Thursday, July 28, 2016

Murphy Bill --Now With Guns?

Pretend there's a photo of the U.S. Capitol here.  Blogger is not cooperating.

Let me first send you to Pete Earley's blog to read about the Murphy Bill, HR2646, which was passed by the House of Representatives with a vote of 422-2.  The Helping Families in Mental Health Crisis Act had bipartisian and broad support, but not until it was sanitized of it's controversial issues: patient advocacy groups remained funded, outpatient commitment was de-emphasized, and the right of a  patient with a psychiatric disorder to refuse release of their health information to family/caregivers remained intact (at least for now).

Honestly, as a psychiatrist I was perplexed that these things would hold up the bill.  Access to good -- or any-- psychiatric care is a huge issue in our country.  Civil rights are important, psychiatry has a history of abuses, and patients should have access to advocacy.  HIPAA rights and outpatient commitment pertain a few patients  and while these may be pressing issues in the lives of the parents of the sickest of the sick, they are issues that don't come up everyday for your average psychiatrist.  So was I pleased when the Act was sanitized of some of the more controversial issues and I've deemed the newest version of HR 2646 the Vegetarian Version : not enough meat for the carnivores and too much for the vegans.  And P.S., none of these issues were going to prevent mass shootings anyway.  I just hope that if the legislation goes through, it leads to meaningful change in access to good care for the patients.

So a vote of 422 to 2; It seems we have a pizza bill with bipartisian support and little opposition -- all but two vegans knocked off the cheese and voted in favor.  Surely, such a bill will pass in the Senate, but if you read Pete's blog post, you know that the bill has hit a wall because Senator John Coryn of Texas wants to tack on a gun issue to the legislation.  Pete has gone into the details of the gun legislation Coryn wants to add, and I won't, because really, does it matter?  It's a mental health care bill;  it's not a gun bill.  It's time to separate these issue, and it's not the time to throw a bunch of controversial pepperoni on legislation that  has finally gotten agreement after three years of debate.  

Can we go home now? Oh, wait, Congress left already.

Wednesday, July 27, 2016

Boy or Girl and Are You Sick?

First, let me send you to an article in the New York Times: W.H.O. Weighs Dropping Transgender Identity from List of Mental Disorders.

There are lines we've drawn in medicine: a fever above a certain degree is not normal and indicates a pathological process.  A tumor that will spread and debilitate you is not normal and indicates a pathological process.  To be pervasively sad, uninterested in the things you enjoy, and want to kill yourself is not normal and indicates a pathological process.  And to hear voices and believe that someone is monitoring you when no voice or stalker or agency is there, is not normal and indicates a pathological process.  

In psychiatry, the line gets blurry at times: to be sad, fatigued, and uninterested is normal if you're grieving.  And even with that tumor -- suddenly, as ClinkShrink will tell you -- there is this funny question of whether doctors should remove your tumor or just kill you with physician-assisted suicide.  In some cultures, those voices you hear, or those seizures you have,  may not indicate pathology but visitations from God that hold you not as ill, but as superhuman and special.  You prefer your intimacy with little boys?  In Ancient Greece, it may have been fine,  but in modern America, if you act on it you spend time in prison and get labeled, stigmatized, and restricted as a sex offender for life.  And homosexuality with a consenting adult-- who even notices anymore?  Unless of course you live in Saudi Arabia or a variety of other middle eastern countries where they just execute you.

When I was in training (oh, that was a while ago), Gender Identity Disorder was considered rare and pathological.  Even before that, I remember a lecture in my college Abnormal Psychology class.  The professor was Martin Seligman, well known for his book, Learned Helplessness, and in discussing gender disorders, he mentioned that he traveled a lot and when he woke up disoriented in strange hotel rooms he always knew two things: Where the bathroom was and that he was a man.  Okay.   It was his introduction to his lecture on disorder of gender: it's not normal and you're not supposed to feel like something you're not. I have no idea if Dr. Seligman's ideas have morphed with the decades.

In my clinical experience, it seems that gender identity issues came with a slew of distress.  People with these problems often have other issues as well: problems regulating their mood, self-injury, and a host of emotional and interpersonal issues.  Are these issues part and parcel of Gender Identity Disorder, or are they the result of societal disapproval?  If we just accept transgenderism (is that a word? It should be) as being perfectly normal --or at least not pathological -- would the distress that accompanies it just go away?  Can we create a world where people choose their gender, or where they lie along a spectrum of male-femaleness, and their parents and society are completely open to the idea that one can choose and this is fine?  At what age would we allow for hormonal treatments?  For irreversible surgeries?  Does health insurance pay for these treatments if it's not a disorder?  I have no answers for this, but I find it fascinating that illness --and criminality-- are things of flux that change in time and with culture.  Funny to grapple with in a world where we make such a big deal out of which bathroom you choose to use.

Sunday, July 10, 2016

News. News. And Too Much News.

Oh my, time has been getting away from me  and it's been a bit since I've written a blog post on Shrink Rap!  

First let me steer you over to Clinical Psychiatry News where ClinkShrink has written an article called "New Mexico High Court States that Assisted Suicide is not a Right."  If you surf over, you'll also note that Clink has a lovely new head shot up next to her article.

As I've mentioned before, the Boston Globe's famed spotlight team is doing a series on the trouble public mental health system in Massachusetts.  The second installation went up on July 7th and discusses the roll of the police, and police training, in handling psychiatric emergencies.  It read just a little like the chapter from our forthcoming book, Committed, only I liked our chapter on the police and Crisis Intervention Training much better (perhaps I'm biased?).  In writing our chapter, I was privileged to have the help of Montgomery County PD officer Scott Davis and he is a treasure.  Also, our chapter had more meat to it,  so you can check out the Globe's piece and when Committed is available, let me know which you like better.

Otherwise, I have to say that the news is leaving me rather despondent.  I tend to be an optimist, to have at least a little trust in the system and in the goodness of people, and it's all being tested.  341 million people in this country and we can't find two smart, honest, kind, capable and energetic people to run for president.  The stories of police officers shooting people leave me ill, and the mass murders in Orlando (which now seems to be old and forgotten news) and Dallas, are just horrific.  Baltimore has always been a dangerous city, and the Freddie Gray trials are wearing on us all.  There are protests, sink holes, random murders of children.  In the last two days, a former Hopkins professor was murdered while walking her dogs (the assailant remains at large) and a 21 year old young man in the suburbs was shot and killed while walking his girlfriend home.  Between the election and the crime, I may be due for a social media vacation.  I'm sad.  Can't we make America Kind Again?

Monday, June 27, 2016

Guns and Violence

Oh there is so much to say and so little time.
I'm sending you to two different sites today:

My post on Guns & Mental Illness over on Clinical Psychiatry News.  It never fails to amaze me that suspected terrorists get due process before losing their  constitutional rights to own a gun, but law-abiding people with psychiatric disorders have no such rights.   Please do read my article and share you own thoughts here.

And the famous Spotlight group of the Boston Globe is taking on the failures of the mental health system in Massachusetts. They start with an article about mentally ill people who murder their families.  Oy.  The article was good,  and access to care is an enormous problem.  And unfortunately, the sensationalism is stigmatizing at a time when we are trying to get rid stigma so that people will not hesitate to seek the help they need.  But if you show up for help, you may be forced into treatments you don't want, lose your gun or your career, and be looked at as a potential mass murderer and family killer.  And at least some of the people with mental illnesses kill family members for reasons unrelated to their mental illness -- like others who kill, they are angry &/or intoxicated but not necessarily psychotic.  Most end up in prison, found to be responsible for their acts.  And some are actively in treatment at the time they commit violent acts, so psychiatry may not be everyone's answer.  There is a facebook group for those who want to comment, so I'll send you there for a rich conversation with input from everyone with an opinion.

Monday, June 13, 2016


No, not again.  I looked at my Twitter feed and learned about yet another mass shooting.  

I can't even imagine what it's like to feel the kind of fear the people in that nightclub felt, to die in such a horrible way, to live with the aftermath, or to be a family member and know that someone viciously targeted my loved one and purposely inflicted such horror on them.  My heart goes out to the victims and their loved ones, and I'm so sorry they are going through this unnecessary tragedy.

I heard on the news that the gunman's ex-wife said he was physically abusive and mentally unwell, but I don't know if there was a clinical diagnosis or simply the observation that he was an angry and violent person.  She also has not seen him in 7 years, and if he mentally ill, he has been able to hide that fact from his employer.  The press reported that he was steadily employed for nearly nine years and his employer, a security firm, did not see this coming.  I say this only because the initial news reports seem to imply that the gunman was a radical extremist, twice investigated by the FBI as a terrorism suspect, he obtained a military-grade assault weapon legally, and he called 911 during the event and pledged his support to a terrorist group.  What does this have to do with psychiatry?  If the facts are as they now appear (and they may change or be slanted by the press),  but the answer is Nothing.  The Orlando terror/hate mass murder, as currently reported, does not seem to be about something in the realm of psychiatrists.    People who sign on may be angry --I believe it takes anger to kill innocent people -- but so far, we're not hearing that there is something here for psychiatrists to treat, or that if only he'd sought help, this never would have happened.  But these days, we talk about mass murders as defined by the number of victims in a public place, and terrorists get lumped together with those who commit such acts because of delusional states.  

And just in case you missed it, an Indiana man was arrested in LA with a car full of assault weapons and explosives, perhaps enroute to a Gay Pride parade, on that same day.  The horror of the day could have been even worse than it was.

It's no secret that I believe gun control measures would help.  I don't believe they would prevent all the deaths that guns cause, and there are certainly other ways that terrorists have of killing people.  We saw that on 9/11 and we saw that with the Boston Marathon bombing.  But I find it strange that we allow for the manufacture of firearms that enable one person to kill dozens of people within minutes, we allow for the easy access of these weaponsby civilians  (even a previous terror suspect with a history of domestic violence)  and then we're surprised when people buy these weapons and use them for exactly what they were made to do: kill lots of people quickly.   Should we ban them? Of course.  They are not a household item that anyone needs, and while we will still have terrorism and hate crimes, there is no reason to hand terrorists or haters the easy means to their evil end. 

It's funny, because after the fact, there is blame, finger-pointing, and questions of who missed what and how could we not have known.  Who should have seen it coming?  Yet know one says, when someone buys an assault weapon with lots of ammunition, maybe a flag should be raised. Maybe someone should go ask this person why they need such a weapon, check up on their history, look at whether the weapon is being kept securely and whether someone else in the household who should not have a gun might have access to it.  Or maybe we simply shouldn't have assault weapons as legal machines to be owned by any citizen who wants one, short of felons.  

No, I'm not suffering the way the victims and their families are, but each one of these events takes just a little out of all of us.  Whether it's a an act of terror, an act of hate, an act of violence perpetrated by someone who is very ill, or routine gang violence that we see in our city everyday, it touches us all.  I hope this does not leave you afraid, because if it does, the terrorists win.  

Saturday, June 04, 2016

Book Review: Ordinarily Well: The Case for Antidepressants by Peter Kramer

My post for today is a review of Peter Kramer's new book over on Clinical Psychiatry News.  You may remember him from Listening to Prozac, and he's back now with more on the science that supports the use of anti-depressants.

The review of Ordinarily Well can be read here:


Tuesday, May 24, 2016

Grief, Twice Removed

Good morning.  I'm typing very quickly because I'd like to put up a blog post before the power company de-electrifies me for the day.  This is the 5th attempt to take down our dying old oak tree, and it looks like it may actually happen today. 

And there went the power..... 12 hours later, the power is back and now my house looks naked without it's oak tree.  Not a person-- and it wasn't safe to leave it up any longer-- but I am feeling a bit of grief for both the tree and the shade and the way my house looked when I woke up today.

That said, I wanted to share an article with you that I read in the NYTimes Opinionator.  Grieving my Patient's Friend is a heartwarming piece by Galit Atlas who is a therapist who comes to feel attached to his patient's friend, and then learns she is dying.  I loved this piece because I identified with it so strongly -- I've listened to the stories of other people, imagined what they were like, and gone through their traumas, celebrations and, like the author, even their deaths.  Oddly enough, I sometimes hear about the same people and their stories from several patients, or learn the fate of a friend or family member of one patient years later from another patient.  

So Altas writes:

It isn’t unusual for therapists to feel that they know intimately their patients’ friends, lovers and family. In some ways, we get attached to these people, their stories, their successes and struggles. We accompany them at once closely and from far away, as if they are favorite characters in a beloved book.

She tells the story of her patient, Naomi, and of Naomi's dying friend Isabella.

Naomi had looked at me and then added, “Can you believe it really happened? I lost Isabella. She will never come back.”

Oddly, I felt that I had lost something as well. But mine was an unusual, unrecognized loss. I grieved for a woman I had never really known, and no one could see or acknowledge my pain. I was alone with it.
 It's a poignant piece so I hope you enjoy it.


Wednesday, May 18, 2016

Mental Illness and Violence: Dispelling the Myths and Managing the Risks

I'm passing along this information so that readers can register for this forum if interested:

Mental Illness and Violence: Dispelling the Myths and Managing the Risks
Washington, D.C. – In the aftermath of highly publicized cases of violence, there is a big disconnect about mental illness and its connection to violence. Research shows that people with mental illness are more likely to be victims rather than perpetrators of violence. On Thursday, May 26, the global research institute RTI International will host a policy forum “Mental Illness and Violent Events: Identifying, Managing and Reducing Risks,” where expert researchers working on these issues will clarify the scope of mental illness in relation to violent events, including suicide, gun violence, and victimization.
Often policymakers develop mental health policies as a response – and solution – to incidents of gun violence instead of an investment in needed mental health services, systems, and supports. Panelists will discuss the nuances these policies fail to take into account, and recommend steps for managing and reducing the risk of violence through evidence-based interventions, trainings, and services.
To attend the policy forum, please register here. The forum will also be live streamed. To view the webinar, please register here. Find more information about the event here.
·         Opening address: Tim Gabel, Executive Vice President of Social, Statistical and Environmental Sciences, RTI International
·         Moderator: Richard Van Dorn, PhD, Senior Mental Health Services Researcher, RTI International
·         Duren Banks, PhD, Senior Research Criminologist, RTI International
·         Leslie Citrome, MD, MPH, Clinical Professor of Psychiatry and Behavioral Sciences, New York Medical College
·         Sarah Desmarais, PhD, Associate Professor of Psychology, North Carolina State University
·         Joshua Horwitz, JD, Executive Director, Educational Fund to Stop Gun Violence
·         Jeffrey Swanson, PhD, Professor of Psychiatry and Behavioral Sciences, Duke University              
When: Thursday, May 26, 2016
  Lunch and Registration: 12:00 EDT
  Forum: 12:30 – 2:00 p.m. EDT
Where: Holeman Lounge, National Press Club, 529 14th Street N.W., Washington, D.C.

About RTI International
RTI International is one of the world's leading research institutes, dedicated to improving the human condition by turning knowledge into practice. Our staff of more than 3,700 provides research and technical services to governments and businesses in more than 75 countries in the areas of health and pharmaceuticals, education and training, surveys and statistics, advanced technology, international development, economic and social policy, energy and the environment, and laboratory testing and chemical analysis. For more information, visit

I just couldn't seem to get the colors right from the copy and paste, but if you're interested, go or listen anyway.

Monday, May 16, 2016

Tweets from APA

APA is in Atlanta this year and I'm not there.  ClinkShrink and Roy are, however, and they are tweeting. With their permission, here's a sampling of what's Twitter-worthy.  I was told not to discuss the zombie game.

May 15

Atul Gawande: "Assisted dying is about our failure to give assisted living."
May 15
Atul Gawande: "Your wellbeing is bigger than your health." opening ceremony 

Today Assembly voted to adopt a position against euthanasia of people with mental illness.

I will vote for any presidential candidate who mandates and enforces the Oxford comma.  

Awesome demo of in-home by Jay Shore & “Rachel” (patient actor). Makes it real

Shore: considerations for in-home .
Roywrote and  retweeted:Great book to pick up at . Thank you, Patrick!

I’ll be signing copies of A Common Struggle in the Exhibit Hall at 1 PM—stop by and say hello.
APA President-elect Dr Maria Oquendo discusses the year ahead & some key priorities

Bennett: “In rural Illinois, the price of gas dictates whether patients show up.” The value of .  

In sum, ClinkShrink is thinking about physician assisted suicide (thumbs down for patients with psychiatric disorders) and Roy is thinking about telepsychiatry.
The Zombies are on their own. 

Friday, May 13, 2016

Book News and More

Greetings from Baltimore -- and if you're looking for me at APA in Atlanta this year -- do look for both Roy and ClinkShrink instead--they are both there as APA Assembly members. I decided a while back that a Springtime graduation was all the traveling I wanted to do, and I am pleased to tell you that all went well with my youngest's graduation from #GoBlue.  I enjoyed Michael Bloomberg's commencement speech, the dinners, the celebrating, being with family, seeing my lovely daughter thrive, and knowing that for the foreseeable future, there is no college tuition to be paid.  Young One is off for a couple of weeks in the Middle East traveling and will then work as a camp counselor for the summer before moving across the country to teach biology and conservation in an outdoor school.  She's an adventurer.

As many of you know, from many past posts, ClinkShrink and I have been working on a book since 2013 on forced/involuntary care. Many of you have helped by giving us insights into what it is to have treatments you did and didn't want, some of you (and you know who you are) are  quoted in the book, and many people led me others whom I interviewed and shadowed and learned from.   
I wanted to give you an update. The book, which we originally  called Committed: The Battle Over Forced Psychiatric Care is now called Committed: The Battle Over Involuntary Care.  We preferred the smoothness of a shorter title, and the full impact of the word 'forced,' but authors don't get the final say in book names or covers, and so a committee of marketing folks felt 'forced' conveyed the wrong message.  If you think the title isn't strong enough, don't worry, the cover art is striking and powerful.
The page proofs have been corrected.  Pete Earley wrote the most amazing foreword-- it's not to be missed. I love that Pete's foreword completes the book by adding the perspective of a family member in a way that only Pete can do.  So far, the publisher's reviewers have been very positive (they nix the book if they aren't), and page proofs have been sent out for cover blurbs.  Advance copies for media reviewers will be ordered and sent in June, and the official release date is November 1st, so stand by, I'll have more to say later.  The Johns Hopkins University Press Fall Catalog (see page 21) just came out, and the book has an early Amazon page, waiting for more details.  I just wanted to let you know what's happening, and for those who wonder why we've slowed down on blogging, well, there has been a lot to distract us.

 For the moment, November is tied in my head to this interminable, angst-filled presidential election and it's feeling like it can't come soon enough. 

On another personal note, I am sad to report that the giant oak tree in front of my house needs to come down, and I'm waiting for the power to go off for that to happen today.  I've been slowly mourning the loss of this tree for years.  No, it's not a person, but it's hundreds of years old and it's part of my home.  

Thursday, April 21, 2016

Shrink Rap Turns 10 Years Old Today!

Get out your tuxedos and gowns, the galas are about to begin!
Yes, Shrink Rap is now 10! We are the longest running psychiatry blog and with thousands of posts and years of faithful readers, we couldn't be more excited!

Okay, so no black tie gala.  We had planned a party with chili and beer and a cake with a duck on it, but a family emergency delayed the event -- to be rescheduled soon.

So let me tell you how much I've loved having this blog (a lot) and over the years, there's been a lot of evolution.  I write less than I used to, but I still write.  Clink comes by with updates on conferences and spends more time on Twitter.  Roy is still in it for the food and friendship, but he's moved on to some other endeavors-- perhaps he'll post an update to tell you about them.  We've blogged, we've have 70 episodes of our podcast, My Three Shrinks, there's been our book: Shrink Rap: Three Psychiatrists Explain Their Work, and our columns in Clinical Psychiatry News and Psychology Today, not to mention Twitter and Facebook.  As I've mentioned, our umbrella organization, The Accessible Psychiatry Project, is up for a Scattergood Innovation Award and you are still welcome to add a comment on their website because we'd really like to win!

Now, we're getting for the release of our second book in the fall -- details to follow. Also, Dinah has been working on a website that helps people find psychiatrists quickly in Maryland:

So ten years and going strong.  Thank you for being part of our rather unusual psychiatric adventure, and thank you for being part of our lives!

Clink and Roy may have more to add soon.


Tuesday, April 12, 2016

Pushing 70 and Sharing the Wisdom: Guest Blogger Dr. Bruce Hershfield Shares His Experience with Younger Psychiatrists

The article below is being reprinted from this month's edition of The Maryland Psychiatrist.  Dr. Hershfield shares his wisdom on outpatient treatment of patients, and of running a private practice.  Please note the intended audience for this wisdom is younger psychiatrists, in particular, those just starting out.  I'm not a younger psychiatrist just starting out, and in fact, I'd fail on a couple of these measure -- we all have to figure out for ourselves how best to practice in the context of our personality's and in the context of who are patients are and what they need.  Overall, however, I thought Dr. Hershfield makes some excellent points and I wanted to share his wisdom.  With thanks to Bruce Hershfield and to Dr. Nancy Wahls, editor of The Maryland Psychiatrist, for allowing this to be reprinted. The Shaw quote is for Jesse.

By Bruce Hershfield, MD

Now that I’m getting ready to turn 70, I thought I’d summarize what I’ve learned since I finished my residency at the University North Carolina, when I was 28.  Of course, , I didn’t learn all this only by being a psychiatrist, since I would hope that most folks have also learned lots in the last 41 years., But our field  has really changed, and so have I. This is what I tell the Residents, when I get a chance to meet them in a  group:

1      Psychotherapy is important, particularly if the patient is on the right medication.
I won’t do “med checks”, since I would not want them if I was a patient. I figure if it’s simple enough to do in a few minutes, my family doctor can probably handle it or learn how to do it. If it’s complicated, it’s going to take me more than a few minutes. I knew when I was a Resident that psychotherapy was important. I realize now, if you have a severe psychiatric disorder like schizophrenia or bipolar disorder and you are not on the right medicines, you’re in a lot of trouble, no matter how skilled your therapist-- psychiatrist or non—psychiatrist-- is.
2      Splitting the treatment, which was tried at least as far back as the’ 70s, is a serious matter, only to be used when both treaters know and trust each other and are able to  communicate easily. You just don’t know what the other treating professional is actually saying to the patient. Splitting the treatment puts a psychiatrist at great risk of a suit, with little reward.

3   Try to get along with colleagues, even when they are being provocative. You may need to walk away, and you probably will need to apologize and also to forgive at times. Never fight with secretaries; learn from their observations. I should have read “How to Win Friends & Influence people” long before I turned 60.
4 Try to have as few bosses as possible. If everybody loves the boss, he or she  probably isn’t effective. Never have more than one boss to whom you are reporting. All people – – not just patients – – have transferences, and they usually complicate relationships with bosses.
5 If you’re always agreeing with the general wisdom, particularly if money is involved, you will eventually be dead wrong on something. Atypical antipsychotics helping the negative symptoms of schizophrenia is a good example of conventional wisdom that turned out to be wrong. Beware of fads, don’t trust ads, don’t take professors or studies too seriously.
6 The more we know, the less magic is associated with us and the less respect we receive. It’s part of our attempt to climb out of the Middle Ages.
7 Psychotherapy is more about healing, which usually occurs in – between sessions, than about insight. Patients who are asking for insight are usually unwilling to change their behaviors. Patients who don’t do the homework probably will not learn new ways of handling problems.
8 You can’t tell who is going to be a good patient. Some people with little education and little command of the language can change and get well. People who have addiction problems are the hardest to predict.  You probably should give them a chance if they ask. Even after seven years of chronic depression, for example, some patients recover.
9 People will pay for good medical care, particularly for their children. It is not an accident most psychiatrists are now practicing outside the managed-care system. Don’t allow managed-care companies to tell you how to practice. It doesn’t look good ethically and it doesn’t impress juries. Do what is right, even if it costs you in the short run. You still may get in trouble, for example with administrators, but someone may be impressed and maybe you’ll be rewarded. At least, be kind, if you can’t do any more than that.
10 Stay out of court, if possible. Don’t sue people, don’t dismiss the possibility that anyone can sue you, and be sympathetic when your patients get involved in proceedings. Lincoln was right when he advised a group of lawyers to “eschew litigation”.
11 Join societies and ask for advice from other members. If you’re willing to ask for a consultation, you are almost certainly not negligent. Patients are reluctant to get them. Arrange for consultations with someone whose advice you’ll almost automatically take. Don’t criticize colleagues to others, including to patients.
12 Don’t steal other people’s patients. Ask potential patients if they have ever seen a psychiatrist, when they first call. If it’s in the recent past, ask to have their psychiatrist refer them to you and say you’ll get back to them if that happens. Clarify beforehand if it’s for a one – time consultation or for ongoing treatment. If patients don’t show up for the first visit for any reason, or give you a hard time on the phone, you will eventually regret taking them into your practice.
13 Be available. Return calls. Have a call hour. Answer letters. Encourage patients to call you if they need you. Find someone to substitute for you whom you can trust when you’re away from the office for any significant time. Be very careful about prescribing for the patients of others when you cover for colleagues. Don’t charge for phone time. Most people won’t abuse it. If patients call too much, you probably need to see them more often. Don’t let patients go for more than 90 days without seeing them.
14 Document.  Too much is better than too little. There’s more paperwork each year – – more work in general. Real earnings have been going down since the’ 70s. Follow up on lab tests. Write legibly. Your reputation may depend on the quality of your notes.
15 Be cheerful, even optimistic. It turns out it wasn’t Lincoln, but i someone else who said that he reckoned that people are as happy as they allow themselves to be. You can’t expect depressed patients to be optimistic, and someone has to be, at least to balance their pessimism. If you are a psychiatrist, chances are that most people, and virtually all of your patients, have it worse than you do. Don’t complain.
16 Keep learning. Read books, acquire new skills. I’ve heard that almost everything we know we’ve learned since 1950. Accept that what you know will probably turn out to be wrong or useless. They call that progress. Beware of people who tell you they know the answers. Your training will probably turn out to be a small fraction of your career.
17 Patients are probably right about side effects. Be suspicious about claims made by drug companies, including maximum recommended doses. Ask patients about drinking and about caffeine, not just about illegal drugs. Check with families. Be suspicious if patients forbid you to contact their families or the professionals who used to treat them.
`18 Get to know families. It’s crucial if something like a suicide occurs. Get a family history. I understand the average person carries the genes for 20 disorders, of which four are lethal.
19 Don’t treat members of the same family, or close friends, if you can help it. Don’t write prescriptions for your friends or coworkers. You can’t successfully treat everybody. Somebody else may be a better match. Sometimes, patients return after they drop out.
20 You work for the patient, not the other way around. Dress accordingly, use honorifics like Ms. or Mr., and ask what the patient wants. Set up a valid treatment contract, early on. Be wary of double agentry, like working for the patient and the hospital, or for the patient and the managed-care company.
21 Use “we” interpretations. This is not Europe; people expect to be treated as equals and they aren’t as tied to their traditions and their families as in other places. Sometimes a story or a fairytale can illustrate a point. Be careful about using your own life as the example. Patients can sometimes change if they are laughing, but be careful. If you offend someone, apologize. Patients don’t expect their psychiatrists to be perfect, but they do expect them to display good manners, like holding the door for them or offering them a tissue when they cry. Psychiatric disorders are common and chances are that someone you know, or even you, will get one.
22 If you’re going to work for yourself, you have to stay healthy. Take frequent vacations. Learn how many patients you can safely see in a row and what your personal clock tells you. If you are sleepy, excuse yourself and get some coffee. If you bring it into the session, offer the patient a cup.
23 Make sure you get paid. If you get cheated, learn from it. Don’t pursue it too hard; there are too many ways that disgruntled ex—patients can make you miserable. Be careful to document when patients pay you in cash.
24 When patients miss an appointment the first time, don’t charge. Make sure you call to find out what happened. If they can come later that day, let them. Patients tend to resent paying for missed appointments.
25 Be on time, or at least apologize if you’re not. Try to give extra time of people need it. They rarely abuse it and often appreciate it. Give plenty of warning before you raise your fees.
26 You will like some patients more than others. Some patients will like you more than others. You are neither as good or as bad as your admirers or detractors say you are.
27 Things go wrong. Admit it when you make a mistake. We are always on the verge of disorganizing, as is everything else in the universe according to the second theory of thermodynamics.
28 Diagnoses can be important. Hand the patient the DSM-V if you think that a personality disorder is present. That book has his limitations, but at least it uses a common language we’ve had since 1980. Watch out for indications of learning disorders. You may not want to make a diagnosis of a personality disorder, but it may be present anyhow and completely ignoring it may complicated or destroy the treatment.
29 The public system is in worse shape than the private, since government is not in the business of building reserves and sooner or later finds itself in a financial crisis. Also, there are too many bosses and too many political influences affecting patient care for it to be very good for very long.
I hope I haven’t finished learning. It is upsetting to realize how little we still know about what causes psychiatric problems. Our patients live better lives now than they did 41 years ago and I’m optimistic that we can help them live still better lives in the future. I used to think that I would retire when I turned 70, but I decided not to do that. There’s too much going on for me to quit now.

Sunday, April 10, 2016

Will Changing Privacy Laws Help Patients?

Over on Twitter, one of my pals, @namipolicywonk wrote: I'm a big proponent of civil rights, but whose rights are we protecting in a situation like this?

Please do read the article, but in a few sentences, here's the synopsis.  A mom is writing an oped piece about her daughter who lives in a group home in New York and has a chronic mental illness.  The daughter went missing from her group home, off her medications, and reportedly because of HIPAA laws, the group home did not tell the parents the daughter was missing. In fact, they repeatedly said she was "not home," which in my book is dishonest.  The story gets worse, the police initially wouldn't take a report, and eventually the daughter was located 28 days later in a shelter in a terribly deteriorated state.  If that's not bad enough: the daughter was on Assisted Outpatient Treatment (the mom call's it Kendra's Law ) and known to be dangerous off her medications, so she was court-ordered to treatment, and the group home still didn't report this to the parent or the police for some prolonged period of time.  The point of the article is a plug for Rep. Tim Murphy's Helping Families in Mental Health Crisis Act, now stalled in Congress, because the mom contends that if this law passed then the group home would have had to release information to her and they could have helped their daughter if they'd known she was  missing.

If you've been paying attention here, you know that I'm not a fan of this segment of the proposed legislation that essentially says that a person with a psychiatric diagnosis can not refuse to allow his mental health professionals to communicate certain information (diagnosis, medications, follow-up appointments) to his caretakers.  I've written before about my concerns, but I'll restate them: such a law singles out those with mental illnesses as the only people who can't decide not to share their medical information: it's stigmatizing, and it may lead people to avoid getting care because it will be translated as "psych patients don't have HIPAA rights."  It's not that I'm any great fan of HIPAA, but HIPAA is misunderstood.  It doesn't say who a doctor can't talk to without permission, it says who medical folks can talk to without permission (and there are plenty of entities that can get your medical information without your permission).  Before HIPAA ~and yes, I'm old enough to remember this~ we didn't release information to family members without permission and patients had the right to confidentiality, this is not new.  Furthermore, I think most of these catastrophes are about a misinterpretation of the bill or even laziness.  'I can't tell you if your family member is hospitalized on our unit because of HIPAA. ' But, dear unit clerk, you can go see if the chart has a release to talk to family, or you could go tell the patient his family is looking for him and ask if you can call them back.  Finally, The no-HIPAA for psych patients legislation assumes that the sick person is sick and the family is well.  What if a person with mental illness doesn't want their family involved because they hound him, because they've been abusive, or because a psychotic relative believes he's in danger from the KGB and is intrusive with his own delusional beliefs?  What if family has previously discouraged treatment or medications and is critical of a person's decisions to get care?  The bill assumes the caretaker will facilitate treatment and that may not be correct.  That's why I don't like the HIPAA exclusion.  

So back to the story, and let me start by saying I don't know the mom, the patient, the group home, or anyone else.  So my first thought is: a potentially dangerous patient disappears from a group home and no one is notified?  Is a group home even a health care facility?  If you don't answer your phone and your parents call your building superintendent, they'll look in your apartment.  Isn't there an emergency number listed with the group home--if so, disappearing off medications seems like an emergency and it would be okay to notify the emergency contact?   The patient is court-ordered to treatment and off medications, can't the police be informed and told to bring the patient to an Emergency Room for evaluation as Kendra's Law allows for?  And the police can certainly inform parents--they have no HIPAA issues. It seems that if the parents have been involved all along then someone at the group home would know them to communicate-- and it seems mom knew that the patient was off her medications and psychotic before she left, so she was likely in communication with her daughter.  Is there more to this story --we only heard one side-- because it seems like there must be.  Or is the group home misinterpreting the law to say they can't release information when really they could?  Perhaps they've been negligent and are hoping the patient will return so their negligence won't be noticed and questioned?  I don't know the case, but nothing I've read of HIPAA says that a living facility can't report a missing person to the police, notify an emergency contact when they go missing, or even just tell an involved family member that someone has left their facility.  Is the facility afraid that a vulnerable, psychotic, person who is court-ordered to care is going to sue them for releasing information? Shouldn't they be more afraid that they'll be sued or sanctioned for a bad outcome?  What about doing the right thing?  Would it ever be the right thing to say a very sick person has gone missing and no one will be notified?

Lastly, let me say that I don't think the provisions of the Murphy Bill would have changed this.  The changes in the bill allow for a mental health professional to release specific information to the caretaker.  In this case, the patient is living in the facility-- they are the caretaker.  I don't believe it covers an interested parent who is not the one responsible for getting the patient to appointments or helping the patient obtain medications.

We don't need to revise HIPAA just for mental health patients; though it would be nice if we got rid of it for everyone for many other reasons.  We do need to talk with patients.  When they are well, we need to ask them who we can share information with during an emergency.  The issue isn't the legislation, it's how it is interpreted, and new legislation will be misinterpreted.  We need to use common sense.  Really, as health care providers, we need to do the right thing.   

Wednesday, April 06, 2016

No Escape From Aetna....

On March 13th, I wrote a post: "To Aetna: I am NOT in Your Network about how I was trying to reach Aetna to clarify that I am not a psychiatrist in their network.  I wanted this clarified because I was getting so many calls from people asking to see me because I am listed on Aetna's website.  I called and called again, but the voicemail prompts left me with no where to go.  When I reached a live person, I was told that Network Services would contact me within 48 hours.  That never happened.  I wrote in through their website.  Nothing.  And finally, I contacted the Maryland Insurance Commission, who contacted Aetna, and  a real live, very helpful person at Aetna did in fact call me.  

So I spoke to the real live person at Aetna who had a name and an direct line phone number.  Why did they think I was in their network?  People have to apply for this, and I had no memory of filling out paperwork.  The real live person, whom I fist spoke with on March 23rd, clarified that I had been an Aetna provider through two clinics where I had once worked.  These are different from my private practice, and participation is based on the billing address.   So I was registered as a provider at an outpatient clinic that I left in 1998, and at another clinic that I left in 2013.  Hmmm, so why did they have me registered at my private office?  Well, apparently last May they received a claim form for out-of-network services and a clerk 'updated' my file, added my address, phone number, tax information, and Voila! I was an involuntary Aetna provider.  No worries, the real live person would fix this and call me.  Only that has not yet happened.  

So the Aetna referrals continue to come, and this continues to take up my time as I call prospective patients back only to explain that I'm not actually in their network.  So I called back the real live person --it's been weeks, and still I'm listed as a participating provider on their website.  How long can it take to remove someone from a website?  Ah, they'll work on it and call me. The days go by, and then the weeks, and Aetna,  I'm waiting......
Update on 4/9: phone call from Aetna saying they had taken me out of their system.  

Tuesday, April 05, 2016

Utah : Just Say "NO!"

This is not a post on abortion.  Let's not even go there.  This is a post on who gets to practice medicine.

So Utah passed a law -- signed by their governor after how many years of medical school? -- that mandates doctors to give general anesthesia to women having abortions after 20 weeks of gestation.  Legislators sometimes unwittingly attempt to practice medicine and pass laws that interfere with the doctor patient relationship, but this is the first time I've heard of legislation that demands a procedure that endangers a patient's life.  The theory is that the fetus might feel pain and that general anesthesia given to the mother might alleviate any pain felt by the fetus.  I'm not sure there is any basis for that-- at one time mothers were routinely given general anesthesia and I believe the babies still cried upon arrival into the world (~alas, I was one of those babies born during the era of giving anesthesia to the moms, but I can't say I remember much).  Babies are no longer born with the routine use of general anesthesia for the mother in childbirth because it's dangerous.  You can read about the Utah law here.

So doctors in Utah, how does this work?  Do you unnecessarily endanger the life of a mother for no valid medical reason, not to mention jacking up the cost of procedure, because a legislative body says you must?  Or do you refuse and risk sanctions?  Or do abortions for woman who are more than 20 weeks pregnant just stop?

So if law makers can mandate risky procedures and the unnecessary administration of powerful medications, regardless of patient need, then where does it stop?  Can they mandate that all patients brought to psychiatry ERs  by the police must be injected with anti-psychotics, regardless of whether they are indicated?  Can they mandate that everyone who has had a suicide attempt must take Prozac for life?  Where does it stop?  

Utah, what are your doctors thinking?  Why aren't they screaming their heads off?  Congratulations, your governor is now your doctor.