The Well Person

March 21, 2012

What does it mean to be “normal”?  We’re all unique, aren’t we?  We differ from each other in so many ways.  So what does it mean to say someone is “normal,” while someone else has a “disorder”?

This is, of course, the age-old question of psychiatric diagnosis.  The authors of the DSM-5, in fact, are grappling with this very question right now.  Take grieving, for example.  As I and others have written, grieving is “normal,” although its duration and intensity vary from person to person.  At some point, a line may be crossed, beyond which a person’s grief is no longer adaptive but dangerous.  Where that line falls, however, cannot be determined by a book or by a committee.

Psychiatrists ought to know who’s healthy and who’s not.  After all, we call ourselves experts in “mental health,” don’t we?  Surprisingly, I don’t think we’re very good at this.  We are acutely sensitive to disorder but have trouble identifying wellness.  We can recognize patients’ difficulties in dealing with other people but are hard-pressed to describe healthy interpersonal skills.  We admit that someone might be able to live with auditory hallucinations but we still feel an urge to increase the antipsychotic dose when a patient says she still hears “those voices.”   We are quick to point out how a patient’s alcohol or marijuana use might be a problem, but we can’t describe how he might use these substances in moderation.  I could go on and on.

Part of the reason for this might lie in how we’re trained.  In medical school we learn basic psychopathology and drug mechanisms (and, by the way, there are no drugs whose mechanism “maintains normality”—they all fix something that’s broken).  We learn how to do a mental status exam, complete with full descriptions of the behavior of manic, psychotic, depressed, and anxious people—but not “normals.”  Then, in our postgraduate training, our early years are spent with the most ill patients—those in hospitals, locked facilities, or emergency settings.  It’s not until much later in one’s training that a psychiatrist gets to see relatively more functional individuals in an office or clinic.  But by that time, we’re already tuned in to deficits and symptoms, and not to personal strengths, abilities, or resilience-promoting factors.

In a recent discussion with a colleague about how psychiatrists might best serve a large population of patients (e.g., in a “medical home” model), I suggested  that perhaps each psychiatrist could be responsible for a handful of people (say, 300 or 400 individuals).  Our job would be to see each of these 300-400 people at least once in a year, regardless of whether they have psychiatric diagnosis or not.  Those who have emotional or psychiatric complaints or who have a clear mental illness could be seen more frequently; the others would get their annual checkup and their clean bill of (mental) health.  It would be sort of like your annual medical visit or a “well-baby visit” in pediatrics:  a way for a person to be seen by a doctor, implement preventive measures,  and undergo screening to make sure no significant problems go unaddressed.

Alas, this would never fly in psychiatry.  Why not?  Because we’re too accustomed to seeing illness.  We’re too quick to interpret “sadness” as “depression”; to interpret “anxiety” or “nerves” as a cue for a benzodiazepine prescription; or to interpret “inattention” or poor work/school performance as ADHD.  I’ve even experienced this myself.  It is difficult to tell a person “you’re really doing just fine; there’s no need for you to see me, but if you want to come back, just call.”  For one thing, in many settings, I wouldn’t get paid for the visit if I said this.  But another concern, of course, is the fear of missing something:  Maybe this person really is bipolar [or whatever] and if I don’t keep seeing him, there will be a bad outcome and I’ll be responsible.

There’s also the fact that psychiatry is not a primary care specialty:  insurance plans don’t pay for an annual “well-person visit” with the a psychiatrist.  Patients who come to a psychiatrist’s office are usually there for a reason.  Maybe the patient deliberately sought out the psychiatrist to ask for help.  Maybe their primary care provider saw something wrong and wanted the psychiatrist’s input.  In the former, telling the person he or she is “okay” risks losing their trust (“but I just know something’s wrong, doc!“).  In the latter, it risks losing a referral source or professional relationship.

So how do we fix this?  I think we psychiatrists need to spend more time learning what “normal” really is.  There are no classes or textbooks on “Normal Adults.”  For starters, we can remind ourselves that the “normal” people around whom we’ve been living our lives may in fact have features that we might otherwise see as a disorder.  Learning to accept these quirks, foibles, and idiosyncrasies may help us to accept them in our patients.

In terms of using the DSM, we need to become more willing to use the V71.09 code, which means, essentially, “No diagnosis or condition.”  Many psychiatrists don’t even know this code exists.  Instead, we give “NOS” diagnoses (“not otherwise specified”) or “rule-outs,” which eventually become de facto diagnoses because we never actually take the time to rule them out!  A V71.09 should be seen as a perfectly valid (and reimbursable) diagnosis—a statement that a person has, in fact, a clean bill of mental health.  Now we just need to figure out what that means.

It is said that when Pope Julius II asked Michelangelo how he sculpted David out of a marble slab, he replied: “I just removed the parts that weren’t David.”  In psychiatry, we spend too much time thinking about what’s not David and relentlessly chipping away.  We spend too little time thinking about the healthy figure that may already be standing right in front of our eyes.


Is The Criticism of DSM-5 Misguided? Part II

March 14, 2012

A few months ago, I wrote about how critics of the DSM-5 (led by Allen Frances, editor of the DSM-IV) might be barking up the wrong tree.  I argued that many of the problems the critics predict are not the fault of the book, but rather how people might use it.  Admittedly, this sounds a lot like the “guns don’t kill people, people do” argument against gun control (as one of my commenters pointed out), or a way for me to shift responsibility to someone else (as another commenter wrote).  But it’s a side of the issue that no one seems to be addressing.

The issue emerges again with the ongoing controversy over the “bereavement exclusion” in the DSM-IV.  Briefly, our current DSM says that grieving over a loved one does not constitute major depression (as long as it doesn’t last more than two months) and, as such, should not be treated.  However, some have argued that this exclusion should be removed in DSM-5.  According to Sidney Zisook, a UCSD psychiatrist, if we fail to recognize and treat clinical depression simply because it occurs in the two-month bereavement period, we do those people a “disservice.”  Likewise, David Kupfer, chair of the DSM-5 task force, defends the removal of the bereavement exclusion because “if patients … want help, they should not be prevented from getting [it] because somebody tells them that this is what everybody has when they have a loss.”

The NPR news program “Talk of the Nation” featured a discussion of this topic on Tuesday’s broadcast, but the guests and callers described the issue in a more nuanced (translation: “real-world”) fashion.  Michael Craig Miller, Editor of the Harvard Mental Health Letter, referred to the grieving process by saying: “The reality is that there is no firm line, and it is always a judgment call…. labels tend not to matter as much as the practical concern, that people shouldn’t feel a sense of shame.  If they feel they need some help to get through something, then they should ask for it.”  Bereavement and the need for treatment, therefore, is not a yes/no, either/or proposition, but something individually determined.

This sentiment was echoed in a February 19 editorial in Lancet by the psychiatrist/anthropologist Arthur Kleinman, who wrote that the experience of loss “is always framed by meanings and values, which themselves are affected by all sorts of things like one’s age, health, financial and work conditions, and what is happening in one’s life and in the wider world.”  Everyone seems to be saying pretty much the same thing:  people grieve in different ways, but those who are suffering should have access to treatment.

So why the controversy?  I can only surmise it’s because the critics of DSM-5 believe that mental health clinicians are unable to determine who needs help and, therefore, have to rely on a book to do so.  Listening to the arguments of Allen Frances et al, one would think that we have no ability to collaborate, empathize, and relate with our patients.  I think that attitude is objectionable to anyone who has made it his or her life’s work to treat the emotional suffering of others, and underestimates the effort that many of us devote to the people we serve.

But in some cases the critics are right.  Sometimes clinicians do get answers from the book, or from some senseless protocol (usually written by a non-clinician).  One caller to the NPR program said she was handed an antidepressant prescription upon her discharge from the hospital after a stillbirth at 8 months of pregnancy.  Was she grieving?  Absolutely.  Did she need the antidepressant?  No one even bothered to figure that out.  It’s like the clinicians who see “bipolar” in everyone who has anger problems; “PTSD” in everyone who was raised in a turbulent household; or “ADHD” in every child who does poorly in school.

If a clinician observes a symptom and makes a diagnosis simply on the basis of a checklist from a book, or from a single statement by a patient, and not on the basis of his or her full understanding, experience, and clinical assessment of that patient, then the clinician (and not the book) deserves to take full responsibility for any negative outcome of that treatment.  [And if this counts as acceptable practice, then we might as well fire all the psychiatrists and hire high-school interns—or computers!—at a mere fraction of the cost, because they could do this job just as well.]

Could the new DSM-5 be misused?  Yes.  Drug companies could (and probably will) exploit it to develop expensive and potentially harmful drugs.  Researchers will use it to design clinical trials on patients that, regrettably, may not resemble those in the “real world.”  Unskilled clinicians will use it to make imperfect diagnoses and give inappropriate labels to their patients.  Insurance companies will use the labels to approve or deny treatment.  Government agencies will use it to determine everything from who’s “disabled” to who gets access to special services in preschool.  And, of course, the American Psychiatric Association will use it as their largest revenue-generating tool, written by authors with extensive drug-industry ties.

To me, those are the places where critics should focus their rage.  But remember, to most good clinicians, it’s just a book—a field guide, helping us to identify potential concerns, and to guide future research into mental illness and its treatment.  What we choose to do with such information depends upon our clinical acumen and our relationship with our patients.  To assume that clinicians will blindly use it to slap the “depression” label and force antidepressants on anyone whose spouse or parent just died “because the book said so,” is insulting to those of us who actually care about our patients, and about what we do to improve their lives.


Two Psychiatries

March 12, 2012

A common—and ever-increasing—complaint of physicians is that so many variables interfere with our ability to diagnose and treat disease:  many patients have little or no access to preventive services; lots of people are uninsured; insurance plans routinely deny necessary care; drug formularies are needlessly restrictive; paperwork never ends; and the list goes on and on.  Beneath the frustration (and, perhaps, part of the source of it) is the fact that medical illness, for the most part, has absolutely nothing to do with these external burdens or socioeconomic inequalities.  Whether a patient is rich or poor, black or white, insured or uninsured—a disease is a disease, and everyone deserves the same care.

I’m not so sure whether the same can be said for psychiatry.  Over the last four years, I’ve spent at least part of my time working in community mental health (and have written about it here and here).  Before that, though—and for the majority of my training—I worked in a private, academic hospital setting.  I saw patients who had good health insurance, or who could pay for health care out of pocket.  I encountered very few restrictions in terms of access to medications or other services (including multiple types of psychotherapy, partial hospitalization programs, ECT, rTMS, clinical trials of new treatments, etc).  I was fortunate enough to see patients in specialty referral clinics, where I saw fascinating “textbook” cases of individuals who had failed to respond to years of intensive treatment.  It was exciting, stimulating, thought-provoking, and—for lack of a better word—academic.  (Perhaps it’s not surprising that this the environment in which textbooks, and the DSM, are written.)

When I started working in community psychiatry, I tried to approach patients with the same curiosity and to employ the same diagnostic strategies and treatment approach.  It didn’t take long for me to learn, however, that these patients had few of the resources I had taken for granted elsewhere.  For instance, psychotherapy was difficult to arrange, and I was not reimbursed for doing it myself.  Access to medications depended upon capricious, unpredictable (and illogical) formularies.  Patients found it difficult to get to regular appointments or to come up with the co-payment, not to mention pay the electric bill or deal with crime in their neighborhood.  It was often hard to obtain a coherent and reliable history, and records obtained from elsewhere were often spotty and unhelpful.

It all made for a very challenging place in which to practice what I (self-righteously) called “true” psychiatry.  But maybe community psychiatry needs to be redefined.  Maybe the social stressors encountered by community psych patients—not the least of which is substandard access to “quality” medical and psychiatric services—result in an entirely different type of mental distress, and demand an entirely different type of intervention.

(I should point out that I did see, at times, examples of the same sort of mental illness I saw in the private hospital, and which did respond to the same interventions that the textbooks predicted.  While this reaffirmed my hope in the validity of [at least some] mental illnesses, this was a small fraction of the patients I saw.)

Should we alter our perceptions and definitions of illness—and of “psychiatry” itself—in public mental health?  Given the obstacles found in community psychiatry settings (absurdly brief appointment times; limited psychotherapy; poor prescription drug coverage; high rates of nonadherence and substance abuse; reliance on ERs for non-emergency care, often resulting in complicated medication regimens, like dangerous combinations of narcotics and benzodiazepines), should we take an entirely different approach?  Does it even make sense to diagnose the same disorders—not to mention put someone on “disability” for these disorders—when there are so many confounding factors involved?

One of my colleagues suggested: just give everyone an “adjustment disorder” diagnosis until you figure everything out.  Good idea, but you won’t get paid for diagnosing “adjustment disorder.”  So a more “severe” diagnosis must be given, followed closely thereafter by a medication (because many systems won’t let a psychiatrist continue seeing a patient unless a drug is prescribed).  Thus, in a matter of one or two office visits (totaling less than an hour in most cases), a Medicaid or uninsured patient might end up with a major Axis I diagnosis and medication(s), while the dozens of stressors that may have contributed to the office visit in the first place go unattended.

Can this change?  I sure hope so.  I firmly believe that everyone deserves access to mental health care.  (I must also point out that questionable diagnoses and inappropriate medication regimens can be found in any demographic.)  But we psychiatrists who work in community settings must not delude ourselves into thinking that what’s written in the textbooks or tested on our Board exams always holds true for the patients we see.  It’s almost as if we’re practicing a “different psychiatry,” one that requires its own diagnostic system, different criteria for “disability” determinations, a different philosophy of “psychotherapy,” and where medications should be used much more conservatively.  (It might also help to perform clinical trials with subjects representative of those in community psychiatry, but due to their complexity, this is highly unlikely).

Fortunately, a new emphasis on the concept of “recovery” is taking hold in many community mental health settings.  This involves patient empowerment, self-direction, and peer support, rather than a narrow focus on diagnosis and treatment.  For better or for worse, such an approach relies less on the psychiatrist and more on peers and the patient him- or herself.  It also just seems much more rational, emphasizing what patients want and what helps them to succeed.

Whether psychiatrists—and community mental health as a whole—are able to follow this trend remains to be seen.  Unless we do, however, I fear that we may continue to mislead ourselves into believing that we’re doing good, when in fact we’re perpetuating a cycle of invalid diagnoses, potentially harmful treatment, and, worst of all, over-reliance on a system designed for a distinctly different type of “care” than what these individuals need and deserve.


How To Think Like A Psychiatrist

March 4, 2012

The cornerstone of any medical intervention is a sound diagnosis.  Accurate diagnosis guides the proper treatment, while an incorrect diagnosis might subject a patient to unnecessary procedures or excessive pharmacotherapy, and it may further obscure the patient’s true underlying condition.  This is true for all medical specialties—including psychiatry.  It behooves us, then, to examine the practice of clinical decision-making, how we do it, and where we might go wrong, particularly in the area of psychiatric diagnosis.

According to Pat Croskerry, a physician at Dalhousie University in Canada, the foundation of clinical cognition the “dual process model,” first described by the Greek philosophers (and reviewed here).  This model proposes that people solve problems using one of two “processes”:  Type 1 processes involve intuition and are largely automatic, fast, and unconscious (e.g., recognizing a friend’s face).  Type 2 processes are more deliberate, analytical, and systematic (e.g., planning the best route for an upcoming trip).  Doctors use both types when making a diagnosis, but the relative emphasis varies with the setting.  In the ED, quick action based on pattern recognition (i.e., Type 1 process) is crucial.  Sometimes, however, it may be wrong, particularly if other conditions aren’t evaluated and ruled out (i.e., Type 2 process).  For instance, a patient with flank pain, nausea, vomiting, and hematuria demonstrates the “pattern” of a kidney stone (common), but may in fact have a dissecting aortic aneurysm (uncommon).

This model is valuable for understanding how we arrive at psychiatric diagnoses (the above figure is from a 2009 article by Croskerry).  When evaluating a patient for the first time, a psychiatrist often looks at “the big picture”:  Does this person appear to have a mood disorder, psychosis, anxiety, a personality disorder?  Have I seen this type of patient before?  What’s my general impression of this person?  In other words, the assessment relies heavily on Type 1 processes, using heuristics and “Gestalt” impressions.  But Type 2 processes are also important.  We must inquire about specific symptoms, treatment history, social background; we might order tests or review old records, which may change our initial perception.

Sound clinical decision-making, therefore, requires both processes.  Unfortunately, these are highly prone to error.  In fact, Croskerry identifies at least 40 cognitive biases, which occur when the processes are not adapted for the specific task at hand.  For instance, we tend to use Type 1 processes more frequently than we should.  Many psychiatrists, particularly those seeing a large volume of patients for short periods of time, often see patterns earlier than is warranted, and rush to diagnoses without fully considering all possibilities.  In other words, they fall victim to what psychologist Keith Stanovich calls “dysrationalia,” or the inability to think or act rationally despite adequate intelligence.  In the dual process model, dysrationalia can “override” Type 2 processes (“I don’t need to do a complete social history, I just know this patient has major depression”), leading to diagnostic failure.

Croskerry calls this the “cognitive miser” function: we rely on processes that consume fewer cognitive resources because we’re cognitively lazy.  The alternative would be to switch to a Type 2 process—a more detailed evaluation, using deductive, analytic reasoning.  But this takes great effort and time.  Moreover, when a psychiatrist switches to a “Type 2” mode, he or she asks questions are nonspecific in nature (largely owing to the unreliability of some DSM-IV diagnoses), or questions that confirm the initial “Type 1” hunch.  In other words, we end up finding we expect to find.

The contrast between Type 1 and Type 2 processes is most apparent when we observe people operating at either end of the spectrum.  Some psychiatrists see patterns in every patient (e.g., “I could tell he was bipolar as soon as he walked into my office”—a classic error called the representativeness heuristic), even though they rarely ask about specific symptoms, let alone test alternate hypotheses.  On the other hand, medical students and young clinicians often work exclusively in Type 2; they ask very thorough questions, covering every conceivable alternative, and every symptom in the DSM-IV (even irrelevant ones).  As a result, they get frustrated when they can’t determine a precise diagnosis or, alternately, they come up with a diagnosis that might “fit” the data but completely miss the mark regarding the underlying essence of the patient’s suffering.

Croskerry writes that the most accurate clinical decision-making occurs when a physician can switch between Type 1 and Type 2 processes  as needed, a process called metacognition.  Metacognition requires a certain degree of humility, a willingness to re-examine one’s decisions in light of new information.  It also demands that the doctor be able to recognize when he or she is not performing well and to be willing to self-monitor and self-criticize.  To do this, Croskerry recommends that we develop “cognitive forcing strategies,” deliberate interventions that force us to think more consciously and deliberately about the problem at hand.  This may help us to be more accurate in our assessments:  in other words, to see both the trees for the forest, and the forest for the trees.

This could be a hard sell.  Doctors can be a stubborn bunch.  Clinicians who insist on practicing Type 2,  “checklist”-style medicine (e.g., in a clinical trial) may be unwilling to consider the larger context in which specific symptoms arise, or they may not have sufficient understanding of that context to see how it might impact a patient.  On the other hand, clinicians who rush to judgment based on first impressions (a Type 1 process) may be annoyed by any suggestion that they should slow down and be more thorough or methodical.  Not to mention the fact that being more thorough takes more time. And as we all know, time is money.

I believe that all psychiatrists should heed the dual-process model and ask how it influences their practice.  Are you too quick to label and diagnose, owing to your “dysrational” (Type 1) impulses?  On the other hand, if you use established diagnostic criteria (Type 2), are you measuring anything useful?  Should you use a cognitive forcing strategy to avoid over-reliance on one type of decision-making?  If you continue to rely on pattern recognition (Type 1 process), then what other data (Type 2) should you collect?  Treatment history?  A questionnaire?  Biomarkers?  A comprehensive assessment of social context?  And ultimately, how do you use this information to diagnose a “disorder” in a given individual?

These are just a few questions that the dual process model raises.  There are no easy answers, but anything that challenges us to be better physicians and avoid clinical errors, in my opinion, is well worth our time, attention, and thought.


Disruptive Technology Vs. The Disruptive Physician

February 26, 2012

The technological advances of just the last decade—mobile computing, social networking, blogging, tablet computers—were never thought to be “essential” when first introduced.  But while they started as novelties, their advantages became apparent, and today these are all part of our daily lives.  These are commonly referred to as “disruptive technologies”:  upstart developments that originally found their place in niche markets outside of the mainstream, but gradually “disrupted” the conventional landscape (and conventional wisdom) to become the established ways of doing things.

In our capitalist economy, disruptive technology is considered a very good thing.  It has made our lives easier, more enjoyable, and more productive.  It has created no small number of multimillionaires.  Entrepreneurs worldwide are constantly looking for the next established technologies to disrupt, usurp, and overturn, in hopes of a very handsome payoff.

In medicine, when we talk about “disruption,” the implication is not quite as positive.  In fact, the term “disruptive physician” is an insult, a black mark on one’s record that can be very hard to overcome.  It refers to someone who doesn’t cooperate, doesn’t follow established protocols, yells at people, discriminates against others, who might abuse drugs or alcohol, or who is generally incompetent.  These are not good things.

Really?  Now, no one would argue that substance abuse, profanity, spreading rumors, degrading one’s peers, or incompetence are good.  But what about the physician who “expresses political views that are disagreeable to the hospital administration”?  How about the physician who speaks out about deficiencies in patient care or patient safety, or who (legitimately) points out the incompetence of others?  How about the physician who prioritizes his own financial and/or business objectives over those of the hospital (when in fact it may be the only way to protect one’s ability to practice)?  All of these have been considered to be “disruptive” behaviors and could be used by highly conservative medical staffs to discipline physicians and preserve the status quo.

Is this fair?  In modern psychiatry, with its shrinking appointment lengths, overreliance on the highly deficient DSM, excessive emphasis on pharmacological solutions, and an increasing ignorance of developmental models and psychosocial interventions among practitioners, maybe someone should stand up and express opinions that the “powers that be” might consider unacceptable.  Someone should speak out on behalf of patient safety.  Someone should point out extravagant examples of waste, incompetence, or abuse of privilege.  Plenty of psych bloggers and a few renegade psychiatrists do express these opinions, but they (we?) are a minority.  I don’t know of any department chairmen or APA officers who are willing to be so “disruptive.”  As a result, we’re stuck with what we’ve got.

That’s not to say there aren’t any disruptive technologies in psychiatry.  What are they?  Well, medications, for instance.  Drug treatment “disrupted” psychoanalysis and psychotherapy, and represent the foundation of most psychiatric treatment today.  Over the last 30 years, pharmaceutical companies (and prescribers) have earned millions of dollars from SSRIs, SNRIs, second-generation antipsychotics, psychostimulants, and many others.  But are people less mentally ill now than they were in the early 1980s?  Today—just in time for patent expirations!—we’re already seeing the next disruptive medication technologies, like those based on glutamate and glutamine signaling.  According to Stephen Stahl at the most recent NEI Global Congress, “we’ve beaten the monoamine horse sixteen ways to Sunday” (translation: we’ve milked everything we can out of the serotonin and dopamine stories) and glutamate is the next blockbuster drug target to disrupt the marketplace.

Another disruptive technology is the DSM.  I don’t have much to add to what’s already been written about the DSM-5 controversy except to point out what should be obvious:  We don’t need another DSM right now.  Practically speaking, a new DSM is absolutely unnecessary.  It will NOT help me treat patients any better.  But it’s coming, like it or not.  It will disrupt the way we have conducted our practices for the last 10 years (guided by the equally imperfect DSM-IV-TR), and it will put millions more dollars in the coffers of the APA.

And then, of course, is the electronic medical record (EMR).  As with the DSM-5, I don’t need to have an EMR to practice psychiatry.  But some politicians in Washington, DC, decided that, as a component of the Affordable Care Act (and in preparation for truly nationalized health care), we should all use EMRs.  They even offered a financial incentive to doctors to do so (and are levying penalties for not doing so).  And despite some isolated benefits (which are more theoretical than practical, frankly), EMRs are disruptive.  Just not in the right way.  They disrupt work flow, the doctor-patient relationship, and, sometimes, common sense.  But they’re here to stay.

Advances in records & database management, in general, are the new disruptive technologies in medicine.  Practice Fusion, a popular (and ad-supported) EMR has earned tens of millions of dollars in venture capital funding and employs over 150 people.  And what does it do with the data from the 28 million patients it serves?  It sells it to others, of course.  (And it can tell you fun things like which cities are most “lovesick.”  How’s that for ROI?)

There are many other examples of companies competing for your health-care dollar, whose products are often only peripherally related to patient care but which represent that holy grail of the “disruptive technology.”  There are online appointment scheduling services, telepsychiatry services, educational sites heavily sponsored by drug companies, doctor-only message boards (which sell doctors’ opinions to corporations), drug databases (again, sponsored by drug companies), and others.

In the interest of full disclosure, I use some of the above services, and some are quite useful.  I believe telemedicine, in particular, has great potential.  But at the end of the day, these market-driven novelties ignore some of the bigger, more entrenched problems in medicine, which only practicing docs see.  In my opinion, the factors that would truly help psychiatrists take better care of patients are of a different nature entirely:  improving psychiatric training (of MDs and non-MD prescribers); emphasizing recovery and patient autonomy in our billing and reimbursement policies; eliminating heavily biased pharmaceutical advertising (both to patients and to providers); revealing the extensive and unstated conflicts of interest among our field’s “key opinion leaders”; reforming the “disability” system and disconnecting it from Medicaid, particularly among indigent patients; and reallocating health-care resources more equitably.  But, as a physician, if I were to go to my superiors with any ideas to reform the above in my day-to-day work, I run the risk of being labeled “disruptive.”  When in fact, that would be my exact intent:  to disrupt some of the damaging, wasteful practices that occur in our practices almost every day.

I agree that disruption in medicine can be a good thing, and can advance the quality and cost-effectiveness of care.  But when most of the “disruptions” come from individuals who are not actively in the trenches, and who don’t know where needs are the greatest, we may be doing absolutely nothing to improve care.  Even worse, when we fail to embrace the novel ideas of physicians—but instead discipline those physicians for being “disruptive”—we risk punishing creativity, destroying morale, and fostering a sense of helplessness that, in the end, serves no one.


Measuring The Immeasurable

February 9, 2012

Is psychiatry a quantitative science?  Should it be?

Some readers might say that this is a ridiculous question.  Of course it should be quantitative; that’s what medicine is all about.  Psychiatry’s problem, they argue, is that it’s not quantitative enough.  Psychoanalysis—that most qualitative of “sciences”—never did anyone any good, and most psychotherapy is, likewise, just a bunch of hocus pocus.  A patient saying he feels “depressed” means nothing unless we can measure how depressed he is.  What really counts is a number—a score on a screening tool or checklist, frequency of a given symptom, or the blood level of some biomarker—not some silly theory about motives, drives, or subconscious conflicts.

But sometimes measurement can mislead us.  If we’re going to measure anything, we need to make sure it’s something worth measuring.

By virtue of our training, physicians are fond of measuring things.  What we don’t realize is that the act of measurement itself leads to an almost immediate bias.  As we assign numerical values to our observations, we start to define values as “normal” or “abnormal.”  And medical science dictates that we should make things “normal.”  When I oversee junior psychiatry residents or medical students, their patient presentations are often filled with such statements as “Mr. A slept for 5 hours last night” or “Ms. B ate 80% of her meals,” or “Mrs. C has gone two days without endorsing suicidal ideation,” as if these are data points to be normalized, just as potassium levels and BUN/Cr ratios need to be normalized in internal medicine.

The problem is, they’re not potassium levels or BUN/Cr ratios.  When those numbers are “abnormal,” there’s usually some underlying pathology which we can discover and correct.  In psychiatry, what’s the pathology?  For a woman who attempted suicide two days ago, does it really matter how much she’s eating today?  Does it really matter whether an acutely psychotic patient (on a new medication, in a chaotic inpatient psych unit with nurses checking on him every hour) sleeps 4 hours or 8 hours each night?  Even the questions that we ask patients—“are you still hearing voices?”, “how many panic attacks do you have each week?” and the overly simplistic “can you rate your mood on a scale of 1 to 10, where 1 is sad and 10 is happy?”— attempt to distill a patient’s overall subjective experience into an elementary quantitative measurement or, even worse, into a binary “yes/no” response.

Clinical trials take measurement to an entirely new level.  In a clinical trial, often what matters is not a patient’s overall well-being or quality of life (although, to be fair, there are ways of measuring this, too, and investigators are starting to look at this outcome measure more closely), but rather a HAM-D score, a MADRS score, a PANSS score, a Y-BOCS score, a YMRS score, or any one of an enormous number of other assessment instruments.  Granted, if I had to choose, I’d take a HAM-D score of 4 over a score of 24 any day, but does a 10- or 15-point decline (typical in some “successful” antidepressant trials) really tell you anything about an individual’s overall state of mental health?  It’s hard to say.

One widely used instrument, the Clinical Global Impression scale, endeavors to measure the seemingly immeasurable.  Developed in 1976 and still in widespread use, the CGI scale has three parts:  the clinician evaluates (1) the severity of the patient’s illness relative to other patients with the same diagnosis (CGI-S); (2) how much the patient’s illness has improved relative to baseline (CGI-I); and (3) the efficacy of treatment.  (See here for a more detailed description.)  It is incredibly simple.  Basically, it’s just a way of asking, “So, doc, how do you think this patient is doing?” and assigning a number to it.  In other words, subjective assessment made objective.

The problem is, the CGI has been criticized precisely for that reason—it’s too subjective.  As such, it is almost never used as a primary outcome measure in clinical trials.  Any pharmaceutical company that tries to get a drug approved on the basis of CGI improvement alone would probably be laughed out of the halls of the FDA.  But what’s wrong with subjectivity?  Isn’t everything that counts subjective, when it really comes down to it?  Especially in psychiatry?  The depressed patient who emerges from a mood episode doesn’t describe himself as “80% improved,” he just feels “a lot better—thanks, doc!”  The psychotic patient doesn’t necessarily need the voices to disappear, she just needs a way to accept them and live with them, if at all possible.  The recovering addict doesn’t think in terms of “drinking days per month,” he talks instead of “enjoying a new life.”

Nevertheless, measurement is not a fad, it’s here to stay.  And as the old saying goes, resistance is futile.  Electronic medical records, smartphone apps to measure symptoms, online checklists—they all capitalize on the fact that numbers are easy to record and store, easy to communicate to others, and satisfy the bean counters.  They enable pharmacy benefit managers to approve drugs (or not), they enable insurers to reimburse for services (or not), and they allow pharmaceutical companies to identify and exploit new markets.  And, best of all, they turn psychiatry into a quantitative, valid science, just like every other branch of medicine.

If this grand march towards increased quantification persists, the human science of psychiatry may cease to exist.  Unless we can replace these instruments with outcome measures that truly reflect patients’ abilities and strengths, rather than pathological symptoms, psychiatry may be replaced by an impersonal world of questionnaires, checklists, and knee-jerk treatments.  In some settings, that that’s what we have now.  I don’t think it’s too late to salvage the human element of what we do.  A first step might be simply to use great caution when we’re asked to give a number, measure a symptom, or perform a calculation, on something that is intrinsically a subjective phenomenon.  And to remind ourselves that numbers don’t capture everything.


Do What You’re Taught

February 5, 2012

In my mail yesterday was an invitation to an upcoming 6-hour seminar on the topic of “Trauma, Addiction, and Grief.”  The course description included topics such as “models of addiction and trauma/information processing” and using these models to plan treatment; recognizing “masked grief reactions” and manifestations of trauma in clients; and applying several psychotherapeutic techniques to help a patient through addiction and trauma recovery.

Sound relevant?  To any psychiatrist dealing with issues of addiction, trauma, grief, anxiety, and mood—which is pretty much all of us—and interested in integrative treatments for the above, this would seem to be an entirely valid topic to learn.  And, I was pleased to learn that the program offers “continuing education” credit, too.

But upon reading the fine print, credit is not available for psychiatrists.  Instead, you can get credit if you’re one the following mental health workers:  counselor, social worker, MFT, psychologist, addiction counselor, alcoholism & drug abuse counselor, chaplain/clergy, nurse, nurse practitioner, nurse specialist, or someone seeking “certification in thanatology” (whatever that is).  But not a psychiatrist.  In other words, psychiatrists need not apply.

Well, okay, that’s not entirely correct, psychiatrists can certainly attend, and–particularly if the program is a good one—my guess is that they would clearly benefit from it.  They just won’t get credit for it.

It’s not the first time I’ve encountered this.  Why do I think this is a big deal?  Well, in all of medicine, “continuing medical education” credit, or CME, is a rough guide to what’s important in one’s specialty.  In psychiatry, the vast majority of available CME credit is in psychopharmacology.  (As it turns out, in the same batch of mail, I received two “throwaway” journals which contained offers of free CME credits for reading articles about treating metabolic syndrome in patients on antipsychotics, and managing sexual side effects of antidepressants.)  Some of the most popular upcoming CME events are the Harvard Psychopharmacology Master Class and the annual Nevada Psychopharmacology Update.  And, of course, the NEI Global Congress in October is a can’t-miss event.  Far more psychiatrists will attend these conferences than a day-long seminar on “trauma, addiction, and grief.”  But which will have the most beneficial impact on patients?

To me, a more important question is, which will have the most beneficial impact on the future of the psychiatrist?   H. Steven Moffic, MD, recently wrote an editorial in Psychiatric Times in which he complained openly that the classical “territory” of the psychiatrist—diagnosis of mental disorder, psychotherapy, and psychopharmacology—have been increasingly ceded to others.  Well, this is a perfect example.  A seminar whose content is probably entirely applicable to most psychiatric patients, being marketed primarily to non-psychiatrists.

I’ve always maintained—on this blog and in my professional life—that psychiatrists should be just as (if not more) concerned about the psychological, cultural, and social aspects of their patients and their experience as in their proper psychopharmacological management.  It’s also just good common sense, especially when viewed from the patient’s perspective.  But if psychiatrists (and our leadership) don’t advocate for the importance of this type of experience, then of course others will do this work, instead of us.  We’re making ourselves irrelevant.

I’m currently experiencing this irony in my own personal life.  I’m studying for the American Board of Psychiatry and Neurology certification exam (the “psychiatry boards”), while looking for a new job at the same time.  On the one hand, while studying for the test I’m being forced to refresh my knowledge of human development, the history of psychiatry, the theory and practice of psychotherapy, the cognitive and psychological foundations of axis I disorders, theories of personality, and many other topics.  That’s the “core” subject matter of psychiatry, which is (appropriately) what I’ll be tested on.  Simultaneously, however, the majority of the jobs I’m finding require none of that.  I feel like I’m being hired instead for my prescription pad.

Psychiatry, as the study of human experience and the treatment of a vast range of human suffering, can still be a fascinating field, and one that can offer so much more to patients.  To be a psychiatrist in this classic sense of the word, it seems more and more like one has to blaze an independent trail: obtain one’s own specialized training, recruit patients outside of the conventional means, and—unless one wishes to live on a relatively miserly income—charge cash.  And because no one seriously promotes this version of psychiatry, this individual is rapidly becoming an endangered species.

Maybe I’ll get lucky and my profession’s leadership will advocate more for psychiatrists to be better trained in (and better paid for) psychotherapy, or, at the very least, encourage educators and continuing education providers to emphasize this aspect of our training as equally relevant.  But as long as rank-and-file psychiatrists sit back and accept that our primary responsibility is to diagnose and medicate, and rabidly defend that turf at the expense of all else, then perhaps we deserve the fate that we’re creating for ourselves.


Whatever Works?

January 29, 2012

My iPhone’s Clock Radio app wakes me each day to the live stream of National Public Radio.  Last Monday morning, I emerged from my post-weekend slumber to hear Alix Spiegel’s piece on the serotonin theory of depression.  In my confused, half-awake state, I heard Joseph Coyle, professor of psychiatry at Harvard, remark: “the ‘chemical imbalance’ is sort of last-century thinking; it’s much more complicated than that.”

Was I dreaming?  It was, admittedly, a surreal experience.  It’s not every day that I wake up to the voice of an Ivy League professor lecturing me in psychiatry (those days are long over, thank Biederman god).  Nor did I ever expect a national news program to challenge existing psychiatric dogma.  As I cleared my eyes, though, I realized, this is the real deal.  And it was refreshing, because this is what many of us have been thinking all along.  The serotonin hypothesis of depression is kaput.

Understandably, this story has received lots of attention (see here and here and here and here and here).  I don’t want to jump on the “I-told-you-so” bandwagon, but instead to offer a slightly different perspective.

A few disclaimers:  first and foremost, I agree that the “chemical imbalance” theory has overrun our profession and has commandeered the public’s understanding of mental illness—so much so that the iconic image of the synaptic cleft containing its neurotransmitters has become ensconced in the national psyche.  Secondly, I do prescribe SSRIs (serotonin-reuptake inhibitors), plus lots of other psychiatric medications, which occasionally do work.  (And, in the interest of full disclosure, I’ve taken three of them myself.  They did nothing for me.)

To the extent that psychiatrists talk about “chemical imbalances,” I can see why this could be misconstrued as “lying” to patients.  Ronald Pies’ eloquent article in Psychiatric Times last summer describes the chemical-imbalance theory as “a kind of urban legend,” which no “knowledgeable, well-trained psychiatrist” would ever believe.  But that doesn’t matter.  Thanks to us, the word is out there.  The damage has already been done.  So why, then, do psychiatrists (even the “knowledgeable, well-trained” ones) continue to prescribe SSRI antidepressants to patients?

Because they work.

Okay, maybe not 100% of the time.  Maybe not even 40% of the time, according to antidepressant drug trials like STAR*D.  Experience shows, however, that they work often enough for patients to come back for more.  In fact, when discussed in the right context, their potential side effects described in detail, and prescribed by a compassionate and apparently intelligent and trusted professional, antidepressants probably “work” far more than they do in the drug trials.

But does that make it right to prescribe them?  Ah, that’s an entirely different question.  Consider the following:  I may not agree with the serotonin theory, but if I prescribe an SSRI to a patient with depression, and they report a benefit, experience no obvious side effects, pay only $4/month for the medication, and (say) $50 for a monthly visit with me, is there anything wrong with that?  Plenty of doctors would say, no, not at all.  But what if my patient (justifiably so) doesn’t believe in the serotonin hypothesis and I prescribe anyway?  What if my patient experiences horrible side effects from the drug?  What if the drug costs $400/month instead of $4?  What if I charge the patient $300 instead of $50 for each return visit?  What if I decide to “augment” my patient’s SSRI with yet another serotonin agent, or an atypical antipsychotic, causing hundreds of dollars more, and potentially causing yet more side effects?  Those are the aspects that we don’t often think of, and constitute the unfortunate “collateral damage” of the chemical-imbalance theory.

Indeed, something’s “working” when a patient reports success with an antidepressant; exactly why and how it “works” is less certain.  In my practice, I tell my patients that, at individual synapses, SSRIs probably increase extracellular serotonin levels (at least in the short-term), but we don’t know what that means for your whole brain, much less for your thoughts or behavior.  Some other psychiatrists say that “a serotonin boost might help your depression” or “this drug might act on pathways important for depression.”   Are those lies?  Jeffrey Lacasse and Jonathan Leo write that “telling a falsehood to patients … is a serious violation of informed consent.”  But the same could be said for psychotherapy, religion, tai chi, ECT, rTMS, Reiki, qigong, numerology, orthomolecular psychiatry, somatic re-experiencing, EMDR, self-help groups, AA, yoga, acupuncture, transcendental meditation, and Deplin.  We recommend these things all the time, not knowing exactly how they “work.”

Most of those examples are rather harmless and inexpensive (except for Deplin—it’s expensive), but, like antidepressants, all rest on shaky ground.  So maybe psychiatry’s problem is not the “falsehood” itself, but the consequences of that falsehood.  This faulty hypothesis has spawned an entire industry capitalizing on nothing more than an educated guess, costing our health care system untold millions of dollars, saddling huge numbers of patients with bothersome side effects (or possibly worse), and—most distressingly to me—giving people an incorrect and ultimately dehumanizing solution to their emotional problems.  (What’s dehumanizing about getting better, you might ask?  Well, nothing, except when “getting better” means giving up one’s own ability to manage his/her situation and instead attribute their success to a pill.)

Dr Pies’ article in Psychiatric Times closed with an admonition from psychiatrist Nassir Ghaemi:  “We must not be drawn into a haze of promiscuous eclecticism in our treatment; rather, we must be guided by well-designed studies and the best available evidence.”  That’s debatable.  If we wait for “evidence” for all sorts of interventions that, in many people, do help, we’ll never get anywhere.  A lack of “evidence” certainly hasn’t eliminated religion—or, for that matter, psychoanalysis—from the face of the earth.

Thus, faulty theory or not, there’s still a place for SSRI medications in psychiatry, because some patients swear by them.  Furthermore—and with all due respect to Dr Ghaemi—maybe we should be a bit more promiscuous in our eclecticism.  Medication therapy should be offered side-by-side with competent psychosocial treatments including, but not limited to, psychotherapy, group therapy, holistic-medicine approaches, family interventions, and job training and other social supports.  Patients’ preferences should always be respected, along with safeguards to protect patient safety and prevent against excessive cost.  We may not have good scientific evidence for certain selections on this smorgasbord of options, but if patients keep coming back, report successful outcomes, and enter into meaningful and lasting recovery, that might be all the evidence we need.


Where Doctors Get Their Information

January 24, 2012

Doctors spend four years in medical school, still more years in residency, and some devote even more years to fellowship training.   All of this work is done under direct supervision, and throughout the process, trainees learn from their teachers, mentors, and supervisors.  But medicine changes very rapidly.  After all of this training—i.e., once the doctor is “out in the real world”—how does he or she keep up with the latest developments?

Medical journals are the most obvious place to start.  Many doctors subscribe to popular journals like the New England Journal of Medicine or JAMA, or they get journals as a perk of membership in their professional society (for example, the American Journal of Psychiatry for members of the APA).  But the price of journals—and professional society memberships—can accumulate quickly, as can the stacks of unread issues on doctors’ desks.

A second source is continuing medical education credit.  “CMEs” are educational units that doctors are required to obtain in order to keep their medical license.  Some CME sources are excellent, although most CMEs are absurdly easy to obtain (e.g., you watch an online video; answer a few multiple-choice questions about a brief article; or show up for the morning session of a day-long conference, sign your name, then head out the door for a round of golf), making their educational value questionable.  Also, lots of CMEs are funded by pharmaceutical or medical device manufacturers (see here), where bias can creep in.

Direct communication with drug companies—e.g., drug sales reps—can also be a source of information.  Some universities and health-care organizations have “cracked down” on this interaction, citing inappropriate sales techniques and undue influence on doctors.  While docs can still contact the medical departments (or “medical science liaisons”) of big drug companies, this source of info appears to be running dry.

So what’s left?  Medical textbooks?  They’re usually several years out of date, even at the time of publication.  Medical libraries?  Unless you’re affiliated with a teaching hospital, those libraries are off-limits.  “Throwaway” journals?  Every specialty has them—they arrive in the mail, usually unrequested, and contain several topical articles and lots of advertising; but these articles generally aren’t peer-reviewed, and the heavy advertising tends to bias their content.  Medical websites?  Same thing.  (WebMD, for instance, is heavily funded by industry—a point that has not escaped the attention of watchdog senator Charles Grassley.)

Thus, the doctor in the community (think of the psychiatrist in a small group practice in your hometown) is essentially left alone, in the cold, without any unbiased access to the latest research.  This dilemma has become starkly apparent to me in the last several months.  Since last summer, I have worked primarily in a community hospital.  Because it is not an academic institution, it does not provide its employees or trainees access to the primary literature (and yes, that includes psychiatry residents).  I, on the other hand, have been fortunate enough to have had a university affiliation for most of my years of practice, so I can access the literature.  If I need to look up the details of a recent study, or learn about new diagnostic procedures for a given disorder, or prepare for an upcoming talk, I can find just about anything I need.  But this is not the case for my colleagues.  Instead, they rely on textbooks, throwaway journals, or even Wikipedia.  (BTW, Wikipedia isn’t so bad, according to a recent study out of Australia.  But I digress…)

Obviously, if one uses “free” resources to obtain medical information, that info is likely to be as unbiased as the last “free” Cymbalta dinner he or she attended.  Many doctors don’t recognize this.

When it comes to journals, it gets potentially more interesting.  All of the top medical journals are available online.  And, like many online newspapers and magazines, articles are available for a fee.  But the fees are astronomical—typically $30 or $35 per article—which essentially prohibits any doc from buying more than one or two, let alone doing exhaustive research on a given subject.

Interestingly, some articles are freely available (“open access” is the industry term).  You can try this yourself:  go to pubmed.gov and search for a topic like “bipolar disorder” or “schizophrenia.”  You’ll get thousands of results.  Some results are accompanied by the “Free Article” tag.  You can guess which articles most docs will choose to read.

Why are some articles free while others aren’t?  What’s the catch?  Well, sometimes there is no catch.  For one, the National Institutes of Health (NIH) requires any research done with its funding to be freely available within six months of a paper’s publication.  This makes sense: NIH funds are our tax dollars, so it’s only fair that we get to see the data.  (But even this is coming under attack, since the publishers want to protect their content—and revenue stream.)

Interestingly, though, some journals also have a “pay-for-open-access” policy, in which an author can pay a higher publication fee to make his/her article freely available.  In other words, if I publish a (non-NIH-funded) study but want it to reach a wider audience than simply those ivory-tower types with access to fully-stocked libraries, I can just pay extra.  That’s right, some publishers give me the option to pay to attract readers like community docs, the lay public, journalists, and others (not to mention potential investors in a company with which I’m affiliated).  The policy for Elsevier, one of the world’s largest academic publishers, on such “sponsored articles” can be found here.

You can see where this might lead.  Call me cynical, but paying for more eyeballs sounds a lot like advertising.  Of course, these are peer-reviewed articles, so they do meet some standards of scientific integrity.  (Or do they?  A recent article suggests that “narrative reviews” often misrepresent or overstate claims of medication efficacy.  See also this summary of the article by Neuroskeptic.)

Anyway, the take-home message is, unfortunately, one that we’ve heard all too often.  Science is supposed to be pristine, objective, and unbiased, but it’s clearly not.  Even when you take out the obvious advertising, the drug-rep showmanship, and the pharma-funded CME, there are still ways for a product-specific message to make its way to a doctor’s eyes and ears.  And if our medical journals supposedly represent the last bastion of scientific integrity—the sacred repository of truth in a world of direct-to-consumer advertising, biased KOLs, and Big Pharma largesse—we should be particularly cautious when they fail to serve that purpose.


The Unfortunate Therapeutic Myopia of the EMR

January 19, 2012

There’s a lot you can say about an electronic medical record (EMR).  Some of it is good: it’s more legible than a written chart, it facilitates billing, and it’s (usually) readily accessible.  On the other hand, EMRs are often cumbersome and confusing, they encourage “checklist”-style medicine, and they contain a lot of useless or duplicate information.  But a recent experience in my child/adolescent clinic opened my eyes to where an EMR might really mislead us.

David, a 9 year-old elementary school student, has been coming to the clinic every month for the last three years.  He carries a diagnosis of “bipolar disorder,” manifested primarily as extreme shifts in mood, easy irritability, insomnia, and trouble controlling his temper, both in the classroom and at home.  Previous doctors had diagnosed “oppositional defiant disorder,” then ADHD, then bipolar.  He had had a trial of psychostimulants with no effect, as well as some brief behavioral therapy.  Somewhere along the way, a combination of clonidine and Risperdal was started, and those have been David’s meds for the last year.

The information in the above paragraph came from my single interaction with David and his mom.  It was the first time I had seen David; he was added to my schedule at the last minute because the doctor he had been seeing for the last four months—a locum tenens doc—was unavailable.

Shortly before the visit, I had opened David’s EMR record to review his case, but it was not very informative.  Our EMR only allows one note to be open at a time, and I saw the same thing—”bipolar, stable, continue current meds”—and some other text, apparently cut & pasted, in each of his last 3-4 notes.  This was no big surprise; EMRs are full of cut & pasted material, plus lots of other boilerplate stuff that is necessary for legal & billing purposes but can easily be ignored.  The take-home message, at the time, was that David had been fairly stable for at least the last few months and probably just needed a refill.

During the appointment, I took note that David was a very pleasant child, agreeable and polite.  Mom said he had been “doing well.”  But I also noticed that, throughout the interview, David’s mom was behaving strangely—her head bobbed rhythmically side to side, and her arms moved in a writhing motion.  She spoke tangentially and demonstrated some acute (and extreme) shifts in emotion, at one point even crying suddenly, with no obvious trigger.

I asked questions about their home environment, David’s access to drugs and alcohol, etc., and I learned that mom used Vicodin, Soma, and Xanax.  She admitted that they weren’t prescribed to her—she bought them from friends.  Moreover, she reported that she “had just taken a few Xanax to get out the door this morning” which, she said, “might explain why I’m acting like this.”  She also shared with me that she had been sent to jail four years ago on an accusation of child abuse (she had allegedly struck her teenage daughter during an argument), at which time David and his brothers were sent to an emergency children’s shelter for four nights.

Even though I’m not David’s regular doctor, I felt that these details were relevant to his case.  It was entirely possible, in my opinion, that David’s home environment—a mother using prescription drugs inappropriately, a possible history of trauma—had contributed to his mood lability and “temper dysregulation,” something that a “bipolar” label might mask.

But I’m not writing this to argue that David isn’t “bipolar.”  Instead, I wish to point out that I obtained these details simply by observing the interaction between David and his mom over the course of ~30 minutes, and asking a few questions, and not by reading his EMR record.  In fact, after the appointment I reviewed the last 12 months of his EMR record, which showed dozens of psychiatrists’ notes, therapists’ notes, case manager’s notes, demographic updates, and “treatment plans,” and all of it was generally the same:  diagnosis, brief status updates, LOTS of boilerplate mumbo-jumbo, pages and pages of checkboxes, a few mentions of symptoms.  Nothing about David’s home situation or mom’s past.  In fact, nothing about mom at all.  I could not have been the first clinician to have had concerns about David’s home environment, but if such information was to be found in his EMR record, I had no idea where.

Medical charts—particularly in psychiatry—are living documents.  To any physician who has practiced for more than a decade or so, simply opening an actual, physical, paper chart can be like unfolding a treasure map:  you don’t know what you’ll find, but you know that there may be riches to be revealed.   Sometimes, while thumbing through the chart, a note jumps out because it’s clearly detailed or something relevant is highlighted or “flagged” (in the past, I learned how to spot the handwriting of the more perceptive and thorough clinicians).  Devices like Post-It notes or folded pages provide easy—albeit low-tech—access to relevant information.  Also, a thick paper chart means a long (or complicated) history in treatment, necessitating a more thorough review.  Sometimes the absence of notes over a period of time indicates a period of decompensation, a move, or, possibly a period of remission.  All of this is available, literally, at one’s fingertips.

EMRs are far more restrictive.  In David’s case, the EMR was my only source of information—apart from David himself.  And for David, it seemed sterile, bland, just a series of “check-ins” of a bipolar kid on Risperdal.  There was probably more info somewhere in there, but it was too difficult and non-intuitive to access.  Hence, the practice (adopted by most clinicians) of just opening up the patient’s most recent note—and that’s it.

Unfortunately, this leads to a therapeutic myopia that may change how we practice medicine.  EMRs, when used this way, are here-and-now.  They have become the medical equivalent of Facebook.  When I log on to the EMR, I see my patient’s most recent note—a “status update,” so to speak—but not much else.  It takes time and effort to search through a patient’s profile for more relevant historical info—and that’s if you know where to look.  After working with seven different EMRs in the last six years, I can say that they’re all pretty similar in this regard.  And if an electronic chart is only going to be used for its most recent note, there’s no incentive to be thorough.

Access to information is great.  But the “usability” of EMRs is so poor that we have easy access only to what the last clinician thought was important.  Or better yet, what he or she decided to document.  The rest—like David’s home life, the potential impact of his mother’s behavior on his symptoms, and environmental factors that require our ongoing attention, all of which may be far more meaningful than David’s last Risperdal dose—must be obtained “from scratch.”  If it is obtained at all.


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