The Myth of "Rescue" Medications

First off a clarification.  I am talking about the specific case where a short acting medication is added to a long acting form of the same medication and not "as needed" medication in order to determine the correct daily dosage.   In my line of work it occurs in two situations, long acting stimulants and their immediate release versions and long acting opioids and their immediate release versions.  I will illustrate that these practices are driven by myths about the medication rather than pharmacokinetics.  There is always the additional consideration about addiction lurking in the background, but the conscious and unconscious determinants of addiction frequently depend on the myths that I will be discussing about medication effects.

The example that I will use here is Concerta (long acting methylphenidate) compared with immediate release methylphenidate.  The graph from the package insert above shows the plasma concentration from a single 18 mg dose of Concerta and three successive 5 mg doses of immediate release methylphenidate.  As noted in the comparison of the curves and additional pharmacokinetic parameters the curve associated with three successive doses of immediate release methylphenidate is nearly identically replicated by a single dose of Concerta.

What is happening when additional doses of a immediate release methylphenidate are prescribed to a person who is already taking Concerta?  I  have seen this happen with sustained release stimulants and sustained release opioids.  I have seen it happen as a single dose of the immediate release preparation or multiple doses over the course of the day.  The patient is usually advised that this is a "rescue" medication that they should take if needed.  The first possibility is that the dose of sustained release medication has not been optimized and a higher dose of the sustained release medication needs to be given.  That is usually not the case.  The most frequent reason for taking the rescue medication is that the patient believes they are experiencing breakthrough symptoms and for a moment they need a higher dose of a medication.  There are serious problems with that concept.  As can be seen from the curves comparing Concerta and methylphenidate it does not make pharmacokinetic sense.  Any additional dose of immediate release methylphenidate on top of Concerta would greatly increase the expected plasma concentration at that point.

The main problem is that both ADHD and non-cancer pain are chronic conditions.  By definition they do not respond well to medications and they will not resolve typically with any amount of the medication.  Many people who take stimulants for ADHD assume that the human brain can be fine tuned with a medication.  There is also a widespread myth that they are cognitive performance enhancing drugs.  The real effects of stimulants are modest at best and there is no good research evidence to support a cognitive enhancing effect.  A similar bias exists for the use of opioids for chronic non-cancer pain.  The person believes that "If I take enough of this medication - my pain will be gone."  Study after study of opioids for chronic non-cancer pain shows that pain relief with opioids is modest at best, with results very similar to what would be expected with non-opioid medications like gabapentin and antidepressants.

There are secondary problems with believing a medication will produce perfect cognition or perfect pain relief.  The first is a tendency to see any medication with such powerful abilities as being able to solve a number of problems that are not the primary indication for the medication.  As an example, with a stimulant - if this medication has such a profound effect on my cognition maybe it can help with with other difficult problems like excessive appetite and weight problems or feeling like I don't have enough energy at certain times during the day.  With the opioid the  thought typically is that it can be used for mental pain as well as physical pain and it is used to treat anxiety, depression, and insomnia.  Whenever a medication is not used strictly for the prescribed indication there is a risk that it will be used for "what ails you."  The danger is dose escalation and addiction.  There is also the risk of attributing too much of an effect to the medication when it does not appear to be doing much.  A person may start to believe that they can't function without the medication but a detailed review of their target symptoms and ability to function shows that there has been a negligible effect.  And finally there is the danger of taking a medication that may produce euphoria, increased energy, and create a sense of well being and not realizing that at some point that is the only reason the medication is being taken.  I have had many people tell me that the medicine did nothing for their pain or cognition but that they kept getting refills because they "liked taking it."

There is what I call the Talisman effect, but probably to a lesser extent than with benzodiazepines.  Many people develop the idea that they are taking a medication that is much more effective than it really is and therefore they have to take it with them wherever they go.  They are conferring what are essentially magical properties to the medication and at some level thinking that they are unable to function in life without it.  They get anxious if they think about not having it or running out.  This not only causes a lot of unnecessary anxiety, but it also prevents the person from using other psychological or conditioning techniques that may work as well or much better than the medication.

These are some of the problems with the idea of taking a rescue medication if you are already on a long-acting form of the medicine.  Physicians in general do not do a good job of explaining these potential problems or even the basic problem of taking a medication that causes euphoria or reinforces its own use.  A more widespread recognition of these problems would go a long way toward curbing overprescription, overuse, and addiction to these medications.    

        

George Dawson, MD, DFAPA

References:

1.  Graph of plasma concentrations of Concerta and methylphenidate is from the package insert on FDA web site at:  http://www.accessdata.fda.gov/drugsatfda_docs/label/2007/021121s014lbl.pdf

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 years of Rationing

It is clear to me that Minnesota doesn't want to hear from any psychiatrists.  Psychiatrists in this state have been complaining about managed care, prior authorization of medications and hospital treatment, managed care medical necessity criteria and mismanagement of the state mental health systems by the State of Minnesota for as long as I have worked here and that is now 27 years.  All of that work at various levels has basically been ignored by the politicians and responsible bureaucrats in this state who are quite happy to address the problems of severe mental illness by progressive rationing at all levels.  That is their only response.  This march toward the managed care approach to mental health has been inexorable and has resulted in major problems with access and quality of care.

I have been writing in various formats about the problem of mismanaging acute care beds in Minnesota for at least 15 years.  What do I mean about mismanagement?  The problem started in the late 1980s when the state of Minnesota gave carte blanche to one of the local insurance companies to start denying alcohol and drug related admissions to inpatient psychiatric units.  Anyone with a sparse knowledge of addiction knows that about 70% of people with addictions have significant psychiatric morbidity and many are at much higher risk of aggression or suicide if intoxicated.  That was not enough of a deterrent to prevent this insurance company (with full collusion of the State) to start denying psychiatric admissions to anyone with an addiction or eventually to anyone with acute alcohol or drug intoxication.  The effects of those denials filtered through the entire acute care system and eventually intoxicated people were held in emergency departments until they were less intoxicated, sent to county detox units where they got no medical or psychiatric care, sent to jail, or discharged to the street.  In some cases people were discharged to the street with a bottle of benzodiazepines and expected to manage their own detoxification.  Many of those patients take the entire bottle the first day.  None of those pathways leads to sobriety or treatment of associated medical and psychiatric conditions and it is not an acceptable level of medical care.

Treatment of mental health conditions has fared no better.  At some point the vague concept of "dangerousness" became the only reason that a person with a severe mental illness could be hospitalized.  In some cases it was a "dangerous enough" standard.  In other words if you happened to have chronic suicidal ideation or self injurious behavior, the gatekeeper (who is usually an emergency department (ED) social worker) has to decide if you are dangerous enough to admit.  That combined with bed availability, other persons needing admission, the availability of psychiatrists to cover the beds, any associated intoxication states, and even the likelihood that a probate court would hold or commit the person led to a gauntlet that even outpatient psychiatrists could not negotiate.  Outpatient psychiatrists from the same clinic could not admit their outpatients to hospitals run by their colleagues.  That led to more and more psychiatrists advising patients and their families to just go the the ED and "let them sort it out."  The ED provides no psychiatric care - only a triage decision on admissions.  This quasi-system of care results in a large circulating pool of people who are never stable, at risk for incarceration or victimization, and who never receive standard care for their problems.

The unstated toll that this chaotic system takes is on the psychiatrists and nursing staff who work in it.  They are frequently the first ones to be blamed for a lack of beds and timely discharges.  A completely unrealistic bed situation becomes a psychiatrist not discharging people soon enough.  Psychiatrists and nursing staff end up treating the consequences of patients being held too long in hospitals that are not equipped to be long term care hospitals.  Patients and family members can become frustrated or irate as a result of this situation and the only people to blame are not the people who caused the problem in the first place.

The quasi-system of mental health care was well described by Karl Olsen, a Hennepin County Crisis Intervention nurse in the Star Tribune about three weeks ago.  He describes the backlog of patients in the ED and crisis centers due to a lack of psychiatric beds.  He describes the risk to both the patients and staff in this setting as well as the impossibility of trying to provide care that can only occur in a hospital setting in an emergency department or crisis unit.  But most of all, he describes the ongoing active discrimination against people with severe mental illnesses by insurance companies and the state.  A more recent article is written by a reporter interviewing a state bureaucrat who reports that the situation is "the worst I have seen it in 20 years."  How can representatives of the State get away with these remarks when the State of Minnesota is largely responsible for the problem?  The article describes the lack of beds in State hospital facilities as being the problem and the State has made no secret of the fact that they are closing down State Hospital facilities and until very recently planned to close the last facility.  This article goes on to conclude:

"Hennepin County Sheriff Rich Stanek was in Washington, D.C., Thursday, helping brief members of Congress about mental health issues and seeking additional funding for treatment beds in a state that has the 50th lowest rate of mental health beds for its population..."

It is truly a sad state of affairs when a county sheriff is advocating for treatment of the mentally ill in Congress.  On the other hand it is also a direct result of the opinions of psychiatrists being actively ignored in this state for decades.

We have seen the bottom of the managed care rabbit hole - and it is called Minnesota.  We take the prize with the lowest rate of psychiatric beds in the US.  There are only two groups of people in this State with any credibility when it comes to critiquing this failed system of care - psychiatrists and psychiatric nurses.  There is no politician or bureaucrat interested in proposed solutions - they are directly responsible for the 30 years of rationing that led to this problem.   One of the retorts by state officials has been: "What's your solution?".  It is time to acknowledge that this is little more than political rhetoric.  They have ignored the solutions including many that have been proposed right here on this blog.

Until the psychiatrists and psychiatric nurses are heard - expect continued deterioration in the treatment of mental disorders that we have witnessed here over the past 30 years.


George Dawson, MD, DFAPA



References:

Jeremy Olsen.  Shortage of state psychiatric beds leaves local hospitals jammed.  Star Tribune. November 2, 2015.

Karl Olsen.  Minnesota's mental health system is in crisis.  Star Tribune.  October 16, 2015.


Supplementary:

Supplementary 1:  The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons.  The original image was Photoshopped with a graphic pen filter.

Supplementary 2:  For a detailed post on some of what happened try this.

UW 3rd Annual Update - Treatment Resistant Depression

There were two presentations relevant to depression that were given at the UW conference this year.  The first was from Karen Dineen Wagner, MD, PhD from the University of Texas Medical Branch in Galveston, Texas.  Her message was a mix of the old and the new.  The old is the state of pharmacology of depressed children seems to have changed very little over the past 20 years.  This seem largely due to the fact that there have been few successful antidepressant trials in children.  This has led to the state where there are only two FDA approved medications fluoxetine and escitalopram based on a total of 4 clinical trials.  She  showed an additional 14 clinical trials of typical antidepressants including 3 that were positive for citalopram and sertraline but an additional negative study for the FDA approved medication escitalopram.  The difficulty in many of these trials is a high placebo response rate in the trials (40% greater than in adult clinical trials).  She recommended an informed consent approach explaining to the parents any time an off label approach was being used and the rationale for using any medication based approach.  She also recommended starting with the FDA approved medications for pediatric depression.

Her suggested approach to depression in children and adolescents is to start out with an FDA approved SSRI plus cognitive behavior therapy (CBT).  This is the most evidence based approach with the evidence rapidly disappearing at subsequent levels where the usual augmentation and substitution steps that are typically used in adults were suggested.  The Treatment for Adolescents with Depression (TADS) study was presented with the recovery rates for fluoxetine, fluoxetine + CBT, and CBT alone at 12, 18, and 36 weeks were presented.  The fluoxetine + CBT arm had superior results at 12 and 18 weeks but at 36 weeks the recovery rates were similar at 86% versus 81%.  Those are good results for any antidepressant trial and the placebo response rate in this study was more similar to the adult placebo response rate.  The results of this study were presented as a rationale for using antidepressants in adolescents with severe depression and/or suicidal ideation since the response rate for fluoxetine + CBT were faster than fluoxetine or CBT alone at 12 and 18 weeks and essentially the same at 18 and 36 weeks.

The issue of strategies for addressing SSRI resistant depression were presented in the form of a previous trial where 334 adolescents with SSRI treatment failures were randomized to a different SSRI or venlafaxine or SSRI + CBT or venlafaxine + CBT.  The trial done by Brent, et al showed that there was no difference in response rates switching to another SSRI or venlafaxine but switching antidepressants and adding CBT produced superior results.  Sides effects were greater for the venlafaxine arm with a slight increase in diastolic blood pressure and heart rate and a four fold increase in skin rashes - a complication that I have rarely seen in adults.  The overall impression was that CBT was the most effective intervention for adolescent depression but I am sure that most psychiatrists in the crowd were left wondering: "If I can't find CBT therapists for my adult patients with depression - what are the odds I can find them for my adolescent patients?  To me that has always been the critical shortage in psychiatry - not the number of people who can prescribe medications.

Others trials of medical interventions (omega-3 fatty acids, ECT, TMS, bright light therapy), psychotherapies (Interpersonal Therapy(IPT), family based IPT), and exercise were sparse.  Computer-based CBT has always been an underutilized modality and it showed that there were similar response rates between treatment-as-usual and an interactive fantasy based CBT called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts).  In the game the child chooses an avatar and the goal is to restore balance in a fantasy world dominated by GNATS (Gloomy Negative Automatic Thoughts).  The SPARX game is available free online to residents of New Zealand.  New Zealand and Australia have been pioneers in the area of online CBT.  To find resources just Google "SPARX virtual therapy for depression".

Paul Holtzheimer, MD provided the adult perspective in the topic Management of Treatment Resistant Depression in Adults.  He made the epidemiological point that treatment resistant depression (TRD) is present in 10-33% of patients with major depressive disorder and in the U.S. that is about 1-3% of the population.  He had a fairly comprehensive agenda covering pharmacotherapy and augmentation strategies, electroconvulsive therapy, more recent non-invasive electromagnetic therapies and deep brain stimulation.  There was nothing new on the medication front.  After reviewing the basic medication groups, he suggested that the newest antidepressants offered no advantage over earlier medication.  He suggested that monoamine oxidase inhibitors (MAOIs) were being underutilized as a treatment for depression unresponsive to standard agents.  In the moderated discussion Ned Kalin, MD - the head of the department of psychiatry at the University of Wisconsin agreed.  The speaker said that he typically used phenelzine and tranylcypromine.  I personally have not prescribed either of these agents in some time.  I recall using them in situations where the person has treatment resistant depression and did not have any responders.  In those situations, response rates tend to be low anyway.  The other problem is that you have to think that your chronically depressed patient is going to be motivated and cognitively intact enough to adhere to the necessary diet, report what could be significant side effects and not try to kill themselves with the medication.  During the discussion there was a report of one patient who decided to eat high tyramine content food (prohibited on this diet due to a the risk of a hypertensive reaction) - have a stroke and die.  The patient in this case did have a stroke but did not die.  I personally know of situations where strokes have occurred, so this strategy is not without risk.

The augmentation strategies discussed were right out of STAR*D with the exception of using atypical antipsychotics with antidepressants.  Dr. Holtzheimer said that this was probably the most common augmentation strategy and the risks were discussed.  He and Dr. Kalin were advocates of augmentation with lithium and triiodothyronine (T3).  There were three slides on STAR*D showing cumulative remission and remission rates across all levels of care.  Those rates were 33% with initial monotherapy and 66% after 4 treatments and as expected less remission rates at each level of treatment change.  Dr. Holtzheimer made the point that the current rates of remission with medication and psychotherapy have really not changed since the 1950s and that makes electroconvulsive therapy (ECT) the most effective antidepressant treatment with a 50-75% remission rates and a >50% relapse rate in the first 6 months.  He touched on novel pharmacological agents categorized by neurotransmitter, neuroendocrine, or immunological systems.  He did not say much about ketamine (there is an intranasal preparation in clinical trials right now) but did mention that there is a IL-6 (cytokine) antibody trial going on right now.

He moved on to talk about more invasive therapies.  He presented a graphic that was a drawing by Papez.  To anyone trained in neuroanatomy around the time I was in medical school, many anatomy professors would present a saggital section of the brain and refer to the limbic structures as the Papez circuit.  At first I thought the drawing had a surprising amount of detail for a 1937 publication but then I went to the original article online (AMA web site) and found that the original drawing was not used.  The 1937 drawing had the surface anatomy correct but no tracts.  Papez mentions the amygdala three times in the last few paragraphs of his article but does not label it in the drawing.  Dr. Holtzheimer used this slide as a prelude to an article by Mayberg (3) providing a rational for deep brain stimulation as treatment for depression.  I plan to come up with a separate post in this technology based on several sources but right now there are a number of centers looking a deep brain stimulation for depression and addiction.  Dr. Holtzheimer briefly commented on transmagnetic stimulation (TMS).  There are apparently 4 FDA approved devices, use is expanding and insurance reimbursement is expanding.  He said it was 50% effective for treatment resistant depression.  I am highly skeptical of that number based on the people I see, but I also realize that I am seeing a highly treatment resistant with multiple comorbidities.  Seizure risk was listed as the most significant side effect.

Vagus nerve stimulation (VNS) has been around for about a decade.  I have seen a few of these patients and never referred anyone for placement of this device.  There is limited third part reimbursement and in my opinion waning enthusiasm for this technology.  The last time I interviewed a person with VNS, their speech quality changed every time the stimulator was active.  That is a significant side effect and I don't know if that has been addressed with current technology.   Transcranial direct current stimulation (tDCS), transcutaneous vagus nerve stimulation, and cranial electrical stimulation were all listed as having limited data.

Deep brain stimulation (DBS) was clearly the main focus of Dr. Holtzheimer's presentation.  The first article suggesting that it may be effective for obsessive compulsive disorder (OCD) was in the Lancet in 1999.  Based on that research DBS of the anterior internal capsule is an FDA approved indication for DBS.  An open label study suggested that it may also be effective for TRD and there were no adverse effects or neuropsychological effects.  Three additional pilot studies of DBS to the nucleus accumbens suggested that it may be useful for TRD and features of TRD like anxiety and anhedonia.  Since then there have been two randomized controlled trials of DBS to the ventral striatum subcallosal cingulate gyrus (SCC).  The first study (ventral striatum) was negative and the second (SCC) was stopped after a futility analysis.

The overall conclusion had to be that TRD was still a common and disabling condition.  The mainstays of treatment at this point are still the medications and ECT that we have had throughout my career.  My experience is that I can help most people get well, but there are significant obstacles even to standard care.  Every lecturer here emphasized the utility of cognitive behavioral therapy.  Like most psychiatrists, I can do cognitive behavioral therapy but by myself I can't meet the demand.  The people responsible for mental health policy and insurance standards certainly do not want to fund the recommended research courses of CBT for chronic depression.  There is no distinction for TRD versus non-TRD depression and no differential resource allocation.  That leaves most patients with TRD and non-TRD depression looking for "prescribers" who can see them for 10-30 minute appointments to get advice on how to recover and try various prescriptions.  None of the available care matches what top researchers recommend in these CME seminars, in articles, or in books.

We could do a lot better trying to live up to that standard while additional diagnostic and treatment strategies are developed.          


George Dawson, MD, DFAPA

References:

1:  David Brent Adolescent depression references  

2:  Papez JW. A proposed mechanism of emotion. 1937. J Neuropsychiatry ClinNeurosci. 1995          Winter;7(1):103-12. PubMed PMID: 7711480.

3: Mayberg HS. Targeted electrode-based modulation of neural circuits for depression. J Clin Invest. 2009 Apr;119(4):717-25. doi: 10.1172/JCI38454. Review. PubMed PMID: 19339763

Should Science, Engineering and Math Majors Go In To Psychiatry?

I got an e-mail from a young electrical engineer the other day who was interested in psychiatry and asked me about some ideas he had to increase his exposure to the process of talking with patients.  He was interested in some experience with this before considering a change to medical school and psychiatry.  As I thought about it today, it brought back some memories about how science and math majors have been discriminated against at times in the medical school admissions process.  Back in the day when I was initially considering an application to medical schools, there was a General Knowledge section on the MCAT - (Medical College Admissions Test).  It was there purportedly to select people who were "well-rounded" and not just science majors with their shoulder to the wheel studying math and science.  Well rounded seemed to mean liberal arts majors and people with a broad exposure to art galleries, museums, theatre and culture in general.

There were a couple of things wrong with that theory.  First of all, it biased the test toward anyone who lived in a major city.  If you were a hayseed like me, you made a school trip to the Guthrie Theatre in Minneapolis exactly once in your high school career.   For everything else - you better be paying close attention to what happened in your English literature class.  Not a very dynamic approach to learning.  Contrast that experience with a friend of mine who is a New York born and raised Internist.  He had very broad experience with all forms of art including opera and ballet before high school and is one of the most brilliant people I have ever met when it comes to discussing and critiquing art of all forms.  All of that most likely originating in a childhood and adolescence steeped in the artistic milieu of New York City.  I know he didn't learn it in medical school.  Who do you think would do better on the old General Knowledge test?

The second problem is the general assumption that people involved in the humanities are more likely to be interested in people and take a humanistic approach to medicine.  There seems to be a bit of a loose connection there between temperament, personality and your intellectual pursuits.  People in the hard sciences must be rigid, lack warmth, be oblivious to the human condition, and lack empathy - right?  I have never found any solid evidence to support this.  I will concede that Communications majors do an outstanding job at weddings.  I recall going to a wedding where I knew the groom since he was an infant.  When he grabbed the microphone and launched into 30 minute impromptu act, I asked him where that came from.  His answer: "Communications major."  Apart from that, I have asked many good psychiatrists what their major was as an undergrad and a surprising number were Chemistry majors.  Those chemistry majors had no defects at all as physicians or psychiatrists.   They did as well as anyone else and I was glad that they were in the field.

As far as I can tell, the previous bias against science majors getting into medical school did not have a rational basis.  I can't be certain about whether or not it exists today but I can be sure that administrators keep manipulating the entrance exam.  In this commentary from a couple of years ago I point out that the stated goals of aspiring to think like a scientist is probably very congruent with being a senior level science major.  But I don't think that will translate to an admissions bias in favor of science majors.

Are there reasons to encourage engineering, math and science majors to go into medicine and psychiatry?  I think that there most definitely are.  At the highest levels, the technical aspects of brain science are exploding and future physicians and psychiatrists with a grounding in scientific thought and information science will be able to make the best use of it clinically and at the research level.  All of medicine is currently in the throes of very crude clinical trials that are often limited by a lack of specificity.  Most medications prescribed have limited efficacy and significant side effects.  That means just from the medical side, physicians in the forseeable future will be managing these medications and their side effects.   I think that a few dimensional comparisons across medicine and science and engineering may be useful:

1.  Economics - physicians are currently overworked and much of that work has little to do with patient care.  Practically all of the people managing physicians are right out of a Dilbert cartoon.  Most of medicine has been reduced to a rapid prescribing paradigm and businesses are recruiting non-physicians to do it.  That has already led to a reduction in the quality of care in psychiatry largely by eliminating psychotherapy, time spent with individual patients, and systems considerations of care.   Engineering in particular may be a more financially sound career with the opportunity to escape the fate of Dilbert.  Economics are not the only consideration.  I recently encountered a young petroleum engineer involved in oil exploration who was very successful and decided to go into medicine.  When I asked her about her motivation she said she wanted to work with and help people - even if it meant a significant hit to her salary and autonomy.

2.  Intellectual Satisfaction - scientific endeavors especially at the business level produce clear measurable results and the process frequently incorporates the theory that you learned along the way if you are an engineer.  Medicine and psychiatry are much more diffuse.  There are administrators and politicians ordering you around under the mantle of science who clearly know nothing about it.  You may find colleagues that are really not interested in the cerebral aspects of the field only the practical.  In medicine and psychiatry that can be stultifying when you realize that this involves a series of political arguments about conflict of interest and drug trials.

3.  Conflict of Interest -  Medicine and psychiatry have been under attack for some time by people who believe that there should be no contact with private industry, at least at the level of reimbursement for work being done.  All payments from private industry need to be reported in a national database and needless to say that discourages physicians from working with with the pharmaceutical or medical device industry.  This is a significant difference with engineering. As an  example, I contacted the IEEE and asked them about their policy on standards and was told that they encourage the participation of industry in the discussion of standards because of the expertise distributed within the industry and the need for those active discussions.  Medicine and psychiatry, largely due to the questionable theory that the industry will affect treatment decisions has embarked on a period of isolation from medical industries that may be alien to technical fields - especially to engineers.

4.  Politics - We are in a 30 year period of unprecedented discrimination against physicians by state and federal governments.  Like most American politics the implicit goal seems to have been to bring all physicians under the management of companies that are proxies for governments and on the face of it that strategy has been highly successful.  Practically all physicians are employees of large health care companies and supervised by people who know practically nothing about the work they do, but who are quite content to tell them how to do it.  Many of these policies, like recertification have a significant impact on physicians and their families.  They are not conducive to the idyllic balanced lifestyle.

5.  Subjectivity/Uncertainty - There is a high degree of subjectivity in medicine and in many circles that is considered a dirty word.  Most non-physicians fail to see the importance of subjectivity and how it relates to information transfer in biological systems.  The least creative try to pretend that it doesn't exist and they try to reduce everything to a 10 point scale.  They mistake these "scales" for objectivity and some sort of measurement.  They don't really understand what scientific measurement is.   They base entire systems of care on these failed measurement systems.  They can't be reasoned with and there has been a large proliferation of measurements that are quasi-scientific at best but that are used to assess physicians and processes.  Frequently meaningless data is collected and used to make decisions about care and how systems of care operate.  Physicians in these settings with a knowledge of science and measurement can be very frustrated.

6.  People - I have posts about the interpersonal dimension of treating people as a psychiatrist.  It is more rigorous than the interpersonal landscape of other physicians.  Psychiatrists treat a broad spectrum of problems and in some cases there are significant conflicts with the people you are trying to help that are based on an underlying mental illness.  Some of these conflicts affect some physicians more than others.  You may already be able to tolerate interpersonal conflicts better than your peers and that may make psychiatry easier for you.  Psychiatrists are also unique in that they are the only medical speciality that has groups of people who dislike them and routinely disparage them whenever they have the chance.  Being able to tolerate that will also make it easier for you to go into psychiatry.

These are some of the issues to consider if you are thinking about switching careers and going into medicine or psychiatry.   Medicine and psychiatry are not sciences - but we need scientists, engineers, and mathematicians.  They make good doctors and I am hoping that they can help medicine move out of the morass of political regulation and business theories and back toward the light.  At the same time, it is only fair to consider that in engineering it may be more possible to find a better work environment, a better lifestyle, more intellectual stimulation and better reimbursement.

That's about all I can think of tonight.  If you are a science or engineering student with additional questions - please feel free to post here and I will try to answer them about any specifics.  Please see the disclaimer below.



   George Dawson, MD, DFAPA          


Supplementary 1:   The e-mail I received suggested that I was an electrical engineer.  I am not an electrical engineer.  My major was biology and chemistry, but I am  member of the IEEE largely though my work with a number of electrical engineers on electroencephalgraphy.  I have been an IEEE member for 18 years.

University of Wisconsin 3rd Annual Update

I just finished the 3rd Annual Update and Advances in Psychiatry at the University of Wisconsin in Madison Wisconsin.  It is familiar turf to me because that is where I finished psychiatric residency training.  I was impressed with the first two updates and have covered my experience at the 1st Annual and 2nd Annual Updates on this blog in the past.  During the introductory comments, the Department Chair Ned Kalin, MD paid tribute to John Greist, MD and James "Jeff" Jefferson, MD who ran the conference for 37 years before it was taken over by the Department of Psychiatry.

The absolute high point of day one was a discussion of schizophrenia by Daniel Weinberger, MD.  I had seen him speak before.  In talking with Dr. Kalin about the conference Dr. Weinberger gave a more research oriented talk the day before in the department that was focused on more science and neuroscience that I wish I had seen, but the lecture he gave to clinicians at this conference was outstanding.  From the introduction Dr. Weinberger had apparently left the NIMH and is now working as Director and CEO and  for the Lieber Institute for Brain Development.   They have quite a unique website and faculty.  The title of his discussion was Neurobiology of psychosis in the era of genetic medicine and he offered some unique perspectives that I doubt are available in many places.  It was useful to see a focus on schizophrenia in a conference of this nature and a focus on how at least some of the cutting edge research is looking at therapeutic modalities that are unique rather than the usual isomeric approach to drug discovery.  It was also refreshing to hear that there is optimism out there rather than the usual doom and gloom about the the "pipeline" from Big Pharma is running dry and there will be limited options for the future.

The Weinberger lecture had an interesting introduction that focused on brain imaging studies in psychiatric disorders.  It was well done, well argued, and based on his American J Psychiatry article that was published earlier this year (2).  He points out that while brain imaging has been the "centerpiece" of neuropsychiatric research that it is still fraught with technical difficulties.  In many of the articles that seem to make the lay press there is almost nothing that is not associated with brain changes.  He showed examples attempting to correlate viewing pornography with the frontostriatal network, increased gray matter volume secondary to lithium use, and other common artifacts and he concludes that most illness associated imaging findings are likely epiphenomenal.  To anyone trained as a chemist in their undergrad major who has experience with nuclear magnetic resonance (NMR) scanning of organic molecules a lot of this comes as no surprise.  To anyone used to reading decades of similar research (like quantitative EEG) and realizing that the pilot studies never panned out even after some were published in very prestigious journals this should also not come as a surprise.  Weinberger offered the technical explanations for why these issues occur and also some studies that seemed to be sound.

The bulk of his lecture was dedicated to the genetics of schizophrenia.  The opening slide not only contained a lot of information it was a tutorial in how to present information in PowerPoint format.  It was titled "The emerging genetics of schizophrenia".  In the upper left corner was a graphic from Gottesman's work with 11 bar graphs above the same axis showing risk for schizophrenia based on relationship to the index case.   Right below that was a table of Exome Sequencing: Rare Variants showing rare structural variants in schizophrenia with the title of a report to the right.  In the upper right hand corner was a Manhattan plot of 108 GWAS loci on all human chromosomes and the reference to the report in Nature.  It was a beautiful slide in terms of presentation and information content.

He went on to discuss genome-wide association studies (GWAS) and what they imply for the genetics of schizophrenia.  Inheritance of schizophrenia is widely considered to be polygenic and has been for some time.  He framed this issue as there being no psychiatric disorder gene and I thought that was a useful reframing because it speaks to studies that are looking at a very few point mutations associated with schizophrenia, and it is easy to think that this gene is the cause of schizophrenia rather than conferring risk for the disorder.  He demonstrated this with a risk profile score (RPR) for developing schizophrenia based on an additive count of all risk alleles.  In the example given the risk profile for the highest risk score had an odds ration of 15-20 to 1 for developing schizophrenia.  He went on to review the evidence for schizophrenia as a neurodevelopmental disorder.  That included some epidemiological data such as artificially imposed famine in China and the Netherlands and the subsequent increase in the incidence of schizophrenia in the respective birth cohorts (1).  He showed that de novo mutation in schizophrenia overlap with more traditional neurodevelopmental disorders like autism spectrum disorder and intellectual disability.  He showed that genes from all three disorders are overexpressed during the fetal period and this is a pattern seen in neurodevelopmental disorders.  

This was compelling stuff.  I come to this conference very year to get rejuvenated and it worked again this year.  The only regret I had was that time has just about run out for me.  I am no longer a young science major with an interest in human behavior and how the brain works.  I don't have time to go back and do a fellowship with Dr. Weinberger or a sleep fellowship or any number of other interesting things that I see at conferences.  I can understand the concepts,  teach them, and advise younger colleagues and residents on what is available and why this is a compelling field whenever I can.  I can also continue to get the word out that psychiatry is alive and well, that the best critics of psychiatry are trained as psychiatrists, and what passes for psychiatric criticism on blogs and in the press lacks a critical element called scholarship.  And as important - you don't have to be Kandel or Weinberger to be scholarly and apply what you know about the science to what you do every day as a psychiatrist.  Equally important - knowing the theory and what can and cannot be applied yet - is an important aspect of being a physician.

It was a good weekend.


George Dawson, MD, DFAPA


References:


1:  Schizophrenia and famine collection (original articles on the Dutch and Chinese famine are references number 39 and 59):

http://www.ncbi.nlm.nih.gov/sites/myncbi/1-MAvBcofi/collections/48942475/public/

2:  Weinberger DR, Radulescu E. Finding the Elusive Psychiatric "Lesion" With21st-Century Neuroanatomy: A Note of Caution. Am J Psychiatry. 2015 Aug 28:appiajp201515060753. [Epub ahead of print] PubMed PMID: 26315983.

Tic - toc......

Or why advising physicians on how to manage their time is not generally a good idea.

I will cut to the chase on this one.  The answer is two fold.  Medical practice is by its very nature inefficient.  Secondly, there are just too many people incentivized to waste physicians' time.   After reading another blog on this topic,  it is apparent that most people attempting to give advice to physicians either think that we are quite slow on the uptake or they have no appreciation of what medical practice is like.  The most misunderstood part is how much time physicians are forced to waste on work that is unnecessary to the work of patient care.

I preface my remarks by saying that in the many visits I have had to physicians of all specialties, I have never been seen on time and consider myself lucky to be seen within 30 minutes.  My all-time record was waiting about 30 minutes to be seen in the emergency department one day and then having to wait another 8 hours to be discharged by the physician who saw me for a rather uncomplicated problem.  So there is no expedited line for physicians in clinics, EDs, or hospitals.  We wait like everybody else.

The premise of efficiency in medical practice is a favorite of administrators and other salespeople pushing valuable time saving devices for physicians.  Primary among them has been the electronic health record or EHR.  I think there is finally a consensus on the fact that it has basically created a large pool of physician-stenographers that spend additional hours each day typing in documents that are designed for billing and coding purposes rather than enhancing the care of patients.  I will roll out my frequently stated comparison.  In 1981, two interns and myself could complete all of the daily documentation on a busy 30 bed neurosurgery service during the 2-3 hours that we were rounding with the senior residents and doing all of the other associated work that day.  Today it would probably take an additional 4-6 hours to do that work and it would mean less time in the operating room learning neurosurgery and attendings wondering about what happened to the team.  I have heard of some surgical services who hire retired surgeons to come in as scribes to do operative notes to reduce the paperwork burden.  The documentation burden is worse in primary care.  All of the advice on how to shift your time around to allow ample time for the documentation never considers the fact that time slots in clinic are rarely set in stone.  People show up 30 - 60 minutes late and expect to be seen.  Emergencies happen, and need to be dealt with while people are stacked up in the waiting area.  Labs need to be reviewed and all of the outgoing tasks (paperwork, phone calls, prescriptions, consults) need to be handled.  None of these are trivial tasks in terms of the time it takes to get them done.  Some of my friends in Endocrinology walk in on a typical morning and have over 250 test results stacked up in a computer queue that they need to review on top of the full patient schedule that day and do something about them - in some cases right away!

Outpatient clinics have certain routines every day depending on the specialties involved and the amount of staff available.  As an example, primary care clinics generally have many more staff to room patients, take vital signs, handle calls, and schedule patients than outpatient psychiatry clinics.  But even clinics that are more fully staffed can easily be overwhelmed by the demands placed on them.  There is no end to nonsensical ideas about how physicians can be more efficient, but there are always several facts that all of the advice givers typically ignore:

1.  There are mathematical laws called power laws that govern how many patients can be seen by physicians.  It is a mathematical fact.  All of the speculation about computers doing thousands of physician tasks per second are really meaningless at this point.  All of the administrators talking about "productivity" are as meaningless.  Productivity happens when real quality treatment occurs that changes a person's life.

2.  Despite all of the business focus on productivity, the business administrators in health care have done nothing but create obstacles to physician work.  Wasting hours every day doing tasks for insurance companies and the government is basically a case in point.  I would estimate at least 40-50% of all physicians time is wasted on these tasks.

3.  Every physician in this country who works in a clinic setting is an independent practitioner.  They don't need supervision, they just need to keep their license current and abide by the medical practice acts in each state.  The only time they are supervised is when they work in a clinic or hospital setting and suddenly they are vertically integrated into departments and placed under a supervisory hierarchy.  That hierarchy is by definition very inefficient.  A lot of time is wasted implementing the next great ideas of the supervisors and in some cases sitting in long drawn out meetings about the financial status of the department.  Apart from the administrators needing to demonstrate that they were actually doing something (that is frequently debatable) - these meetings were generally a waste of time.  I don't discuss all of my cases with business administrators - why would I want to read their spreadsheets?  How can putting 20 or 30 physicians in the same room for a meeting be anything but disruptive to clinic and hospital schedules?  The business and government initiatives to force physicians into these employment situations leads even less time to see patients.

4.  Physicians have been hit hard by the EHR and more.  Like many other jobs there is an implied 24/7 electronic access.  When physicians are not completing documentation after hours or at home,  they are answering e-mails and texts about patient problems.  It is not uncommon to start clinic and notice that is addition to a full schedule of appointments and labs to review that there are also 20 or 30 e-mails and messages through the EHR - many marked urgent.  If you are the first appointment in clinic that day and your physician said that she had to respond to an urgent problem - believe her.

I can understand that this post might elicit widely varying emotions.  Overworked and burned out physicians will see the obvious truths here and will wearily think: "Been there - done that."  There will be readers - like one who suggested that I drive a Porsche rather than a soccer mom van - who will be outraged that a rich doctor dares to complain about working conditions.  There will be readers who think that physicians should not complain on basic principles.  I guess they don't want physicians acting like other workers when this is supposed to be a privileged and noble calling.  They don't recognize that physicians are managed like production workers and not professionals.  There will be those trying to silence complaining physicians by suggesting it is "unprofessional" or characterizing legitimate complaints as "whining".  They generally have their own political agenda  that includes managing physicians like production workers.   It should be apparent that there is no extra time to manage.  There are many people who will say they are working as hard as doctors and therefore doctors don't have a legitimate point.  I would say that I don't doubt it at all that too many Americans are working long and hard hours.  The question is whether there is also a public safety consideration.  Most workers where there is an element of public safety have limitations on their hours.   Practically all physicians are running a huge time deficit that can't be overcome by gaining 5 or 10 minutes from the occasional appointment that goes well.

Irrespective of the emotional reaction to this post there is a very basic thought experiment that anyone can do.  It will highlight a suggested orientation to the problem.  The question is - when you see a physician do you want to see somebody who is burned out, fatigued from people wasting their time and trying to get them to do more busy work?  Or do you want to see a physician who is energetic, enthusiastic and has enough time to dedicate to you or your family member?

I personally will take the physician who is energetic, enthusiastic and has enough time to focus their energy on their family and learning more about their field.  That is not happening in many places today.      

And for all of those people who want to give physicians more advice on how to be more efficient in cramming 12-16 hours of work (much of it unnecessary) into 8 - here is a bit of advice for you.  Step back and let us do our work - we were doing quite well without you.

George Dawson, MD, DFAPA




Attribution:

Clock graphic by Dnu72 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

Is Susceptibility To Terrorism A Developmental Risk?

I think it was about 1967 when I was playing football with my usual group of friends.  We played football every night for about 8 years.  One of them put on his Army jacket after the game and I noticed that he had a small solid blue button affixed to the lapel.  I asked him what it meant and he said "Students For A Democratic Society."  That was the very first time I had heard of the SDS.  In those pre-Internet days, the only access to radical literature was filtered through popular press in articles that were intended to sell copies.  There were some counter culture approaches like the Whole Earth Catalogue that advised on how to access non-mainstream forms of writing.  It was also possible to travel to one of the universities at the time that were the sources of radical thought and listen directly to what some of the student leaders had to say.

As I pondered that blue button, my next contact with radical thought occurred in the freshmen philosophy course of my liberal arts college.  I ended up in that class like several of my football playing colleagues.  The only reason I went to college was to play football and eventually become a football coach and physical education instructor.  My only disappointment so far was that the college did not have a PE major.  One of the texts for the philosophy course was Eldridge Cleaver's Soul on Ice.  The only thing making my life more complicated at the time was that the instructor graded on class participation.  If you didn't speak up, he would scan the list of names and call one out.  It happened that day in the fall of 1969 that he called my name and asked me what I thought of some aspect of Cleaver's radical text.  I was seated in the back row as 44 sets of eyes turned to stare at me.  My voiced cracked a little bit as I delivered a several minute interpretation.  I wish I could recall what I said that day because it was one of many turning points for me in college - but I can't.  All I can recall is the Professor's response:  "That is good Mr. Dawson.  That is very good."  From that point on, he knew I read the stuff and and could be counted upon for reasonable commentary.  When I sat down the introverted football player seated next to me - gave me a thumbs up.

The 1960s and 1970s were turbulent times.  The same guys I played football with - every day for years - were enlisting in the Marines and going to combat in Vietnam.  One of our group died over there and his name is on the Vietnam Memorial.  It was a very unpopular war and in those days protesting unnecessary wars was popular and became more popular as time went by.  My overall recollection was that information about the war was much more tightly controlled in those days than it is now.  That may have been part of the backdrop for protests, but there was more.  My home state of Wisconsin was a hotbed of radical political thought centered at the University of Wisconsin in Madison.  There were protests in the street and riot tactics used against the protestors.  At one point the windows were broken out of the stores so often on State Street that there were replaced with wood.  One of the retail pharmacies there eventually replaced their windows with bricks and mortar so that the store resembled a bunker with small windows up at the top.  It was an exciting place to visit due to the activity on campus and high level of emotion.  There are detailed descriptions of the history of what happened in Madison available around the Internet and I am not going to excerpt them here.  One of the references suggests that the three radicalized university campuses of that era were Madison, Berkeley, and Columbia.

The protesting in Madison seemed to peak on August 24, 1970 when 4 men blew up the East Wing of Sterling Hall.  That explosion killed a 33 year old physics researcher, injured 3 others, and destroyed years of research - in one case 25 years of research.  The apparent target was Mathematics Research Center because it was funded by the US. Army and the motive was to protest the war in Vietnam.  The 4 men involved ranged in ages from 19 to 23.   The same group was involved in an earlier attempt to bomb the Badger Army Ammunition plant in Baraboo, Wisconsin just down the road from Madison.  Depending on who you read, this bombing changed the course of war protests in Madison.  Many people left the anti-war movement when they realized it contained an element that were not concerned about the lives of others.  Even though many seem to agree that the incident seems to be forgotten, I think there are questions about whether the almost total lack of protests and radicalization today is not in part due to this lingering concern.  In his book Days of Rage, Bryan Burrough described the Sterling Hall bombing as having a transformative effect in that it refocused conversation from the Nixon administration to the bombers and assigned a larger responsibility to anyone who encouraged violence either directly or indirectly.

Burrough goes back and does a good job of making sense of what happened in the 1960s and 1970s.  He covers all of the main radical groups and points out that terrorism (of a domestic kind) was much more widespread then than terrorism of all forms is now even though it was less lethal.  To cite a few examples, in 1972 there were 1900 domestic bombings in the United States.  Bombings were occurring daily and an FBI agent in the book referred to it as "commonplace".  One of the commonest sources of explosives for bombs was dynamite stolen from construction companies.  A Senate investigation in 1970 showed that the amount of dynamite being stolen from quarries and construction sites went from a total of 12,381 pounds in 1969 to 18,989 pounds in the first 5 months of 1970 (Burrough, p151).  By the end of that year most states had passed or were considering new laws limiting the sale of dynamite.  Radical groups also targeted police officers in their activity with several municipalities reporting several fold increases in assaults and homicides of police officers.      

Although Burrough's book is not written from the perspective of developmental psychiatry, there are important themes there that highlight what I think is the most plausible answers to both the recruitment of terrorists and some mass shootings that involve men in this age group with no clear mental illness.  First and most primary is emotional maturity.  Emotions  are both necessary for optimal decision making and at the same time can obscure clear decisions.  The factors that result in that optimal decision making are under delineation but brain maturity, the absence of intoxicants, and appropriate social context and boundaries are all important  aspects of the process.  It is clear from reading Days of Rage that the terrorists of the 1970s like many of their peers - lacked a lot of this.  Burroughs documents disagreements based on boundary issues within some of these groups and in some cases naive approaches to building solidarity within the group that was nothing more than sexual acting out.  Envy was a notable dynamic.  Many of the Weathermen were described as being envious of the Black Panthers.  Some of the radicals most notably the Weathermen were so naive in their quest to recruit and save the working class, that they did not realize that the working class did not want to be saved - at least by them.  The violent activity seemed to be driven at times by narcissism more than anything else.  Being the most violent person in a group of otherwise ambivalent terrorists conferred a certain status that seemed to last a long time.  Late adolescence and early adulthood is also the last great moment to be bonded to a group of your peers.  The next life stage for most people involves family units taking priority rather than peers.  Bonding around a life changing event like a revolution or even much less visible military service can be a powerful experience if it really happens.

History tells us that the revolution did not happen.  Several of the radicals from that time are interviewed and talk about being convinced at the time that it would.  The author refers to this thought as delusional at times, but it is more likely quasi-delusional - shared with such emotional intensity that a very low probability event seemed likely.  Some ponder their sparse legacy or rationalize a lot about what happened.  One interesting twist is that many of the radicals who were never convicted and even some who were completed their college degrees and even went on to professional school.  Some became lawyers and teachers.  One became a prominent psychiatrist.  That aspect of their transition from advocates for a violent overthrow of the system to being an integral part of it separates domestic terrorists from those who are involved in countries without that opportunity.  That may be what separates countries who may transiently have several hundred terrorists who fade away in a fraction of a generation to generations of terrorists living in an abandoned country like a revolution has happened.

There are experts in this area who have different ideas about classifying terrorists - but they are generally based on stable adult personality structures.  I  think that there is a lot to be said for a model that looks at susceptibility to recruitment into terrorist organization as a developmental predisposition and one of many decisions that needs to be made in the transition to adulthood.  That transition is fraught with bad decisions that are the product of the highly variable judgment that can be readily observed in adolescents and young adults.  That includes a prominent bias starting in adolescence that you are making the same decisions that adults would make or that you would make if you were slightly older.

What happened to the domestic American terrorists in the 1970s and how quickly they were forgotten is probably a case study in the problems with this process.  It is very likely that process continues to this day when young adults are recruited to work as foot soldiers in organizations that have similar violence-based ideologies that appeal to very few people.


George Dawson, MD, DFAPA     


Reference:

Bryan Burrough.  Days of Rage.  Penguin Press.  New York, 2015.

Note on the reference: If you lived through this time like I did,  this is the best reference I have found to help you figure out what really happened.

        


















Attribution:

FBI wanted posted image at the top of this post uploaded by Magnus Manske, via Wikimedia Commons - on April 12, 2012.


The following photos were taken of some of the historical locations mentioned in the above post in Madison, Wisconsin on Thursday October 22, 2015. 

Sign to commemorate Reform and Revolt just east of Sterling Hall. 

Sterling Hall Sign

Sterling Hall Main Entrance

State Street from the foot of Bascom Hill.