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.

Sunday, April 03, 2016

The Accessible Psychiatry Project, Updated & Please Do Comment on the Scattergood Site

Later this month, Shrink Rap will be celebrating it's 10th anniversary!  More later, but we are the longest running psychiatry blog, and we're looking forward to the cake.

As you may know, Shrink Rap is part of a larger group of projects that the three of us, in various combinations, work on.  The list has morphed over the years, and the Accessible Psychiatry Project is now up for a Scattergood Innovation Award.  The nominations closed last week, and public comment is not being requested.  We'd love to have our Shrink Rap readers visit the Scattergood site and leave an encouraging comment.  The Scattergood site is here and comments can be added at the end of The Accessible Psychiatry Project's description:
If you do add a comment, please accept our thanks.  

For a recap of our projects over time:

The Accessible Psychiatry Project

The Accessible Psychiatry Project
Encouraging dialogue about psychiatry across media.
--Steven R. Daviss, M.D.­­
--Annette Hanson, M.D.
--Dinah Miller, M.D.

Mission Statement:
The Accessible Psychiatry Project strives to encourage dialogue about psychiatric disorders and their treatment in order to explore issues of controversy and misunderstanding in our field. Through open dialogue, in both new media and print, we hope to foster discussion about the work psychiatrists do, and to decrease stigma associated with the treatment of mental disorders.

Components of The Accessible Psychiatry Project include:

Shrink Rap: The longest running psychiatry blog 

on the Internet, since April, 2006

Shrink Rap News: A blog and print column for 

Clinical Psychiatry News

Shrink Rap Today: A collateral blog on the 

Psychology Today Website. 

My Three Shrinks podcast;

November, 2006- 2012,  70 episodes aired

Featured on the iTunes Medical Podcasts Webpage

ShrinkRapRoy tweets about psychiatry and health care.
  • HITshrink tweets about health information technology and health care reform (HITshrink's blog is here).

ClinkShrink tweets about issues pertaining to psychiatry & the law; sometimes about birds

ShrinkRapDinah tweets mostly on mental health issues.

Access to Care: MarylandPsychiatrists.Net  is a website designed to facilitate quick entry to outpatient care.

Find us on Facebook at ShrinkRapBook :

Committed: The Battle Over Involuntary Psychiatric Care, by Dinah Miller and Annette Hanson, In Press, Johns Hopkins University Press for Fall, 2016.

Shrink Rap: Three Psychiatrists Explain Their Work, by Dinah Miller, Annette Hanson, and Steven Roy Daviss,  Johns Hopkins University Press, Baltimore, 2011. 

The Shrink Rappers give talks on: 
~ The Public Face of Psychiatry Across Media
~Access to Care
~Psychiatry and Technology (Dr. Daviss)
~Forensic Psychiatry (Dr. Hanson)
~soon: Involuntary/Forced Psychiatric Care
~soon: Mental Illness, Violence, and Violence Prevention

Sunday, March 27, 2016

The Final Report on the Germanwings Tragedy

Over on Clinical Psychiatry News, I have an article up on the final report about the Germanwings pilot who crashed the plane into the French Alps.  A sad topic, but do read it.

Thursday, March 24, 2016

Guest Blogger Dr. Thomas Franklin Writes About His Own Experiences With Major Depression and Why He's Doing A Triathlon

Becoming an Ironman for Myself and My Patients

The sliver of light coming under the door of the windowless office seemed unbearably bright and offensive. I turned away from it and closed my eyes. There is a flat spot on the back of my head that, if angled just right, would lie on the textbook I was using as a pillow. In a few moments, I would be asleep again. I was supposed to be out seeing patients, but it was all I could do to show up at work and hide in my office. My supervisor was a gentle woman who would come check on me a couple of times a day. She would crack the door and ask, “Dr. Franklin, why don’t you come out and see one of the new patients?” 
“I can’t. I just can’t... I’m no good to anyone.”
Drifting in and out of consciousness in that dark room seemed far superior to being up and about, feeling the pain that seemed to emanate from my chest and flow throughout my body. It was as if my blood had been replaced by some impossibly dense material that could barely flow, making every step I took an effort. If I didn’t lie on that floor and feel my body supported all the way from that flat part of my skull to the small of my back, to the backs of my ankles, it felt like I might fall through to the center of the earth, through the dirt, rock, and then to the molten core where I would be incinerated. I wondered if that might be better than living like this.

Fearing Stigma but Seeking Help

I was a psychiatric intern at the time, and I was depressed. But I couldn’t bring myself to seek treatment. I suffered like that for months until I saw a colleague in consultation, where I described suffering the symptoms of attention deficit disorder, but suggested that a third-line medication for that diagnosis, also used for depression, might help me. I needed so much more than that medication, but my depression, my own inhibitions, and stigma kept me from getting the help I needed. Difficulty concentrating seemed a safer problem to admit to than depression. I was worried that I wouldn’t be taken seriously as a psychiatrist if it became known that I, too, was a patient. 
I continued to suffer off and on for years, finally getting into real treatment for the first time after my training was over. A combination of psychotherapy and medications led to the relief of stabilization. Ultimately, psychoanalysis, a more intensive therapy experience, helped me to fundamentally change how I thought about myself and the world, which led to not just relief, but a transformation of how my mind worked. Eventually, I was able to stop taking medicines. The way I had felt only years before seemed so far away. I felt a part of the human race. 
Until now, I have kept quiet about my experience. A continued fear of stigma has kept me quiet. I felt that if I was known as a psychiatric patient, even a so-called “cured” one, I would be labeled or disgraced or stereotyped. I thought it might hold back my career.
But the only way to combat stigma is to speak out. This is not easy, but I am inspired by those that have travelled before me on this road and by my current patients. I can’t go on urging them to be courageous, to face down the stigma they were feeling, without doing all I can to fight stigma myself. Only by shining the light of truth on people’s lived experience of mental illness will stigma finally become a thing of the past. 

Why a Triathlon?

After my psychoanalysis was over, I took up triathlons. Exercise has not only helped my mood, but I found that endurance sports are a powerful metaphor for what living with a mental illness can be like. In some ways, training for and finishing races makes me feel that I have mastery over that part of me that suffered so much.
In triathlons, like in depression, you have to go on putting one foot in front of another for as long as it takes. It will be painful. Your best-laid plans will go awry. Small mistakes early in the race can turn into big problems before the end of the day. The finish line will seem an impossibly long way away. There are moments of despair, but also moments of triumph. There is beauty around the next corner that can give you hope, if you only look up long enough to take it in. But preparing for and finishing the race is much more about your mind than your body. 
On July 24th, I will be racing the 140.6 miles of the Ironman Lake Placid triathlon to fight stigma, to show people that are suffering that treatment works, and to raise money for the Sheppard Pratt Patient Care Fund so that no one has to go without the treatment they need. 100 percent of the monies donated to this fund are spent on patient care. Maybe someone we help get treated will become the next courageous voice in the fight against stigma. Please give generously, whatever that means for you in your life. Thank you for your support.

Dr. Thomas Franklin is the medical director of The Retreat at Sheppard Pratt. He is a clinical assistant professor of psychiatry at the University of Maryland School of Medicine and a candidate at the Washington Center for Psychoanalysis. He is Board Certified in Addiction Medicine and Psychiatry, and has extensive experience in psychotherapy, psychopharmacology, and addictions and co-occurring disorders. Dr. Franklin previously served as medical director of Ruxton House, The Retreat’s transitional living program, before assuming the role of medical director of The Retreat in 2014.

Friday, March 18, 2016

Finding Help

Yesterday, I was a speaker at the University of Maryland's Cultural Diversity Day.
The theme was Urban Trauma: Understanding Its Impact and Navigating Access to Mental Health Care. I thought I would share some of my slides with our readers.  And now I know how to put a PowerPoint Presentation into a blog.

Monday, March 14, 2016

Listen to ClinkShrink Discuss Physician Assisted Suicide on the Radio

In case you haven't heard, our ClinkShrink has strong feelings about legislation to allow Physician Assisted Suicide.  She has written about it Here and Here.

A few weeks ago, ClinkShrink was on the radio talking about proposed legislation in Maryland.  She did a great job. 
Here's the link, you can listen to the whole show hosted by Sheila Kast.

Sunday, March 13, 2016

To Aetna: I am NOT in your network

Dear Aetna,
I would contact you directly, but believe me, I've tried. 

Perhaps you could help me.  I am a psychiatrist is Baltimore and somehow my name is on Aetna's provider panel.  I never filled out an application or request with Aetna and I have no desire to be on their panel.  Over the last couple of years, I had gotten a few calls from prospective patients, clarified that I am not an Aetna provider, at least not willingly, and left it at that. Recently, the calls have escalated to as many as 5 a week.

I have called Aetna repeatedly, and I can't seem to find a voicemail option that allows me to speak with a human.  I received a call (left as voicemail) from Aetna the other day saying I must refund a patient because I charged more than the allowable rates for an Aetna-cover patient, and the  patient told them I was not in network, and a number was left for me to call. When I dialed that number, the automated answer machine knew who I was (I suppose by my phone number?) but then none of the prompts led to an option to discuss network participation or to speak with a human.  I have also gone to their website, where there is a place to report network issues, and I reported there that I am not in network and never heard anything.  I googled the Chief Medical Officer and tried to call him, without success.  This is a lot of time and effort to dis-enroll from a company I had never enrolled with!  Even your contact page is a fiasco.
  Network inadequacy is an enormous problem for patients and Aetna makes it extremely difficult to address.

Wednesday, March 09, 2016

What Do The Kids Need to Know?

That's a great title for a post, isn't it?
Unfortunately, this isn't going to be about anything all that juicy.  I'm giving a talk on Access to Care next week to 60 or so psychiatry residents in training.  I thought I would ask our readers: What should young psychiatrists know about finding a psychiatrist?  Are there things that make it harder or easier to find someone?  What should they know about health insurance participation?
Write something I hadn't thought of  and I'll read it at my presentation!
Thank you for your help.

Tuesday, February 23, 2016

What Your Psychiatrist Should Be Doing....

First, I'm going to send you over to read Pete Earley's blog post for today: Treatment Rather Than Punishment In Horrific Case But What Can We Do in the Future? 

So just to recap, this terribly tragic case is about a mother with schizophrenia who stopped going to treatment, became psychotic, put her three-year-old son on a swing and pushed the swing for 40 hours.  The boy died and the mother was found pushing her dead child in a swing.  The judge determined that she was not criminally responsible, and she is being mandated to treatment and allowed to stay in the community if she abides by the terms of her release.  This is an unusual outcome, usually if your child dies because of negligence or abuse, you go somewhere-- if not a prison then a forensic hospital.

So the question comes up as to whether this child's death could have been prevented, who is to blame, and how do we keep such things from happening in the future?  According to an article in the Washington Post, the mother had been admitted to a psychiatric unit in February of 2015, was discharged to outpatient care and was seen at a clinic in April of 2015.  She was diagnosed with schizophrenia.  She took medications and had stopped them only days before the tragic event in May.  The father had pursued full custody of the boy, but the parents ended up with joint custody.  The patient lived with her mother and son in a hotel. 

So Mr. Earley looks at the question of who is to blame. Is the adult patient's mother responsible? No, he contends, parents are limited in what they can do to help an adult child with a mental illness.  Should the hospital be responsible for making sure everyone goes to outpatient appointments months after discharge? No, that is too much to ask.  Social services? Too under-staffed.  And then I got to this sentence:

If someone is taking psychotropic medicine, the doctor who issued that medication should be obligated to monitor his patient.

What does that mean and how does that play out?  As a psychiatrist, when we hear the word "monitor," we think of assessing the patient to make sure the medication is appropriate, that side effects are being monitored (and hopefully minimized) and that recommended blood-work is being done.  I guess I could ask Pete what he meant by this, but instead I wanted to write a blog post.  It does seems like everyone else gets a pass -- the parents, the hospital, social services (~did they have a role?  Who exactly is social services anyway?).  But the psychiatrist should be obligated to monitor the patient.  No passes here.

So let's talk for a moment about the logistics.  A patient goes to a clinic and sees a psychiatrist and a social worker for therapy.  She stopped taking her medications, but there is nothing here about missing an appointment.  Should the doctor be watching patients swallow the pills?  Some people get sick even when they do everything the doctor says, our treatments help but they aren't perfect.  What if a patient who has been hospitalized doesn't show up at an appointment?  Actually, in community clinics, approximately 30% of appointments are not kept and it's possible that the doctor could be scheduled to see 12-25 patients each day.  He or she may call a patient who doesn't show up, but probably not-- it happens numerous times a day.  If a patient does not call to reschedule, eventually, the chart gets tagged, and the therapist calls or writes a letter to the patient saying that if he does not come in by a certain date, his case will be closed.  There is not a mechanism in our system for aggressive pursuit of patients. In fact, many clinics discharge patients if they miss 3 appointments in a row.  In outpatient settings, people are free to say they've decided they don't want treatment, they've decided to go elsewhere, they'll call when they want to come in. Just because someone has had an episode of mental illness-- one that required hospitalization-- it does not mean that we have a mechanism to insist they continue in treatment if they aren't in the criminal justice system --which this woman now is. 

What about Outpatient Commitment, or AOT as some call it -- would that have saved this child?  Well, we don't have it in Maryland, but even if we did, this parent was not repeatedly hospitalized, and she had voluntarily gone to care at the clinic the month before.  Even if we had laws for this, she would not have qualified.  And outpatient commitment is not a guarantee of safety: patients may disregard the orders, or get sick between appointments.

What about a system which includes very easy access to care and outreach service for all patients who have had an episode of illness severe enough to require hospitalization?  Maybe that would have helped, and if you agree, please do send your dollars to fund it because the expense would be astronomical. No where has this.

I don't know the details of this case and the press often reports selectively, so I don't even want to venture a guess as to what may or may not have prevented this tragedy.  I do think that there are some tragedies that we simply have no way of predicting.    

Sunday, February 21, 2016

Hotel California

Our group of psychiatrists have a listserv -- it's a wonderful tool for sharing resources and keeping everyone up to date about the latest in professional issues.  From time to time, a discussion will ensue, and one psychiatrist posted his thoughts about patients who want to change psychiatrists.  I thought our blog readers might want to weigh in, and with permission, I'm reprinting that doctor's thoughts.  

Regarding taking patients who want to switch doctors, I have my own particular thoughts about that. Psychiatrists are a very scarce resource these days. Therefore, people who are able to have a psychiatrist are the fortunate  ones. Also, like so many of us, I'm pretty booked so I do not have that many openings to take new patients. So I prefer to use those scarce openings for people who don't already have a psychiatrist. Also, people who want to switch psychiatrists very often are having difficulty communicating with their docs about what's not working for them in their treatment. Or, there are transference issues that have not yet been worked through. Or, any one of another impasses in the treatment alliance. Or, they are on an ineffective medication regimen and the treating psychiatrist hasn't been able to ascertain alternative approaches-- pharmacological or otherwise.  So, I am always available to do a one-time second opinion consultation for such dissatisfied patients. Those consultations  provide a diagnostic reevaluation,  perhaps new ideas about treatment alternatives, recommendations to enhance communication, and observation of psychodynamic issues that might be relevant to the stalled recovery and/or treatment relationship.  I identify aspects of their doctor's practice that could be modified to make for a happier patient (e.g.  returning  the patient's phone calls in a timely manner). I make my written consultation available to both the patient and the treating psychiatrist. I am also available to discuss the case with the current psychiatrist. But, I will not take the dissatisfied patient in transfer.  This is really no less than I would hope if one of my patients has been dissatisfied with our treatment and calls another psychiatrist  to jump ship and short-circuit the process of working it out with me.  I would hope  the colleague would respond in kind to what I have described.  Sometimes, that is been the case, but sadly other times it has not. Just like, sadly, sometimes my patients go to the ER and are hospitalized and  the treating docs there never call me.

I know another psychiatrist who once mentioned that he wouldn't take on patients who are already in treatment with another psychiatrist.  I didn't ask why, I just assumed he didn't like the idea of taking someone else's patient, that perhaps he thought it made for poor professional relationships.  

As you can tell from the title of this blog post, I don't agree.  I think if there are times when treatment comes to an impasse, and it just gets stuck.  I think there may be transferential issues to work through, but that should be the patient's choice.  Sometimes people are less concerned with issues in the therapeutic relationship and are more focused on concerns that they aren't getting better.  Some psychiatrists are better than others in general, and some psychiatrists are better than others with specific patients.  And psychiatrists offer different services: I've heard from many people who've tried med-check only treatment who come looking for psychotherapy as well how, "That fifteen minute thing doesn't work for me."  I'm also not so sure that because a consultant recommends that the treating physician should return phone calls in a more timely manner that it necessarily happens. 

Finally, the psychiatrist assumes that when the going gets tough, the psychiatrist wants to continue.  If a patient isn't getting better, or if therapy has become a war zone, then sometimes everyone agrees that it would be best for a fresh start.  Also, do remember that this is one psychiatrist's personal policy for his own private practice, and certainly, I believe doctors should practice in ways they find ethical and comfortable.  No one has actually suggested a true Hotel California policy where "You can check out any time you like, but you can never leave" and patients can never change psychiatrists.

At the other extreme, Roy once told me that if ever returned to private practice he would see patients for only one year: by that point they should be better or they should try treatment with someone else.  

I think patients should be able to change doctors -- of any flavor-- if they aren't happy with the care they are receiving. I didn't post this to poke holes: the psychiatrist above makes some very good points, and he does a nice job of putting into words what others may not verbalize as well.  His comments gave me the opportunity to think about this, so I wanted to give our readers the chance to ponder and discuss as well.  Note that comment moderation is off, so please do be kind to one another. 

Thursday, February 11, 2016

Interview with Touched With Fire Director Paul Dalio

A few weeks ago, I wrote about a screening I went to for the film Touched With Fire. 

 Last week, I had the chance to interview the film's director, Paul Dalio.  My article about the interview is over on Clinical Psychiatry News, so please click over there to read about this remarkable man and his new movie.