What Would You Do? What Would You Want?

Courtesy of CNN, here are a couple real-life scenarios I thought I'd share with you. Both of these videos represent the kind of cases that a psychiatrist confronts in an emergency room. I'd like you to put yourself first in the position of the patient: suppose you've been sick before, but never this sick (let's take it for granted none of this is due to drugs for now). You have an advance directive in place that says you absolutely don't want treatment even if you're a danger to yourself (again, for the sake of the exercise it's an enforceable advance directive). You never addressed danger to others in your advance directive because you never anticipated it could get this bad.

What would you want done?

If you were the doctor, what would you do?


Now for the second scenario. Is there anything about this situation that might make your wishes or opinions different from the first one? What's the difference? And if none, why not?



Thank you in advance for thinking about these problems. All of you who commented on my Emancipated Patient post have taught me something and I'm grateful. I'm putting this up to learn more about your ideas, opinions and wishes. Please keep talking.

Happy Father's Day and Please Take Care of Yourself

First, I want to wish a happy Father's Day to all those celebrating today.

Next, I want to wish a happy Father's Day to my husband, David, who is the father of my wonderful children.  David is the best of husbands and fathers, and I hope my children realize how fortunate they've been with their random act of birth to have lucked into a life with the kindest, most attentive, loving, and supportive of dads.

Finally, I want to dedicate this post to the legacy of my own father, Jerry, and to the memory of my brother, Ross.  As I mentioned in the post I put up recently where I had my father as a posthumous guest blogger on psychoanalysis, my father died of a heart attack at 40, and he departed this world before I was old enough to sustain memories of him, so I was left only with his wonderful legacy.  My father was among the 30% of people whose first heart attack is fatal. He didn't know he had heart disease and was out shoveling snow when he had chest pain.  He went to the hospital -- this was before the day's of CCU's and cardiac protocols-- was placed in a private room, and was later found on the floor,  presumably having died of either another heart attack or an arrhythmia. 

I last spoke to Ross on Mother's Day.  I had called him two weeks before and he was curt on the phone, "I'm cooking dinner, I'll call you over the weekend."  He didn't call that weekend and I was vaguely annoyed, but the next weekend, I got a warm message wishing me a happy Mother's Day and he mentioned that he had called me back the previous weekend, he just hadn't left a message.  He said I didn't need to call him back, but I wanted to speak to him, and I am so very glad I did call back.  I don't remember much of what we talked about, it was just the usual.  He mentioned he was giving talks in Vancouver and Sweden, and that his wife would be coming to Sweden with him -- their children were finally old enough that they could leave the youngest alone for an extended period of time -- and they would be taking their first trip to Europe together.  He sounded happy and all was good. 

When your father dies at 40, you worry.  Ross worried, I worry.  Ross was meticulous about life style issues, especially as he got older, and his cholesterol had once been high, there was transient concern about a slightly elevated blood pressure reading in his doctor's office.  He did not want to take medications, so he modified his diet, exercised daily, checked his blood pressure, weight, and heart rate daily. He had never smoked or abused any substances.  His numbers all normalized and his lipid profile was fine, because lifestyle changes can do that for you. He'd had a negative stress test years ago, and a normal cardiac echo not as long ago.  So in excellent health, at his high school weight, with the blood pressure of a teenager, my brother did his usual exercise then went to rest.  His wife assumed he was napping, but Ross had died.  He'd had asymptomatic coronary artery disease and hadn't known it.  We didn't live near each other, and I didn't see Ross regularly, but the last few week have been a real struggle for me, and I feel so sad for my brother who had so much to live for, and for his wonderful family who now have to recreate their lives without him.  I keep thinking that I feel so sad, but my poor sister-in-law, his wife and soul mate of 33 years, must be suffering terribly, yet somehow, she and my wonderful nieces seem to be holding up valiantly.  I am so proud of them.

So I want to use my post today to plug for a few things.

• If you have a personal or family history of heart disease, don't assume that you're fine because you feel good and live a healthy lifestyle.  My brother lived significantly longer than our father -- no doubt because of his lifestyle efforts-- but perhaps a more aggressive search for coronary disease would have helped.  If you're at risk, genetics may trump all -- see a cardiologist even if your numbers are normal.  40% of sudden cardiac deaths occur in people with LDL-C's (bad cholesterol) in the normal (less than 130) range.
•  We hear constantly -- in the media and from our doctors -- that lifestyle issues are a major factor in morbidity and mortality and this is likely true, however  there is an underlying harmful message here.  If you're sick and your lifestyle isn't perfect, it's your fault. And if you do everything right, you'll live a good long life.  Neither is necessarily true, but I believe the first message stops people from going to the doctor because who wants to be told that they're problems stem from their weight issue, their lack of exercise, from drinking too much, from eating the wrong things, from smoking, especially if you've tried to make changes and haven't been able to.  If you have lifestyle issues, try very hard to change, but if you can't, go to the doctor anyway.  Address your issues with medications, even if you can't make the necessary lifestyle changes -- you may live a longer and healthier life.  And while it's not in vogue to promote the pharmaceutical industry, the truth is that Americans are fatter than ever and live longer then they did back in the days of thinner people.  I believe this is from less smoking and from the benefit that medicines give people in dealing with blood pressure, heart disease, and diabetes.  If your doctor hassles you and you know you can't, or won't, change, remind your doctor that skinny people have high blood pressure and athletes die of heart attacks.  And if your doctor is not helpful, get a new doctor.

Happy Father's Day, please take care of yourself.

Shrinky Stuff Around the Web

Today, I'm just going to point out some links by others who are talking about the same types of things we've been talking about here on Shrink Rap.

Regarding everyone's favorite topic, involuntary treatment, Dr. Greg Smith talks about his experiences committing people at Are You Ready to Commit? 

On the Huffington Post, Erin Hawkes writes Medicate Me Even When I Refuse.

And Pete Earley talks about the safety of tasers in Tasers: Friend of Foe. 

On the topic of privacy, PsychPractice wrote a post for me defining HIPAA.  See What, Exactly is HIPAA? 

And while Rob has talked about how he does not like it when chronic mental illness is compared to chronic medical illness because we don't know the exact physiology, PsychPractice has a blog up about the politics of defining Type II diabetes, which is surprisingly similar to that of determining the criteria for psychiatric disorders.  See Learning from Diabetes. 



 

HIP HIP HIPAA HOORAY! Where's My Medical Privacy?

And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets. 
   *       *        *
Today, I"m ranting about medical privacy (now gone) and electronic medical records over on KevinMD.  The link is HERE.  Did you know that hospitals now send your medical information to the state (at least in our state), whether you want that or not? 

And while you're reading about privacy, there's a terrific article in the Wall Street Journal called Families of Violent Patients: We're Locked out of Care.

Okay, I'm going to make a confession here.  I have no idea what HIPAA is.  I don't know, I don't care.  My practice is small enough that I don't have to give out privacy notices, and I confine my "HIPAA" comments to "I don't release information without your permission."  I also note that I do release information in case of an emergency and that the state has requirements about the reporting of child abuse.  But from my take on it, HIPAA is not about who doesn't get your information, it's a long list of who DOES get your information, like it or not.  When I go to the doctor, I often cross out some of the listed entities, and tell them I don't want my information released.  But no one reads these things so it's just about making me feel like I have some control.  We all like those delusions.

Before HIPAA, doctors were not allowed to release your medical information without your permission.   There was this guy, way back when, named Hippocrates who had something to say on the matter.  Psychiatrists never did talk about your care without your permission, I remember this from before HIPAA.  

Regarding the Wall Street Journal article -- the implication here is that suddenly HIPAA prevents families from getting information about patients against their will.  I sometimes wonder if there is a reason the hospital/doctor/etc aren't plugging harder to talk with the family.  In the case of a violent patient, no doctor wants to see their patient hurt someone or die, and it's hard to imagine that if it were crucial to to share this information, a psychiatrist wouldn't say, "Listen, I can't treat you if you won't let me include your family."  The slant of the article assumes that the patient is always the sick one and that the family is well and harboring nothing but good intentions.  Perhaps the family has been intrusive, or the patient is really adamant.  Do we really want to tell a psychiatrist our private thoughts knowing they will repeat them to our family members whom we don't want to know them?  There are times when a really psychotic person won't allow communication because in the past, the family has insisted he take medication or go to treatment he didn't like, but which helped him anyway, and perhaps that was the right course of action.  But there are also times when families make the situation worse.  I don't think the issue is HIPAA, but I do imagine that part of it is that hospital staff don't have the time to work with patients and their families to help everyone come to a place where families know how to be helpful without being intrusive, and patients can feel more comfortable and respected.  These things take time (sometimes a lot of time) and if you're fighting with insurance companies for an extra day, and spending your time entering data into the computer, when a patient says "No, don't talk to my family,"  the doctor may just say "HIPAA, I can't," without exploring whether that makes sense or if there is a way the patient might allow communication about some aspects of care.  And finally, there is nothing about HIPAA that prevents family members from giving crucial information to a doctor.    

Okay, I've ranted for today.

My EPIC Meltdown

The hospital where I work one morning a week is changing it's electronic medical record system.  I've never like the current EPR because of privacy issues -- anyone with access can get into anyone else's record.  As an employee of the hospital, I don't like that so many people I know could read my medical record if I got my care there, and so I get care elsewhere.  HIPAA violation, you say?  Yes, but there's no up-front stop on looking at anyone's record, the violation and sanctions come if you get caught.  

Aside from the privacy issue, psychiatry does not add outpatient notes to the record.  Appointments are recorded, and medications are placed in the system, but no notes.   The current system is easy to navigate, I can read medical and surgical notes if it's helpful to me, There's a problem section, a medication section, labs (what I need most) which easily let you click on one to compare the value to those in the past, and a radiology section.  I'm not sure exactly why the upgrade to EPIC, but for a mere $100 million dollars, EPIC is being phased in.  I'm in the third wave.  And yes, psychiatry notes will be included, though there is some system to mark notes as sensitive, and to get into these notes, the reader must click through an extra screen, a process called "breaking the glass."  A psychiatrist has been designated to monitor who breaks the glass, one more responsibility in his already busy job description.

Monday I went to the first day of my two-day training to use EPIC.  The screens are busy.  The instructors were good, but the booklet was not-- we were told to read several sentences ahead, meaning you couldn't just read and follow along.  I was not in the best mental state to concentrate, and  two hours into the training, I just shut down.  I got lost in the screen-after-screen and annoyed by the privacy issues --- good news, now any doctor in the hospital can go in and look at any other doctor's schedule to see which patients are scheduled.  Why is that necessary?  

At some point, I realized that the new system means I'll have to sit with each patient at every appointment and start with the screen to verify allergies.  Each time.  As is, I have template forms I have to fill out at each appointment.  Now I can do all this while staring at a screen.   This is psychiatry?  What happened to listening to the patient?  Is there a screen for that.

I let my screen go black.  One of the instructors came by and asked about that.  "I'm done."  My brain stopped.  No more screens.  This is not the psychiatrist I want to be.  I sat through the rest of the day and and scored a 95% on the test module.  I went home and sent an email to the clinic: I'm resigning.  

So I actually do want to go to the second day of the training.  I want to understand what it is I'm railing against.  I'll work until the end of July, just long enough to test out EPIC, not long enough to master it.

Maybe it's a mistake?  Maybe EPIC will add value to the practice of psychiatry?  I can't really say that I'm leaving because of EPIC, after 15 years, it's time.  I may be the psychiatrist with the longest tenure there now, and I've long ago lost count of how many different social workers I've worked with.   EPIC was the last straw, but I've been thinking of leaving on and off for a long time --oh, did I mention I've quit 4 times before?-- and I needed a nudge.

So does your institution use EPIC?  How's it going?  Is it good to have psychiatry notes in the electronic record?  Has your hospital had security breaches?  Tell me your stories, I'm all ears.

Guest Blogger the Late Rabbi Milton Gerald Miller on Freud, Psychoanalysis, and Conquering our Fears.

At the age of 40, my father died after suffering from a heart attack while shoveling the snow.  I was a toddler, too young to remember him.   I understand that he liked gadgets so I'm assuming he would like the Internet, and techy toys, and that he might even have wanted a blog.  I found this sermon he gave, well before I was born, and decided that I would 'invite' my late father to be a guest blogger on Shrink Rap. It was originally delivered as a sermon/lecture on Friday night, August 12th, 1955 as the second of a series on Modern Classics that Helped Change the World.  Since my father is not here to respond to comments, and a recent tragedy in my family has left me feeling vulnerable, I will ask that commenters be gentle or silent.  The writer is not a psychiatrist, the audience was there with an interest in religion, not mental health, and the year was 1955.  I did enjoy finding this sermon while looking through family papers.
-------------------------------
Conquering our Fears
Tonight, I would like to talk about Sigmund Freud, the father of psychoanalysis.  In approaching this subject, I recognize fully my own limitations.  I am a rabbi and I am not qualified to speak on the medical correctness or incorrectness of the theories of Sigmund Freud.  But Sigmund Freud was not only a medical man.  He also wrote on religious subjects.  He discoursed at length on many aspects of religion.  In three of his works, Civilization and Its Discontents, The Future of an Illusion, and Moses and Monotheism, Freud spoke about religion.  And it seems to me as a religious leader, that if Mr. Freud chose to speak about religion, he should not have too much objection to a religious leader discussing the field of psychoanalysis.

Also, psychoanalysis, even in its own limited field, is concerned about many of the same concepts that religion deals with.  After all, the concepts of sin and guilt used by the psychoanalysts were used by religion long before the growth of the Freudian school.

Sigmund Freud, a Viennese physician, had much more influence upon our society than we realize.  He first began writing in the Victorian Era.  We might call the Victorian Era "the denial of the physical."  Exposure of the human body in any was was frowned upon.  Some Victorians actually put little pantaloons on the legs of their pianos to hide them.  And legs were never called legs -- they were called "limbs."

We might trace the frankness of today's generation to the influence of Freud.  Freud, in many respects, pointed out that the physical desires of mankind were normal and, while they were to be repressed in consance with the needs of society, that we all had these physical desires.  We have today a generation that is much more healthy mentally than that of the the Victorian Era.  And, strangely enough, some studies seem to indicate that morally the present generation is on a par with the Victorian generation.

The mention of Freud generally tends to make the average man react in a number of ways.  He either laughs nervously or tells one of the endless series of jokes about psychiatrists and psychoanalysts.  Very frankky, I do not fully understand or subscribe to the Freudian theory.  There are many schools of though among Freudians and they often disagree.  But among them there seems to be agreement on a number of points-- adn I would like to discuss these particular viewpoints.

Freud's greatest contribution to mankind's thinking was in his understanding of man's fears, and his logical explanation of many of them.  We may say that there are some logical fears.  A man crouching in a foxhole with shells passing over his head is logically afraid.  The Army has an expression "only a fool is not afraid."  If we stnd in mortal danger of life or limb, we are afraid.  The urge to preserve our lives causes us to be afraid.  Horses in a burning barn tremble from fear.  the sensation of fear in times of danger is a logical fear.

But we also have illogical fears-- fears that on the face of evidence do not warrant the reaction we get.  Some people get into an elevator and become panicky.  They cannot stand the crush of other persons, the feeling of closeness.  Few of us enjoy riding an elevator, but not many of us are intensely bothered by it.  The starting and stopping of the elevator annoys us and we do not relish the closed in feeling.  But some people-- luckily, relatively few in  numbers-- become violently ill when they are foeced to enter elevators or closed places.  They have what is called "claustrophobia" or fear of closed places.

We might say that one of Freud's greatest contributions to our civilization was his insistence that a person had to grow up in order to live happily.  Not only grow up physically, but grow up mentally and emotionally.  Freud discovered that many people's fears and anxieties stemmed from the fact that somewhere along the line in their development, they failed to develop emotionally.  While they might be 24 or 25 in terms of years, they still had some emotional attitudes of the three year old.  Thus, as has been explained to me, a child at a certain stage of normal development might hate his father.  Usually, we grow out of that stage-- but some people are unable to do so.  But, say the Freudians, they realize that it is not socially possible to hate your father, so they, at a later age, may turn their hatred into such a way that they "take it out on themselves" or become neurotic.  Their mind interprets this hatred in a number of ways-- by hating himself, by not coping with life's problems or in other fashions.  The Freudian analyst will attempt to get the person to understand what is bothering him, and get him to act out his difficulties.  He may have to re-live the stage of life where he failed to develop emotionally as did other people.  The psychiatrist or psychoanalyst acts as a guide and as a participator in this emotional drama.  Now, I am not competent to judge whether or not the Freudian theories about infant and child influence on later life are correct.  Certainly, the whole of the psycho-sexual development of the infant is beyond my understanding.  But the major point that Freud makes seems to me to be a very true one: that we have to grow up emotionally as well as physically-- that a person who is emotionally immature is unhappy.  In other words, only the truly mature person --mature in the emotional judgements of life-- can be happy in our world.  The emotionally immature person is constantly being confronted by situations that he cannot handle and each situation makes him more and more neurotic.

And this seems to have a particular relevance to religion.  Freud was not especially fond of organized religion.  He felt, and this statement appears in his book, The Future of an Illusion, that religion is a technique by means of which a person afraid of life tries to find a haven of false security. There is no doubt in my mind that Freud's statement were conditioned by the fact that there is a great deal of infantile faith in the world.  We hear quite often of the desirability of a 'child-like faith."  Child-like faith means a willingness to let God do everything, to throw yourself in the lap of the Almighty.  You want to be wealthy-- believe in my faith-- say some religious leaders.  You want to be mentally sound, join my church, say some ministers.  An yet religions, just as individuals, can be mature emotionally.  A religion can preach and teach an abiding belief in God and in the ethics of man.  At the same time, it can say, as Judaism says, there is no easy way to gain an understanding of yourself and of mankind. Study-- concentrate and work for true understanding and you will achieve it. Judaism, I feel, has been such a religion of maturity.  Judaism glories in the freedom of the mind to investigate and seek its own answer.  Even Freud, with all his disbelief, felt this.  In his message to the Vienna lodge of B'nai B'rith in 1926, on the occasion of his 70th birthday, he mad this statement: "Because I was a Jew, I found myself free from many prejudices which limited others in the use of their intellect."  Ours is a religion of maturity, a religion that demands a minimum of prejudice and a maximum of intellect.

Another facet of Freud's work that is of interest to me because of its religious significance is that we can often tell a great deal about the personality of a person and his adjustment to life by even one action.  Thus, a person comes to a psychiatrist with the urge to continually wash his hands, Lady Macbeth fashion.  The psychiatrist can tell a great deal about an individual with this urge.  It becomes the key to his entire personality and emotional makeup.  Many of us use similar bases upon which to make personal judgments.  I once spoke to the head of a rather large firm and he told me something which I though was most interesting.  Before he hired an executive, he took him out on the golf course, provided, of course, the prospective employee could play golf. And the company head cheated shamelessly and openly.  He kicked the other man's ball into the rough.  He deducted strokes from his own score.  He felt that the other man's reaction to his cheating would reveal quite a bit of hidden character.   If the man was silent and acquiesced, the employer felt that that he was too meek and did not have the ability to assert himself.  If he became furious, then the employer considered him unable to cope with situations.  If the prospective employee i ndicationed htat he objected but did so diplomatically, he was then hired as a person who wouldexpress an opinion and was able to handle a situation intelligently.

How many times do we get angry at people for relatively minor acts?  And when are we taken to task for this violent reaction to something trivial, we say "He showed his true character when he did that."  You know, ministers and rabbis and priests have very simple tests for a person's true religiousity.  The judge a person on the basis of just a few facts: Their attendance at service, their community interest, their relationship with their neighbors.  Isolated acts speak very loudly about the total personality of an individual.

Another contribution of Freud to our understanding of ourselves was his explanation of many of our common fears and anxieties.  I believe we have all watched a child approach a new toy.  The child, if he is very young, seems afraid of the toy.  He approaches it gingerly and nervously.  After a t time, he picks it up and plays with it.  Soon, he is playing with it wholeheartedly.  He understands that the toy will not hurt him.  Equally so Freud, by explaining that man's secret fears and anxieties can be understood and conquered, takes much of the dread out of our mental processes.   It is only in the last century that mental disease has been regarded as illness rather than a devil to be exorcised.  And it is considered to be a curable illness, rather than an incurable manifestation of evil.  Religious groups, and among them is Judaism, have often taught that man can subdue his own passions and desires in terms of his personal needs.  In other words, man has nothing to fear from himself.  Man has conquered the heights of Everest and the depths of the sea.  He has harnessed the atom.  The last great frontier of our world will probably be the frontier of man's mind.  And, while we may not fully understand the work of Freud, certainly we have benefited from his exploration of the unconscious mind of man.  Once we learn to deal with our fears in an informed manner, then we will be close to achieving the goal of  the Hebrew sage who said that man is slightly below the angels.  Indeed, man conquering the last frontier of the mind, can enter a new golden age, bringing greater glory both to himself and God.  Amen.

The Emancipated Patient

  

On our last blog post pseudo-Kristen laid the groundwork for what I'm about to say. In a comment there she said:

"I want the same scenario as the cancer patient. I want to say, as someone who is presently competent to make decisions, that this form of intervention was not life saving for me, it was harmful to me personally and drove me further from care. I want to be able to opt out of all forced treatment in case of psychiatric emergency…"

Presently this isn't possible. Although psychiatric advance directives exist, the reaction I've gotten from both doctors and patients is that they are essentially useless. Doctors don't like them because they can lose the ability to give involuntary medications---leading to a patient taking up a hospital bed who can't be treated. Patients don't like them because in many states they can't be used to prevent civil commitment.

This got me thinking. What would happen if advance directives had teeth? What would be the outcome if certain patients, after a certain process, were essentially exempt from ever being subject to involuntary care?

There is an analogous process we can look to in juvenile law. (Forgive the comparison, I'm not implying that psychiatric patients should be or are lesser than adults although I'm sure sometimes it feels that way.)

In juvenile law, if someone can prove that he is living independently of his parents and is not financially dependent on them, or is married and raising a child, he may have himself declared emancipated by a judge. This essentially grants the chronological juvenile the same legal rights as an adult---he can sign contracts, consent or refuse medical treatments, and do other things not otherwise available to children.

Imagine a process by which a psychiatric patient could claim absolute treatment decision rights. He has perfect insight, has a reasonable understanding of what his illness is and what the symptoms are, the effects these symptoms have on his loved ones and employment, and all the possible ramifications of getting sick (yes, even the risk of suicide or criminal acts). Let's temporarily suspend all the obvious objections to this from family, psychiatry, and society in general and assume for the sake of discussion that such a process were magically adopted by the legislature.

Voila. You're free.

What happens next?

Ideally, nothing different. The patient gets better on his own or with the voluntary help of a mental health professional on either an outpatient basis or with a consenting inpatient admission.

Maybe he doesn't get better, but also doesn't want the "help." He struggles along on a daily basis, maybe functional or not-as-functional as he might be. Maybe he doesn't struggle along. He stops eating, stops bathing, stops drinking, loses weight and his family gets worried. He still doesn't want the "help."

Here's the point where everybody really starts getting nervous. The ugly question, the question not to be said out loud by any psychiatrist:

Should a psychiatric patient have the right to let himself die? (I feel a bit sick just writing that.)

At this point let me be clear that my own personal opinion is NO. This is only a theoretical discussion.

Now let's make things even more complicated. I'm going to draw on a real life, actual legal opinion for this hypothetical.

Before our hypothetical patient drew up his motion for emancipation he had to be assessed as competent to file for emancipation. Psychiatric advance directives have a similar requirement. But the Federal Court of Appeals for the state of Vermont has said that this is a violation of the Americans with Disabilities Act since medical patients don't have to prove competence before signing a medical advance directive. In Vermont, a theoretically incompetent person could sign an advance directive refusing all psychiatric care.

Personally I think a formal emancipation process would be better than taking that risk.

I could take this one step further and make the hypothetical even more extreme by pointing out that Vermont also just passed a law allowing physician assisted suicide (what if you want the right to die due to an terminal-if-untreated psychiatric condition?). I think I'll stop here for now. This slope is slippery enough.

Discuss.

Involuntary Psych Hospitalization: Tell Me Your Story!

We haven't written about involuntary psychiatric treatment on Shrink Rap for a while because it gets our readers really stirred up.  Now I'm going to try to stir you up.
 
ClinkShrink and I are talking about writing a book on the different perspectives of involuntary hospitalization -- we'd like to put both sides of the argument on the page and look at issues related to patients' rights as well as families, members of the law enforcement and legal systems, and the doctors, nurses and hospital staff.  Roy is involved in his techy projects and won't be in on this, though we will continue to get his input and to eat pizza and crabcakes with him.

We're at the point where we need a "sample" chapter to illustrate what it is we are trying to write.  This isn't going to be a real chapter in the book (I don't think), but just "here's the idea."  Because the actual chapters will entail a great deal of interviewing and reviewing medical records and speaking with people and their families, I'm looking for an easier way to begin the process, and truthfully, the idea was inspired by our Shrink Rap readers who have written in over the years with stories about how they were damaged by what occurred during their involuntary hospital stays.   It got us thinking that there have to be better ways, while at the same time, it seems that it's shameful that our society leaves terribly psychotic people living on the streets and eating from the garbage because there is no way to treat them.  Maybe if treatment were nicer?

So I need your help.  I need someone with a really good, detailed story to be the subject of my sample chapter.  Will you tell us your story in the comment section, or email it to us at Shrinkrapblog at g mail dot com?  The comment section might be nice because it would allow for others to dialogue.  We don't need your name, but please don't write as Anonymous because I won't be able to the stories straight, a nickname is fine, and you can sign in to Google as "anonymous" as long as you sign the entry with some name that distinguishes you from the others.  Also, I might want to speak with you later, so if that's not acceptable, then maybe you don't want to participate. 

 For the sake of the sample chapter, I would like to hear from people who feel they've been treated badly.  The "so glad they committed me, it saved my life" is for another chapter.  If you're a psychiatrist and you have a patient who feels they've been unduly traumatized by an inpatient admission, please see if they want to participate, and the same goes for family members.  Obviously, books are about stories, and the stories need to be compelling.  

Years ago, we did a poll, and I was struck by the fact that two-thirds of those who had been involuntarily hospitalized said they would not want to be hospitalized again, even if they were a danger to themselves or others. 
 
In advance, thank you so much.

Thank you in advance.

A Reader Asks Questions About Reimbursements with the New CPT Codes

One of our Psychology Today readers wrote in with the following concern:

"The reimbursement for visits to my out-of-network psychiatrist on my plan which is self-funded by my employer have dropped a staggering 57% in 2013!!!  

A 90807 visit in December 2012 yielded a $262.50 check from the insurer for a visit with a $375 allowable amount. Actual bill is higher.

Now a 99212 and 90836 visit (nothing changed but codes) yields a $114.10 check from the insurer for a visit with a $163 allowable amount.

I was considering appealing the claim (now claims as I've submitted many claims at once) but thought there might be a better approach.

Have any ideas? What patient/medical groups could help? Anyone collecting data on this?"

Thanks.

Dinah responded:

Where do you live that $375 is considered reasonable and customary?  Is there housing available there?
You could see if the psychiatrist will code higher and if that will make a difference.  It might not.  To code higher for the E/M portion, the doctor could code a 99213 which entails documenting just a little more in his notes, but perhaps if he tells you what information he needs, you could just hand him that information pre-written each week.  He may not know, many psychiatrists are just coding low because they are afraid of being audited or questioned.  In order to code the therapy portion of the session higher, he would need to be doing 53 minutes of psychotherapy in addition to the E/M portion.  I am coding many sessions as 99213 + 60 minutes of psychotherapy (meaning over 53 minutes) and so far no insurance company has questioned it.  It means I take no break between patients, and your psychiatrist may not want to do this.      Some are being reimbursed much better.  And Medicare rates are certainly better with the new system. 

Oh, you might try your state's insurance commissioner, but I don't know if they deal with self-funded insurance plans -- in Maryland, they do not.

The other issue is that the psychiatrist probably bills separately for the two codes, breaking down the $450 actual charge into parts.  We have no idea how to do this to allow for maximal reimbursement-- the insurance companies tell out-of-network doctors that this is proprietary information, so maybe if you call the insurance company and ask them what the allowed fee is for both codes, you could ask the doctor to break down the components so that you are reimbursed maximally.  So, for example, if the doctor is billing $450 for the therapy and $0 for the 99213 portion, you would only be reimbursed for part of the allowable amount.
If this sounds ridiculous and confusing to you, please rest assured that it's no easier for the psychiatrists. 

The reader replied:

I contacted my insurer since my last email.They told me the data about allowable amounts comes from Fair Health (which used to be Ingenix which I referenced in an earlier email). They said when there aren't 9 doctors billing codes in a particular area, Fair Health uses some formula to come up with the amounts. I've emailed the general email box at Fair Health asking them how they come up with this. I also asked when they would compile actual data (now that it exists in 2013) and adjust the rates accordingly.

I forgot to mention the provider has billed for different sets of codes this year and the reimbursement has been exactly the same. This makes me think the insurer is just assigning a basic charge to all the codes and applying it. I will have to see if the doctor can split the bill according to the codes to see if that makes a difference as you suggested.

Just realized fairhealthconsumer.org lets you input codes and gives you reimbursement amounts.

Haven't found answers to my questions about the new codes and updating reimbursements based on actual billings.

Dinah said: The fairhealthconsumer.org formula may be helpful to both patients and doctors, so I thought I would share it.  It discusses how benefits work if you go in and out of your network, how much you can expect to be reimburse.  And it allows you to look up the expected fees for a service by zip code then CPT code.  I've discovered that I'm worth considerably more in the high rent districts.

Tower of Brains

It may be a pure coincidence, but at the San Francisco Museum of Modern Art they're displaying a tower of brains during APA week. Meanwhile, the DSM5 is officially out:

And if that weren't enough chaos for you, we have the obligatory APA protesters. (Do urologists get protesters at their conventions?)

I'm looking forward to meeting with Roy and our longsuffering Clinical Psychiatry News editor for dinner tonight.

100 Years of Psychiatry at Johns Hopkins

.



In honor of 100 years of psychiatry at Johns Hopkins, Baltimore cinematographer Richard Chisolm, along with Kindall Rende,  created this movie of members of the department talking about psychiatry at Hopkins.  Many of the people shown in the film have been guest bloggers on Shrink Rap, and they include our mentors, colleagues, and friends.  Both ClinkShrink and I are proud to be members of the department and we are both grateful for the education we've received, so we hope you'll spend a few minutes watching Richard's tribute.

Manual of Mishegas, an alternate to DSM-5

Starting 6/1, CMPS will be using an alternative diagnostic system instead of DSM-5.

This will be the only diagnostic system allowed on our new EHR system. See:

The Diagnostic Manual of Mishegas:

potchkied together and .com-piled by 

Jay Neugeboren, Michael B. Friedman, Lloyd I. Sederer M.D. 

THE DIAGNOSTIC MANUAL OF MISHEGAS (DMOM)

The authors cut through the hundreds of categories in the 1000-page D.S.M. by dividing all mental disorders into two realms: mishegas major and mishegas minor. And for each of the sub-categories it analyzes—spilkes major (and spilkes minor), yenta, kvetch, alter kocker, shnorrer, dementia-with-benefits, etc. THE DMOM will enable readers to transform ordinary tsuris and mishegas—the glooms, blues, angsts, and general chazzerie of their lives—into transcendent and easy-to-understand categories. It will turn kvetching into kvelling and guilt into gelt, so that readers will learn to live at peace with their inner mishegas and to treasure its precious and life-giving absurdities.

Comments:

" ich dorf es vi a loch in kop (it's needed like a hole in the head)...."

"A Serotonin Reuptake Inhibitor is no substitute for a good piece of herring!"

"I hate this book!"  (Herbert Luftmensch, Chair, Inner Sanctomonium Sub-Committee, APA)

Changes Keep Coming and Dinah is Grumpy

For today's blog post, I whine over on Clinical Psychiatry News, and whining it is.

See CPT, DSM, EMR, and more: growing weary of alphabet soup.

The Stolen Post, Without Permission, from 1 Boring Old Man

There's a psychiatrist who writes a blog that's older than Shrink Rap called 1boringoldman.  It's a great blog, and Mickey, the blog owner, should have more appropriately named himself 1reallysmartoldman.  I go to it sometimes, but it's more political than I like, it's often filled with graphs and numbers (more of a Roy thing), and .....I hesitate to admit this here because obviously that boring old man has better vision than I do....but the font is painfully small and the layout is hard to follow.  It's archived by month/year, not subject, and sometimes I'm not sure I've expanded what I wanted to read.  Oh, here at Shrink Rap, I change the font to large and we put the whole post, no matter how long, on the page so that no one has to search, though I am terrible about tagging topics.  I know, psycritic says we need a new look, but there is something comforting to me about the familiar, even if it's noisy, and think about all the nonsense that travels through your brain, and then multiply that by 3, because there's three of us fooling with the sidebar, sticking on links and ducks, and books and bacon.  I don't really understand why our sidebar offers "Shrink Rap with Bacon," but it does.

Rambling aside, in need of more coffee, I did love a post by Mickey the other day, so I thought I'd just steal it.  If it troubles you, sir, I will take it down.  With a link to the original post (if you're of a certain age, get your reading glasses):  http://1boringoldman.com/index.php/2013/05/12/a-thought-3/http://1boringoldman.com/index.php/2013/05/12/a-thought-3/

1boringoldman writes:

a thought…

Posted on Sunday 12 May 2013

There was a time – it was a long time ago, maybe 40 years ago – when I could think whatever I wanted to think. I could use a jillion models – be doctor medical model at 8AM, psychoanalytic at 9AM, cognitive behavioral before lunch, and throw in a little existentialism in the afternoon. It was like a toolbox filled with a lot of wonderful ways to think about the problems before me and my job was to bring whatever I could find to help until I found what really mattered – some shared way of understanding that my patient and I could use to make some headway. And in conferences we’d argue back and forth, the various different kinds of us, about what was right and wrong, which was all in fun because there wasn’t any right or wrong just different cameras on the same set, then we’d all go to the pub and be human together. It was an exciting time for me. I miss it – always have.

Then in the 1980s, that all changed. Because I was a psychiatrist, I was supposed to be a biologist. Well, I am a biologist, but that’s just a piece of what I am and what patients needed from me. And because I was a psychoanalyst, I was supposed to be … psychoanalytic, but that’s just a piece of what I am too and what patients needed from me. And so on and so on through the toolbox. And worse, I wasn’t supposed to meander from tool to tool until I found the one[s] that fit that patient on that day, I was supposed to have some consistent evidence-based position that could be validated by some third party to prove I wasn’t a charlatan or a I-don’t-know-what-but-it-was-a-bad-thing. I wasn’t up to it. I’d spent a long time refining my skills at doing it the other way which was some hard work, so I went off on my own and did what I’d learned to do until I retired. I’m so glad I did that.

Now it’s coming full circle. The psychologists are saying that the medical model psychiatrists are off the deep end. The biologists  are at war with each other over which biology is the correct biology. The humanists are after the robots. The analysts have learned to be quiet, but you can bet they’re thinking their thoughts. I’m sure all the existentialists in France and elsewhere are off being existential together. I know a lot of very talented and competent mental health types who come from a wide variety of backgrounds but they are unified by a few simple things – a deeply ingrained practice ethic, a suitable awe for the marvelous and monstrous variability in human beings, a genuine curiosity, broad training and life experience, and humility. If they can’t help you, they’ll at least be able to help you find someone who can.

When I think back on things, the most helpful piece of my training in mental health was becoming a hard science Internist first. The reason is that I knew a secret my psychiatric colleagues didn’t know. The hard science medicine I left was no more precise and assured than the loosy-goosy psychiatry I went to.  Sure there were more tests, more precise diagnoses, more drugs. But there was the wall of physical disease beyond which you couldn’t go. Once you found it, that was the end of the road. With mental illness, there’s no wall. Even with the worst cases of our most devastating illnesses, there’s still something that can be done, even if it is only a small thing. You may not find it, but it’s not because it’s not there.

So in one way, it makes me sad to read all these battles flying back and forth precipitated by the release of the DSM-5. On the other hand, it reminds me of those days long ago when we fought with each other to learn from each other. I’ve missed that more than I knew. And it makes me feel hopeful that what’s up ahead will be a toxic environment for the know-it-all psychiatric KOLs that have so contaminated our world [and detracted from the contributions of biologists with good sense], and their pharmaceutical marketing colleagues, and the opportunistic Managed Care types whose job it has been to keep us from doing ours. Right now, I hope right thinking psychiatrists of all flavors, psychologists of all flavors, social workers, counselors, etc. can brace themselves for a long-needed realignment that is consistent with our shared task. It won’t happen any time soon. We’ve been lost in the wilderness too long for that. But the wind blowing in the trees is at least encouraging to this old man…

Can Psychiatry Ever Really Get Rid of Stigma?

We all think stigma with mental illness is a bad thing.  Because mental disorders are stigmatized, people hide their psychic distress and don't get help, or they live in denial about their problems when the fact that they are mentally ill is obvious to others.  People live in pain, or they simply don't live up to their potential.  Stigma is only part of the problem, of course.  There is also the issue of access to care, access to good care, cost of care, dislike of the care that exists (mean psychiatrists, side effects from medications, lousy food or uncomfortable beds on inpatient units), and the fact that sometimes people lack the insight to be aware that they have a problem.  

Insurance companies, I believe, add to stigma, not because they want to stigmatize patients, but because this is a vulnerable group of people where they can avoid shelling out money.  Inadvertently, however, policies that exclude mental disorders or reimburse them differently, increase stigma.  Whatever the intent, the result is the same.

Some people like to compare mental illnesses to diabetes or hypertension: it's chronic, it's biological (we believe), it's an illness to treat like any other illness.  It's a lousy metaphor for a number of reasons: we don't know the biology behind the disorders, and psychiatric disorders are not predictably chronic.  Okay, actually, some people can get rid of their hypertension with weight loss, and then the disorders don't actually exist, but somehow once you're labeled with diabetes, it sticks (diet-controlled, even if you're not on a medicine, even if your blood sugar is normal).  

But aside from issues of insurance parity and certainty about the biological causes of psychiatric disorders, there is a reason I think that untreated or unresponsive mental disorders will always have  stigma.  In the world of "Reduce Stigma," this is going to be the totally politically incorrect thing to say.  Psychiatric disorders come with stigma because people in the throes of certain psychiatric illnesses sometimes behave in distasteful, frightening, unusual, and disturbing ways.  I think we've done a lot to decrease the stigma of depression and anxiety, and it's been immensely helpful that famous, brilliant, successful, beautiful, rich people have talked openly about their struggles with these disorders.  And while I think we've made progress identifying other disorders as problems/disorders/illnesses and not the 'fault' of the person, if a psychiatric problem makes it such that a person refuses to bathe, or becomes loud, irritable, and irrational in the work place, then no amount of reduce stigma campaigning will make it so that people will want to be next to someone who smells bad or whose behavior is erratic.   I, too, want to see stigma reduced.  But if someone is running down the street naked screaming about aliens, they have a bigger challenge to face than the person who quietly sits in the doctor's office and learns their blood pressure numbers are over a certain level.

The answer?  Better treatments, of course.  And more success stories from those with major mental illnesses.  I remain hopeful.