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Playing The Role

October 16, 2011

One of the most time-honored pedagogical tools in medicine is the “role play.”  The concept is simple:  one individual plays the part of another person (usually a patient) while a trainee examines or questions him or her, for the purposes of learning ways to diagnose, treat, and communicate more effectively.

Last week I had the privilege of attending a motivational interviewing training seminar.  Motivational interviewing (or MI) is a therapeutic technique in which the clinician helps “motivate” the patient into making healthy lifestyle choices through the use of open-ended questions, acknowledging and “rolling with” the patient’s resistance, and eliciting the patient’s own commitment to change.  The goal is to help the patient make a decision for himself, rather than requiring the clinician to provide a directive or an “order” to change a behavior.

MI is an effective and widely employed strategy, frequently used in the treatment of addictions.  Despite its apparent simplicity, however, it is important to practice one’s skills in order to develop proficiency.  Here, simulations like role-playing exercises can be valuable.  As part of my seminar, I engaged in such an exercise, in which our trainer played the part of a methamphetamine addict while a trainee served as the clinician.

The discussion went something like this:

Clinician:  “How would you like things to be different in your life?”
Patient:  “Well, I think I might be using too much meth.”
Clinician:  “So you think you’re using too much methamphetamine.”
Patient:  “Yeah, my friends are urging me to cut back.”
Clinician:  “How important is it for you to decrease your use?”
Patient:  “Oh, it would really make things easier for me.”
Clinician:  “How confident are you that you could cut back?”
Patient:  “Well, it would be tough.”
Clinician:  “What would make you even more confident?”
Patient:  “If I had some support from other people.”
Clinician:  “Who could provide you with that support?”
Patient:  “Hmm… I do have some friends who don’t use meth.”
Clinician:  “I see.  Can you think of some ways to spend more time with those friends?”
Patient:  “I do know that they go swimming on Thursday nights.  Maybe I can ask if I can join them.”
Clinician:  “I think this would be a good decision.  Can I help you to do this by giving you a telephone call on Wednesday?”
Patient:  “Yes, thank you.”

Of course, I’m paraphrasing somewhat.  But the bottom line is that the whole exercise lasted about ten minutes, and in that ten-minute span, the trainee had taken an ambivalent methamphetamine addict and convinced him to spend an evening with some non-meth-using friends, all through the magic of motivational interviewing.

In real clinical practice, nothing is quite so simple.  And none of us in the room (I hope) were so naïve as to think that this would happen in real life.  But the strategies we employed were so basic (right “out of the book,” so to speak), we could have used this time—and the expertise of our trainer—to practice our skills in a more difficult (i.e., real-world) situation.

It reminded me of a similar exercise in a class during my psychiatry residency, in which our teacher, a psychiatrist in private practice in our community, asked me to role-play a difficult patient, while he would act as therapist and demonstrate his skills in front of our class.  The patient I chose was a particularly challenging one—especially to a novice therapist like myself—who had a habit of repeating back my questions word-for-word with a sarcastic smile on her face, and openly questioning my abilities as a therapist.

During the role-play, I played the part quite well (I thought), giving him the uncomfortable looks and critical comments that my patient routinely gave me.  But this didn’t sit well with him.  He got visibly angry, and after just a few minutes he abruptly stood up and told me to leave the class.  Later that day I received a very nasty email from him accusing me of “sabotaging” his class and “making [him] look like a fool.”  He called my actions “insubordination” and asked me not to return to the class, also suggesting that my actions were “grounds for dismissal from the residency.”

[He also went off on a tangent about some perfectly reasonable—even amiable—emails we had exchanged several weeks earlier, accusing me now of having used “too many quotation marks” which, he said, seemed “unprofessional” and “inappropriate” and demanded an apology!!  He also wrote that in the several weeks of class I had shown him a “tangible tone of disrespect,” even though he had never said anything to me before.  While I believe his paranoid stance may have betrayed some underlying mental instability, I must admit I have not spoken to him since, although he continues to teach and to supervise residents.]

Anyway, these experiences—and others over the years—have led me to question the true meaning of a role-playing exercise.  In its ideal form, a simulation provides the novice with an opportunity to observe a skilled clinician practicing his or her craft, even under challenging circumstances, or provides a safe environment for the novice to try new approaches—and to make mistakes doing so.  But more often than not, a role-playing exercise is a staged production, in which the role-player is trying to make a point.  In actual practice, no patient is a “staged” patient (and those who do give rehearsed answers often have some ulterior motive).  Real patients have a nearly infinite variety of histories, concerns, and personal idiosyncracies for which no “role playing” exercise can ever prepare a therapist.

I’m probably being too harsh.  Role-plays and simulations will always be part of a clinician’s training, and I do recognize their value in learning the basic tools of therapy.  The take-home message, however, is that we should never expect real patients to act as if they’re reading off a script from our textbooks.  And as a corollary, we should use caution when taking our patients’ words and making them fit our own preconceived script.  By doing so, we may be fooling ourselves, and we might miss what the patient really wants us to hear.

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Dr. Quickfix, Redux

March 7, 2011

Last weekend’s NY Times article, which I wrote about in my last post, has, predictably, resulted in a deluge of responses from many observers.  The comments posted to the NYT “Well” blog (over 160 as of this writing) seem to be equally critical of Dr Levin and of our health care reimbursement system, which, according to the article, forced him to make the Faustian bargain to sacrifice good patient care in favor of a comfortable retirement.  Other bloggers and critics have used this as an opportunity to champion the talents and skills of psychologists, psychotherapists, and nurse practitioners, none of whom, according to the article, face the same financial pressures—or selfishness—of psychiatrists like Dr Levin.

While the above observations are largely valid (although one colleague pointed out that psychologists and NPs can have financial pressures too!), I chose to consider the patients’ point of view.  In my post, I pointed out that many patients seem to be satisfied with the rapid, seemingly slapdash approach of modern psychopharmacology.  I wrote how, in one of my clinic settings, a community mental health center, I see upwards of 20-30 patients a day, often for no more than 10-15 minutes every few months.  Although there are clear exceptions, many patients appreciate the attention I give them, and say they like me.  The same is also true for patients with “good insurance” or for those who pay out-of-pocket:  a 15-minute visit seems to work just fine for a surprising number of folks.

I remarked to a friend yesterday that maybe there are two types of patients:  those who want hour-long, intense therapy sessions on an ongoing basis (with or without medications), and those who are satisfied with quick, in-and-out visits and medication management alone.  My argument was that our culture has encouraged this latter approach in an unfortunate self-propagating feedback cycle:  Not only does our reimbursement process force doctors (and patients) to accept shorter sessions just to stay afloat, but our hyperactive, “manic” culture favors the quick visits, too; indeed, some patients just can’t keep seated in the therapist’s chair for more than ten minutes!

She responded, correctly, that I was being too simplistic.  And she’s right.  While there are certainly examples of the two populations I describe above, the vast majority of patients accept it because the only other option is no care at all.  (It’s like the 95% of people with health insurance who said during the health care reform debate that they were “satisfied” with their coverage; they said so because they feared the alternative.)  She pointed out that the majority of patients don’t know what good care looks like.  They don’t know what special skills a psychiatrist can bring to the table that a psychologist or other counselor cannot (and vice versa, for that matter).  They don’t know that 15 minutes is barely enough time to discuss the weather, much less reach a confident psychiatric diagnosis.  They don’t know that spending a little more money out of pocket for specialized therapy, coaching, acupuncture, Eastern meditation practice, a gym membership, or simply more face-time with a good doc, could result in treatment that is more inspiring and life-affirming than any antidepressant will ever be.

So while my colleagues all over the blogosphere whine about the loss of income wrought by the nasty HMOs and for-profit insurance companies (editorial comment: they are nasty) and the devolution of our once-noble profession into an army of pill pushers, I see this as a challenge to psychiatry.  We must make ourselves more relevant, and to do so we have to let patients know that what we can offer is much more than what they’re getting.  Patients should not settle for 10 minutes with a psychiatrist and a hastily written script. But they’ll only believe this if we can convince them otherwise.

It’s time for psychiatrists to think beyond medications, beyond the DSM, and beyond the office visit.  Psychiatrists need to make patients active participants in their care, and challenge them to become better people, not just receptacles for pills.  Psychiatrists also need to be doctors, and help patients to understand the physical basis of mental symptoms, how mental illness can disrupt physical homeostasis, and what our drugs do to our bodies.

Patients need to look at psychiatrists as true shepherds of the mind, soul, and body, and, in turn, the psychiatrist’s responsibility is to give them reason to do so.  It may cost a little more in terms of money and time, but in the long run it could be money well spent, for patients and for society.

Psychiatrists are highly educated professionals who entered this field not primarily to make money, but to help others.  If we can do this more effectively than we do now, the money will surely follow, and all will be better served.


Dr. Quickfix Will See You Now

March 5, 2011

A cover story by Gardiner Harris in Sunday’s New York Times spotlights the changes in modern psychiatry, from extensive, psychotherapy-based interaction to brief, medication-oriented “psychopharm” practice.  The shift has transpired over the last decade or longer; it was brilliantly described in T.R. Luhrmann’s 2000 book Of Two Minds, and has been explored ad nauseum in the psychiatric literature, countless blogs (including this one), and previously in the New York Times itself.

The article shares nothing new, particularly to anyone who has paid any attention to the rapid evolution of the psychiatric profession over the last ten years (or who has been a patient over the same period).  While the article does a nice job of detailing the effect this shift has had on Donald Levin, the psychiatrist profiled in the article, I believe it’s equally important to consider the effect it has had on patients, which, in my opinion, is significant.

First, I should point out that I have been fortunate to work in a variety of psychiatric settings.  I worked for years in a long-term residential setting, which afforded me the opportunity to engage with patients about much more than just transient symptoms culminating in a quick med adjustment.  I have also chosen to combine psychotherapy with medication management in my current practice (which is financially feasible—at least for now).

However, I have also worked in a psychiatric hospital setting, as well as a busy community mental health center.  Both have responded to the rapid changes in the health care reimbursement system by requiring shorter visits, more rushed appointments, and an emphasis on medications—because that’s what the system will pay for.  This is clearly the direction of modern psychiatry, as demonstrated in the Times article.

My concern is that when a patient comes to a clinic knowing that he’ll only have 10 or 15 minutes with a doctor, the significance of his complaints gets minimized.  He is led to believe that his personal struggles—which may in reality be substantial—only deserve a few minutes of the doctor’s time, or can be cured with a pill.  To be sure, it is common practice to refer patients to therapists when significant lifestyle or psychosocial issues may underlie their suffering (and if they’re lucky, insurance might pay for it), but when this happens, the visit with the doctor is even more rushed.

I could make an argument here for greater reimbursement for psychiatrists doing therapy, or even for prescribing privileges for psychologists (who provide the more comprehensive psychotherapy).  But what’s shocking to me is that patients often seem to be okay with this hurried, fragmented, disconnected care.

Quoting from the article (emphasis mine):

[The patient] said she likes Dr. Levin and feels that he listens to her.

Dr. Levin expressed some astonishment that his patients admire him as much as they do.

“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”

It is sad.  I’ve received the same sort of praise and positive feedback from a surprising number of patients, even when I feel that I’ve just barely scratched the surface of their distress (and might have even forgotten their names since their last visit!), and believe that I’m simply pacifying them with a prescription.  At times, calling myself a “psychiatrist” seems unfair, because I feel instead like a prescription dispenser with a medical school diploma on the wall.

And yet people tell me that they like me, just as they like Dr. Levin.  They believe I’m really helping them by listening to them for a few minutes, nodding my head, and giving a pill.  Are the pills really that effective?  (Here I think the answer is clearly no, because treatment failures are widespread in psychiatry, and many are even starting to question the studies that got these drugs approved in the first place.)  Or do my words—as brief as they may be—really have such healing power?

I’ve written about the placebo effect, which can be defined as either the ability of a substance to exert a much more potent effect than what would be anticipated, or as a person’s innate ability to heal oneself.  Perhaps what we’re seeing at work here is a different type of placebo effect—namely, the patient’s unconscious acceptance of this new way of doing things (i.e., spending less time trying to understand the origins of one’s suffering, and the belief that a pill will suffice) and, consequently, the efficacy of this type of ultra-rapid intervention, which goes against everything we were trained to do as psychiatrists and therapists.

In an era where a person’s deepest thoughts can be shared in a 140-character “tweet” or in a few lines on Facebook (and Charlie Sheen can be diagnosed in a five-minute Good Morning America interview), perhaps it’s not surprising that many Americans believe that depression, anxiety, mood swings, impulsivity, compulsions, addictions, eating disorders, personality disorders, and the rest of the gamut of human suffering can be treated in 12-minute office visits four months apart.

Either that, or health insurance and pharmaceutical companies have done a damn good job in training us that we’re much less complicated than we thought we were.


To Treat Depression, Just Give ‘Em What They Want

February 23, 2011

A doctor’s chief task is to determine the cause of a patient’s suffering and to develop a course of treatment.  In psychiatry, the task is no different: examine the patient, determine a diagnosis, and initiate treatment.  However, “treatment” comes in many forms, and what works for one patient may not work for another.  A good psychiatrist tries to figure out which approach is ideal for the patient in his office, rather than reflexively reaching for the prescription pad and the latest drug option.

How to determine what’s the best course of action for a patient?  Recent research suggests one potentially foolproof way:  Ask him.

A paper in this month’s Psychotherapy and Psychosomatics by Mergl and colleagues shows that patient preference (that is, whether the patient prefers medications or psychotherapy) predicts how effective a treatment will be.  In their study, patients who expressed a preference for medications at the beginning of treatment had a better response to Zoloft than to group therapy, while patients who preferred therapy showed the exact opposite response.

In an even larger study published in 2009 by James Kocsis and colleagues at Weill-Cornell in New York (comparing nefazodone, an antidepressant, with a cognitive therapy approach called CBASP), a similar result was obtained:  patients with chronic major depression who entered the study expressing a preference for drug treatment had higher remission rates when receiving medication than when receiving psychotherapy, and vice versa.

The numbers were quite shocking:

Patients who preferred medication:

Treatment received Remission rate Avg. depression score (HAM-D) at end of study (high score = more depressed)
Meds 45.5% 11.6
Therapy 22.2% 21.0

Patients who preferred therapy:

Treatment received Remission rate Avg. depression score (HAM-D) at end of study
Meds 7.7% 18.3
Therapy 50.0% 12.1

(original HAM-D scores were approximately 26-27 for all patients, constituting major depression, and patients in this study had been depressed for over two years)

Thus, if a depressed patient wanted therapy but got medications instead, their chances of “remitting” (ie, having a fully therapeutic response to nefazodone) were less than 1 in 12.  But if they did get therapy, those chances improved to 1 in 2.  Interestingly, patients who preferred therapy and got combination treatment (meds and therapy) actually did worse than with therapy alone (remission rate was only 38.9%), leading the authors to conclude that “few patients who stated a preference for psychotherapy benefited much from the addition of medication.”

It’s not surprising, at first glance, that people who “get what they want” do better.  After all, a depressed patient who insists on taking meds probably won’t get much better if he’s dragged into psychotherapy against his will, and the patient who believes that a weekly session with a therapist is exactly what she needs, will probably have some resistance to just getting a pill.

But then again, isn’t depression supposed to be a hard-wired biological illness?  Shouldn’t a medication have a more profound effect, regardless of whether the patient “wants” it or not?

Apparently not.  The fact that people responded to the treatment they preferred means one of two things.  There may be two different types of depression, one that’s biological and one that’s more behavioral or “exogenous,” and people just happen to choose the appropriate treatment for their type due to some predisposition or innate tendency (self-knowledge?).  Alternatively, the “biological” basis of depression is not all it’s cracked up to be.

One question raised by these results is, why don’t we listen more to our patients and give them what they say they want?  If half the people who want therapy actually get better with therapy, doesn’t that make it hard to justify meds for this population?  Conversely, when we talk about “treatment-resistant depression,” or “depression that doesn’t respond to antidepressants alone,” could it be that the people who don’t respond to pills are simply those who would rather engage in psychotherapy instead?

I believe the implications of these findings may be significant.  For one thing, insurers are becoming less likely to pay for therapy, while they spend more and more money on antidepressant medications.  These studies say that this is exactly what we don’t want to do for a large number of patients (and these patients are easy to identify—they’re the ones who tell us they don’t want meds!).  Furthermore, trials of new antidepressant treatments should separate out the self-described “medication responders” and “therapy responders” and determine how each group responds.  [Note:  in the large STAR*D trial, which evaluated “switching” strategies, patients were given the opportunity to switch from meds to therapy or from one med to a different one of their choosing, but there was no group of patients who didn’t have the option to switch.]  If the “therapy responders” routinely fail to respond to drugs, we need to seriously revamp our biological theories of depression.  Its chemical basis may be something entirely different from how our current drugs are thought to work, or maybe depression isn’t “biological” at all in some people.  This will also keep us from wasting money and resources on treatments that are less likely to work.

While it’s often risky to ask a patient what he or she wants (and to give it to them), depression may be just the opportunity to engage the patient in a way that respects their desires.  These data show that the patient may know more than the doctor what “works” and what doesn’t, and maybe it’s time we pay closer attention.


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