Showing posts with label clinkrants. Show all posts
Showing posts with label clinkrants. Show all posts

Thursday, July 19, 2012

Those Evil Med Checks

Join me for a brief Clink rant over at Clinical Psychiatry News as I provide a counterpoint argument to people who think that med check practices are destroying psychiatry.

I'd like people to acknowledge that all medication management practices are not the same and that it is possible to provide good care while working in a "split treatment" or team model. With health care reform on the horizon, more practices---psychiatric and otherwise---are going to have to move to the "medical home" model and this is likely to require closer involvement with non-psychiatrist therapists. Medication management is here to stay, the team approach works, and more psychiatrists are likely to be involved in it. Psychiatry needs to adapt and it helps no one to paint all med management with the same negative brush.


Thanks for listening, I feel better.

Wednesday, January 27, 2010

Rage Against The Machine


I'm posting this for ClinkShrink at her request. She's in jail at the moment and they block Blogger. This is in honor of the Apple Tablet announcement today, and she's looking to pick a fight with Roy!

Rage Against The Machine

---by ClinkShrink.

With the pending announcement of the long-awaited Apple tablet, and on the heels of my new programming project (an
iPhone app), I'm thinking about health information systems. This blog post is a blatant attempt to yank Roy's chain, but I know he's smart enough to see right through it. Nevertheless, if he totally agrees with me I'm going to be quite disappointed.

The fact of the matter is, I'm a geek and I love technology but I really really dislike
health information systems. I've yet to meet one (other than stuff I've designed myself) that doesn't drive me screaming into banshee land.

I know all the supposed benefits of
healthcare information systems: they're supposed to improve care by allowing communication between providers, they're supposed to reduce healthcare costs by improving efficiency, they're supposed to contribute to medical knowledge by collecting aggregate data about diseases for research.

I also am concerned about the downside of health information systems: potential threats to information security, harmful uses of the data that's collected, breaches of confidentiality and loss of independent medical decision-making.

Fine. That's not why I've hated them. The reason I strongly dislike most systems I've used is because they make it harder to figure out what my patient really has.

Psychiatry is a descriptive art. You make a diagnosis through observation and description. You treat people through language and free communication. Information systems stifle all that. Instead of being able to document that the patient "believed he was the President so he hopped on a bus to Washington, camped out on Pennsylvania Avenue for three weeks, then climbed over the fence of the White House", I only get to check a little box that says "delusional". Now, that really loses something.

Even when the
computer programmers give me a textbox instead of a checkbox, I run out of room to document the treatment history of a really complicated patient. I could type for ten minutes about the stuff I want the next clinician to know, only to discover that my keystrokes have been brutally ignored and rejected by the $#@!J$#* healthcare interface.

I am a geek. I want my machines to obey me. Instead, I am forced to let the machine convert my prose into categories, to shave off the nuances and color and "flavor" of the people I treat, all because the system is designed by engineers rather than clinicians. I am peppered by little popup warnings about contraindications and medication interactions that only occur in one out of every 10,000 people. I have ignore these so regularly that I fear missing the one that might truly be dangerous.

Will the benefits of a
national health information system outweigh the risks? Better yet, will doctors be able to use them without wanting to smash a keyboard over somebody's head? Only time will tell.

So, that's my take on the 'con' side of the
national information system. I'll leave to Roy to be the 'pro'.

******

Tuesday, April 07, 2009

Why I Hate In Treatment


Dinah, I still love you even though you ignore my opinion and write about In Treatment.

A while ago Dinah wrote about why she hates the television show House. I didn't have strong opinions about the show, I had only watched a few episodes and I thought they were OK. If Dinah hated it and wanted to blog about it that was cool with me. So now, I'm taking my turn.

In the interests of full disclosure, I'll tell you first that I've never had cable TV. Not only that, but since about last July I haven't had a television. I really haven't missed it. I've been to places that had cable TV and what I saw just reinforced the idea that there was a lot of content that just wasn't worth watching. I spent more time channel surfing than viewing. So that's my disclaimer. (I watched the first week of In Treatment on the Internet.)

In general I think it's a bit unsettling to be immersed in TV culture. I notice it more now that I'm not part of the American "viewership", but it feels odd to go somewhere and listen to people absorbed by characters who aren't real and life stories that don't actually exist. I mean really, there are earthquakes and wars and important international events going on and we're wondering who is going to get voted off American Idol? Don't we have real issues to talk about?

As far as the show specifically, I don't like it because it's neither treatment nor is it therapy. Face it, the guy's a goofball whether he's a psychiatrist, a psychologist or a licensed angel adjuster. If you're going to be that far off base from reality you might as well write a show around the complicated dysfunctional relationships between an auto mechanic and his customers. (Oh wait, there was that Taxi series---that's pretty close.) It's too laughable to be drama and too self-important to be comedy. Like I said when it first came on, I'd rather have a more realistic series about seriously mentally ill folks making their way in the world than a gossipy pseudo-introspective contrivance like In Treatment. Dinah didn't like House because the doctor was obnoxious and the show wasn't realistic. Oddly enough, the same reasons I don't like In Treatment.

I'd even prefer blog posts about ducks.

Saturday, June 07, 2008

I Didn't Hurt Anybody


I am not a happy ClinkShrink right now. I'm a bit hot under the collar. In fact, I'm a bit hot everywhere right now.

I have no air conditioner. I know, I know, I should be used to this by now. I don't have a phone, I don't have a desk, I have to hunt for chairs to sit on every day. I should be used to this.

I am, I'm just not used to this at home.

This isn't something I typically blog about. I generally keep my personal life off the Internet and stick to mainly professional-type topics, but I promise I will make this relevant to psychiatry.

I called up the local heating and air conditioning guy, who took one look and pointed out what was wrong. He saw it immediately, and I can't believe I didn't.

Someone stole my copper freon pipe. It was four or five feet long, leading from the external pump up into the side of my house. It had been clipped off neatly at either end, so neatly I didn't even notice it was gone. I'm told it's going to take four hours of labor (at an hourly rate nearly 50% higher than what I make as a physician) and four gallons of freon (at $60 per gallon) to fix and there is no guarantee it will work. Depending on how long the pipe was gone, both my external compressor and internal unit may be toast. Replacing both units is ridiculously expensive, not to mention time lost from work and loads of inmates who aren't going to get psychiatric care while I'm out.

I'm going to think about this incident the next time I hear someone say drugs should be decriminalized because drug addicts are only hurting themselves. I will think about this the next time a non-violent substance abuser says, "I'm an addict but I never hurt anybody."

Horse hockey.

Like most people who live in big cities, I've been a victim of crime before. I've also had my car window smashed in by someone looking to steal a bag of used spark plugs (long story). Again, metal recycling is used to support drug addiction. (Maybe we need a registry of people selling metal like we do for pawn shops??) Once upon a time, someone even stole the brass doors off of our circuit court house (200 pounds apiece, metal value estimated at a quarter of a million). Drug addicts don't only hurt themselves and the most hardcore addicts need to be picked up involuntarily and taken off the streets to make them stop using.

So anybody who really wants to debate this is welcome to come over to my place this weekend. The forecast is for a hundred degree heat index.

Bring ice.

*********

For more on the scrap metal theft epidemic, see also:

How hot are metals?

---
Note from Dinah: my guest room has a window unit. You're always welcome

Thursday, February 28, 2008

For The Sake Of Argument

[Subtitle: Clink Takes The Bait]

But first, Good News for those following the HBO In Treatment Sub-Blog: Post on Sophie below this: Click Here.

If I were a trout I'd be three feet out of the water by now. Dinah's post "When A Shrink Picks A Benzodiazepine" is like a bright colorful feathered fly with a tantalizing spin. I tried resisting, but I just had to leap for it.

In my clinic today two patients had benzodiazepine issues. Patient One had been taking his mother's Xanax. Patient Two had his parole violated for a dirty urine. He said he had been getting his psychiatric care through a local program, but that they had only prescribed Xanax "to help me with my marijuana problem". I asked him what they were giving him for his bipolar disorder, and he said, "Oh nothing. Between the marijuana and the Xanax I was alright." Right.

I'd like to think the outpatient doctors for both Patient One and Patient Two were both as careful as Dinah. Hopefully they both took good substance abuse histories and knew their patients well. I'm sure they were well-intentioned. Right. The problem with the approach Dinah suggests is that people with active addictions aren't going to tell you about them. They're going to conceal their substance abuse histories and lie about the pharmacies they go to. Taking a history isn't going to help too much.

So for the sake of argument (and we do like to argue here at Shrink Rap!) let's say Patient One's mother has, as Dinah suggests, a fear of flying that necessitates occasional benzodiazepine use. So nervous flying mom also has a pot-smoking son who also drinks a bit (but is smart enough to hide the empties), a son who also snorts his Ritalin. Patient One's doctor takes a history and learns nervous flying mom has never abused alcohol or been dependent on drugs. He doesn't find out about snorting, pot-smoking son because nervous flying mom is clueless. He writes a prescription for a benzodiazepine and now pot-smoking son mentally blesses him whenever he opens his mom's medicine cabinet. And I have a new parole-violating patient. And mom's doctor never has a clue this is going on.

So when I hear about free society docs who never have a problem with patients on benzodiazepines, I can't help but wonder if the problems are truly that rare or if they just never find out about them. The patients disappear when the med gets tapered (or they get arrested) and the doc never hears the end of the story.

And I wonder why, when working in a public clinic, it is "very rare" that Dinah will start benzodiazepines in that setting. I suspect it's because with those patient the substance abuse issues are a little harder to conceal, especially when they come to her freshly released from jail. Thus, addicts from low socioeconomic classes are pretty much stuck buying their stuff off the street.

So I agree with Dinah that prescribing involves a risk-benefit assessment. I just don't get the part where the risk of temporary nervousness while flying outweighs the risk of diversion, misuse, abuse and dependence. I'm still working on that part.

(Dinah and I could keep this up until people beg for more In Treatment posts. I'll try to contain myself.)


Saturday, January 12, 2008

Soylent Brown



Dinah wanted me to talk about the alleged Texas cannibal that PETA is using to promote vegetarianism.

I have to say, cannibalism is not nearly as interesting as what's being served on the prison menu these days.

I've eaten in the officer's dining room, and it's an experience. Most of the bugs stay on the walls but occasionally you see a little baby bug crawling along the edge of the salad bar. The inmate workers who serve the food all wear gloves and hair nets. I really don't notice the tattoos anymore. They're friendly and polite. They ask if you want the soggy vegetables or the dry white bread or they'll ladle a few scoops of thick sludgy soup into a styrofoam cup for you. On fried chicken days the line is always long, but they still ask if you want extra fries with that. There's always enough little ketchup packets to go with the fries. On non-chicken days, they have a brown square of some meat-type thingie. I'm still working on that one, trying to figure out if it's from the land, from the sea or from the air. At this point I just call it Soylent Brown.

One of the kitchen cadre workers told me that Soylent Brown is a staple of the inmate diet. It's from the food contractor, who I guess buys it by the truckload. For inmates who want a vegetarian diet I guess they can be reassured---my cadre worker tells me Soylent Brown is 90% soy and ten percent meat flavoring, according to what's listed on the box.

Several years ago there was a science fiction movie called Soylent Green. Like all great science fiction movies it starred Charlton Heston. It was set in the future when human overpopulation and global warming had killed off all the world's resources, and the entire human race was dependent on a type of food called Soylent Green. To make a very long story short, Heston played a detective who eventually discovered that Soylent Green was made out of recycled humans. I've included a UTube link to the crucial scene at the top of this post.

(Incidentally, when people talk about physician-assisted suicide I always free associate to the euthanasia scene from Soylent Green.)

So anyway, most of the civilian staff bring their lunches to work rather than risk the food in the officer's dining room. That worked fine until some unspecified employees (whether civilian or custody staff, I don't know) started smuggling contraband in inside their lunch bags. So then all the employees were required to bring their lunches in using clear plastic containers to make it easier to inspect the food on entry. So fine, everybody gets a clear plastic container.

Then more stuff gets smuggled in. Security rules change. There is a proposal to ban all outside food from coming in to the institution. The civilians are horrified that they might have to choose between starvation (only having a half hour for lunch means you can't really go out to eat) and eating Soylent Brown. We're talking Survivor-type reality show here. We're talking 'I may be forced to eat my co-worker' decisions. Fortunately, the no-outside-food rule gets voted down. Somehow the warden's office still gets to bring in catered food for special events; don't ask.

The bottom line is that news stories about cannibalism aren't nearly as interesting to me as the ever-changing security rules related to prison food. It's one of the things about my job that makes the work consistently challenging.

Sunday, December 16, 2007

Shooter Psychology


It appears that I'm destined to blog about this. Every time a shooting spree hits the news and several people get killed, I get a note from somewhere asking if I heard about the story and my thoughts about it.

I have to say up front that I'm reluctant to blog about spree killers. I didn't blog about Cho and the Virginia Tech shootings or about the Amish school shootings or about the shootings at the Omaha shopping mall. And now we have the shootings in Colorado. These high profile media blitzes just strike me as disrespectful and hurtful to the victims and the victims' loved ones. I don't want to be another mental health talking head discussing the pop psychology of criminals. It makes the criminal take on an almost fictional quality, like a character in a television series, and turns a real human being into nothing more than a profile:

"He was drunk, he was high, he was poor, he was desparate, he was abandoned by his wife or girlfriend, fired from his job, facing jail time, always a loser, always a loner, he was quiet or cantankerous or paranoid and litiginous. He listened to heavy metal, listened to rap music, wore dark clothes, wore a trench coat, never spoke, he said hi to the neighbors, seemed like a nice guy, never thought he would do something like this."

For me, these stories aren't theoretical. They are my patients. I've known more than one spree killer and several hostage-takers, and I can tell you that there is no single monolithic answer to the question of why someone pulls the trigger. For me the most concerning reason was reflected in the suicide note left by the Omaha shooter. It said: "I want to be famous." And now, thanks to the New York Times, he is.

This leads me to the final reason I don't want to blog about spree shooters. Because somewhere out there, right now, there is a sad, angry, desperate person who also wants to be famous. I want that person to know that he will not be, at least not here on Shrink Rap.


Thursday, November 15, 2007

Is This Psychiatry?

In her post Why Shrinks Don't Take Your Insurance Dinah talked about insurance reimbursement for psychiatrists and the effect of patient volume on revenue. She speculated that someone who ran purely a medication management practice could make a fair amount of money, but then she added this caveat: "I'm not sure I'd call it psychiatry, and I'm not sure how long I'd survive or how much better the patients would get, but hey."

I think I'm pretty qualified to answer those questions because I have the kind of practice Dinah is talking about. My clinical practice is entirely a medication management clinic within a prison. I have a high volume practice---two months ago I had the most patient contacts of any correctional psychiatrist in the state. I don't do high patient volumes for the money. I get paid the same hourly wage whether I see one patient in an hour or four. On the average, I see about three patients an hour. I see a large number of patients because there are a lot of people who need care and the majority of them have at least three risk factors for suicide. I see large numbers of patients for medication management because any one of them could die if I don't. And I don't do therapy sessions.

So is this psychiatry? Absolutely. I didn't become a psychiatrist because I wanted to be a therapist. I had no interest in psychotherapy and I honestly still don't. I became a psychiatrist because I enjoyed neuroanatomy and was really good at it and because I was fascinated by the functioning of the human brain. I wanted to be a 'real' doctor who treated people with serious brain diseases.

Do my patients get better? Some of them do, some of them don't, just like in private practice or any other branch of medicine. I can say that it's easier to tell if my medication management patients get better because I know what I'm treating and I have specific symptoms I can monitor. I think it's a little tougher to say that for psychotherapy; how do you know the therapy is working---because the patient says it helps and they say they like it? Because they keep coming back for more? Hard to tell.

Most psychiatrists practice in a range of settings, with a variety of patients, using a combination of therapeutic interventions. I don't have therapy sessions but I do provide crisis intervention and brief supportive counselling because sometimes the patient needs it right then, and you can't just cut them off and walk them into a counsellor's office. Psychiatrists in private practice usually have some patients who come only for medication management, and there are some patients who don't want psychotherapy. Some people might feel that advocating a med management-only practice exemplifies all that's wrong with the profession today, the death of the patient as an individual and the constriction of the profession. I counter that to cling to a private practice therapy model at the expense of public service med management is to abandon the most functionally impaired, at-risk patients whom only we are qualified to treat.

Sunday, June 24, 2007

Dr. Crippen, Blog Fodder

Oh he's done it now. He has truly done it. I have spent several years of my life working to become a doctor, only to have Dr. Crippen suggest that perhaps I and other women physicians don't have a right to certain specialties or job flexibility. He quotes a Dr. Sarah Blayney, who writes:

"The training jobs as they stand are all or nothing. You either do all the hours or don't get the post. I want to pursue a career in hospital medicine, which will mean me committing to a minimum of five years of fairly hefty on-calls. "

At the moment I am 24, single and am enjoying life. But in four or five years time my situation may have changed and I may not want to work those hours."

She said flexible working would be particularly relevant to female colleagues wanting to start a family, but said male colleagues were also interested in changing their hours. For example, some wanted to take time out to travel, she added."
Note that the need for flexible job hours is cited as a concern for both men and women. However, Dr. Crippen takes it upon himself to limit this issue to women:
"It is right and proper that women can pursue a career in medicine. But at what stage do we decide that the needs of medical training can no longer be subsumed by the needs of working mothers?"
Perhaps Dr. Crippen would do well to remember that not all women are, or are planning to be, mothers. Perhaps he would do well to remember that here are many other reasons for limiting on-call and extended working hours---like retaining one's sanity. But that's OK because he also suggests that: "Sarah lives in cloud-cuckoo land. She wants the job but she is not prepared to do the hours....You need to grow up a little.... Just because you are a girlie, you can’t expect medical training to be turned on its head."

Good God. I thought we had grown beyond that. I thought I had left thinking like that behind on my surgery rotation, along with the bra-snapping resident and the resident who once complained about me scrubbing in: "I found a medical student to help, but she's a girl." Given that over half of all medical students in training today are female, it's truly time for this discrimination to be over.

So please feel free to visit NHS Blog Doctor today and leave a comment. The only comment I have to say right now is: "Sic 'em!"


[From Clink: Sigh...she insists on modifying my post again...At least I can modify her awful color choice.]
Guess What? The first half of Chapter 10 is up on Double Billing.

Thursday, February 08, 2007

Discover Your Inner Hero

I have to admit I've never seen the television show Heroes. I understand the idea behind the show is that ordinary people discover they have extraordinary powers. That got me thinking about medical heroes. Usually when I hear that term I think about people like Dr. Edward Jenner who discovered the vaccination for small pox, or Walter Reed and his colleagues who voluntarily infected themselves with yellow fever to see if their vaccines worked. Medical heroes are people who do big, great things and cure diseases.

I dunno, I'm more fond of the television Heroes' common-man definition. I like the ordinary anonymous docs who go out every day and do extraordinary things. I like the public psychiatrists.

I wish there were more of them. Of the six remaining state hospitals in Maryland, three have psychiatrist positions that have been standing vacant for months. I won't even mention how tough it is to find public psychiatrists to work in corrections.

It's not for lack of trying. In the 1970's our state created the Maryland Plan, a program sponsored jointly by the University of Maryland and the Maryland Department of Mental Hygiene to train and recruit psychiatry residents for employment in the public sector. The Maryland Plan was supposed to be a model program that would fill the physician recruitment needs of our state facilities. It hasn't, not even after closing one hospital.

So where are the doctors? There are 180 psychiatry residency programs in the country; Charm City has two of them and they turn out a dozen or so psychiatrists a year. One of the programs is within walking distance of my prison. They're not walking in my direction.

According to the U.S. Department of Health and Human Services health workforce analysis for Maryland:

"There were 1,093 psychiatrists, 5,390 psychologists and 8,000 social workers in Maryland in 2000. This was equal to 21.3 psychiatrists, 101.5 psychologists, and 150.6 social workers per 100,000 population. Maryland ranked 5th among states in psychiatrists per capita (emphasis mine), 1st among states in psychologists per capita, and 31st among states in social workers per capita."
A search of the Maryland Psychiatric Society's directory will turn up 24 doctors under the category "public mental health system" but you'll get 192 if you search for "psychotherapy".

To add insult to injury, we can't even get public health service docs to work here because the Federal government has decided our need isn't great enough. To qualify for the loan repayment program psychiatrists have to work in a designated Health Professional Shortage Area (HPSA) with a need score of 19 or higher (on a scale of 0 to 100). The HPSA score is based on a convoluted algorithm involving poverty levels, demographic data and the number of mental health professionals in a given population. With a psychiatrist-to-resident ratio of 5000 to 1, Maryland doesn't even come close to the required 20,000 to 1 ratio needed to be a HPSA. There are no sites in Maryland with a need score this high. Correctional facilties get their own scoring system based on annual intakes and average length of stay, but again none of our facilities meet HPSA criteria even though we have longstanding open vacancies.

We're missing a few heroes. And they don't know what they're missing.

Thursday, January 11, 2007

My Big Fat Hissy-Fit


[Note: I sat on this post for a day to cool down and think about it. The title has been changed three times and I also removed a few triple exclamation marks. I've downgraded my rant from a Category IV to a Category II.]

I am about to have a screaming banchee hissy-fit. Consider yourself warned. I've been blogging for almost nine months now and so far have never gone on a full-fledged, died-in-the-wool rant. I am about to make up for lost time.

The topic is an article on CNN that was just posted an hour ago. It's a story about a New England Journal of Medicine paper regarding mortality rates of prisoners who have just been released. I haven't seen the full article yet, but as reported it involved "26,270 men and 3,967 women released from Washington state prisons from mid-1999 through 2003". It doesn't say how the causes of death were confirmed, but the study found that newly released offenders were 3.5 times more likely to die within two weeks of release than an age, race and sex-based comparison group. The most common cause of death was overdose followed by cardiac disease, homicide and suicide.

To all of this I say: "No kidding! How much money did you spend figuring this out?" We knew twenty years ago that incarceration had some protective effect. In 1987 the Johns Hopkins School of Public Health looked at mortality rates among Maryland prisoners and found that age-matched prisoners actually lived longer than men out in free society. The CNN article also noted that the increase in post-release death rates were replicated in studies done in Europe and Australia.

What am I ranting about? It's this except here:

Other experts said the results don't surprise them, because inmates have far more physical and mental health problems than other citizens, (and) often get inadequate treatment behind bars...
There ya go. It's obvious, isn't it? If they're locked up then by definition they are getting inadequate care. It's axiomatic. It's also a knee-jerk stereotype.

Excuse me? Didn't you just say that they die after they get out? Who do you think has been keeping them alive all those months? Are you about to suggest that every patient who dies after discharge from a hospital was obviously neglected while they were inpatient? What planet are you on?

The thing they aren't mentioning is that they have no way of knowing how long the offenders would have lived had they not been incarcerated. These people live dangerous, high risk lifestyles. They annoy other criminals and get murdered. They kill themselves. While they are incarcerated we generally manage to keep all of that from happening. I don't like reading about my patients in the newspaper when they turn up dead after release, but it happens. I really don't like it when people suggest it's because I didn't do a good enough job while they were inside.

The only useful thing about this article that I liked was the conclusion:

Rather than saddling emergency rooms (and taxpayers) with the cost of providing post-release health care, we need to find a model of continuing care for ex-offenders.

Amen. And when we get that accomplished we will have a model for the rest of free society. Ya gotta start somewhere.

Thanks. I feel better.
*********

Addendum: The print version of this story that came out later that day did not include that aggravating phrase. Instead, it concluded this:
Cause (of death) often is overdose of narcotics after forced clean years, study finds
In other words, they lose their tolerance for drugs when they're locked up and so they are more likely to die of accidental overdose when they relapse after release.