Thursday, January 1, 2015

2015 and......



I was going to try to post about alcohol consumption prior to New years Eve, but am still working on that post.  Instead, I found myself reacting to a post on LinkedIn entitled "10 Warning Signs That Your Psychiatrist Is Not A Good Fit" by Amanda Itzkoff, MD.  Look for it on LinkedIN if you are a member and see what you think.  I found it fairly stark and negative.  I found myself immediately typing up my own top ten list on how you know you have found a competent psychiatrist.  That may not fit the usual blogger message that critical statements that apply to only a few is the only reason for commentary.  One of my reasons for writing this blog is that the tremendous number of colleagues who I personally know are all very competent and the list is a composite of what anyone would find walking in to talk with any one of them.  That list follows.

I had thought about posting a list of what I plan to continue to do here in the coming year but decided that was unnecessary.  You can certainly go to any number of blogs to find out what is wrong with psychiatry or psychiatrists.  Much of it is hyperbole.  I hope that you will find what I write here is a realistic antidote to those other sites.



    Top Ten Signs Your Psychiatrist Is Competent


1.  You are understood.

Your psychiatrist makes it very clear to you that he/she understands the problem and all of the mitigating factors by formulating the problem and treatment plan, restating it to you, and giving you useful advice.  That also includes discussing the relationship that you have with the psychiatrist and any concerns that you have about it.  That is one aspect of seeing a psychiatrist that differs from seeing other physicians.  You should be comfortable bringing up any concerns and clarifying any potential misunderstandings.  Your psychiatrist should also be able to answer the basic question about whether you have any diagnosis or problem that requires treatment.  Your psychiatrist should be focused on a discussion of your problems and your best interest should be the focus of treatment.

2.  Your psychiatrist is an expert.

Your psychiatrist has technical expertise in the field and is comfortable discussing new treatments and innovation in the field ranging from psychotherapy to brain science.  That includes an awareness of the current limitations of treatment.

3.  Your psychiatrist knows medicine.

During the initial assessment and beyond, your psychiatrist pays close attention to any other medical problems that you have and how the treatment he/she prescribes might affect those conditions.  That includes being able to diagnose new medical conditions that can lead to psychiatric presentations and ordering the appropriate tests to follow potential complications of any new treatments or how new treatments might impact existing conditions.  That includes a willingness and an ability to talk with the other generalists and specialists providing your medical care.

4.  Your psychiatrist takes enough time.

The assessment and treatment of complicated problems takes time.  Many psychiatrists are in clinics where there are allowed only brief periods of time (10 to 20 minutes) for assessment and treatment.  Many people are satisfied with that amount of time, but if you are not - a different treatment setting may offer more time.  That can be discussed with the current psychiatrist and a referral to psychiatrists practicing in different settings can be obtained.

5.  If medications are involved your psychiatrist thoroughly explains the risks, benefits, and limitations of treatment.

Like most areas of medicine, medical treatments have their limitations.  That includes medications that are not completely effective in alleviating symptoms, side effects, and occasional very serious side effects.  Your psychiatrist should be able to help you negotiate that area and provide you with more detailed information for further study on request.  You should believe that your psychiatrist is taking any concern you have about side effects very seriously.  The discussion of side effects is as important as a discussion of potential therapeutic effects.  Any informed discussion of medical treatment should also include a discussion of non-medical approaches.  Many people are surprised to learn than non-medical approaches are more effective than medications in the treatment of several severe mental health problems.

6.  Your psychiatrist knows about addiction.

A significant number of people being treated by psychiatrists have problems with addiction.  Addiction can cause psychiatric problems and complicate the care of psychiatric problems.  Even if your psychiatrist is not an addiction specialist, he/she should be able to advise you in how to get well and not increase the risk for relapse if you are sober.  Your psychiatrist should also be able to advise you in approaches to your problems if you are not sober.  Chronic pain is also an associated problem and your psychiatrist should be able to make an assessment of your chronic pain problem and how it affects associated mental health and addiction problems.   

7.  Your psychiatrist is able to tell you about things that you do not want to hear.

That can cover a broad range of topics from your expectations about medication and psychotherapy, to unrealistic expectations, to boundary problems involving what appear to be straightforward problems like filling out a disability form.  One example would be concerns about a diagnosis of Attention Deficit-Hyperactivity Disorder (ADHD).  A lot of adults seek treatment for this problem and in many cases they are also expecting an approach that leads to enhanced cognition.  A consulting psychiatrist should be able to say that they do not have ADHD and that stimulant medications are not currently indicated for cognitive enhancement.  


8.   Your psychiatrist is concerned about your safety.

One of the characteristics of some mental health problems is that the safety of the person involved is compromised.   Psychiatrists are trained to make these assessments and determine a plan to address the problem.  Many psychiatric disorders result in impaired insight and judgment that is restored once the primary problem is treated.  It is often useful to have a discussion about that in advance.  Some states have a psychiatric advanced directive that is useful to direct your care in the event of an acute episode of illness that affects your judgment.  We live in a litigious society and physicians are often accused of “covering” themselves by making very conservative decisions.  These decisions are most likely driven more by safety concerns than malpractice concerns.  

9.   Your psychiatrist is willing to talk with your family.

You should be certain that your confidentiality is protected at all times per an explicit agreement with your psychiatrist.  That agreement should include emergency contingencies and advise you about the statutes in your state that affect confidentiality.  You should also expect that when you want your psychiatrist to talk with your family that he/she will do that.  For certain aspects of treatment planning such as discharge planning from hospitals and gathering diagnostic information, discussions with family are critical.

10.   Your psychiatrist is mindful of your financial concerns.

Mental health services are the most rationed services in medical care in the US.  That typically results in more out-of-pocket costs for people receiving psychiatric care than other types of medical or surgical care.  Your psychiatrist should be able to discuss the cost aspects of all forms of care.  That includes medication costs and also the cost of ongoing psychotherapy. Cost effective alternatives for both psychotherapy and medical assessment and treatment should be as easily discussed as any other aspect of treatment.  Your psychiatrist is often placed in an impossible situation by the insurance industry.  The insurance industry often makes it seem like your psychiatrist is responsible for decisions that are really the result of insurance industry rationing.  Any concerns you have about the financial basis for decisions should be clarified with your psychiatrist.




Happy New Year!

George Dawson, MD, DFAPA




Sunday, December 28, 2014

Snow Shoveling Theory and Plasticity

I drove back from my home town to the Twin Cities area yesterday  In this age of connectedness, there are times when you get a false sense of information.  My wife called her friend who was driving north to Duluth on Hwy 35.  She got the message that there was about 6 inches of snow on the freeway and numerous vehicles in the ditch.  I don't mind driving in the snow.  I used to drive north in the winter in some notoriously unreliable vehicles.   Rear wheel drive and no limited slip differential.   Poor weight distribution was an added bonus.  Some of the worst engineered cars in the world.  Most people my age all still use the brand name Positraction, rather than the generic limited slip differential.  More evidence that pharmaceutical companies don't differ much from other businesses in terms of branding of inserting themselves into the public consciousness.  Like most people, when you get to the point where more safety is affordable you buy it.  I am driving a modern four wheel drive sport utility vehicle (4WD SUV).  I was confidant that 6 inches of snow would only be a problem if there was congestion from large trucks and snow removal vehicles.  I was also confidant that would only happen close to the Twin Cities.  Competency in snow removal seems to vary directly with latitude with northern latitudes being the best.   I thought about that as I drove down Hwy 2 across northern Wisconsin.  The road was clean down to the pavement about 4 hours after white out conditions.

As we turned the corner in Duluth, the grey skies lifted and it turned out to be a bright sunny day but 10 degrees colder than the day before (about 22 ℉).  There was no bad road all the way back to the Twin Cities.  That only happened when we pulled into our neighborhood and there was 6 inches of snow in the driveway.  All of my neighbors driveways were clear and in many cases the pavement was dry and clear.  The physical chemistry of snow is always interesting.  In this case the bottom few millimeters of the snow was liquefied, but the upper 5 inches plus was medium density snow, the kind that is good for cross country skiing.  Clear it off and the liquid evaporates in the direct sunlight, even when it is well below the freezing temperature.  In some cases sublimation occurs and the snow vaporizes directly from the solid state.  But I was focused on additional theories.

People living in northern climes think a lot about moving snow.  We have had some epic snowfalls.  Some of my fantasies coming into this season included getting an enclosed tractor with climate control and the ability to move a massive amount of snow.  The image I have is a condensation of a couple of images.  The first is a cola commercial from many years ago - a set of combines cutting wheat.  All of the operators in their climate controlled cabs drinking Coke (or Pepsi?).  The second is a show about building ice castles in Norway and a small vehicle that was described an an airport runway snowblower that could move a tremendous amount of snow through a chute directly over the operators cab.  Those are my grandiose commercial induced fantasies.  Even a small tractor with a cab set up to move snow is ridiculously expensive and it needs a lot of ongoing maintenance.  I have never been able to locate the manufacturer of the Norwegian snow blower.

The reality is that I have a 15 year old Toro 2 stage snow thrower and about 200 square feet of sidewalk and 1,000 square feet of driveway to clear.  The snow thrower cuts a 24 inch path.  In many ways the strategy is mathematical and practical.  What is the most efficient way to clear away the snow?  Is it just going back and forth and turning the chute on the snow blower on every turn or is it something else?  Since moving into this house I have decided it is a right angled arc starting up the left hand side of the driveway and then turning back (and turning the chute on the snowblower) and heading back in the same direction.  This moves all of the blown snow to the eastern side of the lot, away from the sidewalk and areas where ice might accumulate.  It also results in fewer change in the chute direction that just going back and forth or the length of the driveway.

Mathematics aside - what are the practical aspects?  The first of course is the weather.  Is more snow expected?  Do you really want to concentrate the effort if there is going to be another foot?  In some cases of wet and heavy snow it is imperative.  That layer cannot be allowed to freeze and it is the most difficult to handle with a snow blower.  In this case I was left with about 1/2 inch of translucent slush that I had to scrape up with shovel before it all froze in the colder temperatures.  The second is the surface that you are clearing.  There are some web sites that recommend snowblower sizes based on whether your driveway is finished (asphalt or concrete) or not (gravel).  In my case I have two different surfaces - a concrete driveway and a textured concrete sidewalk.   I can't use the steel shovel on the textured concrete.  I use a plastic shovel very similar to the metal shovel that my father used to shovel coal into a steam engine on the 1950s.  One of my earliest recollection was being placed in the cab of a steam locomotive.  My father was a locomotive fireman at the time and the engine was hand fired.  His job was to keep coal burning to keep the steam pressure up.  He explained to me at the time how the scoop shaped shovel was designed to slide large amounts of coal off of it and into the furnace without wasting any energy.  To clear the sidewalk - I clear one edge and then cut across that using the same motion my father used to shovel coal.  Snow is a lot lighter than coal but it takes me about 50 passes to clear it using this motion.

With every pass, I am careful to extend the stroke out onto the grass by about 2-3 inches.  When my father first taught me to shovel snow, he said this was critical in the event that there was any melting of the snow.  Without that 2-3 inch margin the water pooled on the sidewalk and created ice.  With the margin the water soaked into the grass and no ice was formed.  I have tried to pass that knowledge along to other sidewalk shovelers, but it falls on deaf ears.  Either they don't believe me or they have their own theories of shoveling.

In addition to the theory of clearing snow and carrying it out, I get another thought from about 50 years ago.  I have always been an insomniac and one night back then I was waiting for my father to come home from work.  By then he was a railroad engineer and drove freight and iron ore trains.  It was about midnight.  It was snowing and drifting to a depth of about 3 or 4 feet on the street outside of our home.  He told  me that day before he left that they might need to plow snow off the tracks.  The worst case scenario would be hitting deep snow and blowing it into the diesel engine air intakes on the top of the locomotive.  That would kill the engines and result in a long restarting process that would slow him down.  I kept staring out the window.  The wind was so intense that I could not hear any trains even though we were only about 3 blocks from tracks.  I could finally see him leaning into the wind and snow.  He always wore union style clothes and none of it was really made for winter weather.  He wore a chromer cap with ear flaps that offered limited protection.  He was carrying a leather satchel that he called a "grip" that contained all of his important paperwork.  He was wading through hip deep snow, using the exaggerated hurdler motion that you had to use to travel in deep snow without snowshoes.  I was very happy to see him and even happier when he burst into the kitchen and it smelled like the fresh air version of diesel fuel, Lucky Strikes and leather.

I have a greater appreciation of these events than I used to.  Early on it was easy to grasp the psychodynamic significance, especially when it came to countertransferences toward mechanics and anyone else who might smell of diesel fuel and cigarettes in my office.  There were the associated issues of blue collar rage, exploitation of union workers, and a stronger affiliation with workers rather than management.  These days I can think of it in terms of the brain systems that are represented and the underlying mechanisms that allow for this experience.  I still feel happy when I have that image of my father pushing through deep snow toward home.  It probably accounts to some degree for my affiliation with snow and winter weather.  Every month or so I give a lecture and talk about the time frame, neuroscience and structures that are probably responsible for that experience.

Most of all I remind the students about how these structures allow for unique human experience.  I like to say that if there are 7 billion humans on Earth, there are 7 billion unique conscious states.  I suppose planning and fantasizing about clearing the snow is not that unique in the upper midwest.

But I doubt that any two of us learned to do that in the exact same way.


George Dawson, MD, DFAPA    




          

Sunday, December 21, 2014

Psychiatry and Torture



For me - torture has never passed some basic thought experiments.  The first is whether or not there is any information that critical that could be memorized by individuals that would be worth the effort to either conduct torture to get it or resist torture to prevent its disclosure.  Reading Alan Turing's effort  to crack German cryptography  in World War II comes to mind.  Those messages had to do with the deployment of German submarines.  In that case there was a elaborate code that could only be decrypted by a team of geniuses and a computer they invented.  That was 70 years ago.  Is it likely that information in the computer age would be easier and more efficient to hide outside of human memory?  It certainly seems like it to me.  In the case of relationships, wouldn't surveillance be a much more reliable source of information?   The second is the mindset of the person being tortured.  If I knew the information was redundant, carried by multiple sources,  or subject to fail safe why would I not tell any captor what they want to know?  Third, if my captors either did not believe me or decided to proceed for other reasons, why would I not tell them exactly what they want to know or make up any story they wanted to hear to get them to stop?  The cinematic stereotype of resisting any disclosure at all costs while undergoing various forms of torture seems totally irrational to me.  All of these considerations taken to their conclusion would produce information that was accurate but possibly rejected because it was easily obtained or information that was inaccurate but accepted because it was made up under duress.  Either way it seems like a very poor source of information.

The Senate Report on the CIA interrogation and detention methods came out a few days ago and there is the expected media enhanced political furor.  The entire document is 499 pages long.  It is also redacted to remove details that could not be declassified.  I decided to take a look at it because I saw one of Atul Gawande's tweets decrying the involvement of the medical profession that he described as "doctors, psychologists, and others sworn to aid human beings......".  That struck a chord with me because I was aware of this issue and how the American Psychiatric Association reacted to it in 2005.  Then president Steven Sharfstein, MD took the initiative in making it explicit that it is unethical for psychiatrists to participate at any level in torture, enhanced interrogation or even deceptive interview practice.  There was some lag in a similar response from organized psychology but eventually both organizations came out with a joint statement on the issue.

Psychiatry and the CIA have crossed paths on occasion most notably on the notion of being able to profile political leaders.  The original ethical conflict with CIA psychiatrists was the Goldwater Rule (see reference 3). That rule states that it is not ethical to diagnose a person (usually a public figure) without actually interviewing that person and disclosing the information with their consent.  It came about as a result of the 1964 Presidential election.  The candidates were Barry Goldwater and Lyndon Johnson.  One of the more infamous attack ads in political history suggested that Senator Goldwater would put the US at higher risk for involvement in a nuclear war.  A survey of psychiatrists suggest that he was unfit for the office.   That same article points out that even today despite the rule, there appear to be no shortage of psychiatrists willing to offer their opinions about people they have never personally examined.    

I decided to take a course on profiling political figures by one of the original psychiatrists who worked on these methods -  Jerrold Post, MD.  The course was offered at the Door County Summer Institute in August 2003.  He provided a disclaimer at the outset that "psychological interpretation" based on childhood experiences was a scientific fact that could be applied to the analysis of the personality of political leaders.  Over the next 4 days he reviewed personality and its development in political leaders, how personality is a factor in political decisions and decision making in hundreds of different compromised and uncompromised political leaders.   The final day was devoted to a look at terrorism.  He made the argument that terrorists were psychological normal meaning that they had no major psychiatric diagnoses.  He suggested that that there were predominant personality types attracted to terrorism including aggressive sociopaths and angry paranoids and that a common externalizing defense could be observed in both groups.  He discussed theories about personality types that might comprise terrorist groups.  The issue of the Goldwater Rule seemed irrelevant.  Dr. Post presented profiles that were based on actual historical data about the lives of political leaders rather than the self report that typically forms the basis of most psychiatric evaluations.  It was after all his job and he and his cohort of colleagues specializing in the psychology of political leaders developed methods for this work.  It culminated in a text of how this analysis proceeds (see references).  The text provided a fuller appreciation of the limits of this kind of analysis than the PowerPoints:  

"Understanding and predicting the behavior of smart, highly functioning individuals, who are acutely aware of their circumstances and what might be needed to surmount them,  make it a very tricky undertaking.  It is possible that, in spite of their own psychological inclinations, such persons, if not alone, then certainly with the help of many advisers, whose only occupational purpose is to help leaders pursue their own personal and political self-interest."  (p.  300).

Translation: the psychological profiling done by psychiatrists and psychologists with decades of experience is less of a sure thing than the television profilers that you can see on a nightly basis.   At that point I decided that the analysis of the psychology of political figures by the CIA was really not the same as somebody on the local news speculating about the next mass shooter.  In many ways this analysis has much more relevant data than any typical psychiatric evaluation.

The ethics of the psychological profiling of politicians seemed resolved.  What about interrogations and coercion.  It turned out that there was a course the next year  called "A Law Enforcement Approach To Behavior Analysis" taught by Dale Mueller, a 30 year veteran with the FBI.  The course covered crime scene analysis, terrorist personality types and interview strategies, hostage and crisis negotiations,  interviews for deceptive verbal behavior, and interrogation techniques that answer the question: "What does law enforcement do to get a confession?"  That course was an eye opener in terms of the differences between interrogation and a clinical interview.  He described interrogation techniques and the reliability of various observations that suggested a person my be lying.  He described the optimal environments and mindset of the professional conducting the interrogation.  He emphasized good preparation and a non-threatening manner.  Interrogations are not without stress for the person being interrogated because at some point the strategy may become a direct confrontation like:  "Because of A, B, and C you are lying."  The interrogator may stand directly over the the person being interrogated for additional effect.  Some famous interrogations were reviewed and a tape of an interview was shown.  It was a product tampering case.  The suspect had social and possibly psychiatric problems.  The main focus of the interview was to convince her to admit to the crime and she did.  Specific interrogation techniques were discussed for different terrorist personality types.  Interrogation is an alien interaction with people for a clinical psychiatrist like me.  Psychiatrists are clearly not trained in these techniques and generally do not have much interest in who is guilty of crimes or not.  During the actual interrogation of a person who appeared vulnerable, I would probably have veered off to discuss  those problems and solutions rather than focusing on a conviction.  Interrogation seems to be the sole purview of law enforcement and nothing that a psychiatrist would do.

The issue with psychiatrist employees in the CIA or any other organization - even at the contract level is the ever present conflict-of-interest between professional standards and the interest of the organization signing the pay check.  In many cases that is a changing point of reference and it is not always clear.  I have consulted with expert witnesses for example who felt that at some point they were massaged into a position that they really did not want to testify to by the attorney who hired them.  Physicians can clearly be manipulated into doing whatever other entities want them to do and that is why it is imperative that professional organizations take a stand that is unequivocal, based on professional standards and faster than any other response.  In this case, organized psychiatry - specifically former APA President Sharfstein was at the forefront.  I applauded his position then and I applaud it now.  There is always some criticism that this just involved jumping on the bandwagon with everyone else but the public opinion result at the time was far from certain.  After the opinion was public, there was hardly any acknowledgement that anybody cared.  That opinion came out 8 years before the current Senate document.

Searching the document reveals exactly 1 reference to psychiatry/psychiatrist, 56 references to psychologist/psychology, 58 references to medical officer, and 5 references to physician/physician assistant.  The most specific references include this section in the summary about contract psychologists who "devised" the enhanced interrogation techniques.



The political rhetoric is always interesting:

1.  Does torture produce results?  After reviewing the evidence I don't think there is any evidence that it does.  In fact, it is daunting to think about the millions or billions of people who have been tortured at one point or another in human history with this goal in mind.  In retrospect much of the contested information was trivial and meaningless in the course of human history.  I don't recall any major battle or war where the outcome was determined on information produced by torture.  I think there is a stronger argument that terrorism or what used to be called guerilla warfare produces more results than torture.  And let's not forget that a contractor with the National Security Agency probably released more secret data that all of the people tortured since the dawn of time.  And all of that data was accurate.

2.  Does torture inflame the enemy and lead to more adverse consequences for the torturers?  I heard an interesting discussion of this issue on Fareed Zacaria's Sunday morning show on CNN.  The discussant was an Arab from the Middle East and it was clear that his sympathies did not align with the US.  When asked about the impact of this document on public opinion, he said that he did not think it would have much of an impact because of a baseline issue.  Most people had such a low opinion of the United States that they would expect something like this to happen.  There was after all the Abu Ghraib prison incident in 2003.

3.  Are there qualitative differences in torture?  Certainly these techniques were bad but they pale in comparison to the atrocities described in the middle east and the atrocities inflicted by some of these combatants on their own countrymen.  As one of the consulting psychologists pointed out about 48 hours after the report was leaked there is also the question of what is worse a slap in the face during an interrogation or "sending in a Hellfire missile that kills grandma and the kids."  (ABC news Thursday AM show)

4.  How is the release of this document relevant to the concept of American democracy and American life?  Interestingly one of the critics on the Sunday morning show gave the opinion that self disclosures like this report does seem to distinguish American democracy from other political systems and raises the general awareness  that this is true.

5.  How can I make the most of this story?  Certainly media outlets and bloggers are motivated to whip this story up to attract viewers to their sites.  I saw a very funny comedy sketch by a stand up comedian who ranted against "Cheeto eating bloggers.." who were destroying his comedy act by posting politically incorrect experimental pieces that he was trying out in his routine as though he was serious.  The blogosphere likes to see itself as more innovative and more pious than the press but conflicts of interest remain.  It has gone from a corporate conflict of interest to conflict of interest at an individual level.  At many levels bloggers are more strident, argumentative, and hyperbolic.  It is not too surprising that they attract a like-minded following.  That being said, there have been few psychiatric bloggers that seem to have picked up on the torture issue.  It was an active area of discussion on the APA Listserv with several psychiatrists taking the role of human rights advocates.

Professionals often find it difficult to resist government interventions.  I have criticized the lack of an adequate response from organized psychiatry and organized medicine to any number of government interventions.  In other cases, they have come through with an exceptional response.  On the torture issue, Dr. Sharfstein took an unequivocal position on torture.  I was involved in a discussion of the issue at the time and there was speculation that there would be political pressure from "CIA psychiatrists".   There is always the question of whether a small special interest group within an organization can affect its policy.  In this case, the clinical focus of the membership, the maxim to do not harm and the modern conceptualization of the physician-patient relationship.  In the end there was no commentary that I am aware of from CIA psychiatrists.  I am not sure that there are any CIA psychiatrists.  I applied to be a CIA psychiatrist at about 15 years ago and the focus of the position was on interviewing potential employees rather than terrorists.

I think it is important to clarify any role that psychiatrists were involved in these activities.  They are not trained in interrogation techniques and I think that most psychiatrists would balk at the techniques.  On the other hand, it is clear that programs can be developed within government agencies that have little to do with clinical training and may clash with patient centered ethics.  It is also true that psychiatrists or physicians can abandon their usual clinical roles and use their knowledge for other purposes.  I am very skeptical of the science behind any of these techniques.   That sounds like an absurd statement on the face of it, but keep in mind the references to the program being based on a "learned helplessness model".  That is a scientific model that has been used to study depression.  Any review of that model would show that using it to develop an interrogation program is quite a stretch.  Actual human research would not pass the scrutiny of any Human Subjects Review Committee that I am aware of and it certainly is not associated with any standard of care.  The acceptance of these ideas indicates that there is really nobody in the CIA capable of scientifically reviewing a program like this or they just did not care.  As to the ultimate question of psychiatric involvement, I have a more definitive source on order (reference 5) and will report any differences here.  There is also an online database (reference 6) but it does not have much granularity but some of the linked reports contain a some details that I have not seen anywhere else (reference 7).


George Dawson, MD, DFAPA



References:

1.  Senate Select Committee on Intelligence.  Committee Study of the Central Intelligence Agency's Detention and Interrogation Program.  Foreword by Senate Select Committee on Intelligence Chairman Dianne Feinstein.  Findings and Conclusions.  Executive Summary.  Approved December 13,2012.  Updated For Release April 3, 2014.  Declassification Revisions December 3, 2014.

2.  APA Official Actions.  Position Statement on Psychiatric Participation in Interrogation* of Detainees.  Approved by the Board of Trustees, May 2006.  Approved by the Assembly, May 2006

"The American Psychiatric Association reiterates its position that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture of any person. Psychiatrists who become aware that torture has occurred, is occurring, or has been planned must report it promptly to a person or persons in a position to take corrective action........"

3. American Psychiatric Association: Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Arlington, VA: American Psychiatric Association, 2013 (p.9):

"...On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."

4.  The Psychological Assessment of Political Leaders: With Profiles of Saddam Hussein And Bill Clinton.  Jerrold Post, MD (ed). The University of Michigan Press, Ann Arbor 2003, 462 pp.

5.  Steven H. Miles.  Oath Betrayed: America's Torture Doctors.  University of California Press, 2009, 312 pp.

6.  Doctors Who Torture Accountability Project.  Link.

7.  Physicians for Human Rights.  Doing Harm: Health Professionals’ Central Role in the CIA Torture Program.

This document is interesting because it has the qualifier "physicians (including psychiatrists)" four times in the report even though it is based on the original Senate Report.


Supplementary Info:

Supplementary 1:  Photo credit as suggested on WikiMedia:  Derived from File:911 - FEMA - Areas debris impact (graphic).png by Therese McAllister, Jonathan Barnett, John Gross, Ronald Hamburger, Jon Magnuson of the Federal Emergency Management Agency (FEMA) of the United States Department of Homeland Security. As a work of the United States government, it was released to the public domain.

Supplementary 2:  I sent Physicians for Human Rights an e-mail on December 21, 2014 to clarify the qualifier they use in their analysis of the Senate document  "physicians (including psychiatrists)".  I will post their response here as soon as I get it.



Friday, December 19, 2014

Question For APA Candidates? OK Here It Is.

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"


I got a message today that I should craft a question for the American Psychiatric Association (APA) candidates.  It is election season and the LinkedIn forum is apparently the place for political debate.  I can recall asking a question last year along with James Amos, MD (The Practical Psychosomaticist).  The questions had to do with Maintenance of Certification (MOC) and the arduous recertification schedule that was essentially invented by the American Board of Medical Specialties.  Dr. Amos has done more to maintain this issue at a high level of visibility than any other psychiatrist.  That includes looking at the paucity of evidence that it is superior to life-long learning and CME as we all know it.  I  went to LinkedIn to look for my post from a year ago and it wasn't there.  The earliest post is from April 29, 2013.  This is a forum that was suggested to replace the long running member-to-member (M2M) listserv managed by the APA.  It was in M2M that members learned their concern about the MOC issue would be ignored despite overwhelming support on the basis that only 25% of the members voted and a 40% vote was required to pass the measure (see supplementary info below).

The events associated with that vote continue to bother members greatly.   It is seen as a continuing symptom that APA membership does not translate into any support for front line psychiatrists.  We have witnessed decades of increasing rationing and onerous regulations that have been basically brushed off at the level of the APA.  There has been minimal activity in responding to politicians, regulators, and businessmen.  It seems that whatever these special interests want to do - the APA is willing.  We had a billing and coding debacle in the 1990s with the rest of medicine.  Instead of pointing out that this was a purely subjective scheme designed to allow the persecution of any physician, the stance of both the APA and the AMA was "we will give you what you need to be better billers and coders."  We have had three decades of managed care utilization review, prior authorization, and pharmacy benefit managers and the response from the APA has been literature on how to be a better managed care psychiatrist.   There was a lawsuit against some managed care payers for a lack of parity but I don't think there is any evidence that the members who were forced to provide free care have gotten much benefit from that.

The most telling event about where the APA and AMA are at is their full scale cooperation with the PPACA (aka Obamacare) and so-called collaborative care.  In many if not most of those models of care, a psychiatrist collaborates with primary care physicians in treating depression or anxiety in their clinics.  In many of the models, the diagnosis hinges on a rating scale determination of depression or anxiety.  The rating scale score is the diagnosis.  The treatment modality is a medication - usually an antidepressant.  In some models the psychiatric consultant never sees the patient.  I just realized it, but this is all eerily similar to managed care reviewers several states away telling attending psychiatrists how to manage their patients.  This is managed care - a business centered model of providing medical care.  A model that many (myself included) do not consider a valid method of providing medical care.  And yet, the President of the APA and several other psychiatrists promote this as a model of care.  What physician would do 4 years of residency training to sit in an office, look at rating scale scores, and recommend antidepressant doses?  Why would you train all of those years and know all of that theory for such a simple task?

That simplistic collaborative care model captures the primary problem in psychiatric leadership today.  Here we stand at a crossroads.  We are studying the most complex organ in the body and we clearly know more about it now than at any point in the past.  The literature in brain science as it applies to psychiatry is growing exponentially.  We have some of the best thinkers in the world in all areas of the field ranging from pure neurobiology to psychopharmacology to imaging to neuropsychiatry to medical psychiatry to community psychiatry to psychotherapy.  There is so much to learn about the brain and psychiatry and what are we doing with it at a global level?

Nothing as far as I can tell.  The leadership of the APA is locked into a mindset from the Clinton administration.  The APA is acting like we have a responsibility as a profession to address bloated mental health statistics and provide population-based psychiatric care to the masses.   We have a responsibility to provide cost-effective care to the masses.  We have a responsibility to fight stigma wherever we find it because this is the real reason why people, governments, and insurance companies discriminate against psychiatrists and their patients.  We have to grin and bear it when some clown attacks the profession despite the fact that thousands of our colleagues go to work everyday and many toil with inadequate resources, impossible conditions, a lack of cooperation and they still get the job done.  Thrown into the breech with no support, front line psychiatrists are still getting the job done.

The APA on the other hand has done very little to support that effort.  APA officials seemed to breathe a sigh of relief about the vote on the MOC issue.  I heard one of them speak about it at a local meeting.  She told us all about how the new certification fees were really not a windfall for the American Board of Psychiatry and Neurology (ABPN).  This was really an expensive process after all.  I finally learned that this was really an initiative by the ABMS and that participating boards did not really have a choice.  If most of the boards voted for recertification all of the boards had to participate even if they voted against it.  I had learned about 10 years ago that the American Board of Obstetrics and Gynecology ( ABO+G) had a robust program that consisted of didactic material every year that was designed to bring all members up to speed.  A test was taken every year on that well defined information.  At the time there was no MOC and to me it seemed like an ideal program to assure that all members of a particular specialty were up to date and studying relevant information about what was important for the specialty.  For a while, I promoted this model as the preferred model for ongoing professional learning.    The APA does provide a similar program called Focus that could naturally fill the same role.  Typical MOC exams are not on a focal body of material and the pass rates are high.  Candidates of all specialities typically take time off of work (an off of vacation) to study for these examinations in addition to paying high examination fees for a test that is designed for the test makers and not the test takers.  A test of random facts for the purpose of recertification is not the same thing as a test for professionals to assure they are all up to the same standard.

The APA has just completed a much criticized multi-year effort of revising the DSM and producing the DSM-5.  I think that has been a good effort and with the associated online material it is a definite advance relative to previous editions.  That does not mean I am in agreement with everything in the book, or think that all of the diagnoses in that text exist.  I do think that it covers all of the major diagnoses and severe mental illnesses that psychiatrists treat.  On an academic and clinical level the APA needs to do much more.  Hospitals and clinics currently are being run by administrators with mixed agendas.  We are seeing business people conduct psychiatric care.  The APA used to provide comprehensive guidelines for the treatment of aggression in inpatient settings.  It used to have timely treatment guidelines describing the role of psychiatry and what the standards of care are.  By abdicating that role, we now have business organizations and nonprofessionals dictating care for people with severe mental illnesses.  We have psychiatrists who have to defend their care against those nonprofessional guidelines every day.   That is hardly the expected behavior of a professional organization.

Any psychiatrist should be concerned about the fact that their professional organization does not seem to support the members doing the work of psychiatry.  Any psychiatrist should be concerned that the APA does not vigorously defend the profession and that it seems to have adapted the pseudoscientific methods of governments and managed care organizations.  Any psychiatrist should be concerned that the APA has adopted the questionably valid ABMS preparatory school model of professional education that is unfocused and a waste of time and money.  Any psychiatrist should be concerned about the fact that we have some of the greatest minds in American medicine in our medical institutions and our professional organization is lurching back to the Clinton administration of the early 1990s.  Back to the time when a few political insiders thought that managed care was a good idea.  All of these things considered the question I will post to the candidates is:  

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"
 
That is how I was trained and how every psychiatrist I know was trained.  It is time our professional organization consistently gives us what we really need.


George Dawson, MD, DFAPA



Supplementary 1:  This was the APA 2011 election report I got on the following referendum to basically eliminate patient feedback and maintain a cognitive exam very 10 years.  Although the APA maintains that it requires a vote of 40% of the voting members, the vote to support these measures exceeded the votes for the President Elect and the Secretary (both national candidates) by 1373 and 1388 votes respectively. (Reported February 18, 2011)


The APA was petitioned by members to hold a referendum on the issue of informing the ABPN as follows regarding its proposed maintenance of certification requirements.

1) The patient feedback requirements for the purpose of reporting to the Board is unacceptable, as it creates ethical conflicts, and has the potential to damage treatment.
2) The requirements other than a  cognitive knowledge examination once in 10 years, regular participation in continuing medical education, and maintenance of licensure, pose undue and unnecessary burden on psychiatrists.
Member Referendum
Support
5,525 (80%)
Do not support
1,418 (20%)


The referendum did not pass. APA received ballots from 25% of the voting members.
The APA Operation Manual states the following regarding member referendums: “The adoption of a referendum shall require (a) valid ballot from at least 40 percent of the voting members, (b) the affirmative vote of at least one-third of all the voting members of the Association, and (c) the affirmative vote of a majority of those members who return a valid ballot.

Supplementary 2:  Another one of the sorry miscalculations made by the APA and its officers is the image it projects to potential trainees.  Applying the dynamic I point out in this post, any potential resident ends up asking themselves:  "Why would I want to join a speciality that seems to want its members to have less expertise than they used to rather than more?  What other speciality does that?"  I tried to address that as a response to a current resident written on his blog and for some reason the response was never posted.  You can read his original post here and my response below:


The most significant reasons why psychiatry has the image problem that you discuss is that the profession is politically inept and our largest professional organization is not addressing the problems that psychiatrists face on a day-to-day basis on the front lines. The biggest front line problem is that practically all systems where psychiatrists work have mercilessly slashed resources for treating the mentally ill. We also seem to attract a number of ideas from critics that are not helpful. The example you posted about a prescriber with watered down qualifications is a case in point. In what other specialty does anyone suggest that the practitioners of the future should be less qualified?

That type of nonsense only happens in psychiatry and it is completely inconsistent with current research. In this weeks’s Neuron there is a perspective on Computational Neuropsychiatry. As neuroscience becomes more relevant to daily practice psychiatrists need that level of training in addition to medical and psychotherapy skills. We seem to have a lack of visionaries right now who can put all of that together.

I would encourage psychiatrists of the future to be thinking more along these lines, than the rationed managed care model of care that is currently being promoted. It turns out that “cost-effective” psychiatric care is frequently the same as no care at all.


GD







Wednesday, December 17, 2014

Survey-Centric Versus Customer-Centric Versus Patient-Centric




Over the past decades of managed care we have evolved from a medical model that mandated specific behaviors toward the patient to a business model that is supposedly based on customer satisfaction.  After all, the business theory is basically that satisfied customers are more likely to come back and do additional business. As any customer knows that model does break down in a number of ways.  My recent post illustrates a marked difference in the level of customer assistance available through many Internet companies over the past 15-20 years.  And yet, large managed care companies and other health care companies continue to adopt the customer satisfaction approach even when it can be demonstrated that this approach can result in increased mortality and morbidity for the satisfied patients.

It recently came to my attention that there is another variable in play that would have never been an issue in the days of patient centric care.  The best way to point it out is with the example.   Two separate people recently talked with me about their experience buying new cars.  I am going to maintain their anonymity because it could be traced back to the salesperson and have repercussions as you will see in a few lines.  New cars are high tech vehicles with an impressive array of electronics.  All of these electronics require more than a manual or a DVD.  The salesperson generally gives you an orientation to the vehicle and helps you with the preliminary setup.   In both cases that occurred taking about an hour each time.  At the end of the hour the salesperson approached with the customer satisfaction survey and said something like this:

"This is the customer satisfaction survey.  It is rated on a scale of 1 to 10.  1 is the worst and 10 is the best.  I have  to tell you that if you liked my service I would really appreciate it if you could rate me a 10.  If you rate me a 9 or lower I am out of here!  They will replace me in a month."

The first time I heard that, I thought "Incredible - this is just like the scripting that occurs at major hospitals and clinics."  Scripting is basically an exit interview set up to capture the elements of the customer satisfaction survey and inflate the scores.  The best way to get a high rating on a question about whether or not your nurse provided you with information on how to take your medication, is to have that nurse go through a standardized protocol about that right before he or she hands you the satisfaction survey.  What can you do at that point?  It just happened and it matches the survey question.  In compiling that kind of information, it should not surprise anyone when you find that all of the facilities in your area are in the 90th percentile.

I had a second thought.  I remembered the times that a patient was clearly satisfied with my work and said so right during the appointment.  Having been "scripted" about the importance of customer satisfaction at a recent staff meeting I had the thought: "Well if you really feel that way, it would greatly help me if you said that on the survey that they will send out to you on your satisfaction with my care."  I admit to thinking about it, but never said it.   I would never say it because I consider it to be a boundary violation.  Since when is it proper to suggest to a patient that they do something to advance your interests?  To my way of thinking (and the thinking of psychiatrists who preceded me) - never.  It is such a natural thought that it would not surprise me if it happens.  I think it is more likely to happen with clinicians schooled in business model of medicine.  If it was ever disclosed I can imagine that there are any number of administrators waiting to jump on it.  I can recall a physician telling me that his administrator insisted that he tell all patients coming in to see him that they need to bring in their insurance card.  He was actually reprimanded for not doing it a few times.  It only took a couple of complaints about that physician being too focused on the insurance card to get him fired by the same administrator who insisted that he should ask about it in the first place.

It is internally consistent that the MBAs who currently run America's healthcare system with seemingly little input from physicians would force the customer satisfaction issue.   They consider it a tool even though I would question its validity these days.  It seems like customer service is just common sense - why shouldn't it be rated?  There are a number of reasons.  Many ratings appear to have an unusual level of complexity.  Does it really take 10 or 20 different Likert scales or is a simple "yes" or "no" global rating better?  Clinical trials technology would suggest that there is an important role for both.  What about the manner in which the data was collected?  Should a rating that was coached by the subject who is being rating have the same validity as the rating that was not coached?  I would say no - again based on clinical trials technology.  Data needs to be collected in the same way to be comparable.  Either everybody uses scripting or nobody uses it.  There could also be a correction factor for ratings where scripting occurs.  It may result in a more realistic look at health care resources in local communities.  We also know that the way health care companies are managed has nothing to do with customer satisfaction.  One of the leading texts in how MBAs are taught shows very clearly that profitability counts and mental health services are considered the "dog" quadrant.   Are you really going to pay much attention to ratings of providers in the "dog" quadrant?  Only if you need it for leverage with those providers.  And finally does everything have to be rated?  If I am desperately searching for a way to fix my computer so that I can complete a document for a deadline, are pop-ups asking me to rate whether or not suggested fixes that did not work were helpful?  Probably not.   On the clinic or hospital rating from those questions focus on services that are peripheral to the provision of care.  How does the lack of parking or an ATM machine affect a patient's attitude toward their doctor when it comes to those ratings?

The most important consideration that nobody seems interested at all in - what is lost when we apply business ratings to physicians.  It allows us to consider that physicians are just like any other group of hucksters bound only by their ability to separate you from your money.  Caveat emptor right?  It neglects an entire system of checks and balances that have evolved over centuries from the professional relationship between patients and their physicians.  It also neglects a massive bureaucratic structure that regulates physicians and demands certain behaviors and concessions when they engage in certain types of business transactions.  Rating physicians, even with multiple Likert scales seems to put them on the same plane as the pizza delivery guy.

With the current business emphasis in medicine,  it may be that some day physicians will have the same level of responsibility as the pizza delivery guy especially if governments and business interests succeed in their efforts to erode professionalism.  Until then, I think it pays to remember that your physician is obligated to treat you in a certain way - irrespective of any rating systems.

That includes not requesting a certain rating.  



George Dawson, MD, DFAPA


Supplementary 1:  No offense to pizza delivery guys everywhere and I hope you don't have to hand out customer satisfaction surveys with the pizza.




Thursday, December 11, 2014

More On Violence And Aggression In Minnesota Hospitals

There was a recent incident (see link within that article) that occurred in a Minnesota hospital a few weeks ago that resulted in serious injuries to nursing staff.  There are various sites on the Internet where you can view the videotapes that were obtained from the hospital's security cameras.   It shows an out of control man chasing and striking nursing staff with a metal bar or pipe, in some cases repeatedly.  The patient in this case was eventually apprehended outside of the hospital and died suddenly after he was tasered, taken to the ground, and handcuffed.   Preliminary information suggested that the patient involved in this situation was probably experiencing an acute change in his conscious state because it was a total departure from his personality and he had no previous episodes of aggression or violence.  Nursing staff sustained serious injuries including a pneumothorax.  Autopsy results have not been released at this time.

Many people were shocked by this activity and yet is is a fairly common occurrence.  People may expect this kind of agitated and aggressive behavior to occur only on psychiatric units, but the reality there is that is happens only on a few psychiatric units.  Most psychiatric units are managed to limit the admission of patients with a high potential for violence.  It happens on medical-surgical units for a number of reasons and the effects are more dangerous at times because of the availability of objects that can be used as weapons.  I have seen stands used for hanging intravenous solutions being swung in a wide circle through an intensive care unit.  These stands have heavy bases that can inflict serious injuries and destroy a lot of equipment in an ICU.  There are many possible reasons for this kind of aggressive behavior ranging from delirium and psychosis on one end of the spectrum to antisocial behavior and wanting to intimidate medical staff on the other.  Although it seems incongruent with a controlled hospital environment, many families have an experience with a family member who suddenly loses control.  The proscription on aggression and violence and the moral interpretation of this behavior often makes it difficult for families to comprehend what is happening.  Families and medical professionals alike often lack the vocabulary for describing this behavior and can just lump it together as "bad" behavior.

I saw the preliminary description of this incident and the video clips and decided not to comment on it until after the results of the autopsy and investigation were known.  The idea that  this problem would be approached by making this behavior illegal made me change my mind for a couple of reasons.  First, there is a very high probability that this behavior was precipitated by a medical problem that led to a change in consciousness to the point that this individual had no control over his behavior.  Anyone who has been delirious has experienced this at one point or another.  In my own family one of the male relatives who was a well driller was apparently "blown up" in a well one day and the resulting brain injury led to permanent and extreme changes in his behavior.  From that day on he was extremely aggressive and the aggression was directed toward property.  He continuously overturned furniture and smashed dishes until the entire house was trashed.  In those days before any care or containment was available, the expectation was that the family would care for him and they did until he died.  The home environment was constantly disrupted by rage attacks until that day.  In my capacity as an inpatient psychiatrist, I would routinely see people brought to the hospital after they suddenly became aggressive at home.  When their relatives arrived they were always shocked to find that the patient had been admitted to a psychiatric unit.

My second reason for concern is the involvement of politicians in what is a misunderstood medical problem.   An acute medical problem causing aggressive behavior in not a criminal act - it is a medical problem.  Attempting to incarcerate or fine a person for aggression that occurs in that circumstance does not make any sense at all.  It may be a way to secure political capital from a special interest groups, but criminalizing a medical problem is not a reasonable approach.  Even suggesting that this is something that should be debated in a court of law is questionable.  I base that on the known track record of the not-guilty-by-reason-of-mental-illness defense.  It is widely known that there is a low probability of that defense succeeding.  It is also widely known that people who have committed criminal acts and who clearly have severe mental illness  are typically convicted.  All it usually takes is a expert testimony suggesting that despite any mental illness diagnosis, the defendant appeared to be taking planned steps to achieve a goal.  In the case of aggression those steps would involve assaultive behavior and destruction of property rather than random activity.  I can say that in every case of aggressive behavior that I have witnessed in a hospital, even in cases where the patient had no subsequent recall of the incident that their behavior appeared to be planned and the assaults were directed.

On the non-medical side of the spectrum, there are people whose conscious state is not altered at all and they have directed violence as part of their personality structure.  Threatening and assaulting people are a way of life.  They frequently have criminal backgrounds or an arrest record.  They often give a history of fighting and may have harmed someone when they were defenseless or felt no remorse if their aggressive behavior resulted in injury or disability.  In my experience the majority of these persons can control themselves in medical settings with a few exceptions.  Any drug or alcohol intoxication state makes them more unpredictable.  Seeking prescriptions for controlled substances like opiates or stimulants can also create confrontations if they don't get the prescription that they are seeking.  There may be a question about whether any special legislature penalizing what is essentially criminal assaultive behavior would be useful.  My guess is that it would not for the same reason that civil commitments fail to work - the laws are not utilized.  Hospital administrators and courts tend to ignore aggression toward medical and nursing staff from patients who are willfully directing violence toward them as a product of their usual conscious state.  Administrators always explained it to me as an occupational hazard, especially on the part of the nursing staff.  That casual attitude often leads to inadequate safeguards at every step.  There should be a zero tolerance attitude for personality disordered violence and that should include prosecutions for assault.

The key to protecting medical and surgical staff and their patients from aggression associated with acute changes in consciousness is to have a heightened level of awareness.   The patient's history prior to admission is critical.  Prompt recognition of delirium from many causes and acute drug and alcohol intoxication and withdrawal states is necessary.  Adequate staffing is critical.  There needs to be a definite team approach, all of the staff on the unit need to be aware of the potential for violence, and the priority needs to be on protecting the nursing staff delivering direct care to the patient.  Medical staff and nursing have to be on the same page and there can be no factors present that lead to split treatment.  Enlightened administrators may be helpful in preventing that dynamic, but in my experience I have not found any.

One of the common problems is that staffing on some of these cases involves 1:1 observation preferably by a trained psychiatric technician or nursing assistant who knows how to help patients de-escalate.   Just having a reassuring person in the room can often have the same effect.  There are protocols that address the physical environment to reduce the likelihood of post operative delirium.  Where necessary it is useful to have experienced staff treat acute agitation in hospital settings with medications.  Some large hospitals have psychiatric consultation 24/7 to address the problem and in some cases where the patient is medically stable transfer them to a more secure psychiatric environment for assessment and treatment.  Medical and nursing staff need to be in close contact 24/7 in order to make rapid adjustments in the treatment plan.

Making the aggressive behavior associated with explainable medical problems a crime is the wrong approach.

When I see legislators talking about what medical professionals do or do not know about containing violence and aggression my typical response is to cringe.  I put it on the long list of all of the other things that legislators think they needed to train physicians in - like how to prescribe opiates (in the year 2000) and then how not to prescribe too many opiates (in the year 2010).  There are plenty of people who come out of training who known how to assess and treat aggression.

They are called psychiatrists and psychiatric nurses.




George Dawson, MD, DFAPA