Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Friday, August 15, 2014

K'vetch Fest 2.0

First off, let me apologize for the radio silence. I've been on vacation, literally and figuratively, and I haven't been able to get myself to so much as look at a draft of a post, let alone work on one, or even read the usual blogs I follow, with the exception of my favorite crochet blog. That's how mindless I've been keeping things.

Mea culpa.

Moving on, I'm going to pick up where I left off on a post I started before vacation.

In the mid-70's, the comedian Alan King had a TV special called, "Final Warning", in which he joked about everything that was wrong with the world. The next year, he had another special called, "2nd Annual Final Warning", and the year after that, "3rd Annual Final Warning."

It's been a year since I wrote The Culture of Medicine and the Art of Kvetching, in which I asked the age-old question, "How did we get to this place?" And I listed a few of the things that make practicing psychiatry a crazy endeavor. And I know crazy.

Last year's list, in brief:

E/M coding
Insurance Companies

Well, a lot has happened in the past year. The concerns that plagued me then have evaporated, while other woes have befallen me. Here's a partial list of what's bothering me now:

Collaborative Care Model
Insurance Companies
+/- ICD-10
DSM-IV vs. DSM-5 on the board exam
Big Pharma not releasing data

Oh, wait. I guess not that much has changed, after all. E/M doesn't bother me anymore because I use a template for notes, which make my notes completely meaningless, and I'm pretty much on autopilot. In fact, I'd have to reread my own post if I wanted to remember the nitty gritty of coding.

The NY SAFE gun act that is supposed to prevent the "dangerously mentally ill" from obtaining access to firearms has simply not been relevant in my practice, and I hope it never becomes so. And I-STOP is now I-Just Do It and I-Don't Care.

Beyond that, it looks like things have gotten worse. HIPAA is still on my list because now it's not clear if doctors who prescribe electronically, which will be all doctors starting in March, are subject to HIPAA. I got a letter from my risk management about this the other day. They're researching the eRx issue, and they also sited cases where there were breeches of security because some management bozo left 70 boxes of medical records out on the street. Ya think?
They also wrote about the lack of security for those who somehow still use Windows XP, now known as Windows RIP. Mac rules!

EHR's are still worse than useless, and the CDC has been actively pursuing me to get my opinion on a "brief" and "voluntary", but not "anonymous" survey. Seriously, I mean stalking. I got one copy of the survey, which sat on my desk while I contemplated whether I would fill it out. A week later I got a postcard reminding me to fill it out. That's when I placed it in the circular file. I've since gotten two more copies of the survey, and two irritated phone calls.
I thought about filling the thing out. It asked about whether and how I use an EHR. I had some qualms about chucking the thing because if I'm really concerned about the use of EHR's, then I should fill out the survey and express my opinion. But it didn't really provide a way for me to describe the fact that I have an EHR, but I don't use it, and the only reason I have it is because I don't want to have to pay a lot of money to e-prescribe, come March. It also wasn't anonymous, and asked some stuff related to meaningful use that seemed like a good excuse for private insurance companies, in the not-too-distant future, to reimburse less for doctors who don't use EHRs, consistent with medicare/medicaid policy. And they were a little cagey in their description of how the information was to be used.

I thought I was good with the Erx situation, but it turns out I need to re-verify my credentials. And I may have used up the three chances I get to do so, because I started the process at work, and then realized the answers to some of their questions involving old mortgages and addresses were at home. I'm gonna try again, but if it doesn't work, I'm not sure what I'll do in March.

The Collaborative Care Model makes me want to cry-I have half a post written about it, so maybe I'll share that if I can finish it. And I don't understand why no one of importance has come out and stated that the reason Big Pharma is withholding its data is because they're worried that if they reveal the full data, people will realize that their drugs either don't work, or are harmful. Or both.

But the big one, of course, is MOC. I registered for my exam today. I put it off as long as I felt I could tolerate, but I finally bit the bullet and did it. All $1500 of it. I did read through the terms pretty carefully, and even though I've agreed that the board can decide my test results are invalid, even if they don't think I did anything wrong, I did notice that that particular clause does not say anything about my needing to pay to retake the exam under those circumstances. It doesn't say I don't need to pay, either, but at least I can make an argument for myself. Yup, that's how positive I'm feeling about the experience.
And a few days ago I ordered the cheapest version of DSM-5 that I could find. That would be the Desk Reference to the Diagnostic Criteria from DSM-5(TM) (Paperback), which set me back $26.27, as opposed to the $62.02 spiral-bound version. It's sitting in an unopened box on my desk, along with a bottle of granite cleaner. I felt like there was no way I could figure out the changes from IV to 5 without seeing 5. But it pains me.

So once again I ask, "How did this state of affairs come to be?" You know how there are legends about babies being trained to be Ninjas, and their parents dislocate their shoulders for them so they can do it more easily as adults, and get themselves into or out of tight spaces because they can contort themselves unnaturally? Well maybe there's a cult of some kind that drops babies on their heads or deprives them of oxygen so they can grow up to make rules about insurance coverage. Or come up with systems of psychiatric care that have everyone BUT psychiatrists seeing patients.

There's a Talmudic phrase that applies here. Roughly translated, it means,

The world has been given over into the hands of idiots.

Thursday, July 31, 2014


If you read my post, Why would I do that?, you'll learn that I've been puzzled about an insurance phenomenon. I get these faxes from insurance companies, asking me to agree to an expedited fee for my services. For example, if the patient has submitted my bill for $300, the insurance company will suggest I accept $186. In addition, my signature on the form indicates that not only will I accept that amount, but I agree not to bill the patient for the difference.

I also get phone calls from the company asking me to call back and "negotiate" a fee, meaning I'll agree to accept less than my actual fee.

I could never understand how this constitutes a negotiation, since the insurance company is saying, "If you accept this amount, in exchange, we'll give you absolutely nothing. Would you like to be paid $300, or $186 for the same service?"

Hence the title, "Why would I do that?"

I think I've figured out why they think I would do that. In my disgust with these forms, I seem to have missed 2 key points.
1. The claim that this is a "time sensitive document." I assumed that was just an attempt to get me to sign it without thinking. And
2. the line, "Provider agrees to accept the above, provided that payment is released within 10 business days from date of receipt of faxed/digital signature."

It seems what they're offering in exchange for a lower fee is quick payment. I'm guessing this means that my lack of signature/agreement indicates my willingness to wait around indefinitely for my payment, if it's sent directly to me, or for my patient to wait around for his reimbursement.

So once again, the insurance company wins. Either they have to pay me quickly, but much less than my actual fee, or they can pay me whenever they feel like it, with all the snags and wrenches that can be encountered along the way, in order to delay payment.

It also tells me that the insurance company is more than capable of paying in a timely manner, but they consider themselves exempt from any such reasonable behavior. What do they do if a client is chronically several months late in paying her premiums?

Sunday, July 27, 2014

Summer Books

I have a week of work left before my August break, so for me, the summer is just starting, even though it's half over for most people. And I have BIG READING PLANS.

I plan to finish 2 of the 3 books sitting on the shelf in my bathroom: A Confederacy of Dunces, by John Kennedy Toole, and Microbe Hunters, by Paul De Kruif. I started reading both of these books ages ago, and just never got through them.

The third book on the shelf is Psychoanalytic Terms & Concepts, edited by Auchincloss and Samberg. It's described in its Introduction as "a hybrid of dictionary, encyclopedia, annotated bibliography, textbook, and intellectual history". There's no way I'm going to "finish" reading it any time soon, but I do plan to work my way through it slowly, letter by letter, all the way from "Abreaction" to "Wrecked by Success". I guess there are no X, Y, or Z terms.
This book was given to me by my analytic institute as a graduation gift. True, the guy who handed it to me is married to one of the editors, but it was still a generous and meaningful gesture. It's a fascinating book that not only teaches things about psychoanalysis, but gives one a real sense of what a Herculean task it is to create such a lexicon.

Another book I received as a gift about two years ago, and did finish reading, is Robert Jay Lifton's, The Nazi Doctors: Medical Killing and the Psychology of Genocide It's about as far from beach reading as a book can get. Dr. Lifton, who is a psychiatrist, researched the book over the course of many years by interviewing survivors of Auschwitz, other people who knew the Nazi doctors at Auschwitz, and many of the doctors, themselves.
The basic premise of the book is that Germany did not go directly from barely tolerating Jews to The Final Solution. There had to be a more gradual shift in thinking, and this shift, according to Lifton, was facilitated by the medical profession. First there was the "euthanasia" program, in which mentally limited children and adults, not all of them Jews, were quietly done away with, often by slowly starving them into a debilitated state, and then putting them out of their misery. This was done, ostensibly, to create more resources for Germany's finest, who were fighting for their country. And this early killing was performed by physicians, paving the way to Auschwitz.

In Auschwitz, itself, doctors didn't lock the inmates in a chamber and turn on the gas. But they did determine who would be sent to the gas chamber. All the selections were performed by doctors, and the heart of Lifton's book is about an internal process he calls "doubling", which allowed these physicians, trained in the art of healing, to pervert their knowledge, skills, and position into the art of killing.
Many of the doctors, most notably Mengele, also performed cruel experiments on inmates, justifying them as necessary for the furtherance of medical science. Lifton explores how they lived with themselves. Or didn't. One-and only one-doctor refused to participate in selections. Mengele indulged in the power and cruelty. All of them drank heavily. And the medical chief of Auschwitz, Eduard Wirths, was somewhere in the middle. He was a devoted family man, and used his love for his family as a support system to carry out what he believed to be a necessary evil. He was never cruel to inmates, and he occasionally went out of his way to save the lives of a few individuals. But it was he who streamlined the process and turned Auschwitz into the ultimate killing machine. He hanged himself after the war.

I'm sure it won't surprise you to learn that it was a tough read. I could only tolerate a little at a time. I often read chapters, or sections, out of sequence. And I found myself conceptualizing it as, "This is a book about a fictional place called Germany in the 1940s." I couldn't read about it and believe it at the same time. It was my own kind of doubling.

As hard as it was for me to read, it was even harder for Dr. Lifton to write. In 2011, he published Witness to an Extreme Century: A Memoir, in which he describes what it was like for him to do the research for the Nazi Doctors book, including the interviews with the doctors, themselves.

So on that fateful day at the library when I checked out the book I subsequently lost on the subway, I also checked out "Witness", which I didn't lose, and proceeded to read. And the reason I'm writing all this is that I learned a powerful professional lesson from these two books.

Lifton writes about how he prepared himself for the interviews with the Nazi doctors. Steeled himself, really. He resolved not to tell any of them that he is a Jew, although some figured it out. He also resolved to maintain his moral position, which is that these men are evil. They participated in horrors, and nothing can change who that made them.

He politely extracted himself from any appeals to his understanding of their position, as a "fellow doctor". And he was especially uncomfortable with any non-research interactions. The interviews took place over many hours, and he and his German interpreter would take lunch breaks, and go to eat lunch in some local restaurant. But one of the men they interviewed lived out in the countryside, and there was nowhere to go, so he (the interviewee) invited them to stay and have lunch with him and his wife. They did so, but Lifton had tremendous difficulty with this kind of social connection with his subject.

He interviewed Eduard Wirth's daughter, who was a small child when her father died. Growing up, she was not told about his role in Auschwitz, but she gradually became aware of what he had done, and continues to struggle with that knowledge, and the inconsistency with the memories she and her family have of her father. She asked, "Isn't it possible for a good man to do bad things?"
Lifton's response was, "Yes, but then he is no longer a good man."

None of the men he spoke with demonstrated any real remorse. They rationalized, talked about "what it was like back then", minimized, externalized. All kinds of defenses. None of them said, "What I did was terrible. I regret it. It's hard to live with myself."

In reference to Wirths, one of the survivors said, "At least he did the decent thing and killed himself." But Lifton's take on it was that his suicide was an act of cowardice.

I got the impression that Lifton was defending himself in all these interviews. Not in the obvious ways. He's particularly insightful about his feelings of anger, and describes his experiences clearly. My sense was that he would not allow himself to see the humanity in these men. The good father and husband in Wirths. The pleasant company over lunch. The fellow physician.

I had several thoughts about this. I couldn't help wondering if, had he let himself relate more to these men, Lifton could have gotten more from them. As it was, he learned a tremendous amount, and his doubling concept is a powerful conclusion. But I wonder if they would have been more willing to reveal their vulnerabilities if he had let himself be more open to them. More vulnerable, himself.

More importantly, I felt that, in denying their human frailties, Lifton was doing to these men what they had done to the prisoners at Auschwitz. He writes about the Nazi concept of "life unworthy of life", which was the foundation of all the murder. The ability to view another as less than oneself allows one to discount the other's humanity. It felt like Lifton was acting out something these Nazi doctors experienced, but could no longer openly acknowledge.

It made me think about my work with patients, and maybe the take home lesson ought to be that I need to be open to all the awful humanness in my patients. But it seems to me that Lifton was afraid that if he was open in this way, he would understand them and identify with them well enough to realize that he could be one of them. And this was intolerable. It's hard to fault him for that. And maybe there are times when I need to exercise a similar restraint in my work.

Sunday, July 20, 2014

The Journey Continues-Weathertop

Picking up where I left off, I'm on my way to Mordor. Make that, my Board Recertification. In theory, the first stop after the Shire should be Tom Bombadil's (for those who only saw the movie, read the book to find out who he is), but in the research I've done thus far, nothing that cheerful has come up. This is not going to be a honeycomb and clotted cream kind of trip.

Next would be the Barrow Downs, and then Bree. But somehow, I thought of Weathertop, and when I searched for an image, this came up:

Lego Weathertop

Can somebody tell me what Darth Vader is doing in Middle Earth? Turns out, there are all kinds of lego Lord of the Rings models. Everything from Moria to Minas Tirith.

This stage of the journey involves finding a way to study for the exam. Preferably one that won't put me in debtor's prison.

First, I need to figure out what I need to know. The ABPN site does provide a detailed list of topics covered in the 2015 exam. Note that for each topic tested:

I guess I better brush up on my psychiatric genetics. I wouldn't want to disappoint the NIMH, now would I.

So now I'm searching around for a review course that will help me learn the useless information I need for the exam. I think what I really need is a question bank. But here goes.

I got an email from MGHAcademy, and the subject line was, "Superior Study Tools for Psychiatry Exams". There's a Board Exam Mastery Course, intended for passing the boards the first time around, a Child and Adolescent Update and Study Course, which is not relevant for me, and the Mass General Hospital Review and Update Book.

I ordered a sample of this book on Kindle, just to see. A quick perusal of the contents revealed, "Chapter 3 The DSM-IV: A Multi-Axial System for Psychiatric Diagnosis. The rest of my perusal revealed nothing about DSM-5. So I guess this one won't be helpful, because as we know, DSM-IV diagnoses that have different names in DSM-5, or have been split into multiple diagnoses in DSM-5, or have been lumped together in DSM-5, will be tested. And DSM-IV diagnoses that are obsolete in DSM-5 will not be tested.
There's a whole section on "The Psychotherapies", and it includes everything from brief therapy to group therapy to hypnosis, but no psychodynamic psychotherapy. I guess I better brush up on my hypnosis.

I found an in-person course in (Yay!) NYC on the Kaufman Courses site (of the Neurology for Psychiatrists Kaufmans). The course took place back in January (Boo!). Maybe they're planning another one for this coming January, but there's no evidence to support that theory on the site. And I couldn't check to see how much it cost, which may or may not be a good thing.

Another site I found with a course that already took place is CMEinfo. It was a 5 day class for $1195, and it took place in Atlanta.

Honestly, for these kinds of prices, they could update their sites.

The Osler Institute offers an audio course for $220, as well as a recertification syllabus for $55. There's also a question book, Psychiatry: 1200 Questions to help you pass the boards for $68. This seems to be the least expensive option.

So far, the best option I've come across is the one I mentioned in my last post, Beat The Boards. They seem to have a large question bank, with explanations and testing strategies, and the cost is $1097 for the online course.  They claim to "teach to the test"-bad for elementary school, great for MOC. That probably says everything you need to know about MOC.
There's also something called the Pass Machine for $500, which claims it's optimized for iPad use, and includes a new iPad. but there's no description of what the content is. I already own an iPad, and the online course can be accessed through one, so I don't know what the difference is. They also claim to have some free resources, including a Medquick Guide, geared to the boards. But when I tried to enter my information to receive it, I got an error.

The only good news in this whole situation, so far, is that according to the ABPN MOC Statistics page, as of December 31 2013, there's a 99% pass rate.

And here's something to make you smile:

Lego Rivendell

Thursday, July 17, 2014

The Journey Begins

I strongly recommend playing the "video", which is really just a soundtrack, while reading this post.

I'm about to leave the safe, familiar bounds of the Shire, and venture forth on a bitter journey to a destination from which there may be no return.

I'm registering for my Board Recertification Exam.

Requirements for admission to the 2015 maintenance of certification examinations include:

A full, active, unrestricted medical license.  Check.

Completion of 270* Category-1 CME credits in the past 10 years, with 150 in the past five years. Check.

Completion of at least two self-assessment activities that provide 24** SA CME credits in the past ten years. Check.

Completion of one Improvement in Medical Practice (PIP) unit. Check.

Now the fun part:

DSM-5 Conversion
Updated April 28, 2014

With the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the American Board of Psychiatry and Neurology (ABPN) will adapt its examination specifications and content to conform to DSM-5 classifications and diagnostic criteria for all of its computer-delivered certification and maintenance of certification (MOC) examinations according to the following timeline:

Computer-delivered examinations administered in 2013 and 2014
Will continue to use DSM-IV-TR classifications and diagnostic criteria

Computer-delivered examinations administered in 2015 and 2016
Will use classifications and diagnostic criteria that have not changed from DSM-IV-TR to DSM-5, as follows:

1. Diagnoses and diagnosis subtypes from DSM-IV-TR that are obsolete with the publication of DSM-5 will not be tested. Example: Substance-induced mood disorder is obsolete.
2. Diagnoses and diagnosis subtypes in DSM-5 that were not mentioned at all in DSM-IV-TR will not be tested. Example: Hoarding disorder is new to DSM-5.
3. Diagnoses that are exactly or substantially the same in both DSM editions will be tested. Diagnoses that are substantially the same are defined as:
(a) those that have had a name change only
Example: Phonological disorder (DSM-IV) is called speech sound disorder in DSM-5.
Example: Factitious disorder (DSM-IV) is called factitious disorder imposed on self in DSM-5.
(b) those that have been expanded into more than one new diagnosis
Example: Hypochondriasis (DSM-IV) has been expanded into two new diagnoses in DSM-5: somatic symptom disorder and illness anxiety disorder.
(c) those that have been subsumed or combined into a new diagnosis
Example: Alcohol abuse (DSM-IV) and alcohol dependence (DSM-IV) are combined into alcohol use disorder in DSM-5.
For these diagnoses, both DSM-IV-TR and DSM-5 diagnoses will be provided on examinations.

I'm so confused.

Here's  some more good news:

Applications must be completed on-line by September 01, 2014 (11:59 PM Central Time). Applications completed on-line after September 01, 2014, require an additional $500.00 late fee. Applications will not be available after November 03, 2014

The late fee is over and above the $700 Application Fee and the $800 Examination Fee.

Since I don't want to have to take the exam a second time, I better start studying. Where to begin?

Here's an online review course for just $1097! If you fail, you get a 100% refund of your tuition, PLUS an additional $500, PLUS online course access until you pass, tuition free!

If you pass, you get a set of Ginsu Knives!

The course includes:

High-Yield Content! utilizing '“Question-Based Learning.” Lectures are constructed from a series of board-style multiple choice questions, each coupled to a mini-lecture on that question’s topic.'


Anytime, Anywhere Access!


Board-style Practice Exams!

I can't wait to see how it turns out.

Tuesday, July 15, 2014

More Analytic Wierdness

I'm wondering what other psychiatrists do when they see their patients in a setting outside the office. I'm not talking about boundary violations-inviting a patient for a drink, attending a patient's wedding. I just mean you're simply walking down the street, and there's your patient.

My own policy is that I won't approach the patient, nor will I even acknowledge her, unless she acknowledges me first. And then I'm polite and I smile and nod or say hello. Then I walk away. This has been tricky a couple times, on the subway. I can't really walk away. It's true, you can walk from one car to the next, but ever since I got a $75 fine for doing so, I stay put.

The lack of acknowledgement is not intended to be rude. It's just that there have been occasions when a patient was clearly uncomfortable seeing me, and didn't want to interact at all, so I feel like it's not right for me to put her in that position.

And I know from my experience as a patient just how uncomfortable that can be. I've written before about taking the stairs at the Institute to avoid getting into a small elevator with my analyst. I've occasionally avoided eye contact when I see her on the street or in a restaurant near her office. And at the annual dinner, it's all I can do (well, me and a glass of wine) not to run when she's in my vicinity, or when I see her talking to someone I'm friendly with, or standing with her husband.

Over the course of my analysis, I've gotten better about this. A couple of months ago, I was at a talk at the Institute, and in walks my analyst. I was sitting in the back, so I could cut out early (I'm on the scientific program committee, so I'm sort of required to be there, and I enjoy the talks, but I also just want to get home). I was actually reading something on my phone, but as she walked by me, I recognized her boots.  And I was fine with that. Of course, I didn't need to make eye contact with her. And I had the strange experience of second guessing myself. "Was that really her? I only saw her from the back. Maybe it was someone else." She's kind of short, so I couldn't see her well from where I was sitting.

I know from speaking with colleagues that I have a more extreme reaction to "outside" encounters with my analyst. Some people are a lot more comfortable in those settings. And I have one friend who's at the other extreme, and  will actively approach her analyst and say hi, or wave at him. I actually think she and I share the same feeling, but with differing responses.  We're both intensely, maybe grotesquely interested in our analysts' personal lives, in the fantasy of being part of those lives, only I'm avoidant, and she's counter-phobic.

And I find the experience of exclusion particularly painful, since I know that I am both my analyst's patient, and her colleague, and if I had worked with a different training analyst, I might have even been her friend.

Or not. She's a little annoying.

My analyst's office is on the Upper East Side, and my office is in Greenwich Village. For those unfamiliar with New York City, we're not neighbors. The actual distance is just under 5 miles, but Manhattan is made up of micro-neighborhoods, so we might as well work on different planets.

Tonight, I was walking to the subway from my office, taking my usual route, and way up ahead of me, walking right towards me, is a woman who looks a lot like my analyst. I can't see details from this distance, but she has the same distinctive walk I recognize. A kind of brisk, side-to-side movement.

There's no one else on the block, nothing to stop us from looking straight at each other.

I panic and cross the street. It takes a while because I'm in the middle of the block and there are a bunch of cars I have to wait for. I hope she doesn't spot me skulking between two parked vehicles.

I tell myself she wouldn't have noticed it was me. She was on the phone so she was probably distracted. But I recently got a new bag, which is kind of, well, pink and obvious, even from a distance.

I cross the street and keep my back to the side she's walking on. I feel like an idiot and try to think of something to do that would make it seem like there's a reason I abruptly crossed the street. One that has nothing to do with her.

I take out my phone and start to take pictures of a building on my side of the street. I've taken photos of this particular building before, but she doesn't know that, so I can just tell her tomorrow that I'd been planning to photograph that building for a long time, and this seemed like the perfect opportunity, at the end of the day, in bad light, when I'm dead tired, and it's about to rain.

I take a lot of photos of my work neighborhood. It's an older part of the city, with these lovely tree-lines streets and townhouses galore. All kinds of cool stuff. Mark Twain and Eleanor Roosevelt both lived within 100 yards of my office.

This is the building:

The Building

It's the 2nd in a row of 6 Greek Revival/Federal style buildings that were clearly built at the same time. You can see what the other five look like in the building to the left. But this one has that weirdo modern angled facade. Now, I generally prefer modern architecture, but it doesn't work here. And I could never understand why anyone would go to the trouble of completely altering the facade,  as was obviously done, and have it look like this.

It turns out, as I recently learned, that this is the building where the Weathermen constructed and unintentionally detonated their bomb. Which explains why the building needed a new facade. But not why whoever payed for it chose this particular style.

So I definitely needed to take this picture. I wasn't avoiding my analyst at all.

I waited for a bit, and was going to continue to the subway, but then I had that same nagging feeling that maybe it wasn't my analyst. After all, I didn't really see her. And she was wearing a different dress earlier today. But then she was obviously coming from the west side subway, so she may have gone home to change (she lives on the Upper West side, don't ask how I know).

But it couldn't have been her, because if it were, she would have been walking one block north, where the subway exit is, to the building where her husband works (don't ask how I know where he works, I just do, and it's a block from my office).

So I did the obvious and completely natural thing. I followed her. I had to hurry to catch up, and then I had to lag behind so I wouldn't get too close. I trailed her for about a block, only seeing her back, and when I finally convinced myself that it couldn't have been her (yes, "she" is grammatically correct, but I'm trying not to sound pompous in my writing), I saw her go into a restaurant that's a block from my office.

Well, that left me across the street from my office, wearing a raincoat that was making me swelter, so I decided to go back to my office and leave my raincoat.

I was feeling pretty good at that point. quite convinced that it wasn't my analyst, and that I therefore wouldn't have to bring this ridiculous and embarrassing experience up in my session tomorrow, even if I really ought to.

I left the office, planning to walk my usual route to the subway. That's when I saw her husband crossing the street. I stayed on my side, he stayed on his, and I followed him until I saw him go into the restaurant.

I hovered in place for about a minute, torn between turning around and taking my usual route, or walking past the restaurant and getting onto the subway at a different stop. Then I worried that she might see me if I walked right by the restaurant. I resolved to walk another block out of my way and take the next street. Then at the last minute, and only because the light was in my favor, I walked along the same block as the restaurant, but on the opposite side of the street.

This will all be "grist for the mill" tomorrow, unless I completely lose my nerve. And writing it kind of makes me wonder how effective analysis has been for my general neurosis.

But the August break is coming up, the great analytic migration to the Hamptons, and I'm sad when I anticipate the feeling of loss.

And it reminds me to keep in mind, with all the compassion I can muster, and before my own August break, how important I am to my patients.

Wednesday, July 9, 2014

Of Note

I hope people got to see this piece in the NYTimes, What the Therapist Thinks of You. I don't know, maybe my life is just really boring, and that's why I have to get so incensed over stuff like this. But it feels like one of those slap-your-forehead moments.

BI Deaconess is conducting an experiment in which mental health patients are given online access to their session notes. The article includes the expectable hype. What a great idea! This will revolutionize mental health care! Doctors should be open with their patients about their thinking! Studies have shown that patients with access to (non-mental health) medical notes are more involved in their treatment!

One psychologist in Newton, MA has been doing this for a while, and her patients really like it. Some even view it as a "security blanket" between sessions.

The article points out that notes are often written in language that may be difficult for a lay person to understand. It makes an argument in favor of using less technical language. It conversely cites an argument recognizing that notes are used for communication between doctors, so that technical language is appropriate and helpful.

To the article's credit, there's also some discussion about the notion that it might not be helpful for some patients to read their notes.

Here's what I think is right with this idea: There should be open communication between mental health providers and their patients. And the world is just too damn litigious, so let's not worry about that so much and let the patients see our "sacred" notes.

Here's what I think is wrong with it:

Uch, where do I begin?

Patient's shouldn't need to resort to reading notes to find out what their doctors are thinking. It's incumbent upon the doctor to create an environment in which, if a patient has questions or concerns or gripes about what the doctor is doing or thinking, the patient can talk about it with the doctor.

Much of my thinking about my patients stays in my head. Reading my notes won't enlighten anyone.

There are many times when I feel a patient is not ready to hear what I'm thinking. It's part of my job to be able to pick a good moment to communicate what's important. I don't want to blurt things out prematurely, because that's not helpful. And I certainly don't want patients to read things about themselves that can be misconstrued or misunderstood, without having me there to elaborate.

Sure, I could spend some time each session reviewing the notes from the last session with the patient. To me, that seems like a waste of precious time. If a patient wants to bring up something from the last session, she can go ahead and do so. If I think there's a topic that needs to be considered, I'll bring it up. We don't need to formally look at the notes for that.

One of the problems I have with seeing therapy patients only once a week is that it's like treading water (that's my former therapist's expression, to give due credit, though I doubt she'll ever read this). The patient just ends up reporting what happened in the past week, and you never really get to what they're feeling, or how that plays out with you. If part of that time was spent reviewing notes from the last session, there would be even less time to get to what's important.

I've had patients who take their own notes after a session, for a lot of reasons. To hold me to what I might have said. To make sure they don't forget. To have some part of me to hold on to once therapy ends. Mostly it's defensive, and it needs to be discussed.

Inter-session note-reading as a security blanket sounds to me like something that needs to be addressed as part of the reason the patient is in treatment, not encouraged as the "new normal", in the Newton psychologist's language.

But my biggest problem with this idea is the irony of it. It used to be that doctors kept notes and other types of patient records so they could learn things about their patients, for the purpose of helping those patients, and sometimes others, as well, using the notes as research observations. Think "The Wolf Man"and "The Rat Man". And much of what we know about transference started with "Dora".
Eventually, lawyers got involved, as they always do, and notes became part of legal documents, to "protect" doctors in case of malpractice suits. This changed the way notes were written, to more formalized, cautious documents with less useful information about the patient.
More recently, notes have gone through another change, particularly EHR-style notes, to documents that still protect doctors legally, but also allow for more streamlined billing. (See E&M Coding in All its Glory). What they don't do is tell anyone anything useful about the patient, or what's going on in treatment.
So now what? Are we supposed to take these clinically useless notes and give them to patients so they can learn what we're thinking? I can't tell what I'm thinking from those notes. Or are we supposed to somehow alter the way we write these notes so they protect us legally, streamline billing, AND allow patients learn what we think about them, in language they can understand?

Good luck with that.