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.

Tuesday, September 16, 2014

Learning New Things

I hope people are familiar with the Khan Academy. It's a wonderful resource created by Sal Khan, an MIT graduate who went on to work in business. While he was working, he started making little You Tube videos on the side, to teach math to his cousins. Then he realized that people who weren't his cousins were also interested in his videos. He thought about charging for his educational efforts, but then he remembered MIT's Open CourseWare.
There are a lot of online learning sites these days, including MIT/Harvard's EdX, Coursera, Codecademy, and Udacity, but Open CourseWare started it all. MIT decided to make all of its course materials, including syllabi, homework assignments, and lecture videos, available online, to the public, for free.

The Khan academy teaches a huge range of topics, from statistics to art history, from kindergarten level math to immunology. Recently, they even started offering test prep for standardized tests like the SAT, to level the playing field with students whose parents can afford private tutoring, and they have a college admissions section for some guidance.

I get periodic emails from them, and I recently received a link to this video, entitled, You Can Learn Anything:

For those who didn't bother to watch it, the video claims that no one is born smart, that learning requires struggle for everyone, and that this is a good thing. And ultimately, with enough effort, anyone can learn anything.

I applaud the notion that learning requires struggle. It casts frustration in a new light, and reminds people to persevere. But I don't believe that anyone can learn anything.

I studied math as an undergraduate, and for a miserable year in graduate school. And one of the few bits I've retained from all the math I learned and subsequently forgot is that math is HARD. Medical school was a lot of work, and what I do now requires intense effort and a certain kind of smarts. But nothing I've encountered comes close to the shear reasoning ability required for math.

Math beats everyone. Mathematicians, people who have chosen math for their professional lives, rarely produce new research past age 30.

One notable exception was the Hungarian mathematician, Paul Erdos (pronounced AIR DISH).

Paul Erdos

He produced new material pretty much until his death in 1996 at age 83. Erdos never married or had any romantic relationship that anyone was aware of, gave away all his money in contests he devised for young mathematicians, lived with his mother until her death, and subsequently by hopping from the home of one mathematician to the next ("Another roof, another proof"), and used amphetamines most of his life so he could spend 19 hour days working on math ("Plenty of time for rest in the grave").

To give you a little more flavor, he once wrote a letter to a fellow mathematician that went something like this:

Dear So and So,
Today I am in Australia. Tomorrow I leave for Hungary. 
Let k be the smallest integer such that...

Sure, Erdos never stopped learning. Math. But at what price? It's not clear that he was able to learn much of anything else. Certainly normal social interactions eluded him.

It's great that the Khan Academy has taken it upon itself to encourage people to learn. Learning is awesome! But I think there's a danger in encouraging the idea that anyone can learn anything, that the most difficult concepts are accessible to anyone with determination, regardless of innate talent or intellect. Because that isn't true. I will never be a Hall of Fame quarterback, or an Olympic sprinter, or even a mathematician like Erdos. And that's okay.

It all reminds me of a short story by Vonnegut, Harrison Bergeron (it was copyrighted in 1961, so I feel okay linking to it because it's been more than 50 years). The story takes place in 2081, when everyone is completely equal. Anyone who is exceptional in any way, be it dance, intellect, music, whatever, is subject to the Handicapper General, who plants noisemaking devices in people's heads to distract them from original thoughts, and attaches weights to anyone of physical prowess. All so no one will feel "less" then anyone else.

Friday, September 12, 2014


I'm addicted to chocolate. When I tell this to people, they usually smile, and I get that it's kinda cute. After all, chocolate doesn't impair my judgment, or make it hazardous for me to drive or operate heavy machinery. I won't go to prison for selling or using chocolate. Chocolate won't put me in rehab, or in danger of dying from overdose or withdrawal. And I won't spend my life's savings on chocolate.

It just tastes great and makes you feel good. But truly, I'm addicted. My longest clean time is one year, but I'm more typically on the wagon for a month or two.

Please understand, I am not making light of addiction. I genuinely have a problem with chocolate. I go on chocolate benders. I experience withdrawal with intense cravings and mood swings. In fact, probably the worst thing chocolate does to me is affect my mood. Or maybe it's the severe GERD. Either way, it gives me tremendous empathy for people suffering from addictions, and I'm just grateful that my substance of choice is legal and relatively benign.

Granted, some of it is about the taste. Because I won't consume just any chocolate. I'm extremely fussy. My favorite chocolate to just munch on or bake with is Callebaut. I'm particularly partial to their semisweet. And my favorite hot chocolate (not cocoa, NEVER cocoa-you can barely taste the chocolate) is the single origin Venezuela source by L.A. Burdick, which has stores in Boston, Cambridge, New York City (unfortunately, right across the street from my old office), New Hampshire, and nowhere else, as far as I know. I'm also partial to a store in the West Village called, The Meadow, which sells small batch chocolates, salt, bitters, and flowers. The guy working there told me he likes to eat dark chocolate ice cream out of a pink himalayan salt bowl, which sounds magnificently indulgent.

There's no question, at least for me, that eating chocolate feels good. It's soothing. It's calming, and it's mildly euphoric. Is it possible to isolate the elements in chocolate that cause those effects, and turn them into an antidepressant? Is it possible to keep those effects from wearing off quickly?

A paper by Parker et al (Summary) claims that while eating chocolate is a pleasurable experience, if eaten to help with a negative mood, it may provide short-lived relief, but then perpetuate the negative mood.

An article in How Stuff Works claims that chocolate contains caffeine, cannabinoids, and Pheylethylamine, the "love drug", technically classified as a hallucinogen. It also causes the release of dopamine and serotonin. The article goes on to claim that these chemicals are present in chocolate in amounts to which we've become habituated in things like coffee, so they don't have much effect on people. I don't smoke, I don't use any illegal drugs, I drink maybe a glass of wine a month, and I don't consume caffeine, except in the form of chocolate. Maybe that's why it effects me so intensely.

Anandamide is an endogenous cannabinoid also found in chocolate. Its effects are mediated by the central CB1 cannabinoid receptors, and the peripheral CB2 receptors. A metabolite of acetaminophen, AM404 is a weak CB1 and CB2 agonist, as well as an anandamide reuptake inhibitor. This may explain some of the analgesic effects of acetaminophen.

Anandamide is degraded by the fatty acid amide hydrolase (FAAH) enzyme, as is AM404. However, an analogous, synthetic compound, AM1172, also inhibits anandamide reuptake, and is not degraded by FAAH. AM1172 is a candidate for the treatment of anxiety and depression (Royal Society of Chemistry, Fegley et al).

Phenylethylamine is sold as a dietary supplement for its purported mood effects. However, it undergoes extensive first pass metabolism by MAO-B, and as such, would need to be ingested in extremely high doses to have any significant effect on mood.

In writing this, I've pretty much exhausted everything I remember from Chemistry, so I'm gonna stop with the technical stuff. But with all the talk about there being nothing in the pipeline in antidepressant development, what happened to these guys? Does anyone know?

I'll leave you with a recipe for the world's best brownies. It's my adaptation of a fantastic recipe from Smitten Kitchen. In my opinion, they taste best frozen.

3 ounces unsweetened chocolate, roughly chopped
1 stick unsalted butter, plus extra for pan
1 cup (packed) dark brown sugar
2 large eggs
1 teaspoon vanilla extract
1/2 teaspoon flaky sea salt
2/3 cup all-purpose flour

Heat oven to 350°F. Line an 8×8-inch square baking pan with parchment, extending it up two sides, or foil. Butter the parchment or foil or spray it with a nonstick cooking spray.

In a medium heatproof bowl over gently simmering water, melt chocolate and butter together until only a couple unmelted bits remain. Off the heat, stir until smooth and fully melted. You can also do this in the microwave in 30-second bursts, stirring between each. Whisk in sugar, then eggs, one at a time, then vanilla and salt. Stir in flour with a spoon or flexible spatula and scrape batter into prepared pan, spread until even. Bake for 25 to 30 minutes, or until a toothpick inserted into the center comes out batter-free.

Let cool and cut into desired size. If desired, dust the brownies with powdered sugar before serving.

*non-linked info from Wikipedia

Tuesday, September 9, 2014

A Duck!

Not talking about emotional support ducks, here. Nor am I referencing Shrink Rap's mascot, cute as it may be. I'm talking about the collaborative care model. I enthusiastically checked out "new and interesting clinical updates from UpToDate", the psychiatry section. And this is one of the things I learned:

Collaborative care for patients with depression and medical illness (May 2014)

Collaborative care that integrates mental health specialists and case managers into primary care practices is an effective way to treat depression and may also improve general medical outcomes. In a meta-analysis of seven randomized trials that included 1895 patients with comorbid depression and diabetes, both depression scores and glycemic control demonstrated greater improvement with collaborative care than with usual care.

Having written about this exact topic a little while back, I wasn't sure where they were drawing their conclusion from. So I went to the link and found this:

 Many studies demonstrate that collaborative care improves depression outcomes:
A meta-analysis of 37 randomized trials (n >12,000 depressed patients) found a significant but clinically small effect favoring collaborative care over standard primary care, which persisted for up to five years; heterogeneity across studies was moderate.
A subsequent meta-analysis of 79 randomized trials (n >24,000 depressed patients) that compared collaborative care with usual primary care (eg, pharmacotherapy alone) found that after six months, response (reduction of baseline symptoms ≥50 percent) occurred more often with collaborative care (relative risk 1.3, 95% CI 1.2-1.4); heterogeneity across studies was large. The benefits of collaborative care persisted for up to 24 months.
In meta-analyses of randomized trials that compared collaborative care with usual care in depressed patients with chronic conditions (eg, arthritis, asthma, cancer, coronary heart disease, diabetes, and HIV), improvement of depressive symptoms, psychosocial functioning, and mental and physical quality of life were greater with collaborative care that usual care. However, other analyses found that diabetic control and all cause mortality were each comparable for the two treatment groups.

I'm not sure how this demonstrates improved glycemic control.

Another study that I know of, by Katon, et al, and published in NEJM in 2012, looked at collaborative care for patients with depression and co-morbid diabetes and/or coronary heart disease. This study found significant blah blah blah. It also changed its primary outcome measures during the course of the study:

The initial primary outcome was the percentage of patients achieving disease control at 12 months on all three disease-control measures...This outcome was changed in August 2009 (before study data became available for analysis in November 2009)...

I assume they're telling us the outcome measure was changed before study data became available so we won't think there was any bias. They didn't know the outcome yet, right? Well then, why change the outcome measure?

NEJM. Oh, yeah.

This is an excerpt from the description of the study intervention, just so we can establish what goes on in a collaborative care model.

The intervention combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia. Patients worked collaboratively with nurses and primary care physicians to establish individualized clinical and self-care goals. In structured visits in each patient's primary care clinic every 2 to 3 weeks, nurses monitored the patient's progress with respect to management of depression (according to the PHQ-9 score), control of medical disease, and self-care activities. Treatment protocols guided adjustments of commonly used medicines in patients who did not achieve specific goals...First-line agents included...citalopram or sustained-release bupropion for depression. Nurses followed patients proactively to provide support for medication adherence.

Using motivational and encouraging coaching, nurses helped patients solve problems and set goals for improved medication adherence and self-care...Patients received self-care materials, including The Depression Helpbooka video compact disk on depression care, a booklet and other materials on chronic disease management, and self-monitoring devices...

Nurses received weekly supervision with a psychiatrist, primary care physician, and psychologist to review new cases and patient progress. An electronic registry was used to track PHQ-9 scores and glycolated hemoglobin, LDL cholesterol, and blood-pressure levels. The supervising physicians recommended initial choices and changes in medications tailored to the patient's history and clinical response. The nurse communicated recommended medication changes to the primary care physician responsible for medication management.

This is a link to the supplementary appendix. It includes, among other things, the power point they used to teach the nurses the study intervention. It's too upsetting to describe. Take a look, if you have a strong constitution. 

About the same time I got the UpToDate email, I read an article in the July 4th edition of Psychiatric News, The First and Last Word in Psychiatry. (It's the APA). It's by Jurgen Unutzer, one of the pioneers of integrated care, and it's entitled, Case Study: Heartbreak and Lessons Learned. In it, Dr. Unutzer laments the abandonment of a collaborative care model by a clinic, the Federally Qualified Health Center (FQHC). It was a 3 year program that worked spectacularly in its first two years. But then there were staff changes, and poor financial planning, and the program was abandoned. "Most importantly, the organization never fully integrated the program into its overall mission, vision, and clinical operations." The poor, lost, misguided souls.

Reading this made me think of the duck.

"Why is collaborative care like a duck?" you ask. Not for the same reason a raven is like a writing desk. 

It goes like this:

Patients seen in primary care clinics often have poor access to mental health care. 
We know that most prescriptions for antidepressants are written by primary care doctors. 
Therefore, all patients seen in a primary care setting should be administered a PHQ-9.
The best treatment for those who qualify as "depressed" is a care manager.
Psychiatrists are trained to treat patients with depression, and should therefore have no contact with the patients in a collaborative care program.
The care manager will administer sequential PHQ-9s via phone contact, to determine if the patient gets better on the medication that is recommended by the psychiatrist and prescribed by the primary care provider. 
When these patients say they are more satisfied with their lives because of the collaborative care model, this means that their diabetes has improved. 
Therefore, all psychiatric care should be practiced via the collaborative care model.

I suspect the reasoning is based on the following logical sequence, from the witch scene in Monty Python and the Holy Grail:

Terry Jones: There are ways of telling whether she is a witch.
Rabble: Are there? What are they? Tell us!
TJ: Tell me, what do you do with witches?
R: Burn them!
TJ: And what do you burn apart from witches?
R: More witches!
R: Wood!
TJ: So, why do witches burn?
(Confused pause)
R: Cuz they're made of...wood?
TJ: Good!
TJ: So, how do we tell whether she is made of wood?
R: Build a bridge out of her!
TJ: Ah, but can you not also make bridges out of stone?
R: Oh, yeah.
TJ: Does wood sink in water?
R: No, it floats. It floats!
R: Throw her into the pond!
TJ: What also floats in water?

Very small rocks!
Lead! Lead!

Graham Chapman: A duck!
TJ: Exactly. So, logically:
R: If she weighs the same as a duck, she's made of wood!
TJ: And therefore?
(confused pause)
R: A witch!

Saturday, September 6, 2014

On Call: A Little Morphine

Sorry I've been out of touch. It's not that I've been busy. More like un-busy. I was on vacation, me and my brain. And I just didn't feel like doing much of anything.

While I was busy doing nothing, I realized that I've recently taken on an increasing number of professional responsibilities, and that something is probably gonna have to give. And the most likely candidate for that something was blogging.

Maybe this is just a long-winded way of saying blogging is a lot of work, and I needed a break. I planned to take that break indefinitely, but enough of my friends have emailed me recently (hint-hint) with links to the NYTimes essay, Why Do Doctors Commit Suicide?, that I feel compelled to comment.

A concise description of my reaction to the essay is, "Well, what do you expect? He's an intern. He doesn't know anything."

In case you didn't get to it, it's written by a PGY-1, seemingly in response to recent suicides by 2 NYC PGY-1s. It contains some stats-400 doctors kill themselves every year; 9.4% of 4th year med students and interns have suicidal thoughts; physicians are twice as likely as non-physicians to kill themselves.

He writes about how residency programs and hospitals are tuned in to the problem, and have things like "reflection rounds". He also mentions that resident hours are now limited to 80 per week.

His main contention seems to be that there is a certain machismo to being a doctor, pretending to be superhuman and knowledgable while feeling intensely inadequate. He was relieved to discover that the feeling is common among interns.

I don't think he appreciates, or at least didn't comment about, other, more problematic elements of medical training and practice. Here are a few:

Patients suffer and doctors feel helpless.
Patients die and doctors feel helpless.
Medicine is a suck-it-up culture.
Humiliation tactics are standard in medical training.
Doctors are asked to do more work than is humanly possible in the allotted amount of time.
Bathrooms and isolated stairwells are often used for crying.
Residents are, at best, cash-cows, and at worst, slaves for the hospital.
The regulations imposed on medicine are incompatible with the practice of medicine.
Doctors, who used to be thought of as respected, well-intentioned authorities, are now perceived as evil money-grubbers who don't care about patients, do everything in their power to take advantage of the generosity of insurance companies and the government, and don't know anything anyway and can easily be replaced by people with far less training or by machines with checklists.

Take the 80 hours per week limitation. This was already in place when I was a resident. For one week each year, in April, we were required to report our hours, just to make sure we were in compliance. And if anyone reported the actual hours they worked, they would have to change their answers to no more than 80 hours. I typically worked 100 hours per week.

This time issue is a great illustration of what's wrong with medicine. Some bozo with a clipboard decides that it's bad for patient care and physician well-being if doctors work more than 80 hours per week. Regulations are put in place to require an 80 hour limit. No additional money is provided so that sufficient house staff can be hired in order to keep to the 80 hour per week limit. So now residents continue to work the same number of hours, but have to lie and say they didn't.

This basically parallels what happened at the VA. If you require people to do something, but make it impossible for them to do it, they're going to lie to you.

I've been reluctant to include this installment of On Call (the vignettes I wrote as a resident: On Call, On Call 2: The Feel of Call, On Call: The Mad Crapper, On Call: Ear-Full), because it's painful and it's very personal. But it's the experience that got me writing On Call, and I think the time has come to share it.

A Little Morphine

I’m a PGY-1, I’m doing my 4 months on Medicine, it’s December, and I’m miserable. I hate Medicine. I’m surrounded by dying people, and I’m expected to help them, and yet, there’s nothing much I can really do, nor do I trust my knowledge enough to think that I would know how to help them, even if there were something to do.
Medicine residents often ask me how I can stand psychiatry, and don’t I find it depressing? I look around at all the old and young sick people, with tubes in their arms and up their noses and inside their penises, hoping that someone will save them, or at least ease their suffering, many of whom end up dying alone in the hospital. My answer is simply, “No.”
It’s my second month on medicine, and there hasn’t been a pleasant moment. The first month was hell. I worked on the infectious disease floor, which these days pretty much means AIDS. These are very sick patients, and there’s a great deal of overlap with the substance-abusing patients we see on psychiatry. They’re a tough, street-hardened bunch. The nurses do nothing for you, and the patient load is very high, meaning that each intern typically works with a large number of patients-I started with 11, and I never dropped below 9.
Now, in my second month, I’m working on the hem/onc (pronounced “hēme-onk”), or hematology/oncology floor. The cancer floor. There’s much less work-I’m averaging about 2 patients at a time-and it’s a much more aesthetically pleasing environment. Also, the nurses are tops. But it’s slowly beginning to wear on me. These are cancer patients-most of them dying. My father died of cancer when I was 15. Working here is dredging up a lot of stuff for me, and I notice myself feeling slowed, not just acutely unhappy. Like I’m walking underwater all the time. Or dragging weights around.
Partially because the workload on this floor is so light, when we take call, we cover not only the hem/onc floor, but the pulmonary stepdown unit, as well. This is a part of the hospital where patients are placed when they are either on their way to getting better after leaving the intensive care unit (ICU), or very sick, but with nothing much to be done, so there’s no point putting them in the ICU. Most are of the latter type. And most are on ventilators.
The problem is that the pulmonary stepdown unit is completely independent of the hem/onc unit, so I know nothing about the patients there. The two units are not even on the same floor. In fact, they’re not even in the same building. So there’s no chance that I might have so much as overheard someone talking about one of the patients there.
The way call works on medicine is that everyone has a “signout sheet”. This is a spreadsheet that you update every day. It includes, or ought to include, everything about all your patients-names, dates, diseases, reason for hospitalization, resuscitation status (whether the patient wants to be DNR), and medications. There’s also a signout column for stuff you need the person on call to do, like check lab results.
So when your call starts, the interns who aren’t on call, and whose patients you’re covering, hand you their signout sheets, and tell you what needs to be done. What you want to see in the signout column is “NTD”, “nothing-to-do”. Most of the time, though, there is something to do. And you carry around these sheets in the pocket of your white coat all through the call, until 9 o’clock rolls around, and you can hand them, updated with anything that happened on call, to the intern who covers overnight. And god forbid you should lose these sheets. They’re the only thing that stands between you and the abyss of ignorance.
So on call on the hem/onc floor, you get signout sheets from the interns on your floor, the physician’s assistants who also work on that floor, and the one intern who covers the eight beds on the pulmonary stepdown unit.
It’s an ordinary evening. I’m checking labs, drawing blood, putting in intravenous lines, and admitting patients from the ER. Then I get paged to the stepdown unit. I call down there, and the nurse tells me that there’s a patient whose blood pressure is extremely low, and there are also some family members visiting him who have some questions, and can I please come down and talk to them.
This is ridiculous. I know nothing, zero, about this patient. The nurse has been taking care of him all evening, and probably on previous days. She knows him, why can’t she speak to the family?
“I’ll be right there.”
As I’m walking over there, I look at the signout sheet. NTD. Nothing about what to do if his blood pressure plummets. But there is a little blurb that reads, “In case of respiratory distress, can give 2mg morphine IV push.” Translation: If the guy’s breathing gets too uncomfortable, you can put 2mg of morphine in a syringe, and push the morphine, via the plunger, into the port in the guy’s IV line.”
Morphine doesn’t just feel good and numb pain. It tricks the body into thinking it doesn’t need to breathe as much, so it slows the respiratory, or breathing rate. A large dose of morphine can stop breathing completely. This is why people die of morphine, or its street cousin, heroin, overdoses. 2mg is a very small dose of morphine. For a normal person. For someone who is already a medical wreck, it’s not so clear.
I get to the stepdown unit, and I get a look at the patient. He’s not conscious, he’s wasting away, and his blood pressure is so low that the cuff can’t pick it up. He’s breathing at a rate of 30 breaths per minute. Normal breathing is 8-12 breaths per minute. It turns out that he had a heart attack at home, and a friend performed CPR before the ambulance got there, but it was too late. He was alive, but he never regained consciousness. That was three weeks ago.
I’m introduced to the family members. There’s the patient’s brother, a big guy, maybe 6’3”. There’s also the friend who performed the initial CPR. And there are two other family members, or so I assume, sitting outside the unit. I’m never introduced to them. One of them is crying.
“Hi, I’m Dr. XXXXXX, how can I help you?”
The brother tells me that he’s concerned because the patient has not gotten his pudding. I look at the patient, and I’m tempted to ask the brother, “Are you serious?”
The nurse keeps asking me about giving him pressors-medications to raise his blood pressure. I look at the chart, and he’s DNR. Pressors don’t seem to be the right thing for someone who doesn’t want to be resuscitated, but the nurse keeps asking me about them, because she’s seen other patients’ families insist. His mother is the health care proxy, but she’s not there.
I ignore the nurse and turn back to the brother.
I ask him if he understands what’s happening.
He tells me he does understand, but that he just isn’t ready to let go yet. And he keeps repeating that the patient was a strong man, a fighter, a big guy like him, and he still believes he may pull through. So he needs his pudding.
The shrink in me is doing a running commentary:
How is it possible that this patient has been here, dead, except for the details, for three weeks, and god knows when he last ate anything, and the staff has avoided talking to the family to such an extent that what they think he needs is pudding?
And then:
If I sit down and talk to them, gently and patiently, I can probably make them understand that he’s likely to die tonight. The other staff either didn’t do this, or tried and fucked it up. But this is what I do. This is what I’m good at. And it’s what they need. And it’s the right thing to do.
And finally:
I don’t have time for niceties like talking to the family. I’ve got a shitload of work to do, and I’m pissed about being on Medicine, anyway. If they want me to do Psychiatry, then they shouldn’t have switched me to Medicine. I don’t feel like staying late to do the work the regular team had three weeks to take care of. And the brother is really big, and what if he gets mad when I tell him the patient is dying?
I tell the brother that the patient looks extremely uncomfortable, and if the family would like it, we can give the patient some morphine, which will make him breathe easier. I don’t tell him it may kill the patient. And I say this in a way that dismisses the possibility of further discussion.
The brother basically concedes. I don’t give him the opportunity to do otherwise. And I know he doesn’t really understand what’s happening, and that I should tell him, but I just want to get the hell out of there.
Then I start to have misgivings. I page my resident, and read the signout to her. I ask her if she thinks it’s okay to give him the morphine, but she, like me, is just covering for a few hours, and has never seen the patient before. She suggests I page the pulmonary fellow.
I ask the nurse who the fellow is, and it turns out it’s Dr. World’s-Biggest-Jerk, whom I’ve encountered briefly in the past, and who is a smug bastard. I don’t want to page him. I really don’t want to page him.
I ask the nurse what she thinks, and she just shrugs.
I page the fellow.
When he calls back, I tell him what’s happening, and he says, “Yeah, just give him the morphine. It’ll probably kill him, but that’s okay.” He hangs up.

It’s July 17th, 1982. I’m 15 years old, and my father is dying of cancer. He was alert last night, but his breathing was difficult, so the doctors gave him some intravenous morphine. This morning, he’s completely out of it. He’s drooling, and unable to speak coherently. My mother and I panic seeing him like this, and we ask the doctors to lower the morphine. They do, and he remains delirious, but now he’s agitated. He rips out his IV, and tries to pull out his urinary catheter. He gets out of bed and wanders unsteadily down the hall. He hallucinates. His breathing is labored. He remains that way all day, and dies early the next morning.

I snap back to the present, and I look at the signout sheet again. 2mg of morphine IV push. IV push meds need to be given by MD’s. For some reason, the nurses aren’t allowed to do it.
It’ll probably kill him.
I don’t want to be the one who kills him. So I write the order for 2mg morphine IV push, pretending I don’t know the rule about MD’s giving IV push meds, and I start to walk out. I’m hoping the nurse will just do it anyway. Some of them will. 
But not this one.
She calls me back before I make it out the door, and tells me the doctor needs to push IV meds.
I page my resident again, and I tell her what the fellow recommended. She says, “Well, if that’s what he said, you should do it. He knows the patient.”
In the weeks and months that follow, I wish that at this point, I had paged the fellow back and told him that if he wants to kill his patient, he better get down here and fucking do it himself.
But that’s not what I do.
The nurse fills the syringe for me, and I approach the patient.
I can’t just give him the morphine and leave. Not that I’m really harming him-just putting him out of his misery. But it shouldn’t be so abrupt. There should be some ceremony or ritual to it. The family should be standing around and holding hands, sad but resigned, and not expecting him to sit up and eat his pudding. I should be communing with him, telling him I’m about to try to kill him.
But I have nothing to say to anyone there.
I’m Jewish, and Judaism has blessings for everything. I try to think of an appropriate one, but the only thing I can come up with is “Blessed is the true judge,” which is what you say when you find out someone died. But he isn’t dead yet, and I’m no judge-just the idiot giving him the morphine.
I pause for a few seconds, hoping to create some solemnity. But I have too much to do.
In the end, I just push the morphine and walk out.
I hear nothing about him for a few hours, which means that dose of morphine wasn’t his immediate cause of death. But this doesn’t comfort me. I know I gave him the morphine with the intention of killing him. And I know that if I had any backbone, I would have refused to do it. But I wimped out.
Just when I’m handing my signout sheets to the overnight person, I get paged to the stepdown, and I’m informed that he died. The overnight intern tells me to go home, and he’ll fill out the death certificate, which is a pain in the ass. So I leave.
I don’t remember the patient’s name.

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.