Free Associating in the MRI Scanner…

 

I finished my second MRI scan this year earlier this afternoon. So far lifetime – I have had 5 and will have 6 by the end of next month.  I am sure that many people reading this have had the experience and I would not rate it as pleasant at all.  Just the obsessive checklist that must be completed prior to the scan is enough to raise the anxiety level. Is my body free of implanted or tattooed or accidentally placed metals?  When they were scanning my pancreas – my first thought was: “What about that laparoscopic cholecystectomy I had done in 2019?”  I had read the operative report and it described two permanent clips being placed on the cystic duct prior to dividing it and removing the gallbladder.  I contacted the surgeon about that and he was certain the clips were not ferromagnetic.

One of the last questions is: “Are you claustrophobic?”  And if you are is your primary care doctor prescribing a sedative and if you take that sedative is there somebody here who can drive you home?” I would be hard pressed to think of many people who would not be claustrophobic in an MRI tube.  After all you are in a tight space with very loud noises for a prolonged period. As the radio frequency waves are generated the tube heats up.  It is better than hurtling through space in a larger tube during air travel – and I smiled to myself as I thought of the comparison.

In all cases I have been given a headset and asked about musical preferences and volume.  So far, the headsets don’t block the sound of the machine and obviously are not noise cancellation devices. It did lead me to think about designing headsets without ferromagnetic materials and what that might involve. The only designs I have seen so far use air conduction through tubes rather than electrical connections.

Music selection is as much of a problem as the low-fi headset.  I forgot to ask if I could use my own playlist – but it was safely locked up far away from the 1.5T magnet. I tried to be more specific this time: “Have you got any Canned Heat?”  My most recent play list starts with 3 Canned Heat songs from 1967 – but looking at the tech I estimated he was born in 1980 and the other in the 1990s.  When they rolled me out of the tube one had been replaced by a woman with brightly colored hair who may have been born in the 21^st century.  I changed my answer to “Classic rock.”  That can be a disappointing genre because too much of it is bubble gum music.  Over the 30 minutes in the tube, the heaviest it got was AC/DC Highway to Hell and James Gang Funk 49.  I did enjoy Steve Perry (Journey)  and was tempted to sing along like I do in the car.  But I am sure that would have not been a good idea and may have resulted in additional imaging time and I can no longer hit the high notes.

My mind wandered to fMRI research. How in the world can research subjects be expected to produce real world results from inside the catastrophic MRI world?  I decided not to include my real catastrophic thinking in this post because it is idiosyncratic and I don't want to affect anyone else's decision to get an MRI scan.  And today I just had one or two brief thoughts. I spend most of the time in the tube actively distracting myself and doing sigh breathing exercises to control my heart rate.  Today I opened my eyes in the tube – briefly for the first time.  All I could see was an expanse of whiteness in front of my face with a row of fasteners bisecting the field.  I was pleasantly surprised to find it was about 6 inches away – farther than I had imagined it.  

While I was thinking about research, I also thought about all of the MRI scans I had ordered on my patients.  Going through the procedure yourself leads to questions about the how it is presented to patients for informed consent. I was careful to describe the issues with confined space and noise as well as the advantage of no radiation and better resolution.  Being hospital based, I had the advantage of an anesthesia team being available to sedate and monitor patients who were unable to tolerate it. As I was showing one person their results by holding the film against a window in their room they fainted and I was able to catch them on the way down.  The realistic appearance of the brain in that scan led to that reaction.

Forty years ago, I was an intern in this hospital. My very first rotation was Internal Medicine.  Back in those days it was a county hospital.  Today it is a massive flagship hospital of one of the largest health care organizations in Minnesota. That included a building program to the tune of hundreds of millions of dollars. The original hospital remains at the center, but it is obscured by new wings and buildings. The parking lot I parked in did not exist at the time.  There was a lot out front that you accessed with a magnetic card.  One night I was working late and a guy approached me for money as I entered that lot. I handed him $20 to avoid what I thought might be coming. It was a tough neighborhood.

Once you enter the building – you can step back in time where old meets new.  One of those places is medical imaging. During internship and in the 22 years I worked there radiology (as we used to call it) was one of my favorite haunts. I knew the radiologists and knew I could ask them questions about films.  Surprisingly many of them had questions about psychiatry. Before the electronic health record, I would make a drawing of the positive findings from CT and MRI scans and redraw it in the patient’s chart.  As radiology became digitized it was easier to cut and past images.  I could still discuss images with the neuroradiologist.  I missed all of that when I left that practice.

The MRI tech comes over the headphones:  “OK we are going to come in and inject the contrast.”  They know I had a mild reaction to CT scan contrast but the MRI contrast is gadolinium based and I have had it before.  The last time they checked my pre and post creatinine levels, but at this facility that is replaced by questions about renal insufficiency and dialysis.  That seems like a low bar.  He checks in again in 5 minutes to make sure that I am not having a reaction.

Another sequence of radiofrequency waves starts and there is a pulsating beat that reminds me of a rock and roll song.  I try to recall the song just based on the beat.  I check my muscle tension and realize my shoulders are rolled forward – so I force myself to relax, move my neck, and do some patterned breathing. I would really like to hear some Nirvana at this point.

The tech is on the headphones again.  “OK you are doing great – 5 minutes left.”  That reminded me of a previous scan when I got a similar message and remembered all of the songs that played afterwards.  This time ZZ Top LaGrange comes on. It is a 4 minute song.  At the end – they roll me out of the tube and tell me I have done a great job.

Last night I was wondering whether I was getting progressively more anxious about MRI scans or whether this was a form of exposure therapy. I was surprisingly calm during this one and more confident that I will live to MRI another day.

 

George Dawson, MD, DFAPA

Supplementary:  I have received some early feedback on why I am getting these MRI scans. First and foremost - I am interested in addressing serious problems and preventing disability. I personally know many people who were disabled as the result of spinal injuries that occurred from seemingly trivial events like turning to see someone walking through the door or turning over in bed. I am also aware of age related injuries that occur in active people. Falling off your bike at age 70 is not the same as falling off your bike at age 30 or 40.  All of these scenarios suggest to me that numerous age-related changes in the spine in the absence of any course of effective strengthening can lead to catastrophic problems.   

In addition to the symptoms, I would like to get an opinion of whether it is safe to do aspects of my exercise routine.  I would really like to get back out on the ice speedskating - but I am not going to if it means I will get progressively disabled from spinal problems.  I saw Lindsey Vonn speak to this recently.  I am certainly not comparing myself directly to one of the greatest skiers of all time - but I could relate to why she finally decided to quit.  

“My body is broken beyond repair and it isn’t letting me have the final season I dreamed of,” Vonn said. “My body is screaming at me to STOP and it’s time for me to listen.”   

A lot of aging athletes like myself have the thought that as long as we exercise and stay very active - we will be able to continue in sports as long as we want.  In retrospect, I think I have shown that you can certainly push it much farther than expected and much farther than average - but like the best there is a breaking point. 

Without yet knowing the result of this scan - the possibilities are significant. In the ideal world, it will show age related changes and that would just indicate continuing the physical therapy that I have been doing for 20 years.  If a potential surgical problem shows up that is more complicated.  I do know skaters who have had back surgery and most back surgery has highly variable results. I have also observed and assisted on many back surgeries in medical school where neurosurgery was my preferred surgical rotation - but I assume surgical technique has improved greatly since then.  Would I get back surgery if there was a high likelihood of symptomatic relief and I could return to skating?  Would I get back surgery without that guarantee?  All of that is up in the air at this point. 

Image Credit:  Image credit and Creative Commons licensing can be obtained by clicking directly on the image at the top of this post.

Are Medication Trials For Depression Too Long In Duration?

Depression is a significant cause of disability in the world.  That is complicated by the fact that there are not enough resources to treat people with depression, access is rationed in many areas including the United States, there is a high rate of attrition during treatment, and depression is often associated with significant medical and neurological disability further restricting access to adequate care. 

Over the past 30 years, strategies for treating depression have increased considerably since antidepressants medications are not uniformly effective and they have side effects that may not be well tolerated.  Antidepressants have evolved over the years from monoamine oxidase inhibitors to tricyclic antidepressants to selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) and norepinephrine dopamine reuptake inhibitors (NDRI).  The suggested pharmacology of more modern antidepressants is even more complex and the initial classifications may mean a lot less than what was initially hypothesized.

Although antidepressant monotherapy is the preferred treatment path – failure of one or two rounds of antidepressants can result in combinations of augmenting agents designed to improve treatment response.  Early augmenting agents included triiodothyronine, thyroxine, and lithium.  More recent augmenting therapies include additional antidepressants (typically bupropion), aripiprazole or brexpiprazole, or buspirone.  There are several additional agents that are used in lower frequencies.  Context is important in considering the origins of the augmenting therapies. When thyroid hormones were added, there was an active research focus on neuroendocrinology including the impact of physical illnesses on thyroid function. Later focus on treatment resistant depression assumed that all depression was treatable - it was just a question of finding the correct treatment. Both hypotheses have had low yields. 

The relative advantage of these approaches is that they are potentially cost effective (most antidepressant medications are generic and prescribed by non-psychiatrists), they are readily available, and they are more culturally accepted than they used to be.  The disadvantages include side effects most commonly nausea, vomiting, diarrhea, sexual side effects, and dry mouth. Patients need close monitoring initially to prevent side effects and assure that the medication is working. The physicians doing that monitoring also have to be aware of rare serious side effects that require emergency treatment – like serotonin syndrome, neuroleptic malignant syndrome, and acute neurological side effects.  A good knowledge of general medicine is also required to avoid treating people with chronic illnesses where there are contraindications. 

Another disadvantage is treatment non-response.  What happens if two different prescriptions are tried for adequate amounts of time and there is no response. Where does the treating physician go from there?  Seeing thousands of patients well into a course of treatment for depression and/or anxiety this is a very common problem – often complicated by additional problems including insomnia and substance use disorder.

Before anyone suggests addition exercise or psychotherapy at that point – practically all patients seeing psychiatrists have already done that.  Most of the people I treated had seen more than one therapist and these days they are branded therapists (CBT, DBT, IPT, etc).  The only non-pharmacological modality that was rarely used was bright light therapy and I typically discussed that as an add on to antidepressants. That therapy requires purchasing a device and using it for set periods of time each day. 

For the people with severe treatment resistant depression, more complicated interventions including electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and ketamine (intranasal, IV, IM) are on the horizon but difficult to find in one place.  As an acute care psychiatrist, I had very easy access to ECT.  As an outpatient psychiatrist there was essentially no access, even when I called the facility where I previously worked. Because of the current systems problems, my patients needing ECT had better access if they presented to emergency departments where they knew ECT was an option and got admitted to that hospital. The same barriers seemed to preclude any contact with me as an outpatient psychiatrist.  No calls for a collegial discussion and in many cases no discharge records from the treating facility.  Siloed care these days is a major impediment to care.

Last weekend, I was exposed to a modern approach that concentrated all the advanced treatment modalities in the same clinic that happened to be staffed by researchers interested in treatment resistant depression. Before I get to their approach – I designed the slide at the top of this post to illustrate the standard approach to moderate to severe depression over the course of my career starting in 1984.  I remind readers that psychiatrists are seeing a highly selected group of patients who have probably already failed several antidepressants and psychotherapies.  As time goes by and the number of non-psychiatric prescribers continues to increase greatly – that selection process will greatly intensify.

Looking at the general scheme of antidepressant approaches to only depressive disorders (DSM major depression and persistent depressive disorder) – there has been a clear progression of newer medications designated by older class names like tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI), serotonin norepinephrine reuptake inhibitors (SNRI), and monoamine oxidase inhibitors (MAOI). These general class names have significant limitations – not the least of which being reuptake blockade by of specific transporters is probably only part of the mechanism of action and some class designations depend more on chemical structure than physiology. If anyone would like a second explanatory slide with all of the current FDA approved antidepressants and more modern nomenclatures – let me know and I will make the slide.

In treating significant depressions – psychiatry added adequate dosing and duration and therapeutic drug monitoring (TDM) to determine adequate trials of antidepressants therapy.  There were active debates and research suggesting 6 weeks might be adequate on the lower end and 16 weeks as adequate duration on the high end. Pharmacokinetic factors came into play with some antidepressants with longer or shorter half-lives. If an adequate trial of medication was completed there was the question of “What’s next?”  The next issue was either changing the antidepressant or adding an augmenting therapy (adjunctive therapy per the FDA).   As noted in the graphic thyroid hormones (Triiodothyronine or T3 and tetraiodothyronine or T4/thyroxine) were both used early on in doses that were typically much lower than physiological doses (25 – 50 mcg) as well as stimulant medications (amphetamines). As time went by additional adjunctive strategies were added.  The first study of adding lithium to tricyclic antidepressants occurred in 1981 (1).  Adjunctive medications started to take off in the early part of the century with pharmaceutical companies getting that indication for newer antipsychotic medications that also had bipolar disorder indications (see specific dates of approval).   

The upside to these strategies was that antidepressant effects could be improved often to the point that depression remitted. The potential downsides were twofold – the burden of taking a second medication that could introduce new side effects or synergistic side effects with the current therapy and the prospect of endless medication trials.  Now there was the additional time of seeing whether any of several adjunctive therapies worked in addition to the antidepressant monotherapy trials. Although I did not indicate it on the diagram – several antidepressant combinations were also suggested and some patients were taking 3 or 4 antidepressants at once.  That was a significant departure from quality metrics used in the late 20^th century where antidepressant monotherapy was the rule.

The concept of treatment resistant depression – generally defined as a failure of a specified course of pharmacotherapy was often stimulus for these trials. The application in clinical practice was not as clearcut because of the number of choices and how individual patient factors affected those choices. Acuity, disability, and access were the usual limiting factors leading to cessation of pharmacotherapy trials and a trial of neurostimulation like electroconvulsive therapy (ECT).

Last week, I saw a unique solution to this bottleneck problem presented by C. Sophia Albott, MD, MA entitled  “Next Generation Treatments for Resistant Depression: The UMN Interventional Psychiatry Approach.”  She described a well-staffed clinic with a stimulating practice environment that offered ECT, transcranial magnetic stimulation (TMS), ketamine (intranasal, IM, and IV), Vagal Nerve Stimulation (VNS), and Behavioral Activation Therapy provided to all the patients in their clinic.  Their general hierarchy was to start with TMS and if that was not effective to branch out into other specific therapies. The overall description of the clinic and some of their early successes suggests to me that this is potentially a good approach.  The idea of these therapies all being concentrated in one place, taking over treatment of the patient until they are in remission, and additional support is what is lacking in most systems of care.

I am sure that some would wax philosophical about similar clinics being the future of the field – but there still needs to be psychiatrists out in the community providing acute care and consultation to primary care physicians. A subspeciality clinic could function well as back-up those psychiatrists who often lack a referral resource for neuromodulation and other advanced techniques.  The largest potential benefit would be to patients who are being maintained in long term medication trials longer than they should be. This approach may be the best way to shorten the period of disability and suffering from difficult to treat depression as well as the adverse effects of polypharmacy.

George Dawson, MD, DFAPA

 

References:

1:  Dé Montigny C, Grunberg F, Mayer A, Deschenes JP. Lithium induces rapid relief of depression in tricyclic antidepressant drug non-responders. Br J Psychiatry. 1981 Mar;138:252-6. doi: 10.1192/bjp.138.3.252. PMID: 7272619.

2:  Trivedi MH, Rush AJ, Crismon ML, et al. Clinical Results for Patients With Major Depressive Disorder in the Texas Medication Algorithm Project. Arch Gen Psychiatry. 2004;61(7):669–680. doi:10.1001/archpsyc.61.7.669

3:  Sonmez AI, Wilson S, Olsen S, Sullivan C, Herman A, Widge A, Nahas Z, Albott CS. Outcomes from University of Minnesota Clinical rTMS Clinic for resistant depression: naturalistic data on suicidal ideation. Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation. 2021 Nov 1;14(6):1652.

4:  Papakostas, G.I., Trivedi, M.H., Shelton, R.C. et al. Comparative effectiveness research trial for antidepressant incomplete and non-responders with treatment resistant depression (ASCERTAIN-TRD) a randomized clinical trial. Mol Psychiatry (2024). https://doi.org/10.1038/s41380-024-02468-x

Two Million Reads - A Blogging Milestone of Sorts

 

Last night around midnight – I noticed that I had crossed the 2 million reads mark on this blog.  The Google Blogger interface that I use is not very granular so it is difficult to tell how many of those hits are actual reads as opposed to something else. By something else I mean hackers, bots, and people trying to use my blog for free advertising.  The products are typically illegal or barely legal drugs or psychiatric services outside of the US.  The increase in VPNs is also probably a factor.  Over the years the number of hits per page has flattened out while the overall number for the blog has increased. My assumption is that individual page reads with a VPN are not counted, but they are counted for the overall blog.

I am reassured and very grateful for the readers of this blog and have corresponded in detail with many of them.   They range from medical students considering a career in psychiatry to very senior medical scientists with hundreds of research publications.  In many cases they are advocating for a specific viewpoint.  In a few they want me to change a blog post in some way.  That rarely happens because of my level of experience and the degree of research I put into these posts.  Somewhere in the past I pointed out that one of my motivations for writing this blog came from colleagues who asked me what I read, where I found certain information, and how I came to know what I know. I hope I am successful at getting that information out there.

I am also very grateful to the academics out there who share their work and give me free advice.  One of the most striking examples was midnight correspondence with two philosophers who wrote a book about diagnostic decision making in the late 1980s. I used it to teach a course in not making diagnostic errors in medicine and psychiatry. Both professors were retired and I sent them emails in a later time zone at midnight. They gave me detailed responses within an hour. I don’t always get a response, but when I do it is exhilarating to be a part of academic discussions with some of the most accomplished people in the world.

It has not always been a walk in the park.  I was confused about gaslighting initially and tolerated too much of that activity before drawing a line.

I often wonder about why people read or do not read this blog.  The appearance is fairly basic compared with other sites that offer better graphics.  I think there is some reluctance or resentment based on the idea that I am profiting from this blog.  I can restate that this is completely non-commercial and not-for-profit.  I not only have not made a cent writing this blog but have had to pay licensing costs out-of-pocket for graphics and permissions.  A friend and colleague recently told me that he never thought about reading blogs.  The era seems to be one of podcasts and TikTok video clips. I have always found reading to be a lot faster.  And unlike TikTok I am intentionally not provocative.

One of the recurrent themes here on my blog is that there is no way to simplify psychiatry and do it well.  A psychiatrist considering themselves to be primarily a psychotherapist or primarily a psychopharmacologist is not considering large areas of the discipline.  The same is true of the psychiatrist who ignores medicine and neurology.  To paraphrase Euclid (325 BCE - 265 BCE)  “There is no royal road to psychiatry.”  You must know it all to do good work.  Complexity is good and necessary in human biology.

I currently have 123 folders in my References 2024 Folder and it’s only March.  I am working on a protocol that will allow me to submit research papers and blog them if they are rejected.  At the rate I am going I will write my own textbook in psychiatry in another 20 years.  Stay tuned!

 

And Thanks again!

 

George Dawson, MD, DFAPA

An Unpublished NEJM Letter

 

 I was notified this morning that a letter I sent in to the New England Journal of Medicine would not be published because they had limited space.  Anyone sending a letter is notified that if the letter does not respond to one of their articles you are limited to 400 words.  If your letter does respond to an article the word limit is 200 words.  I was responding to an essay by Lisa Rosenbaum, MD (1) and whether medicine is a calling or just a vocation and the implications that each of those categories have.   My first attempt at the 400-word mark (374 actual) is below:

 To The Editor:  The essay by Dr. Rosenbaum (1) highlights a critical issue in medical education, research, and practice.  Much of the analysis is dependent on the concept that medicine is either a job or a calling. The critical factor in all settings is the practice environment.  Over the past 30 years we have seen a severe deterioration in that environment and how it impacts physicians. 

Forty years ago – physicians were valued as knowledge workers.  Work quality was emphasized and teaching departments were run by senior physicians who emphasized teaching and research.  They were models for focused lifelong learning and were able to maintain interest and enthusiasm in their departments by balancing clinical demands and those learning tasks. Trainees in the department benefitted from identification with these physicians as well as learning clinical approaches in their specialty.  The department head often had a business administrator in the department, but there was no doubt that the focus was medicine first and business tasks were minimal.

Over the past several decades, business and political interests have changed the physician role to production workers. Physicians are now valued in corporations for productivity and all the administrative time that takes. Department heads are often more focused on business matters than teaching and research.  Meetings take on a business rather than academic orientation.  More time is spent learning about the business environment rather than learning medicine.  The administrative burden alone easily exceeds the time used in the past for teaching rounds and conferences.  This burden has also decreased physician efficiency and added hours per day producing documentation for billing purposes that is repetitive and excessive. It also detracts from the physician patient relationship that is further fragmented by physician extenders.

The modern practice environment is not conducive to producing and motivating physicians.  Rather than an environment where experts can have spirited exchanges about medical care – it is one where experts are second guessed by administrators with no medical training.  It is an environment that does not produce a calling.

Recognition of the severe deterioration in the practice environment is the first step in correcting the problem.  Steps need to be taken to restore practice environments to stimulating settings that can lead to a high level of expertise, quality, and humanistic care.    

 

George Dawson, MD, DFAPA

 

References:

1.  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

 

The final 200-word final submitted version is below:

 

Rosenbaum argues doctors' declining job satisfaction stems from corporatization, generational changes, and a shift to production-style management.¹ Traditionally, senior physicians oversaw the practice, fostering a learning and research environment. Forty years later, business managers treat doctors as production workers² in an increasingly inefficient environment. This clashes with physicians’ role as knowledge workers, requiring intellectual stimulation, collegiality, and patient-centered care.

That change is responsible for a marked deterioration in the training and practice environment.  Business practices have been emphasized to the point that there has been an adverse effect on physician time management for professional and personal activities. It is also a direct cause of burnout.³

Physicians function best as knowledge workers consistent with their training. Physicians have been forced into the role of production workers. The solution is not to develop a rhetorical response to being in that role. The solution is not an idealization of the “good old days” – but recreating and restoring the physician knowledge worker environment.  That is the first step toward making physician sacrifice meaningful again.

 

George Dawson, M.D.

 

1.  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

2.  Drucker PF. Knowledge worker productivity – the biggest challenge.  California Management Review 1999; 41: 71-94.

3.  Lacy BE, Chan JL. Physician burnout: the hidden health care crisis. Clinical gastroenterology and Hepatology. 2018;16(3):311-7.

 

It took me 5 rewrites to get to progressively less words.  When you tend to use as many words as I do that was a painful process.  If you are a blogger the pain is compounded by the fact that editorial control is lost and you cannot publish your comments anywhere else (including a blog) if you hope to get them published in a journal.  The NEJM has a 3-week deadline for letters based on their articles.  It took them 5 weeks to reject it. They obviously can publish whatever they want and provide whatever rationale that they want – but the space argument seems thin.

Let me suggest why I thought this letter – even pared down to 170 words was important enough for me to send.   A brief review of Dr. Rosenbaum’s essay is necessary and if you have access, I encourage you to read it.  The essay begins with standard blue-collar rhetoric rooted in reality – basically that the working man is subjected to the whims of corporations who rarely have their interests in mind.  A young physician from that family concludes that the idea of medicine as a calling is using that term “weaponized against trainees as a means of subjugation— a way to force them to accept poor working conditions.” 

The problem with that analysis is twofold.  First, trainees do not have a monopoly on subjugation by corporations or the government.  It has been a decades long process directed at practicing physicians.  Second, rhetorical “weaponization” of terms applied to the profession is unnecessary.  That battle has already been lost. The current work and training environment has been deliberately shaped by the managed care business and like-minded governments for the past 30 years. Businesses don’t have to use weaponized rhetoric.  All they have to do is replace physicians with non-physicians, tell them they can work somewhere else, or reduce their compensation or just not pay them if they don’t meet their productivity expectations. They can also use internal committees and business practices to scapegoat and gaslight physicians who they do not like.  There is essentially unlimited leverage to get what they want.  All those measures are far more powerful in getting physician compliance than suggesting they need to make sacrifices in the service of a calling.  Physicians today are expected to make significant sacrifices or else – all in the service of their business masters.  It is evident the young physician in the essay knows nothings about it. The only practice and training environment that he knows is the one that has been severely compromised.

From medicine-as-a-calling, Rosenbaum introduces us to workism.  This term was coined in an Atlantic magazine essay to suggest that somehow work is a central part of life, identity, and meaningfulness is life.  That author goes on to suggest that people born between 1981 and 1996 were encouraged in this attitude and found themselves instead in debt and with no meaningful life work.  That led to demoralization and nihilism about capitalism.  When I read these paragraphs, I had to wonder how naïve this generation could be?  How could they possibly think that American capitalism and the economy was good for anybody?  Don’t they read anything about the environment, pollution, climate change, environmental catastrophes, unnecessary wars, near economic catastrophes – all precipitated by American capitalism?  I don’t think the idealization of work or capitalism explains the lack of medicine-as-a-calling.

There is a glimpse of reality in the next section when we hear how of how a long-time residency director of internal medicine stepped down due to a misalignment of the missions of hospitals and training programs. That is really putting it mildly. In many cases that difference was all it took to destroy training programs.  It is common to hear how residents are just used as inexpensive labor – but that has always been the case. The real problem is that the quality of teaching is adversely affected when faculty are told that they must max out their productivity and at the same time – get no credit at all for teaching.  

Rosenbaum’s essay depends on generational stereotypes and barely touches the root of the problem.  I reference the work of Peter Drucker – widely considered a guru in business management.  He pointed out the differences between production workers and knowledge workers. Basically, knowledge workers are quality focused in areas that they have more expertise than the management does. They are generally felt to be critical to the business and the idea is to retain them and give them adequate resources. Establishing a culture of excellence in their knowledge base adds to the environment. Production workers are engaged in repetitive tasks.  Their supervisors generally have worked their way up from doing the same tasks and therefore know as much about their work.  Early experiments in mass production showed that analysis of the repetitive tasks by so-called efficiency experts could improve the overall production.

What has occurred in the past 30 years has been the mass conversion of physicians from knowledge workers to production workers. The associated practice and academic environments have suffered drastic changes. Academic physicians have found that a major part of their work – teaching and research has been devalued in many cases to nothing.  In the meantime, they are expected to see many more patients, often to the point that they find themselves in new clinics – just to increase the overall billing.  The electronic health record (EHR), billing, and coding, and maintenance of certification are all added time penalties with no associated productivity credit. They have little say about how they see patients or how many patients they see.

I will cite one of many examples to highlight these points.  Just 5 years ago,  an internist I know was audited by his managers who had him tracked from 8AM to 4PM by an efficiency expert. That time frame encompassed 90% of his patient contacts, but only 66% of his workload.  Every day when the efficiency expert left – he would ask: “Where are you going? I am here for another 4 hours.”  The managers wanted to use the efficiency expert report to suggest that he was not efficient enough in seeing patients – but the real problem was the lack of clerical support and the EHR. The exercise was enough for the internist to realize he was working in a hostile environment and he moved on.  A clear loss of a knowledge worker.  The corporate myth that everyone is replaceable missed again in this case. This internist had experience and skills that could not be duplicated by anyone else in that clinic. This cycle of corporate flexing repeats itself thousands of times per day.

There can be no calling to work in such an environment where your work is routinely denigrated and devalued.  It plays out as a personal attack. You will necessarily feel like a production worker and start to work on the goals of production workers like standardized working conditions, hours, and benefits.  When you come home at night – you will leave the job behind you and no longer think about the patients who have problems with no solutions or what you need to know to do a better job. There is no esprit de corps of cohesion, support, and invigoration necessary for a stimulating knowledge worker environment.

That is the recent attitude and it correlates directly with the business takeover of medicine – not the newest generations.  It also correlates with prominent editorials in the top journals of our field like the New England Journal of Medicine.  These editorials illustrate on almost a weekly basis that there is no end to the businessmen, politicians, and lawyers who want to run and ruin our profession.  To date – they have been tremendously successful.  There is also no lack of evidence that the medical profession has been completely inadequate advocating for a reasonable practice and training environment.

Medicine will never be a calling again until the work and practice environment has been repaired and removed from the complete control of businesses and governments.

And yes – it is that simple.

George Dawson, MD, DFAPA

 

References:

1:  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

2:  Drucker PF. Knowledge worker productivity – the biggest challenge.  California Management Review 1999; 41: 71-94.

Graphic Credit:

All details at this link.  Coming from 4 generations of railroad workers it was a natural choice:  

https://commons.wikimedia.org/wiki/File:Group_of_laborers_digging_through_dirt_pile_along_railway_bed_LCCN2016647134.jpg

Kendler Keeping It Real…..

 

Kenneth Kendler, MD needs no introduction to anyone even vaguely familiar with the psychiatric literature.  If you need to do your own research his accomplishments and scientific papers are widely available on the Internet. This post is to focus on his recent commentary in JAMA psychiatry (1) over the issue of psychiatric diseases and whether or not they are brain diseases.  He starts out with a 1867 quote from Griesinger stating that the brain is the only logical origin for symptoms of insanity. His analysis is at the level of “pathological and physiological” factors.

He briefly reviews two common arguments about whether psychiatric disorders are brain diseases.  The first Cartesian dualism that a mind emerges from the brain and is not the same as a brain. Since a brain is necessary for all mental phenomenon there is no specific answer to the question about whether the phenomenon observed with psychiatric disorders are diseases.  The second common argument is that grossly detectable brain diseases (lesions at autopsy and sophisticated imaging)  eventually became the purview of neurology.  To complement Kendler’s commentary, I would add that this has never been strictly true since both overt lesions and physiological brain dysfunction has always been studied by psychiatrists.  It has been a common antipsychiatry argument advanced by Szasz and others based on 19^th century concepts.  Ron Pies (2) has recently commented that it involved a misunderstanding of Virchow’s work on pathophysiology.   

An indirect way this problem has been handled is to suggest that it has to do with the vague definitions of disease (3).  Without a clear definition, anyone can use their own to declare that psychiatric disorders are not diseases. That has been a common tactic used to declare that not only that mental illnesses are not diseases – because of the lack of clear gross pathology they do not exist.  Dealing with the problem at this rhetorical level has not been very successful largely due to the lack of interest in rhetoric on the part of medical professionals and constant repetition by the rhetoricians.

More practical philosophical attempts at disease definition like loss of function models seem to not have much traction. Munson and Resnick (4) proposed one of these models and also suggested that the loss of function is related to programming errors in biological processes.    

Kendler suggests a clear path that has appeal to anyone who has studied pathophysiology and treated illnesses without clear lesions or with lesions that had to be the end product of some unknown pathophysiology.  That group of people would be anyone who has done an internship or residency in any medical field.  Anyone with that experience has seen a wide array of medical conditions that are polygenic in nature and have either an unknown or highly speculative pathophysiology.

The suggested path is genetics-> pathophysiology or more broadly “genetics -> brain -> schizophrenia.”  Rather than bemoaning all of the failed GWAS studies and Decade of the Brain, Kendler cites “the most robust empirical findings in all of psychiatry—that genetic risk factors impact causally and substantially on liability to all major psychiatric disorders.”  More specifically he cites a 2022 report that shows that gene expression (as mRNA levels) of risk variants for schizophrenia were noted in the brain and no other tissue.  That brings the brain expression in his causal link into clear focus. 

At that point he hedges and suggests that this may not be robust enough to suggest that a brain disease is occurring. For me it is plenty.  He goes on to suggest that there are 5 advantages of this approach including data driven rather than metaphysical, bypasses the 19^th century need for gross lesions, fits with pluralism or multiple possible etiologies, can potentially provide information about other diseases affecting the brain, and avoids a hard line of demarcation between normal and disease at the physiological level.  The last point has been elaborated in the more recent past as quantitative versus qualitative diseases and the associated variants. 

On the limitation side – a genetics only approach is the main consideration.  The antipsychiatrists that he has alluded to may be realizing that they need to finally modify their 19^th century rhetoric and I have seen the equally absurd claims that there are no genetic effects for psychiatric disorders.  The difference is that Kendler is an expert in the area – so only the most dedicated post modernists will claim that they did their own research and came to a different conclusion.  He does see the innovation of being able to detect tissue levels effects of genetic variants as a good starting point.  The goal is to elaborate the functional networks affected by these variants, describe mechanisms at the molecular level, and how those mechanisms are affected by variants (5).

This is really an inspiring commentary at a time when it is getting more fashionable to attack basic science research in psychiatry. I saw a comment just last week about how biological psychiatry was a drain on mental health research.  And there are frequent comments about how there should be more psychosocial research, even though there is no clear evidence that is necessary.

As a clinical psychiatrist and a physician first, my observations have been that most people go to medical school to gain knowledge about the human body and how to treat, prevent and where possible cure diseases. Speculative pathophysiology and mechanisms are all part of that starting in the first two years of basic science course and extending to clinical rounds at bedside during residency.  Philosophy and endless arguments about the nature of disease or psyche is not.  Psychiatry has lost its way many times due to an inability to recognize and respond to rhetoric. Kendler’s solution to the question of whether mental disorders are brain diseases is an elegant one and it is consistent with the way physicians are trained.  It also establishes a boundary that some questions in psychiatry are not answerable by philosophy.

Finally, what is still lacking?  I think that ultimately, we want medicine and psychiatry to be part of a comprehensive view of human biology. We need more comprehensive theories about human biology and how things really work at the physiological and molecular level.  That knowledge is currently spotty across all specialties. Biology theory rather than biological psychiatry is really the goal here and we can use more input from theoretical biologists of all specialties.

George Dawson, MD, DFAPA

References:

1:  Kendler KS. Are Psychiatric Disorders Brain Diseases?-A New Look at an Old Question. JAMA Psychiatry. 2024 Feb 28. doi: 10.1001/jamapsychiatry.2024.0036. Epub ahead of print.

2:  Pies R.  Did Szasz Misunderstand Virchow’s Concept of disease? Psychiatric Times. Feb 21, 2024.  https://www.psychiatrictimes.com/view/did-szasz-misunderstand-virchow-s-concept-of-disease

3:  Pies RW, Dawson G.  Epistemic Humility in Psychiatry: Why We Need More Montaigne and Less Savonarola.  Psychiatric Times.  Oct 19, 2023.  https://www.psychiatrictimes.com/view/epistemic-humility-in-psychiatry

4:  Albert DA, Munson R, Resnik MD.  Reasoning in Medicine: An Introduction to Clinical Inference.  Baltimore, Maryland: The Johns Hopkins University Press, 1988: 150-180.

5:  van Dongen J, Slagboom PE, Draisma HH, Martin NG, Boomsma DI. The continuing value of twin studies in the omics era. Nat Rev Genet. 2012 Sep;13(9):640-53. https://doi:10.1038/nrg3243

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A Trip To The Dermatologist

 

 

Pattern matching is an important skill for all physicians.  It is rarely discussed these days despite all the continuous hype about artificial intelligence replacing doctors by reading x-rays and other lab tests.  I taught a course in diagnostic reasoning for about 12 years and the examples of pattern matching I used were from dermatology and ophthalmology.   The dermatology experiment was a straightforward comparison of dermatologists to primary care physicians looking at the same slide set of rashes and skin lesions (1).  The dermatologists were correct more often, faster at diagnosing, and able to correctly diagnosis equivocal cases compared with the primary care physicians.

I want to be clear that does not mean that primary care doctors don’t do a good job.  Some are so good that dermatologists know that they need to attend to the diagnosis and treatment of some physicians who refer them significant numbers of patients with melanoma and other types of cancer.  All these factors were probably in my subconscious when I decide to call to see a dermatologist.

It was not easy.  The first appointment was a teleconference and I would call it a swing and a miss. I was given a very expensive prescription for ocular rosacea that did nothing. When I called again to be seen in person, I was given an elaborate algorithm based on how many problems I wanted to be seen about. The more problems – the longer the wait.  I decided to go outside of my usual healthcare providers to a private clinic closer to my home. 

I have noticed a gradual accumulation of dermatology problems with age. I have made every effort to avoid direct sunlight.  If I must be outside at any time when my shadow is shorter than my height, I am wearing a high SPF shirt and sunscreen, a baseball cap, and wrap around polarized sunglasses. I have probably been sunburned twice in my life and tanned once. About 2 years ago I noticed a ring-shaped red lesion on my right forearm.  Every now and then it seemed to burn but generally it was static.  I saw my primary care MD and he did a scraping and potassium hydroxide preparation to see if it was ringworm (tinea corporis). It was not, so he told me to apply the betamethasone ointment that I typically use for eczema to the area.  I did for a couple of weeks and there was no effect.

At about the same time, I happened to notice a blue spot on the lateral aspect of my left ankle.  That is a difficult area to see.  I went into see a primary care MD who used an ophthalmoscope for magnification and concluded it was a collection of pigmented cells that did not look like a melanoma.  She said she would describe it in my chart including recording the diameter so it could be followed along by primary care. 

I described all these problems to the Dermatologist's assistant before he walked in the room.  I had photos of all the dermatology products I had been using and what had been tried in the past.  Even though the pattern matching diagnosis in Dermatology is good, like other areas of medicine – the treatments seem to be hit or miss and even then the response seems to vary over time.  I made a note to myself that I should look for papers claiming that these are placebo treatments or it is just all regression to the mean.  But I doubt that there are any anti-Dermatologists out there complaining about that and too many diagnoses and too many medications.

The intake form that I completed was just 2 pages long and there was an occupation section probably to consider environmental exposures.  When the Dermatologist came in he was very cordial and talkative.  He established that we both went to the same medical school (27 years apart), lived in the same neighborhood while we attended, and knew some of the same professors.  He took the history and clarified the technical points to his assistant who had now become his scribe.  He used a dermatoscope to inspect the lesions and make rapid diagnoses on the right forearm (actinic keratosis), left ankle (fibroma secondary to trauma) and left malar area (actinic keratosis).  He recommended freezing the malar area and forearm with liquid nitrogen and said the fibroma was just a skin reaction to some trauma that did not require treatment. At that point we went into a more detailed discussion of the rosacea and ocular rosacea and failed treatments with doxycycline and tacrolimus.  He recommended a compounded product of azelaic acid, metronidazole, and ivermectin, advised me of the cost, and has his assistant set that up. It was a very efficient process – the diagnoses, freezing treatments, and discussion took about 20 minutes.  At the end all of the follow up, prescriptions, and documentation was done and he was moving on to the next person.

There are times when it pays to see an expert and this is an illustration of one of those times.  I had been looking at these lesions for 2 years and trying to take the next steps.  There are as many barriers to seeing a Dermatologist as there are to seeing a psychiatrist.  I knew enough to monitor these lesions and they did not seem to get worse, but they were also not improving. After 2 years I got the definitive diagnoses and treatment I had been looking for as well as reassurance that the ankle lesion was not a melanoma.

This is an impressive result compared with most physician visits.  Even considering that there were a couple of things that did not fit.  Sun exposure for one.  I am what is referred to as a white fish in upper Midwest vernacular.  That means apart from my blue veins and the redness of rosacea – my skin is generally as white as the background of this page.  I had some early exposure to people with skin cancer and have been very diligent about keeping my skin and retinal exposure to direct sunlight at a minimum.  I suppose there are other factors at play such as age and know there are senile keratoses – but this did not resemble typical lesions in my dermatology texts or online. The Dermatologist predicted that the freezing treatment would cause these lesions to slough off and be replaced by normal smooth skin.  I have a follow up in 3 months to see if that happens and if the compounded topical rosacea medication works.

I am currently studying high prevalence polygenic diseases and have included eczema on that list.  Some estimates say that 20% of the population may have it.  There is the association with asthma but in my case as my asthma improved with age, I developed eczema and then worsening eczema.   I expect there will be many parallels with psychiatric disorders and diseases when my comparison is done. 

In the meantime, a Dermatologist in the right setting is a good consultant to have in your corner.

 

George Dawson, MD, DFAPA

 

References:

1:  Norman, G.R., Brooks, L.R., Rosenthal, D., Allen, S.W., & Muzzin, L.J. (1989). The development of expertise in dermatology. Archives of Dermatology, 125, 1063–1068

 This is the original reference I used in my course on the diagnostic process and how not to make a mistakes.  The first author has written significant papers about this.  

Graphic:

I mapped the dermatology conditions onto the body outline. If someone has a better body outline or one that they use on a standardized form and you want to send it my way - please do.  I can make a much better graphic if the outline is a separate shape.  The actinic keratoses areas on the map are probably both only 2 cm in diameter.  The rosacea can happen anywhere on the face and most annoyingly on the eyelids.  The eczema is a whole body condition that started out subtly as intense pruritis on the extremities and eventually spread to the abdominal area, chest, and back.  Pruritis is the most significant symptom with occasional lesions that looks like abrasions.  It can be exacerbated by skin contact with allergens like ECG electrodes. 

The Retired Consultant

 

I happened across this old post on approaching retirement today and reread it. Of course, I am biased but it holds up well.  It contains information about psychiatrists retiring that you will not see anywhere else – including why we are happy.  I currently spend much of my day doing the usual chores, exercising, and writing.  I have several writing projects going and am near completing one that is unique.

I don’t get out much and I like it that way. I am an introvert and have been subjected to the usual jokes about introversion.  The pandemic was a factor but not the only one.  I just got back from working out in a gym that has Cybex machines.  After that I went to Target to pick up a supply of blueberries and frozen burritos.   

On the way out – I stopped to get a mocha and 2 biscottis.  The barista was young and we talked about the closing time of the coffee shop relative to the store. I associated to what I was doing at that age.  I was a janitor in a dormitory. It was a thankless job.  Luckily with increasing college experience I was able to move on to more technical work as a lab and research assistant.  I wondered if she would reflect on her work as a barista when she got to be my age and I sincerely hoped she would get to my age and beyond.  I thought about writing a poem about that brief encounter, probably because I had just read two Emily Dickinson poems and have a history of writing free verse in the style of ee cummings.

On the drive home, public radio was playing election coverage from South Carolina.  It was the GOP primary and I shut it off. I always have public radio in the background – but listening to this is just too much.  I drove, drank my mocha and crunched on my biscotti in silence. I had some thoughts about biscotti.  A competitor has a much harder biscotti.  It is so hard the almonds are cut sharply with the slices.  The biscotti I was eating was not as hard but still had an almond and vanilla crunchy taste.

I started thinking about a paper I was writing. Even though it was about rhetoric, it seemed quite exciting.  I have not encountered any papers like it.  I thought about where it should be submitted and how I should modify the introduction. One of the most insightful and informative books I have read lately was about rhetoric. It tied together so many things.  The author was gracious enough to respond to two of my emails.  I need to incorporate more of his concepts into the paper – but his book is encyclopedic.

I thought about some advice I had given lately.  Even though I am retired and people know it – they still call me.  I tell them that technically I am not treating them or directly giving them medical advice because we do not have a physician patient relationship, I don’t have a working office setting or records, and I don’t have malpractice coverage.  They understand that and it doesn’t deter them.  I am licensed and recently contacted the Board of Medical Practice about continuing medical education (CME) credit reporting this summer. The pandemic created a lot of confusion about deferred CME reporting.  I need to report 75 credits and I currently have 74 with a 6 CME credit conference in March. I wonder how long I will keep that up in retirement.

On the home stretch, I think about the advice I have given people over the years.  The qualified advice on the system over the past 2 years tells me how bad things have gotten.  Parents calling me about their adult children who are not doing well.  Adult children calling me about parents who are not doing well.  The occasional email directly from a person who is dissatisfied with treatment. Many calls about what happens in emergency situations.  Many calls about what specific diagnoses, imaging findings, and labs really mean.  Was the emergency department trying to talk me out of being admitted? Why wasn’t I treated with anything?  It just seems like I sat there a long time, nothing happened, and they sent me home.  Are these side effects that I am getting from this medication and what can be done about it?  Are there any resources out there that can help me? I don’t seem to be getting any help?

I try to help people negotiate available systems and help them prioritize what should happen first.  There is a general reluctance to call their clinic or doctor and report that there are potential side effects. Overall, there is a lack of help for people with psychiatric disorders. I know that is not strictly true and that there are many large systems of psychiatric care nearby – but even when people get in - there is difficulty getting what they need. I shock them with basic information about when to call their doctor and what might be helpful to discuss.  I never second guess their doctor.  I am focused on how to help them get the answers they need.  It is not at all like practicing psychiatry.  The most valuable product of that work is a patient who feels understood at the end of the session. None of the people calling me feel understood at even a superficial level.

Just a few years ago, I was an insider working in an intense hospital environment. I was generally feeling the stress all day long. I had the physical manifestations of that stress that were measurable – but I pushed through every day and made it home to unwind.  In some cases I could not unwind and ended up calling my nursing staff at 2AM to make sure that things were going OK.  I think about that right after thinking that I should still be working – just based on all these systems problems that people are telling me about.

I come to the realization that I can’t do it anymore. Cognitively and technically it is certainly not a problem. I have no doubts that my diagnostic and treatment skills are still there. Physically it is an interesting story.  I just lifted plenty of weights and will lift more tomorrow.  My aerobic capacity is very good. I have posted some of my chronic health problems here on this blog to illustrate diagnostic, pathophysiology, and treatment concepts. So generally my health is pretty good.  That can always turn on a dime.  I can’t work anymore because of the stress response.  The mental and emotional demands of work become physical demands and that creates significant problems. Doctors reading this in those environments know what I am talking about and I wish them the best because I know nobody is trying to alleviate any of that pressure.  Nobody is trying to help them.

I finish off my mocha and biscotti as I am pulling into the driveway. It is 7PM and dark out here in Minnesota.  I had over 30 years of pulling in my driveway in the dark after work and still feeling tense and in some cases jumpy about what happened that day.  Things are different now.  I can decide how much pressure I am under and when I can unwind. I wish I could do more for all these people who need help – but I can’t. 

It is time to finally take care of myself.

 

George Dawson, MD, DFAPA

Supplementary:

@dahlle on Twitter read this post and posted the NASA Task Load Index - a workload measure that has been validated across a number of settings.  Just looking at the scales - it is easy to see how physicians can max out almost every scale except for the physical demands (at least for non-surgeons).  With enough stress - heart rate and blood pressure increase just like you are running.  

It is also an illustration of how things can get rapidly complicated when there are people actively standing in your way and other people demanding that you do more.  Work setting is critical here as well as adaptation to work.  I have talked with hospitalists who told me their cognitive performance dropped off steeply on day 6 (of 7).  On the other hand I have talked to physicians who were used to seeing 30 patients for a minute or two at a time in an afternoon who were not stressed at all. 

At least one study has established a dose response relationship between physician task load using this scale and burnout:

Harry E, Sinsky C, Dyrbye LN, Makowski MS, Trockel M, Tutty M, Carlasare LE, West CP, Shanafelt TD. Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey. Jt Comm J Qual Patient Saf. 2021 Feb;47(2):76-85. doi: 10.1016/j.jcjq.2020.09.011. 

Graphics Credit:

Biscotti is via Wikimedia Commons.  https://commons.wikimedia.org/wiki/File:Biscotti_1.jpg

Mokkie, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons