More Great Quotable Quotes from People Who Agree with Me About Stuff

Today's post is the second of a series of two containing some of my favorite recent quotes that center around themes discussed in this blog. 

As mentioned, I have been collecting the quotes and putting them on my Facebook fan page at http://www.facebook.com/pages/David-M-Allen-MD/80658565761?fref=ts. The ones posted here started in January of 2014, and are loosely organized by topic. 

Family Dysfunction

"Taking responsibility for something and self-blame are horses of two entirely different colors. The former is empowering; the latter is paralyzing." ~ John Rosemond, Ph.D

Chronic Mental Illness

Our prison population is bigger than Slovenia
Cause we put people in jail instead of treating schizophrenia 
        ~ John Oliver

On trying to find the cause of schizophrenia: "30 wasted years of looking for bad mothers followed by 30 wasted years looking for bad genes." ~ E. Fuller Torrey, M.D.

Psychiatric Practice, Electronic Medical Records, and Managed Care

"The shift from benzodiazepines [for anxiety disorders] to antidepressants is one of the most spectacular achievements of propaganda in psychiatry." ~ Giovanni Fava, M.D., clinical professor of psychiatry at SUNY in Buffalo.

"You're complaining about a Freudian slip? Freud should be able to wear whatever he wants." ~ Tony Kreitzberg

"Why would anyone want to teach me to tolerate my pain? My only interest is in removing it!” ~ Cynthia Mueller, a blog reader, when first exposed to the DBT treatment model for borderline personality disorder.

"Methadone and Buprenorphine [suboxone] should be our first line opiates for use in the treatment of severe acute pain. That way, if patients become addicted to them, they would already be taking the appropriate treatment for their addiction!" ~ Steven A. King, M.D.

"The current EHR has destroyed the narrative, especially in psychiatry, and converted the basis of care to a checklist." ~ George Dawson, M.D.

"It's not just about doing the right thing for your patients, it's about proving to someone else that you've done the right thing, and sometimes "I can't quite remember if I'm an underpaid physician or an overpaid data entry clerk!" ~ Dr. J.D., Family physician.

"The proving [that I did right by a patient] takes longer than the doing." Chrisitine Sinsky, M.D.

"You don't need any research to show that if you are cycling people with serious mental illnesses in and out of short stay psychiatric units in 3 - 5 days and basing their stay there on whether or not they are "dangerous" and using treatments that take weeks to work that by definition you are appearing to treat many more patients but providing adequate treatment to very few. You don't need any research to show that when you shift mental health care from psychiatric units run by psychiatrists to county jails that the outcomes will be worse. You don't need any research to show that when people do not get research-based psychotherapies in the manner that they were designed and instead get a few crisis oriented sessions that do not address their basic problems that outcomes cannot hope to be better. When your attitude is that all mental health treatment can proceed by treating common problems with definite social etiologies with medications as fast as possible and not having an intelligent conversation or working alliance with the person affected - it is logical that treatment outcomes will not improve. Treatment outcomes do not improve if you do not provide effective treatment and that is the mental health landscape at this time." ~ George Dawson, M.D.

"I don’t know if anyone has ever not tensed at being told to relax." ~ Carolyn Hax

"Health care systems that allow patients to rate their doctors on satisfaction ratings without considering that patients might be dissatisfied with reality should be held to task." ~ George Dawson, M.D.

"You want a tale of two cities...look how the financial services industry has captured regulation to their advantage vs. how doctors have been battered by regulation. But it's based on the mind-set of Goldman Sachs vs. the mindset of the family practitioner...who politically shows up for a gunfight with a butter knife." ~ James O'Brien, M.D.

"Managed care has done an expert job of cost shifting by developing business friendly treatment criteria, abandoning the social and community mission of treating difficult problems associated with mental illness and addiction, and removing the element of humanism from psychiatric treatment. When I first started to practice, discharging people from a hospital when a psychiatrist had serious concerns about whether or not they could make it or whether they would be safe was very uncommon. Today those discharges are the rule rather than the exception largely due to the imaginary dangerousness criteria. "~ George Dawson, M.D.

Drug War

"When we talk about marijuana as a gateway drug, we have to remember that the last three occupants of the White House have smoked marijuana. We can very well say marijuana is a gateway drug to the White House” ~ Carl Hart, Ph.D

Psychiatric Diagnosis

"Then there’s the matter of testing a child to determine if he has ADHD. The plain fact is that none of the published diagnostic criteria depend upon test results. They refer to behavior, period." ~ John Rosemond, Ph.D.

"A [mental] disorder does not operate with [social environmental] discrimination. If something was “wrong” with [your child], she would be obnoxious in front of friends, their parents, teachers, and the people in white coats who came to take her away (tra la, for those who appreciate the reference)."
~ John Rosemond, Ph.D.        

            ("Actually, "Ha Ha" and not "Tra La" ~ Napoleon XIV)

A reader writes that her friends 'recently spent around $300 on their daughter’s birthday party—her first. They bought lots of stuff to entertain their young guests and extended family. The child, a baby, obviously had no clue what was going on. I should mention that the parents are struggling to make ends meet.' As my readers know or should know, I am a psychologist. That qualifies me to determine and assign psychological diagnoses. As such, it seems obvious to me that these parents suffer from a now-commonplace parenting malady known as just plain nuts." ~ John Rosemond, Ph.D.

"One symptom does not make a diagnosis " ~ John Rosemond, Ph.D.

"Test anxiety is frequently not an aberrant psychological response - it is instead the normal anxiety anyone would feel in facing a situation for which they were inadequately prepared." ~ Barbara Oakley, Ph.D.

"Under the influence of intense affects, EVERYBODY becomes an idiot."~ Otto Kernberg, M.D.

"Only in America does 'gotta' substitute for 'wanna' so we can avoid the guilt. " ~ The Last Psychiatrist

ADHD

"An often trivialized cause of irritability, difficulty concentrating, reduced vigilance, distractibility, decreased motivation, lack of energy,and disturbed mood: insufficient sleep syndrome. People with this syndrome, common in our 24 hour society, intentionally curtail sleep for work, social, family, or other reasons. According to the International Classification of Sleep Disorders, a practical and effective remedy does exist: more sleep." ~ Psychiatric News.

"The maps of child obesity in the U.S. look suspiciously like those of the ADHD epidemic, with the highest rates in the deep South." ~ Psycritic

"It’s truly surprising how many parents have been told that if their child did not have ADHD the child would not respond to stimulant drugs. In the blitzkrieg of World War II, German bomber pilots took a stimulant drug with a chemical structure similar to that of Adderall. When the American military discovered how much the stimulants helped German pilots, they put stimulants in the kit of every American and British bomber pilot to improve their concentration and alertness on long-haul missions. Surely not all these pilots had ADHD." ~ Marilyn Wedge, Ph.D.

"...after taking the [drug company-designed screening] ADHD quiz, I've realized that both I and my cat have the dreaded disease. I'm off to get us both the treatment we need." ~ Anonymous comment on one of my blog posts.

Evolutionary Psychology

"Selfishness beats altruism within groups. Altruistic groups beat selfish groups. All else is commentary." ~ David Sloan Wilson, Ph.D.

"We mammals are curiously preoccupied with social hierarchy. You may say you don’t care about status, but if you filled a room with people who said that, they’d soon form a hierarchy based on how anti-status each person claims to be." ~ Loretta Breuning, Ph.D.

Adventures in the Veterans' Hospital Mental Health Clinic - Part III

Not everyone, apparently

This post continues on from my post of 4/14/15 about the practice of psychiatry in the outpatient mental health clinic at the Veterans' Affairs Hospital in Memphis. I retired from my part-time position a few months ago. While the bureaucracy and some of their requirements on physicians were annoying, they were also amusing, if not entertaining, in a perverse sort of way.

Human foibles have always interested me, so I managed to put up with practicing there for several years. I was only working part time - just 30%. This limited time made the craziness tolerable for quite a while. I had been planning to stay there until the end of 2015, but I did not make it that long.

Why? There were two developments that made my continuing to work there problematic, and I found myself counting the weeks until I could escape. Then I received a warning letter for my having made comments in some of my patients' electronic medical records (EMR) about the negative effects of some of the VA policies on the well being of the veterans I was treating. 

I knew very well that one is not supposed to do that and I would probably hear about it sooner or later, but complaints at staff meetings went absolutely nowhere - even though many of the other VA psychiatrists agreed with me - and I felt I had to protect myself from being held responsible for negative outcomes over which I had absolutely no control.

The expected write-up, when it finally came, was insulting. It was obvious that the VA was far more concerned about the way I had documented serious problems adversely affecting patients than they were about the serious problems themselves. And they had the nerve to offer me psychological help if I needed it, as if my valid complaints about the mistreatment of our fighting men and women were a symptom of an anger management problem on my part!

In discussing the letter with me, one of my bosses mentioned in passing that if I was unhappy with the practice environment at the VA, I didn't have to work there. I knew she meant that it would be better for her and everyone else if I did not conspicuously challenge VA policy, even though I had kept my complaints in-house. (Going public while still working at the VA was an act of professional suicide). But after she said it, I thought to myself, "You know, she's right!  I don't have to work here." Soon thereafter I gave two months notice of my intent to retire from my VA practice.

Neither of the two problems most responsible for my leaving was actually the subject of my letter of reprimand. The first big issue was briefly mentioned at the end of Part II of this post - a psychiatrist there who seemed to me to have been using almost all the worst practicess of bad psychiatrists that I have been describing in this blog. I'll call this doctor Dr. X. Dr. X had a large caseload. Upon Dr. X leaving the VA after practicing there for several years, I started getting some of Dr. X's patients re-assigned to me.

Dr. X's notes in the electronic medical record (EMR) were next to worthless:  No documentation of diagnostic criteria for the diagnoses that were made. No descriptions of why certain medications were chosen - some of which were not indicated for the diagnoses on the chart. 

Diagnoses were often written as just "depression," which is a symptom and not a diagnosis at all. The notes never discussed psychosocial issues, or if the patient might need psychotherapy, and rarely mentioned any of the patients' personality issues, which were plentiful.

The notes also never mentioned which medication side effects the patients might have complained about. Dr. X would increase the dose or change medications without saying why. If the patients were on antipsychotic medications notorious for sometimes causing increases in a patients' blood sugar and/or cholesterol, no blood test monitoring for this was done.

Worse yet, Dr. X would start someone on a new antidepressant, and then not schedule a follow-up appointment for three months or more. 

Antidepressants, when they work, take 2-3 weeks to start kicking in, and up to six weeks to get the full effect. Often the dose must be increased if the first dose of drug does not work. Different patients may respond to one drug but not another, and to which antidepressant a patient may best respond is unpredictable. Furthermore, certain agents may have serious side effects in a given patient, necessitating a switch to a different one. 

Thus, several changes in medication must often be made for some patients. Each time a change is made, the clock for the long 2-6 week kick-in period starts running from the very start all over again.

Therefore, patients started on these drugs need to be followed up within 3-5 weeks at the longest. Dr. X's patients who did not respond to this doctor's initial prescriptions or who had problematic side effects, on the other hand, had to wait months for a follow-up appointment. At that rate, they would often experience no improvement in debilitating depressive symptoms - unnecessarily - for months and months.

Then there was another issue with an SSRI antidepressant named citalopram (brand name Celexa). The FDA suddenly came out with a warning about the use of higher doses - doses that had previously been recommended - because of some minor EKG (heart rhythm) changes that may occur in some patients, which sometimes but rarely cause serious problems.  

Of course, the VA immediately mandated that dosages above the new recommendations be reduced poste haste with no exceptions, even if the patient had been stable both medically and psychiatrically on that dose for quite some time!

When patients were on the higher dose because they had not responded to the lower dose, Dr. X then unceremoniously reduced the patient's dose to the previously ineffective one, and then said see-ya-later for three to four more months. The patients of course relapsed because the lower dose had never worked for them in the first place. There were other SSRI's to choose from that Dr. X might have considered switching to, since the relapses in these cases were completely predictable. 

Although I occasionally had seen one of this doctor's completely worthless "progress notes" before I inherited some of these patients, I did not of course know about Dr. X's typical practice pattern until after this doctor left and I started treating them. However, Dr. X had been there for years. Because Dr. X kept a very low profile, apparently the powers-that-be played a game of "see no evil."

My getting these patients created two major problems for me. For one, I was getting potential cases of malpractice dumped in my lap.

Second, I started getting a lot of these patients. To understand the problem this created for me, first some background: Before I had taken the job at the VA, I was told that I would have a full hour to see any patient who was "new." Being aware of managed care tricks, I specifically asked: new to me, or new to the clinic? (I insist on not just taking the word of a previous doc but doing my own independent evaluation, although I do take the opinion of the other doc into account). I was told I would get a full hour for any patient who was new to me.

As it turned out, an hour was not the usual allotted time for visits at the VA for those patients who had been seen previously by any of the staff psychiatrists. Any patient who had been seen by another doctor was instead scheduled for the usual 30 minute follow-up. When I insisted on an hour for any patient new to me, and made the people responsible for scheduling patients change appointments which did not have the correct duration, the powers-that-be begrudgingly accepted my demand. This worked fine for quite a few years.

I was officially slated to see two patients that were brand new to the clinic every week, which is fine for someone working 30% time. I could usually get such new patients in for a follow-up appointment in a reasonable period of time. However, when Dr. You-know-who left, I was suddenly seeing 4 or 5 patients who were new to me every single week. And essentially starting from scratch with each of them. The VA, unlike me, did not count Dr. X's  patients as being "new," so according to them, my caseload of new patients had not increased - when in fact, it had more than doubled!

Soon all of my follow-up appointment times started to fill up. I was no longer able to get these patients scheduled in for follow-up within an appropriate time period.

This was made even crazier because the VA does not penalize patients who do not show up for multiple appointments - even if they miss several in a row. Therefore, some of my appointment times for follow up patients were being wasted on patients who had missed three or four appointments, and were therefore not likely to show up.  Of course, if I double booked patients, and everyone did happen to showed up, there would be no way I could see everyone on the schedule.

I knew we were short staffed, but I was not going to enable the system by short-changing the patients whom I was already seeing, which was what seemed to be expected of me.

The issue of being short staffed relates to the second issue that caused me to abruptly curtail my expected period of employment with the VA. That will be the subject of part IV of this series of posts.

Electronic Health Records: A Slippery S.(L) O.A.P.

In the last few years, the federal government has been pushing doctors to adopt software for recording medical records electronically on computer, and in response several companies climbed all over one another trying to sell Electronic Health Record (EHR) systems. 

In Medicare, the law authorized a higher fee for service rates to “reward” those doctors who began to use them - which in actuality is a payment penalty for those who did not. The cost of the software programs is, by the way, exorbitant - almost prohibitively so for doctors in individual practices or small practice groups in relatively low-paying specialties like pediatrics and psychiatry.

The EHR’s were supposed to increase efficiency and produce cost savings. Lab results from all of the patient’s doctors would be instantly available so that tests would not be repeated needlessly. Doctors would have instant access to prior records without having to mail away for them, and every current doctor would be able to see what the patient’s other current doctors were doing.

Those are admirable goals. Unfortunately, there are some problems with the currently available software that actually have had the effect of negatively impacting patient care. 

Whether these problems were foreseen or unforeseen is a debatable proposition.  George Dawson in his blog Real Psychiatry certainly makes the case that some of the “changes” we have seen in recent practice patterns that were caused by the use of EHR’s are highly consistent with the goals of the money-grubbing, profiteering-at-the-expense-of-patient-health managed care insurance industry. Or as we like to call it, mangled care.

I complained about some aspects about one EHR system I was using in a previous post. I must admit I had been wondering if I might be unusual in having noticed  that there are significant problems.

Well, the American Medical Association (AMA) has noticed them, and they have had enough! According to the AMA Wire on 9/16/14, the AMA has belatedly pointed out the obvious and has taken some action. Well, sort of. Of course, it will probably go absolutely nowhere.

It’s no secret that many physicians are unhappy with their electronic health record (EHR) systems, thanks in large part to cumbersome processes and limited features that get in the way of patient care. Now a panel of experts has called for EHR overhaul, outlining the eight top challenges and solutions for improving EHR usability for physicians and their patients.

This new framework (log in) for EHR usability—developed by the AMA and an external advisory committee of practicing physicians and health IT experts, researchers and executives—focuses on leveraging the potential of EHRs to enhance patient care, improve productivity and reduce administrative costs. Here are the eight solutions this group identified to address the biggest challenges.

In my previous post on this issue, I discussed the extraneous forms like treatment plans and symptom checklists that waste my time, as well as the difficulty in locating specific information in the overly-long patient record. In this post, rather than list the eight proposed "solutions," I will instead focus on a problem that was near the top of the concerns expressed in the above article:

Poor EHR design gets in the way of face-to-face interaction with patients because physicians are forced to spend more time documenting required information of questionable value. Features such as pop-up reminders, cumbersome menus and poor user interfaces can make EHRs far more time consuming than paper charts.

Although physicians spend significant time navigating their EHR systems, many physicians say that the quality of the clinical narrative in paper charts is more succinct and reflective of the pertinent clinical information. A lack of context and overly structured data capture requirements, meanwhile, can make interpretation difficult.


EHRs need to support medical decision-making with concise, context-sensitive real-time data. To achieve this, IT developers may need to create sophisticated tools for reporting, analyzing data and supporting decisions. These tools should be customized for each practice environment."

Ah yes, the quality and the interpretability of the proverbial doctor’s progress notes has gone down the toilet.

So what makes a good progress note? A good progress note does not just describe what the patient looks like during a visit at that particular time coupled with a plan concerning what the doctor is going to do next. It should also indicate what the doctor is thinking about the patient, the patient's symptoms, and the diagnosis. Specifically, which of the patient’s symptoms have changed, and if so, what is the change due to? The medication prescribed? Side effects? A misdiagnosis? A placebo effect?

Does a change in the patient’s clinical picture suggest an alternate diagnosis? Are there any side effects from the medications that the doctor prescribed? How does the patient's clinical presentation relate to any treatment that has been rendered? Does any observed changes in the patient's condition mean the doctor should change the treatment or continue it as is? If a change in medication is planned, over which symptoms is the doctor trying to get better control? If there has been no response to treatment, to what does the doctor think this lack of improvement should be attributed?

In reading over a medical report, another doctor can fairly easily ascertain the answers to the above question from a relatively brief narrative.  On the other hand, the answers to these questions cannot be ascertained from a simple checklist. No how, no way.

In the old days when I trained, we were instructed to use a so-called “S.O.A.P” note.  The abbreviation stands for the different types of information that should be included in the note:

Subjective: A description of the report from the patient regarding his or her own symptoms and overall improvement or lack thereof, as well as any reports of side effects. In the case of antidepressants, the timing of any changes in symptoms should also be ascertained and described, to help rule out a placebo effect.

Objective: What does the doctor observe when looking at the patient? Are there any changes in the patient's physical examination? What changes in the patient’s outward mental status have transpired since the last visit? What are the results of any lab tests that have been ordered?

Assessment: What does the doctor think these results mean regarding the patient’s diagnosis and treatment?

Plan:  What is the doctor going to do next to handle any problematic side effects of treatment, or to handle any failure of the patient to improve?

In psychiatry, a good progress note should also contain information about any changes in the patient's psychosocial situation - particularly any stressors: job changes, divorce, major family battles, deaths, children getting into trouble and the like. This information is important in determining whether any changes in the patient's clinical picture are due to environmental stressors or psychological reactions, and not due to the medication or its failure.

At the multispecialty clinic where I work part time, the useful S.O.A.P. progress note format is at risk of being abandoned. There are still good notes, but many of the progress notes contain almost no indication of what the doctor was thinking about the effects, let alone the pro’s and con’s, of the patient’s treatment.  

Between scrolling through all of the the checklists and the extraneous notes and next to worthless notes, I find myself  wasting an amazing amount of valuable time that I could be spending actually talking to my patient.

I certainly wish the AMA well in addressing these problems. I’m not holding my breath.

Electronic Medical Records and Symptom Rating Scales: "Solutions" Making Problems Even Worse

Sometimes an effort to solve a problem just creates different, and at times even more serious problems. Take the electronic medical record (EMR) for example. Please. (Apologies to Henny Youngman).

In a clinic I work at that uses an EMR, we are required to fill out a “treatment plan” on each patient. This is - for me at least - a waste of time since my initial psychiatric evaluation note contains all of the information contained in the treatment plan, as well as important contextual information about the patient that is not included in the plan.

The treatment plan is not only redundant, requiring me to enter information twice, but increases the number of notes in the medical record, making it more difficult for anyone reviewing the chart to find specific information they may need to as they attempt to properly care for a patient. 

Sometimes trying to find specific information in the record is like searching for the proverbial needle in a haystack. Since we aren’t given a lot of time to review charts before patients come into see us in the first place, this takes time away from the all-important face time with patients.

A narrative note is always better than a form with boxes, which often does not provide a “box” that adequately addresses an issue for a patient. But having reviewed the notes of other psychiatrists, I can see why some administrator felt that having a formal treatment plan in the EMR was a good idea. A lot of the information inherent in a good psychiatric evaluation was nowhere to be found in the notes from a good percentage of my fellow clinicians.

Not only that, but many of their follow-up progress notes did not mention what symptoms were being addressed by the doctor's treatment. Nor did they mention what symptoms, if any, had responded to any medications that were prescribed, let alone whether or not the symptoms had actually resolved.

The treatment plan template wisely asked for these target symptoms. Recently, however, the plan template was changed to include a question asking the clinician how symptom improvement was to be measured.

The answer should be, “by clinical evaluation.” And that is what I always write. However, I think the designers of the template are looking for some sort of psychological assessment device, as if that were more valid that a clinician’s evaluation. As I frequently rant about on this and other blogs, such measures are typically screening tests consisting of symptom checklists, and as such are NOT meant to be a measure of clinical progress, let alone of a definitive diagnosis.

The question a good psychopharmacologist asks, particularly with major mood disorders, is not only whether the symptoms the patient has have improved. It is whether the patients have returned to their “baseline,” the way their mood was before they developed an episode of, say, major depressive disorder.

The Hamilton Depression Scale (HAM-D) scale for rating depression is one of the most frequently used symptom checklists, both clinically and in research.

It was published fifty years ago Max Hamilton (1912–1988). Interestingly, Hamilton himself was forever pointing out that the HAM-D was not intended to be used to make the diagnosis of depression. It does not have either sensitivity or specificity—there is a great deal of overlap with symptoms of other diagnoses, particularly anxiety disorders. 

Yet somehow it became the gold standard for not only evaluating the efficacy of antidepressants, but for measuring symptom improvement clinically.

I would much rather the administrators of the clinic solved the problem of absurdly vague “progress notes” by spelling out the minimum information they need to contain, not by asking a stupid question on a treatment plan form.