experience endlessly what Elias Canetti has called the "moment of power" - that is the moment of cure."  p. 499.

Lifton knows full well that the fascist thought process that he describes is not a diagnosis,  but it is the way that large groups of people can think.  It has been present since the time of ancient man.  You can find theories about how it is "hardwired" into the human brain with suggestions that it is adaptive.  The only real way we can combat it is through educating people about what is really going on, improving critical thinking and changing popular culture.  Teach them how to recognize biases and overcome them.  A basic skill would seem to be able to recognize a death cult and realize why participation may not be in your best interest.  It goes without saying that it could not be in the best interest of civilized society, but the philosophy behind that probably needs teaching.

When I turned off my TV set the other day, I was not seeing it as a protest.  But if media producers realize that abhorrent violent content is less interesting that may be an important cultural change.      


George Dawson, MD, DFAPA




References:


1:  Media Violence Commission, International Society for Research on Aggression(ISRA). Report of the Media Violence Commission. Aggress Behav. 2012 Sep-Oct;38(5):335-41. doi: 10.1002/ab.21443. Epub 2012 Aug 10. Review. PubMed PMID: 22886500 (full text available online).

2:  Jerrold Post, MD.  Personality and Political Behavior.  Door County Summer Institute July 21-25, 2003.

3:  Alan J. Kuperman.  The Limits of Humanitarian Intervention - Genocide in Rwanda.  Brooking Institution Press.  Washington, DC (2001) p. 12.

4:  Jeffrey Goldberg.  Is It Time for the Jews to Leave Europe?  The Atlantic.  April 2015.

5:  Robert Jay Lifton.  The Nazi Doctors.  Basic Books, New York (1986) p. 499.




Supplementary 1:    I would not encourage anyone to watch the television program in question that I mention in paragraph 1.  I have seen plenty of media violence, but consider this depiction to be the worst.

What does it cost to stop marketing an addictive drug?

I won't bother to repeat the usual statistics on how addictive cigarettes are or the fact that nicotine is one of the most addictive drugs.  Cigarettes  have a special place in the hearts of psychiatrists in my generation because when we first started practicing they enjoyed significantly more status in terms of public opinion than they do now.  I can recall running a therapy group at a VA Medical Center where at least half of the group was smoking during the session.  The cigarette smoke was so thick that the ceiling panels turned from white to bright orange over the course of a year.  I asked one of the staff what kind of paint they use to make them look so good and he said: "Oh they don't paint them.  They just replace them and throw the old ones away."  Too bad you can't do that with lungs.  As activist attorney generals took over and got more and more smoking regulations, the last bastion of smoking in hospitals was inpatient psychiatric units.

They were two schools of thought on inpatient units that pertained to smoking.  The most benign was also the most paternalistic and condescending.  It went something like this: "Cigarettes are all that some of our patients have.  Taking them away will deprive them of their only sense of enjoyment."  Really?  The second was the theory that without cigarettes or access to cigarettes it was guaranteed to trigger increased anger and aggression if access to cigarettes was denied.  Some of the patients in question were compulsive 2+ pack per day smokers.  The politics of smoking on inpatient units was even more complex.  Battle lines were naturally drawn between staff who were smokers and nonsmokers.  That was complicated by what each faction wanted you to believe.  For example, the nonsmokers doubted that depriving a smoker of his or her heaters would have any effect at all.  People with acute mental illnesses would willingly stop smoking for days or weeks in the interest of everyone's health.  The pro-smoking faction of the other hand knew what going cold turkey was like and they predicted many more incidents of uncontrolled behavior.  I attended conferences where both parties produced data.  The data presented was consistent with the political orientation of the researchers.  The smoking cessation folks always posted data showing that people could acutely stop smoking without any major problems.

Reality always seems to produce a much different result than research.  I won't post any war stories, but I will say that the reactions covered the expected range of quiet resignation to rage.  The proliferation of nicotine substitutes, nicotine substitute polypharmacy, and "smoking passes" led to fewer problems.  Eventually hospitals banned smoking in any area of their campus forcing patients and staff to cross the street for a cigarette.  As the tide began to shift against Big Tobacco they sustained a number of setbacks.  In 1998, there was a record $246 billion settlement with state attorney generals.  Smoking rates began to drop and suddenly smoking in public places including bars and restaurants was the order of the day.  In 2010, the  Family Smoking Prevention and Tobacco Control Act was passed.  This Act set standards for labeling tobacco products and also rules about flavoring cigarettes and marketing them to minors.  It also established some limits in terms of what the FDA could do in their regulatory role with tobacco.  At the clinical level it is known that some psychiatric populations absorb nicotine per cigarette amounts on the higher end of the typical 1-3 mg per cigarette due to more puffs per cigarette and a shorter interval between puffs.  They also take a shorter time to resume smoking another cigarette.  Psychiatric populations are at much higher risk for smoking and increased cardiovascular mortality (Reference 1) and nicotine exposure potentially increase the risk of exposure to other addictive drugs (Reference 2).      

With all of the tightening in the area of tobacco regulation it was quite shocking to learn that these regulations not only do not apply outside the US, but in some cases where countries are trying to develop similar regulations, tobacco companies are fighting back.  In a number of these countries like Australia, Uruguay, and even the United Kingdom, tobacco companies are suing against the use of graphic health warnings and restrictions on advertising.  This legal action has led Bill Gates and Michael Bloomberg to set up a $4 million "anti-tobacco trade litigation" fund to assist with some of the legal costs.  That is not a lot of money but the fund also seeks to set up a network of attorneys, many of whom are going to work pro bono on this issue.  Tobacco companies argue that they are protecting their investments and intellectual property rights.  Gates and Bloomberg argue that it is the sovereign rights of nations to pass laws that protect the health of their citizens and believe it is necessary to support countries defending these rights against tobacco companies.

My take on this is a little different.  There has been a growing movement to liberalize the use of intoxicating and addicting drugs in this country.  The growing legalization and commercialization of marijuana is certainly the best example.  There is also more in the press about how benign hallucinogens are and how cognitive enhancement from stimulants may be a legitimate activity of students at all levels.  There tends to be less debate about opiates in the midst of an epidemic of excessive accidental drug overdoses, but I think it is important to recall that the epidemic started with a call to prescribe more opiates and diagnose more Americans with chronic pain syndromes.  It is one thing to talk about a person with a chronic medical illness smoking marijuana in a contained manner.  It is quite another to think about how the commercialization of addictive drugs works and how a business responds to regulation when there is clear evidence that their product has adverse effects and needs tighter regulation.   Elected officials also frequently get into the act and declare that tax revenues from the commercialization of addictive compounds will be a windfall for taxpayers without a careful analysis of the attendant costs.  

The motivation of tobacco companies could not be clearer - use proven marketing techniques to get people into smoking, all the while knowing that it will be difficult for them to stop.  The lesson here is that addictive drugs are good for business and marketing restrictions are not.  I would not be shocked to find that as marijuana and (possibly) other street drugs are legalized and commercialized that they would get some of the same early regulatory leniency that cigarettes had before there was overwhelming evidence that tobacco should be avoided rather than encouraged.




George Dawson, MD, DFAPA



References:

1:  Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA. 2007 Oct 17;298(15):1794-6. PubMed PMID: 17940236.

2: Kandel DB, Kandel ER. A molecular basis for nicotine as a gateway drug. N Engl J Med. 2014 Nov 20;371(21):2038-9. doi: 10.1056/NEJMc1411785. PubMed PMID: 25409384.

Supplementary 1:  Image is in the public domain courtesy of the CDC and Deborah Cartagena at the CDC Public Health Image Library.   Image #14541 accessed on March 20, 2015.

Neuroscience In Psychiatry Now - It Is A Lot Easier Than It Looks

I read the article "The Future of Psychiatry as Clinical Neuroscience. Why Not Now?" by Ross, Travis, and Arbuckle in JAMA Psychiatry and found little to disagree with.  I was in one of the venues a few years ago when Thomas Insel, Director of the NIMH talked about a clinical  neuroscience rotation for neurology, neurosurgery, and psychiatry residents to bring neuroscience to the clinical side of things.  Unfortunately he was a lot less enthusiastic about it when I sent him a follow up e-mail and at that time suggested it would probably have to wait for some time in the future.  

As a long time neuroscience enthusiast,  I have always found the reluctance to head in this direction puzzling.  On a historical basis, neuroscience has always has a prominent role in psychiatric theory.  One of the arguments against neuroscience has been that there are no clinical applications.  Even back in the day with Alzheimer, Nissl, Kraepelin and other German neuropsychiatrists were studying brain anatomy of patients in asylums, there were important correlations - most notably those consistent with both Alzheimer's Disease and Binswanger's Disease.  About two decades later, Constantin von Economo penned his treatise Encephalitis Lethargica - Its Sequelae and Treatment and described conditions that were relevant right up to the point that I started my training in the 1980s.

Being a practicing psychiatrist with an interest in neuroscience presents a variety of CME events ranging from behavioral neurology and developmental pediatric conferences in Boston to the annual Movement Disorders conference in Aspen.  There were the occasional very unique courses, like the brain dissection course run by the late Lennart Heimer, MD and a faculty of outstanding neuroanatomists.  But most of the neuroscience in psychiatry is typically packed into a course that focuses on the specialized diagnosis and treatment of specific disorders.  A good example would be the American Association of Geriatric Psychiatry (AAGP) courses that would include a detailed discussion of Alzheimer's pathology and vascular dementia and how they might not be that disparate at the microscopic level (that was also an ongoing debate in the movement disorder conferences).  In an AAGP event there would be 1 lecture out of 7 for that day devoted to neuroscience.  On the teaching level, neuroscience has always been there in the form of neurotransmitters, localization of cognitive and neuropsychiatric disorders associated with various brain lesion and insults, cell signaling, and plasticity.  In the past 20 years there has been an unprecedented integration of neurotransmitters and specific brain structures as seen in this diagram of the ventromedial prefrontal cortex.  

I have been fantasizing about a foundation and several years ago came up with the idea that it should fund neuroscience education in psychiatry.  This would be my preliminary plan:


1.  Contract with the top neuroscientists in psychiatry to come up with the syllabus.  

From the reviews in review edition of Academic Psychiatry (reference 4) there are already residency training programs that have come up with a systematic approach to this training.  There should be a place for all programs to post what neuroscientists and researchers consider the top areas for focus.  From the reviews mentioned in the above narrative it is very likely that there are fairly complete syllabi at this point but looking at the reviews in Academic Psychiatry they seem to be fairly disparate in terms of what faculty see as the most relevant.  The vignettes prepared by the NIMH (reference 2 and 3) are illustrative of what is possible.  If I was designing a curriculum, I would want every possible concept that could be illustrated in these vignettes and build the course work around that.


2.  Develop neuroscience teaching as a specialty.

I doubt that there are enough neuroscientists around to teach the subject to psychiatry residents.  A group dedicated to teaching neuroscience and neuroscientific formulations would be a logical approach.  There are currently plenty of nonscientist faculty with an interest and more than a passing knowledge of neuroscience.


3.  Develop a repository of graphics and teaching materials. 

There is no area of psychiatry that could benefit more from high quality graphics for teaching.  Current faculty engaged in teaching need to run a gauntlet of copyright related issues ranging from implicit copyright permission (yes you can use for teaching without going through Copyright Clearance Center) to repetitive licensing fees that are difficult to track.  All of those problems are from publishers controlling these rights and in some cases charging unrealistic amounts for reuse of some of these works.  Open access work is a potential solution but it is doubtful that enough graphics currently exist to illustrate key neuroscience principles.  A coalition of residency programs can potentially contract for the production of custom figures for a central repository that could be used in residency programs across the country.  There is already a precedent for this process with the psychopharmacology course available to residency programs from the American Society of Clinical Psychopharmacology (ASCP) who produce a large number of PowerPoints that are available to residency programs for a very reasonable fee.


5.  Don't forget about addiction science.

The field of addiction has contributed immensely to understanding how the brain functions.  In many cases psychiatry residents have minimal exposure to the treatment of substance use disorders and the associated syndromes and that could potentially strengthen both those areas in any residency program.



6.  Hold annual review courses. 

The field as it applies to psychiatry contains neuroscience spread across gatherings for psychopharmacology, geriatric psychiatry, general psychiatry, child and adolescent psychiatry, sleep medicine, addiction medicine and behavioral neurology.  There should be meetings across the country that focus on the necessary neuroscience and formulations presented by the top experts in the world with that focus.


7.  Suggested readings.

I try to keep up with Nature, Science, and Neuron and the Science Signaling series as a cost effective approach to learning new developments about neuroscience and whatever open access journals that seem to have the best content.  There are top journals that are too expensive or require memberships where the threshold is set for researchers and not teachers.  A good general approach to how to approach the literature would be very useful for most of the teachers and some of the expensive journals might offer packages for teachers rather than researchers.  I can recall that when I interviewed for residency positions and asked about department recommended reading lists there was only one department who provided one in those days.  I will let readers guess about which department that was.


8.  Reviewing imaging studies and teaching files.

Some of the best neuroanatomical preparation and training in my career came from reviewing imaging studies with radiologists, neuroradiologists, neurologists and neurosurgeons.  Current electronic medical records make viewing imaging studies easier than at any time in the past.  There is no better learning procedure than to organize findings, order the test, and confirm the problem.  That is possible currently if you treat a lot of patients with apparent lesions on imaging but functional imaging is becoming more available it has the potential to revolutionize psychiatric practice.  As an example, listen to the story called How To Cure What Ails You and an enthusiastic Eric Kandel talk about the importance of the anatomical substrate (reference 5) in psychiatric disorders.

These are some of my current ideas.  I look forward to the day that a neuroscientific formulation about what might be relevant is contained in the same paragraph that includes social and psychological formulations.  It will also put psychiatrists back where most of us belong - seeing people with the most difficult problems rather giving out advice on how to prescribe antidepressants.


George Dawson, MD, DFAPA




References:

1: Ross DA, Travis MJ, Arbuckle MR. The Future of Psychiatry as ClinicalNeuroscience: Why Not Now? JAMA Psychiatry. 2015 Mar 11. doi: 10.1001/jamapsychiatry.2014.3199. [Epub ahead of print] PubMed PMID: 25760896

2:  National Institute of Mental Health neuroscience and psychiatry modules. 2012a. Available at http://www.nimh.nih.gov/neuroscience-and-psychiatry-module/index.html. Accessed on March 16, 2015.

3:  National Institute of Mental Health neuroscience and psychiatry modules: 2012b. Available at http://www.nimh.nih.gov/neuroscience-and-psychiatry-module2/index.html. Accessed on March 16, 2015.

4:  Coverdale J, Balon R, Beresin EV, Louie AK, Tait GR, Goldsmith M, Roberts LW. Teaching clinical neuroscience to psychiatry residents: model curricula. Acad Psychiatry. 2014 Apr;38(2):111-5. doi: 10.1007/s40596-014-0045-7. Epub 2014 Feb 4. Review. PubMed PMID: 24493360.

5:  How To Cure What Ails You.  Radiolab  Accessed on March 17, 2015.


Supplementary:

The header to this article is all of my copies of The Biochemical Basis of Neuropharmacology and the book I consider to be its successor  Introduction to Neuropsychopharmacology.  New editions of BBN came out in 1970, 1974, 1978, 1982, 1986, 1991, 1996, and 2003.  The copy with the white cover in the middle (a little faded) was the first copy I owned.  In those days I wrote the year I purchased books in the front jacket and that year was 1984.  This book with its elegant little drawings and low purchase price served as an introductory neuroscience text to many classes of psychiatry residents.

How The Ruling Class Impacts Your Health Care and Why They Need To Be Stopped

The truth crops up in unexpected places.  A colleague directed me to an article is USA Today that I found to be very interesting.  It clearly describes the central problem with health care in America.  From that article (see reference for full text, clinic map and video):

"This is the crux of the whole thing," said Wanda Kuehr, a psychologist who agreed to speak out about the problems after retiring Feb. 2 as the program's director of clinical services. Non-medical managers want to "get the reports in on time and fill the slots. They think that makes a good program. Our goal is to give treatment to soldiers. And (the bosses) see that as inconsequential ... What's happening to soldiers matters and the Army can't just keep pushing things under the rug."

The report details what happened when the Army's outpatient substance use clinics were shifted from medical oversight by the Surgeon General's Office to the Installation Management Command.  This change occurred in 2010.  Some of the changes noted are striking including a basic error in hiring an unlicensed counselor.  Since 2010,  90 soldiers committed suicide and 31 of those suicides occurred after reviewers concluded that there was substandard care.   They could not conclude that the substandard care was causal.  Review of additional data showed that 7,000 soldiers were identified as having a problem but not offered treatment.   Half of the 54 substance use clinics were rated as substandard, specialists identified "poor continuity of care" as a problem, and staff attrition as a significant problem.  Only 309 of 352 counseling positions are currently filled.  The same article estimates that 104,000 soldiers have drinking problems.

What is the significance of this report?  I don't think there is anything unique about what happened to the Army's substance use clinics when the management changed.  It has been happening everywhere else for at least 25-30 years.  Before that time, medicine and specialty departments were managed by senior clinicians based on merit.  The department heads were active clinically and they were valued for their clinical and research expertise.  Some of the most valuable teaching experiences I had during my training occurred due to direct contact with these department heads.  Reviewing brain and spinal imaging with the head of the Neurosurgery Department.  Doing rounds at night with the head of the Renal Medicine Department.  The list goes on.  The point is that all of these experts were engaged in treating patients and teaching medical students and residents.  They had an intimate connection with the provision of care and the profession.  Many of them also had great personalities.  So what changed?

They changes were subtle at first.  When the managers took over they decided to replace some of the department heads at the periphery.  Suddenly there was no longer a certain department that people counted on and their duties were subsumed by another department.  The dislocated clinicians either quit in frustration or were relegated to a more peripheral role in the clinic or hospital.  They could no longer support a teaching mission and suddenly that block of knowledge was no longer available to students.  These experts were consulted in complicated cases to back up the generalists who were now seeing their patients.  The next step by the managers was to suggest that productivity in the larger departments was uneven.  They suggested that they had a metric so that would assure that everyone in the department was pulling their weight.  When I first heard that explanation, I looked around and concluded it was a myth.  Everyone in my department was a hard worker and that was borne out by the actual numbers.  The numbers were the real story.  The rhetoric had allowed the managers to introduce a system to manage productivity that was completely subjective.  But that was all the managers needed to develop a system to manage knowledge workers like production workers even to this day.

Why would anyone want to be a manager?  Well it seems like easy work if you can get it.  Instead of dealing with complex problems that require you stay current in a certain body of knowledge, interact with people in an ethical way, and have extremely high levels of accountability why not just manage numbers and tell people what  to do - especially people who are as politically inept as physicians and their professional organizations.  If I ask physicians that question, I usually hear that being a manager or studying business would just be "too boring."  That may be applying a medical metric to business that could be far from the mind of managers.  Some business educators and critics have pointed out that over the past 2 decades, there is evidence that managers have developed who are focused on short term results and in some cases "the pursuit of short-term shareholder interest, as well as naked self-interest on the part of managers, into managerial virtues." (reference 2).  Instead of a manager who knew and was promoted from within the business and who had a vested interest in the quality of the services and interests of the employees, we now have a class of managers who are mobile, highly paid, and have no particular expertise in the affected business.  Piketty notes that the United States has invented a "hypermeritocratic society" of "supermanagers".  These supermanagers are typically executives of large firms who have been able to obtain "historically high, unprecedented compensation packages for their labor."  He also concludes that "the vast majority (60-70%) of the top 0.1 percent of the income hierarchy in 2000-2010 consists of top managers."(p. 302).  I don't know Piketty well enough to say what his conclusions about why this meritocracy exists.  He does point out that it is twice as likely to occur in the financial services industry.

There are interesting parallels in the management of financial services and medicine.  In both cases, the managing class came about largely as an invention of federal and state governments.  The invention of the manager's tools in medicine (billing and coding, utilization management, prior authorization, managed care) parallels the development of credit reporting and the ability of financial manager to put your savings and retirement funds at risk all of the time without offering you any compensation for the use of your money.  Both of these systems are subsidized by huge hidden tax subsidies from American taxpayers.

When I try to talk with people about this problem their eyes glaze over.  Advantage to both the financial and business managers.

In the meantime, when you drive by your local hospital and it claims to be one of the "Top Hospitals in the US" - don't be surprised to learn that there are at least 600 hospitals on that list.              


George Dawson, MD, DFAPA


1:  Greg Zoroya.  Investigation: Army substance-abuse program in disarray.  USA Today.   March 12, 2014.

2:  Rakesh Kurana.  MBAs Gone Wild.  The American Interest.  July 1, 2009.

3:  Thomas Piketty.  Capital in the Twenty-First Century.  The Belknap Press of Harvard University Press.  Cambridge,  Massachusetts 2014.