Moving Pianos

One of the first legitimate jobs I had was moving furniture with my grandfather.  He had been doing it since the days when it was referred to as a "dray line".  His only truck was a 1933 Diamond T and by the time I was in high school he was on his 6th engine and I think that each engine had gone for 150,000 miles.  I was probably in my senior year in high school when he asked me to show up and help him out on the job.  I usually worked with two other guys - my Uncle Bill and a guy who worked with my grandfather for many years - Elwood.  Bill and Elwood were both in their 50s and usually looked pretty tired.  My grandfather was wiry and in his early 70s but no longer did any heavy lifting.   When he walked he was bent in two different directions.  From behind it looked like his torso was walking next to where his hips and legs were located.  Occasionally we were joined by my Uncle Carl who was in his 20's and very physically fit.  Despite that mix of personnel, we took on jobs that I would never consider at this point in my life, even though at the time it seemed like a job I could get into and make a career of.

My grandfather's dray line was preferred delivery service for a local appliance store.  That means moving stoves, refrigerators, and freezers and making sure that they are delivered and set up in pristine condition.   My grandfather was a perfectionist and always reminded us that he had never paid out an insurance claim for damaged appliances or furniture.  One of my early lessons was just how demanding customers are.  We were delivering a refrigerator freezer that weighed about 300 pounds.  After carrying it up about 20 steps to a long porch and across the threshold and into the kitchen without a glitch, the homeowner told us he wanted it dropped through a 4 x 4 foot hole into the floor and into the basement.  The only way down that hole was a ladder.  It meant that one of us would need to slide the unit through the hole and the two guys in the basement would have to catch it.  Elwood looped a piece of rope around two of the casters and lowered it over a piece of padding.  Bill and I caught it and lowered it to the floor.  Even though the entire process only took about 15 minutes we were covered in sweat and not very happy at the end.  It felt like we were just lucky that nothing bad had happened.  That usually explained all of the swearing along the way.  The volume of the swearing usually indicated which one of us was at the breaking point.

But the real problem for us in those days was pianos.  Everybody thought they wanted their kids to play a piano and it took a few years to discover that was not going to pan out.  At that moment we were called to move the piano to the house of the next child prodigy.  My grandfather saw himself as an expert in moving pianos.  We had specialized equipment for moving pianos like pianos trucks for upright pianos.  The upright piano had to be carefully wrapped to prevent damage to the finish and then we could affix a piano truck to each end, tighten the straps and it was fairly maneuverable until we had to lift it.  In some cases we had to move grand pianos and that would typically involve the local college going up a winding staircase for three or four floors.  During one particularly heavy grand piano lift we recruited about 10 college students to keep a rope taught that was affixed to the piano as we slowly moved it up the stairs.  Their job was to prevent it from falling back on us if we lost control carrying it up.  I came away from those jobs realizing that moving pianos was grueling work.  The first time I heard the term "heavy lifting", I understood it as a metaphor and a physical reality.  But was it more than that?

By my late-twenties,  I already knew that the practice of medicine could be physically exhausting.  I would come home from work as a resident or intern and collapse on the floor.  I had just spent 36 hours in the hospital and for at least the last 12 hours of that time, I was falling asleep while I did documentation.  All of the notes were handwritten in those days.  When I finally snapped out of it,  my handwriting would just slide into an incomprehensible scribble when I fell asleep.  One of the medicine residents I worked with had a novel solution to the problem.  In those days I was writing the equivalent of 10 point font.  He went in the other direction.  He wrote as large as he could possibly write.  I marveled at some of his notes - 4 words per line and 4 lines per page.  Sixteen words per page!  I know that he took a lot of heat from some of the attendings.  But he was doing 15-20 admissions per night in an acute care hospital on an Internal Medicine service.  My first lesson about work in medicine was that sleep deprivation and overwork can be as exhausting as heavy physical labor.   There is no way that my grandfather would have expected  us to work as much as interns and residents in the 1980s.  In fact, if my grandfather would have survived that long I am sure he would have had something to say about the working conditions.  

Part of the rich tradition of medicine from that era was that at some point - you completed residency training and moved on.  You realized that there was a whole world out there that did not depend on interns and residents staying up all night long taking care of acute medical problems under the dim fluorescent lights of the hospital.  Like everyone else I moved on and one day about 15 years later, sitting in one of my morning team meetings on an acute care psychiatric unit - I realized I was still exhausted.  I had listened to my social worker tell me that she had tried to get a patient out to local facilities and had called 25 of them and they all turned her down.  She spent her whole day on that one task and we had another 19 patients.  I listened to the usual battles with people trying to send us patients that we could never discharge.  I listened to the passive aggressive comments of county social workers and screeners who were also no help.  I listened to the complaints of our own administrators, blaming us for not being able to work faster and get people out faster.  That is difficult to do when you get absolutely no cooperation from anyone.  I looked around the room at staff who were angry, frustrated, tearful, and burned out.  We clearly had to deal with a lot of people who were supposed to be helping us provide care but they were hurting us.  It was 9 AM and we had not talked with any of the patients yet - the people we were really there to help.

And then I realized, this is just like moving pianos.  Well - moving pianos in hell maybe.  But I said it out loud to my team.  I explained the premise.  I asked them to envision me with a piano on my back and the forces tipping me one way or the other.  In the moving business we would say: "Tip er to me, tip er to you." to make the necessary rapid adjustments.  

I think a few people got it.  I looked over at my OT and she was smiling.

And for a few minutes - the mood in the room was lighter.



George Dawson, MD, DFAPA

Supplementary 1:

The implicit second lesson is that the constant warfare against managed care companies, administrators of all sorts, probate courts, and county bureaucrats is more fatiguing than moving pianos and it leads to burnout on a grand scale.  It is why when I ran into one of my mentors in an airport a few years ago and told him that I was quitting inpatient work after 23 years he said: "3 months wasn't long enough?".

If I had to rank the fatigue factors listed here over piano moving I would say they are:

constant warfare against the people that are supposed to "help" us > overwork > sleep deprivation

They are obviously not independent of one another and in fact the order above could also be viewed as a casual chain of events.

Supplementary 2:

Even though I was not moving furniture at the time, furniture movers everywhere must have rejoiced when the electronic keyboard started to appear.






  

Epidemiology and Toxicology of Aircraft Assisted Pilot Suicides

I thought I would add a few facts to the speculation about what is really known about the epidemiology and toxicology involved in aircraft assisted suicides. It turns out that there are substantial studies that have been written.  If you are a bottom-line kind of person and want to avoid further reading, I can tell you that the events are rare especially events involving commercial aircraft where the incident is ruled a suicide by aviation authorities.  The events are so rare that prediction is doubtful.  In many cases the descriptions of suicidal statements and behavior occur on the day of the events and there are further extenuating circumstances like the use of alcohol and other intoxicants.  If you are really interested in these events, there are numerous places where you can see the analysis of what happened and what the ruling was by the National Transportation Safety Board (NTSB). 

The media reaction is similar to what is seen following mass shootings in the United States.  After the initial shock, there is typically a period of speculation about the causes of the disaster of the form: “What motivates a person to do something like this?”  There is the invariable dissection of their life in the media.  Were they bullied?  What was their personality like? What was on their computer?  Were there any clues that were missed that suggested that one day they would start shooting people?  Were psychiatrists involved?  How did they get the firearms?  When all of those familiar touchstones are exhausted (and it does not take long), the analysis starts to take on the characteristics of groups with agendas.  Gun advocates will suggest that this person was not a typical gun owner and therefore tighter gun laws are not needed.  Gun control advocates will provide the counter arguments that usually involve how easy it was for this person to get a gun.  There is a political impasse largely due to the power of the gun lobby and some politicians start to talk about “being in the wrong place at the wrong time.”  Mental health advocates, especially anyone who wants to talk about the real problems of mental illness and violence are as disenfranchised as the gun control advocates.  Nothing ever happens.  The screening advocates step up and suggest that many of these incidents could be prevented if we just “screened” enough people.  Anyone familiar with Bayesian statistics knows why that won’t work and may cause more harm than good. 

After that impasse, a second wave of speculation starts driven largely by people who ascribe to the theory that psychiatric medications and psychiatric treatment can cause homicidal behavior.  There are a couple of schools of thought on that one.  The first has to do with medications and the idea that specific medications like SSRIs can lead to homicidal behavior.  The other has to do with the fact that seeing a psychiatrist is associated with homicidal behavior and therefore psychiatric treatment must at some level cause homicidal behavior or at the very least the psychiatrist is responsible for not stopping it.  As I explored in a previous posts – there is not a shred of evidence that any of that is true.  There is however more evidence about pilot safety, pilot use of antidepressants, and incidents ruled pilot suicide than I have seen discussed in the media.  Here are a few bits of solid data to ponder during the expected swell of speculation about causes, who is to blame, and possible solutions.

1.  The denominator is huge:  

When the FAA or NTSB looks at all certified pilots in the US that includes a total of roughly 620,000 people per year including classifications for student, recreational, sport, private and commercial.  Roughly 1/3 of the FAA certified pilots are classified as commercial.  The US government also collects detailed statistics on the total number of passengers flown per year (815.3 million), the total number of flights per year (9.821 million) and a host of associated statistics on the Bureau of Transportation Statistics web site. 

2.  The numerator is very small:  

A quick glance at the table below on either antidepressant use by pilots or the total incidents rules as suicide shows that a small proportion of the total deaths are associated with either suicide or antidepressant use.  The proportions of the total pilots in the data base is much smaller and the rates of both suicide and antidepressant use are much lower than expected on a population wide basis.  Data from the Aviation Safety Network suggests that there were 8 to 10 incidents involving commercial aircraft and pilots since 1976 or about 9 in the last 40 years.

3.  The data on pilot use of antidepressants in fatal crashes: 

 Until about 2006, the FAA prohibited the use of antidepressants by commercial pilots.  They have since modified their stance to allow for specific antidepressants.  The European Aviation Safety Administration has publicly posted information of the safety of pilots and necessary screening for psychiatric disorders as well as prohibitions on certain diagnoses.  There have been studies that look at positive toxicology for antidepressants in the cases of fatally injured pilots.  These studies have looked for the presence of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) in in fatal crashes.  Tricyclic antidepressants were the predominant antidepressants prescribed before the approval and release of fluoxetine in 1987.  One study by Dulkadir, et al looked at fatal crashes between 1990 and 2012.  In this study the researchers received biological samples from 7,037 fatally injured pilots out of a total of 8,429 fatal accidents.  2,664 were positive for drugs on toxicological analysis.  Of those positive samples TCAs were found in 31 samples, TCAs alone in 9 and TCAs with other drugs in 22.  None of the pilots involved reported TCA use during their aviation medical exam.  The authors point out that at the time covered in this study that TCAs were not approved for pilot use and that selective serotonin reuptake inhibitor antidepressants or SSRIs were approved on a case by case basis.  That is a prevalence of TCA use in this database is less than 0.5% ( 31/7,037 aviators).  That number is much lower than estimates of population wide use of antidepressants.

Where the blood levels were determined they clearly indicate that some overdoses had occurred (see Table II and III).  Blood concentrations greater that 1,000 ng/ml are usually very consistent with overdoses and that is the case with nortriptyline and imipramine/desipramine in these tables.  The authors were able to determine that the TCAs were prescribed for depression in three cases, pain in two cases, and chronic insomnia in one case.  Other antidepressants were listed along with opioids, anticonvulsants, cold medications, antihypertensives, benzodiazepines, muscle relaxants, diabetes medications and ethanol were detected but the epidemiology was not reported.  In both the studies by Akin and Dulkadir “drugs and alcohol and/or a medical condition” was given as “a probable cause or contributing factor in about 1/3 of the accidents where antidepressants were detected.

There was an earlier study of the epidemiology of SSRIs in pilot fatalities from 1990-2001 (Akin, et al) that showed they were involved in 61/4,128 pilot fatalities or a total of 1.48%.

The available data suggests that pilot suicide by aircraft is very rare and much lower than the pilot suicide rate by all methods.  There is also a suggestion that the suicide rate in pilots has actually decreased.  Searching the NTSB database yielded 74 fatal accidents using the search term "suicide" dating back to 1966. 

Explanations given in the article for the fewer pilots taking TCAs was that they are more toxic and less preferred agents.  Certainly in the 1990s SSRIs were heavily promoted along with the medical treatment of depression.

4.  Intoxicants are found in toxicology specimens –

The study by Canfield, et al identified a greater percentage of specimens that were positive for cannabinoids (relative to antidepressants) and additional performance impairing drugs in 38% of the individuals who tested positive to cannabinoids.  They also looked at the mean THC concentration in the blood and concluded that during 1997-2001 it was 2.7 ng/ml and for 2002-2006 it was 7.2 ng/ml.  The rate of increase in THC levels over those years exceeded the increase in cannabis potency as reported by the National Institute of Drug Use (NIDA) over the same years (2.7 fold as opposed to 1.5 fold).  Some authors have concluded that THC levels between 2 and 5 ng/ml represent the lower and upper ranges of significant impairment from cannabis use on performance tests measuring driving skill (see Ramaekers, et al) in recreational cannabis users.

The study by Bills, et al looked at the toxicology in a cohort of 36 pilots who committed suicide by aircraft during a 21 year period from 1983 and 2003.  Each suicide case was matched against 2 randomly selected control accidents.  In this study, the pilot characteristics included positive toxicology for alcohol, prescription drugs, and illegal drugs in 24.3%, 21.6%, and 13.5% of cases respectively.  An exhaustive list of drugs found was not available in the paper.  The authors were also not able to compare the toxicology of the cases to controls because 84% of the controls survived and their toxicology was unknown.  

5.  The baseline rate of pilot suicide is low or is it? -

Bialik looked at the issue of workplace suicide, the data quality estimates for pilots in the US.  One of the key references was a paper by Tiesman, et al that looked at the issue of workers who suicide in the workplace.  It used databases from the CDC (National Occupational Mortality Surveillance (NOMS)) and  Bureau of Labor Statistics (Census of Fatal Occupational Injury (CFOI)).  The NOMS database has no granularity and does given intentional self harm as a search parameter.  Unfortunately only "transportation occupations"  can be searched grouped by age, race, and sex.  I did not find the number of deaths or the PMR (Proportionate Mortality Ratio) to be useful.  The NOMS did have granularity with specific occupations and there was a homicide definition but none for suicide or intentional self harm.  Bialik concludes that pilots in general may have a slightly higher rate of suicide than the population in general but there are problems with that estimate and he was able to consult with an epidemiologist from the CDC.

Another approach to looking at this issue to to find a study with a very well characterized database that looks at the occupational issue.   Roberts, et al meets that criterion in a 2013 study of high-risk occupations for suicide.  The researchers looked at the numbers of suicides and numbers in all occupations in England and Wales for specific time intervals.  They determined the 30 occupations with the highest suicide rates (generally greater than 20/100,000).  In comparing the time intervals (1979–80, 1982–83) to  (2001–2005) they determined shift in the ranking and discussed possible causes of those changes.  Pilots were not listed in the top 30 occupations by suicide rate.  The only transportation workers listed were "rail transport operating staff".  They noted that suicide rates for professional occupations decreased over the time interval studied while there were sharp increases in the suicide rates for manual occupations.  As a comparison the 2013 suicide rate in the US was 12.6 per 100,000.

6.   The accident rate due to suicide attempts in commercial aviation is lower than that found in general aviation - 

These incidents are tracked  by the Aviation Safety Network and their web site currently lists intentional incidents and accidents caused by pilots dating back to 1976 in commercial flights.   There is a separate list of aircraft accidents caused by pilot suicide and that lists 9 suicides in the same time period but proportionally more associated fatalities. 

7.  Pilots can already self report substance use problems - 

There have been some suggestions that screening would be enhanced if pilots could self report problems without the fear of recrimination - the same way that licensed health care professionals are allowed to do in many states.  The focus would be on treatment rather than punishment.  The health care professional experience demonstrates that this leads to significantly more self reports and that is consistent with the goal of public safety.  Since pilot certification occurs at the federal level and health care professional licensing occurs at the state level - there is an opportunity to develop a more standardized approach to the potentially compromised pilot that depends more on self-report than screening.  There is currently an "occupational substance abuse treatment program" called HIMS that states at least part of their goal is to preserve careers.  A broader focus to include voluntary self- report of psychiatric conditions and suicidal thinking would result in more referrals for treatment and potentially impact the suicide rate.

8.  Aviation regulators and the aviation industry collect data that the healthcare industry can only marvel at - 

Reading through the sheer amount of data and how it is acquired it is evident that anyone involved in aviation has a single-minded focus on safety.  The methods of data acquisition through flight recorders and the checks and balances on the ground are far superior to any safety standards in the health care industry in the United States.  As a basic thought experiment, can you imagine recording similar outcome data from patients rapidly discharged from hospitals in the US?  I am talking about real data and not the survey that the nurse hands a patient after they have coached them on what to check off. 

I don't have to imagine what that data would look like.  I know what that data looks like and it is quite ugly.  It is more than a little ironic that health care experts, especially in this case psychiatrists and other behavioral experts are going to rush in and correct what is wrong with the aviation industry.  By comparison, health care measurement and incident analysis is all smoke and mirrors.  They don't know how to collect relevant data and many of the outcome measures are strictly political and meaningless.  If anything we should be bringing in aviation safety experts to run hospitals instead of MBAs.

With what I have read, I doubt that there is any possible improvement beyond voluntary reporting and making sure that there is always a second crew member in the cabin on commercial airliners.  In some of the commercial aircraft crashes the planes were stolen by staff who were not pilots and crashed.  But in the case of air disasters that resulted in multiple passenger deaths a second person in the cabin is a clear safeguard.  I am not an expert on how many people are in air crews, but I know that there is also a flight engineer in the cabin in some cases.  Given that these incidents are rare by any combination of numerators and denominators that are chosen and the fact that screening for rare events is generally not successful, screening for these rare events is not likely to work.  Flight crews currently undergo random urine toxicology to prevent the use of intoxicants that can impair the ability of a pilot.  Anecdotal evidence would suggest that is useful, but in the case of addictions there are often attempts to circumvent this intervention or use a drug that is not detectable.  The experience of health care professional screening programs would suggest that voluntary reporting can both improve public safety and preserve careers.  That seems like a useful approach for pilots.

Most importantly, the aviation industry is a model for safety assurance and the investigation of incidents where there were lapses.  It holds many lessons for the health care industry.        




George Dawson, MD, DFAPA



Akin A, Chaturvedi AK. Selective serotonin reuptake inhibitors in pilot fatalities of civil aviation accidents, 1990-2001. Aviat Space Environ Med 2003; 74(11):1169–76

Canfield DV, Dubowski KM, Whinnery JE, Lewis RJ, Ritter RM, Rogers PB.  Increased cannabinoids concentrations found in specimens from fatal aviation accidents between 1997 and 2006. Forensic Sci Int. 2010 Apr 15;197(1-3):85-8. doi: 10.1016/j.forsciint.2009.12.060. Epub 2010 Jan 13. PubMed PMID: 20074884.

Zeki Dulkadir,  Gülhane, Arvind K. Chaturvedi, Kristi J. Craft, Jeffery S. Hickerson, Kacey D. Cliburn. Antidepressants Found in Pilots Fatally Injured in Civil Aviation Accidents.  Federal Aviation Administration, Office of Aerospace Medicine, Nov 2014.

Lewis RJ, Johnson RD, Whinnery JE, Forster EM. Aircraft-assisted pilot suicides in the United States, 1993-2002. Arch Suicide Res. 2007;11(2):149-61. PubMed PMID: 17453693.

Russell J. Lewis, Estrella M. Forster, James E. Whinnery, Nicholas L.  Webster.  Aircraft-Assisted Pilot Suicides in the United States, 2003-2012  Civil Aerospace Medical InstituteFederal Aviation Administration. Oklahoma City, OK 73125 February 2014

Ungs TJ. Suicide by use of aircraft in the United States, 1979-1989. Aviat Space Environ Med. 1994 Oct;65(10 Pt 1):953-6. PubMed PMID: 7832739.

Bills CB, Grabowski JG, Li G.  Suicide by aircraft: a comparative analysis.  Aviat Space Environ Med. 2005 Aug;76(8):715-9. PubMed PMID: 16110685.

Ramaekers JG, Moeller MR, van Ruitenbeek P, Theunissen EL, Schneider E, Kauert G. Cognition and motor control as a function of Delta9-THC concentration in serum and oral fluid: limits of impairment. Drug Alcohol Depend. 2006 Nov 8;85(2):114-22. Epub 2006 May 24. PubMed PMID: 16723194.

Roberts SE, Jaremin B, Lloyd K. High-risk occupations for suicide. Psychol Med. 2013 Jun;43(6):1231-40. doi: 10.1017/S0033291712002024. Epub 2012 Oct 26. PubMed PMID: 23098158; PubMed Central PMCID: PMC3642721.

Total FAA Certified Pilots:  http://www.aopa.org/About-AOPA/General-Aviation-Statistics/FAA-Certificated-Pilots

Aviation x Antidepressant Medline Search April 2015:  http://www.ncbi.nlm.nih.gov/sites/myncbi/1-MAvBcofi/collections/47791909/public/

Carl Bialik. We Don't Know How Often Pilots Commit Suicide.  FiveThirtyEight (a very sophisticated blog)

I Don't Need Your Vote

Apple’s CEO Tim Cook came up with quote last week and I thought it was a good one:

“I’m not running for office.  I don’t need your vote.  I have to feel myself doing what’s right. If I’m the arbiter of that instead of letting the guy on TV be that or someone who doesn’t know me at all, then I think that’s a much better way to live.”

The original article began with an introduction about how Steve Jobs took a lot of heat and a lot of praise to protect the executives focused on Apple’s business and products.  Observers also note the activities of so-called “activist investors” trying to influence the management of the company into buying back stock for a quick short-term gain.  Cook is clear that he is all about long-term results and he is accountable for those results.  The same logic applies to what I do and have done for the past 30 years.  On the financial message boards there is constant noise with news and analysis of whether the stock price is going up or down.  After watching those trends it is clear that nobody knows the trends and that far fewer people know anything about the technology.  Many of those posts are placed there to manipulate opinion.  The critics don't know Tim Cook and the critics don't know me and clearly seem to have never met the psychiatrists that I know and work with.  Let’s take a look at how the so-called critics of psychiatry compare with the critics that Cook is addressing.  They can be broken down into several classes:

1.  The professional critic – criticism generally takes the form that I have special knowledge that no other psychiatrist has.  That knowledge can vary from the totally absurd (there is no such thing as mental illness or I am the only person to keep psychiatry honest) to more plausible exaggerations (I am the only person who can do this therapy, detect this side effect, prescribe this medication, etc.).  There is some legitimate criticism but it tends to be very rare.  I think the sheer number of internet articles by the same author saying the same thing may be an indication of volume substituting for quality.  The obvious message in many of these articles is that I am unique and everyone else is either ignorant, crooked, or stupid.   There are varying levels of conflict of interest (books, speaking engagements, the hero worship of various hate groups).  These critics are magnets for the haters of psychiatry who see them as modern day heroes and generally ignore the conflict of interest issues that their heroes use to criticize others.

2.  The journalist looking for an angle – the overall bias of journalism against psychiatry is well documented and wide spread.  Looking to sell papers or in these days mouse clicks is an obvious motivator.  In some cases the journalists just jump to books and web sites as sources of revenues and fame.  Even the most charitable interpretation of their work will note the obvious flaws.  Considering the DSM-5 a treatment manual or overestimating the impact of the DSM-5 when in fact most primary care physicians never use it are good examples.   While telling psychiatrists what their problems are when they have completely ignored the biggest stories in mental health for the past three decades that really have nothing to do with psychiatrists.  Those stories are how managed care companies and state and local governments have decimated the care for people with severe mental illnesses and addictions.  They have only recently picked up on stories related to incarcerating the mentally ill and trying to provide them psychiatric services in jail.  Not a stellar job of mental health reporting over the past 30 years.  As in the first category, some rare legitimate criticism exists.   

3.  The injured patient – certainly the treatment of psychiatric patients has the potential to cause injury like any other medical treatment and injuries do occur.  As I have posted several times on this blog, anyone who takes a medication that is FDA approved is at risk for side effects up to and including death.   As I have pointed out here (where you will not see in many other places) – the FDA decision can be purely political rather than scientific.  As a result, any medical or psychiatric treatment should be entered into very cautiously.   I have also posted here (and you will not see this in many places) that nobody wants to take a non-addictive medication and that people are generally hopeful that it will provide relief from a miserable condition.  I do not believe that people take any medications, especially psychiatric medications lightly.  I have outlined my clinical method to minimize side effects and adverse events.  Even with that high level of caution, side effects and adverse events will occur.  There are no shortage of remedies that can be pursued at multiple levels.  Most people resolve the problem immediately with their physician.   In the case where medical organizations are involved there can be direct complaints to the medical administration, hospital authority, or patient advocates.  At the state and licensing level complaints to the state medical boards and in some cases complaints to a mental health ombudsman can be made.  There are obviously malpractice attorneys.  Injuries caused by medical treatment are legitimate reasons for complaints and criticism but at some point I would hope that it would lead to a solution to a real problem.  I would also hope that nobody is compelled to sacrifice their medical confidentiality for the purpose of a complaint.

4.  The severely personality disordered – there is no good way to say it, but there are people who are very hostile to other people.  In many cases they aggregate around psychiatrists because that is where everyone else tends to send them when they cannot be dealt with.  Like any group of people in contact with psychiatrists, the vast majority of people with personality disorders are able to work on their problems in a productive way and do not turn treatment into a series of personal attacks.  But there are also the small fraction that do.  In many cases they target psychiatrists (and others) and their anonymous criticism is frequently irrational, heated and in some cases threatening.  They can attract like-minded people.

5.  The professional critic who is not a psychiatrist.  I posted my earliest experience of an irrational response by an attending physician when he learned that I was going into psychiatry.  In today’s politically correct landscape it would be classified as harassment and abuse.  Practically all of the psychiatrists I know have similar stories.  In fact, I personally have several more.  The unexamined irrational hatred of psychiatrists is just a fact that any psychiatrist has to deal with.  But when I hear a medical professional come up with some blanket statement about psychiatrists that is what it is all about.  I have examined in a previous post the basis for these generalizations.  Most physicians are at least are circumspect about why they did not go into psychiatry.  Most of them tell me they don’t want to deal with lethal violence or deal with the severely personality disordered.  Unless somebody points out this unexamined irrational thought pattern for what it is – it will never be corrected.  See my previous comment about it.  Or as the kids say these days haters be hatin' and leave it at that.

6.  The people who bristle when psychiatrists speak out against irrational criticism or even offer an alternate explanation are an interesting lot.  Some blogs seems to attract a lot of them, but I don’t frequent the more hateful blogs.  They are a self- righteous lot that looks as far as their own information.  They generally ignore any contradictory information and stick to their story or accusations.  They will attempt to bury any psychiatrist pointing that out with righteous indignation and sophistry usually by invoking victimhood  ("Noooo we are not antipsychiatrists – stop calling us that name!"),  hero worship ("You just aren’t as good as the psychiatrists who we agree with!") or the usual appeals to emotion ("It is so pathetic that these psychiatrists are just so (ignorant, evil, etc) and they just can’t accept our “facts”").  You can apparently say anything and really believe it is true.  Just so nobody forgets – it is true that psychiatrists are bogeymen.

Boo!

I am an experienced psychiatrist with 30 years of experience.   I have specialized in treating the toughest problems and the problem of lethal violence and severe mental disorders, often with significant medical comorbidity.  Like a neurosurgeon said to me at a serious point: “You guys treat the toughest problems that nobody else in medicine wants to treat.”  I have treated many more people than are mentioned in “case reports” and at this point in entire clinical trials.  I have as much experience as anyone in the safe and effective treatment of these disorders.  I encourage people to not tolerate side effects, use psychotherapy, and to be comfortable with the idea that I should be able to answer any questions they might have about my assessment or treatment recommendations.  Like all physicians I have much higher levels of accountability than most other professionals.  Like all physicians there is a rare day where I am not being harassed by someone who thinks they know how to do my job better than I do usually because it suits their business interests.  And I am the one with no conflicts of interest.  This is a non-commercial blog.  I have no books to sell.  I have no financial connections to any industry.   I couldn't care less if anybody ever paid me for my opinion.  So it should not be too surprising when I say:

I don’t need your vote.  I know what I am doing and that has been substantiated time after time – tens of thousands of times.  Further, I know how to read research and interpret the findings as opposed to the general lack of scholarship from those who assume they know more about my job than I do.  There are a handful of psychiatric experts that I consider to be authoritative and none of them are the usual media critics.  In fact, some of the media critics aren’t even psychiatrists and it shows.  But the best part is I am no different from my other colleagues that I consult and collaborate with every day.

They don’t need your vote either.

George Dawson, MD, DFAPA

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.