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.

Wednesday, April 16, 2014

The Nose Knows

I'd really like to just gloss over this topic, but I can't bring myself to do so. Have you read about "Sluggish Cognitive Tempo" (SCT)?

Check it:

...powerful figures in mental health are claiming to have identified a new disorder that could vastly expand the ranks of young people treated for attention problems. Called sluggish cognitive tempo, the condition is said to be characterized by lethargy, daydreaming and slow mental processing. By some researchers’ estimates, it is present in perhaps two million children.

Experts pushing for more research into sluggish cognitive tempo say it is gaining momentum toward recognition as a legitimate disorder — and, as such, a candidate for pharmacological treatment. Some of the condition’s researchers have helped Eli Lilly investigate how its flagship A.D.H.D. drug might treat it.

And there it is, black on white. Researchers helping Lilly market a drug. Really, "identified a new disorder"? Like what, they found a new bacteria under a microscope?

Here's Allen Frances' comment from his article, No Child Left Undiagnosed:

"'Sluggish Cognitive Tempo' may possibly be the very dumbest and most dangerous diagnostic idea I have ever encountered."

Right on Dr. Frances!

When I googled "Sluggish Cognitive Tempo", the first thing that came up was itself, followed by sluggish thyroid and sluggish bowels. I'm not sure what that implies. Anyway, SCT was the main topic in the January 2014 issue of the Journal of Abnormal Child Psychology.

According to the introductory article, SCT is characterized by "drowsiness, daydreaming, lethargy, mental confusion, and slowed thinking/behavior". Then there are a couple articles about the validity of SCT, and more discussing the relationship with ADHD.

One article I found, Symptom Properties as a function of ADHD Type: An Argument for Continued Study of Sluggish Cognitive Tempo, by McBurnett et al,  published in 2000, noted that SCT had been discarded from the inattention symptom list in the DSM IV Field Trials, due to poor negative predictive value. But then McBurnett et al decided to look at SCT again, and found that "Sluggish Tempo Items showed substantially improved utility as symptoms of Inattention, " and that a "Sluggish Tempo factor could be distinguished from an Inattention factor." It wasn't clear to me from reading the abstract why they decided to take another look at SCT.

The thing is, even if SCT is a "real thing", even if a child can "have" SCT, who says that child needs a label, or meds, or even treatment?

Note also the messy interaction between Allen Frances' opinion about SCT and his role as chair of the DSM IV task force. Maybe he does have a conflict of interest. I still think he makes more sense than this crusade to label every aspect of the human condition as pathology.

What's next, pathologic nose-picking?

1. Nose-picking at least 3 times per day, present most days, for at least 2 weeks.
                     a. Booger-Eating Type or      
                     b. Non-Booger-Eating Type

2. The patient is often unaware of the nose-picking behavior while it is happening (in children, the  behavior may be noted by a family member or teacher)

3. The nose-picking does not take place in the context of recent trauma to nose.

4. Nose-picking is not a culturally accepted norm for the patient.

5. The nose-picking is not better explained by another condition, such as OCD.

6. The nose-picking causes significant distress for the patient or patient's family, such as frequent    nosebleeds, teasing at school, or booger-encrusted undersides of furniture.


Monday, April 14, 2014


Sometimes, when I'm in a session with a patient, I wonder how to address beliefs I don't agree with.

It gets pretty complicated. There's the whole issue of religious beliefs. People are entitled to believe in a deity, if they're so inclined. I am curious about these beliefs, particularly if they are significant in a patient's life, and I will certainly ask about them, and encourage the patient to discuss them. But is it appropriate for me to "reality test" when it comes to religious beliefs? Like, "Come on! Do you really believe in resurrection, or weird things happening to large bodies of water (splitting, turning to blood, etc.)?"

Let's assume I lay off religious skepticism. Religions are, after all, culturally acceptable and common phenomena. But what about related ideas, like ghosts? Lots of people believe in ghosts. Is it my place to say, "You're an otherwise rational person, so what's up with the ghosts?"

I don't know the answer to that, but the bigger problem for me is, what about when it comes to health related issues. Like homeopathy. Or crystals.

What if I think these beliefs are dangerous? Like, "My 15 year old son has been having leg pain that's waking him at night and causing him to limp, so I'm taking him to a chiropractor who's giving him orthotics to correct his alignment. No, he didn't have an x-ray, the chiropractor said that would be too much radiation exposure." (A variation of this happened to someone I know, not a patient. Luckily, it wasn't neoplastic, but it did require surgery, and months of pain could have been avoided with a simple, inexpensive x-ray.)  If I were a pediatrician, I would never let that one go unchallenged. But as a shrink, doing therapy, or analysis, I'd be crossing a boundary to say, "Your kid needs an x-ray. Take him to his pediatrician. If he's cleared, then you can go ahead and spend lots of money on useless shoe inserts."

In general, I take the position that if my patient is about to do something I think is a mistake, if I believe it's dangerous, I say something. Otherwise, I don't. But "dangerous" can mean a lot of things. And even when I do say something, I try to be as neutral as I can.

In practice, this is difficult. "Have you discussed this with your pediatrician?" certainly implies that I think my patient OUGHT to discuss this with the pediatrician, so it's not so neutral, but it's better than osteosarcoma that could have been caught early on if only I had said something.

Lately, the issues that have been making me think about this topic have to do with diet. Gluten. Organics. Supplements. Toxins. What is WITH the whole gluten-free thing? Yes, some people have celiac disease, and THEY shouldn't consume gluten products. But just because gluten is bad for them doesn't mean gluten is bad for everyone! It drives me crazy.

And hey, if a hemp oil, flax seed, kale, pomegranate, agave smoothie is your thing, go for it! But if you're drinking it because your current guru claims it will "cleanse you of your toxins", maybe we need to examine why you're so willing to believe this.

I think there are a couple of take home points here:

1. It's a good exercise for me not to feel like I have to agree with everything my patients think or do, or to "correct" them.

2. It's good for my patients to feel safe enough that they can share their beliefs with me, and question the ones that may be causing them problems.

3. Belief is a remarkable phenomenon. People are so willing to believe in the latest health fad, even with poor or no scientific evidence to support it. Bad Science by Ben Goldacre is a good read on the topic of pseudoscience.
I think it goes beyond "sciencey" sounding ideas, though. I think what it comes down to is that we all worry about our well-being, our health, our diet, and by extension, our mortality. And in the face of this worry, we long for certainty. Doctors don't provide certainty. Likelihood in some cases, but not certainty. In fact, I consider it part of my job description to help my patients learn to tolerate uncertainty.
People hawking homeopathic remedies or miracle cures sound pretty sure of themselves. THIS will definitely help you live longer, feel better, boost your immune system (why doesn't it occur to most people that we'd die pretty quickly of an immune system boost?), improve your life. What a comfort that is.

'I love you" is a scary three word phrase.

"I'm not sure" is scarier.


Thursday, April 10, 2014


I got an email from a company called, Software Advice, that provides free recommendations to anyone interested in adopting a new business software system. The company's income source seems to be the software vendors:

Software Advice is 100% free for software buyers. We get paid when we make a good match between a software buyer and a software vendor.

Anyway, the email asked me to take a look at their report, entitled, Mental Health Meaningful Use Market Share IndustryView | 2014. There's also a nice slideshow:

Mental Health EHR Market | MU Attestations from Software Advice

Before I comment on the report, let me answer a question: Why am I writing this? Because I thought it was interesting, because they asked nicely, because the report is well-written and gives due consideration to its limitations. NOT because I'm promoting the company-I guess I'm okay with it if they get more business as a result, but you can take it or leave it, and I certainly have no intention of finding a vendor through them, especially since I already have a free EMR system that I don't use. And NOT because I'm getting paid to do so-I'm not.

There. I said it.

The report looks at the number of providers in psychiatry attesting to meaningful use of an EHR system, and compares 2012 to 2013 results, which were recently released by the CMS.

I haven't written about meaningful use, largely because I'm not a medicare provider, so I'm not affected by it. Briefly, providers (also hospitals) who incorporate an EHR in their practices are eligible for incentives to help cover the cost of implementing the EHR. In order to receive these incentives, they have to demonstrate "meaningful use", which has 3 separate stages and numerous "quality assessment" requirements, see the link if you really want to know the details. In addition, starting in 2015, medicare providers who do not demonstrate meaningful use will receive payment deductions in their medicare reimbursement.

The report also found that the number of Mental Health EHR vendors increased from 2012 to 2013.

This is where things start to get interesting, because it's expected that in the not-too-distant future, there will be consolidation of EHR vendors. There are now too many platforms to be sustainable, many providers are dissatisfied with their current systems, incentive money is drying up, so the bigger fish will buy out the smaller fish, or the smaller fish will just go belly-up.
There's also the issue of interoperability. Say a physician in private practice uses one EHR system, but the hospital he's affiliated with uses another. At some point, these two systems are going to have to share information about common patients, so how do they do that? In all likelihood, the EHR systems that will win out will be the ones with the most flexibility, that can facilitate connections with other systems.

It'll be like Kindle vs. Nook, or VHS vs. Beta, or Cassette vs. 8-track.

So the question is, why were there more Mental Health EHR Vendors in 2013 than there were in 2012?

One reason may have to do with one of the limitations of the report (I'm not getting into most of them, but it's not a long document, and it delineates many of its own shortcomings, so you can check it out for yourselves). There are plenty of psychiatrists who don't accept medicare, and who are, therefore, not interested in any meaningful use attestations, and whose use wouldn't be accounted for.
Also, most EHR's aren't very user-friendly for clinicians. They seem to be designed mainly for billing purposes, which leaves out the real function of a patient record. Could vendors be expanding in the hope of tweaking their systems to be more usable, and wanting to be on the forefront, testing their systems with those who are interested in meaningful use qualification, but really aiming for a larger audience, including non-medicare providers?
Or are they expanding so they can take advantage of the surge in meaningful use providers, with a plan to consolidate once that bubble bursts?

And speaking of notes. The following is the transcript of a 2 page note written, by hand, in 1981. The patient was a relative of mine, now long dead, so this is not a confidentiality violation. I found the chart in a bunch of old papers I was going through. The note is a consultation by a "Radiation Therapy Attending", and it's the real reason I was interested in writing a post about electronic note systems. I'd like to see an EHR spit this out:

52 white male with soft tissue sarcoma R distal thigh. This presented as a painless lump~early 4/81. Needle Bx was nonDxic. Incis Bx 5/22/81 shows a high grade pleomorphic sarcoma, ? rhabdo. Subsequent studies include normal counts, SMA 6/12, bone and liver scans. CXR 5/21/81 showed a 1.1 cm RUL lung nodule, new since CXR of 1/81. This was confirmed by tomog, which also showed a 1 cm LLL nodule; both appear to be mets. (- PPD, no Hx lung disease, cigs 1 ppd x 20y). CT scan of thigh 5/27 showed ~ 10 cm nonenhancing lesion without evidence of bone or vascular invasion. Arteriogram  today showed an 11 x 6 cm highly vascular mass beginning just proximal to R medial condyle; scalloping of popliteal A could represent tumor encroachment.

PE: Well appearing man in NAD, alert, oriented, normal neuro, heart, lung, abdomen, testes. Extrem WNL except firm 9 x 9 cm mass R distal medial thigh with healing 5 cm incision. Mass blends into underlying M of vastos medialis and extends 3 cm distal to incision (just prox to medial condyle) and 1 cm prox to incision, 2 cm post-lat to incision and 9 cm (circumferentially) medial to incision, being just medial to midline. There is a soft 1 cm R inguinal node ? (I can't read this word), no popliteal or other adenopathy. Pulses, M strength, joint function are all good.

Assess: Pleomorphic sarcoma R thigh, G3T2N0M1. LAG pending (was + in 66-89% of children with extremity rhabdo).

Recommend: Begin with chemoRx to try to eliminate micromets and evaluate response of primary, nodes and lung nodules (Children with rhabdo often get good response to VAC-eg Intergroup/Rhabdo Study, Maurer et al, Cancer 40:2015-2026, 1977 had 50% CR and 30% PR, some still in CR at 1y, few at 2y. Also Harvard: Dritschilo et al, Cancer 42:1192-1203, 1978, VAC and lung RT and primary RT +/- conservative surgery, 96% local control. Adults (variety of soft tissue sarcomas) have had 10-12% CR and 45% PR with adria-DTIC +/- CTX and VCR or adria-methyl-CCNU--both SWOG studies, Benjamin et al. pp. 309-315 in Management of Primary Bone and Soft Tissue Sarcomas, year Book, 1977, and Rivkin et al, Cancer 46:446-451, 1980.)(boldface mine)

If he responds well to chemoRx, suggest conservative surgery of R thigh and RT~ 5000 rads R medial thigh from knee to groin +/- iliacs (depending on LAG) and boost of primary to ~6000-6500 rads. Would also consider low-dose whole lung RT ~ 1500 rads/ (can't read) and boost to nodules. If he progresses on chemoRx, then palliative RT +/- chemoRx. Would like to reevaluate in 3-6 weeks. 

Let me reiterate, this was a hand-written note, including all the citations. I've never seen a note like this in any chart I looked at throughout my training. If Software Advice can find me an EHR that can generate this, then I WILL do business with them. But I think the days when a consultant would write this kind of note are long gone. And really, the key isn't the note, it's the doctor who wrote it. 

Sunday, April 6, 2014


I'm becoming increasingly, shall we say, disenchanted with the APA. Even more than I was when I terminated my membership a couple years ago.

The latest escapade contributing to my disenchantment is the Milliman American Psychiatric Association Report, Economic Impact of Integrated Medical-Behavioral Healthcare, Implications for Psychiatry. For some reason, I can't get an independent link to come up for this-it just generates a pdf in my downloads file, but there are links to it, and its summary HERE.

This is a 39 page document prepared for the APA by Milliman, Inc., a firm that provides "actuarial and related products and services". It reads like a piece of PR, wonder why. Phrases like,

The field of psychiatry is poised to become a major participant as IMBH evolves. Psychiatry has a direct role in the value proposition of integrated/collaborative care and stands to benefit from the savings generated by effective integration programs.

are what make me think so.

They estimate that somewhere between $26.3 and $48.3 billion can be saved annually through use of integrated medical/behavioral healthcare systems, like collaborative care.

First, they proceed to demonstrate how they came up with those figures. I'll attempt not to be too detailed, but they claim that, "Medical costs for treating those patients with chronic medical and comorbid mental health/substance use disorder (MH/SUD) conditions can be 2-3 times as high as (for) those beneficiaries who don‘t have the comorbid MH/SUD conditions. The additional healthcare costs incurred by people with behavioral comorbidities are estimated to be $293 billion in 2012 across commercially-insured, Medicaid, and Medicare beneficiaries in the United States.


"Most of the increased cost for those with comorbid MH/SUD conditions is attributed to medical services (more than behavioral), creating a large opportunity for savings on the medical side through integration of behavioral and medical service."

My question is, "How? "

Some of the figures are interesting. I should mention that I basically believe their figures, just not their conclusions, but who knows. They looked at 3 types of insurance, Commercial, Medicare, and Medicaid, and divided these into populations, and then researched how much was spent on each population. Commercial and Medicare were divided into 4 populations: No MH/SUD; non SPMI (severe and persistent mental illness) MH; SPMI; and SUD. Medicaid was divided into No MH/SUD and MH/SUD.

Here's a screenshot of Per Member Per Month Costs per Population for the Commercially insured:

You can see that a lot more is spent on medical care for those with Mental Health and Substance Use problems ($750, average), than for those without ($280).  What I've highlighted is incidental but interesting. $23 per person per month is spent on those with a Non-SPMI MH diagnosis for behavioral treatment, vs. $74 for behavioral meds. In the SPMI population, it's $128 vs. $175.

That's 3 times as much for meds than for other behavioral care in the Non-SPMI MH group. Tell me, what kind of therapy does $23 a month buy? And this is commercial insurance we're talking about, not medicare or medicaid.

In fact, medicare spends $579/month, and medicaid spends $309/month on medical care for Non-MH/SUD, vs. the $280 for commercial insurance. And medicaid spends $286/month on non-pharmacologic behavioral care for those with MH/SUD diagnoses, vs. an average of $75/month spent by commercial insurance. Maybe this is because those with medicare and medicaid tend to be sicker than those with commercial insurance.

Here's another chart with my highlights:

Why are behavioral facility costs roughly the same for those with a Non-SPMI MH diagnosis, and those without? And why are professional behavioral costs for No MH/SUD ($3690) actually greater than costs for SPMI ($3457)? Are there patients who are receiving behavioral treatment without a behavioral diagnosis? And if so, how are providers coding and being reimbursed?

Let's move on to the heart of the document. How can this data help us to provide better and more cost-efficient care in an integrated care model? The answer is something called, Value Opportunity, which is, "The potential for savings if we could manage all of a patient‘s comorbid conditions more effectively."

For example:

The value opportunity for chronic kidney disease is, "$2,251 PMPM ($6,901 - $4,650) additional healthcare spending for those treated for substance abuse and $1,582 PMPM ($6,232 - $4,650) additional costs for those treated for Non-SPMI conditions."

So all we have to do is cure patients of their Mental Health and Substance Use Disorders, and that will put them into the No MH/SUD population, so then their medical costs won't be as high. Right?

The bottom line:

Across all populations (commercial plus Medicare plus Medicaid), we estimate a total annual value opportunity of $293 billion through integration of behavioral and medical services in the U.S.

Well gee, Mr. and Mrs. Milliman, that's a lot of money! Will integrated care really be able to produce this result?

Yes, my boy.

For example:

"The Pathways study focused on the outcomes of a program utilizing specialized nurses to deliver a twelve-month depression treatment program for patients with diabetes. This program was administered through a randomized controlled trial that compared the systematic depression treatment program with care as usual. Total outpatient costs were approximately equal during the 12-month intervention period for both the intervention group and the usual care group, but during the 12-month period following the intervention, median outpatient costs for the intervention group were $50 PMPM lower than costs for the usual care group. Over the entire two year period, including the intervention period, total healthcare costs (including inpatient and outpatient health services) were $46 PMPM lower for the intervention group than for the usual care group. This represents savings of about 5% of total healthcare costs for the intervention group over a 2 year period."

Hold on, there! Where does the $50 PMPM come from? Is it savings in medical care for diabetes?

According to the abstract (check the link to the study, above):

Conclusion: The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.

In fact, most of the abstract doesn't jive with the description above. Maybe they did a follow-up study that I didn't find.

The Milliman document also cites the Multifaceted Diabetes and Depression Program (MDDP) study.

"Although not statistically significant, medical cost savings of approximately $39 per member per month (PMPM) were observed during the eighteen months following the implementation of the MDDP program." (emphasis mine)

They also cite the IMPACT Study, and state that, "Total healthcare costs were tracked for a 4-year period following the intervention, and costs for the intervention group were an average of $70 PMPM lower than costs for those receiving usual care. This represents savings of about 10% of total healthcare costs for the intervention group over a 4 year period. Patients in the collaborative care management program had lower costs in every category that was observed, and the results of a bootstrap analysis indicated that patients in the collaborative care program were 87% more likely to have lower total healthcare costs than those receiving usual care."

I don't like the "total healthcare costs" phrase. Where was the money saved? In "every category that was observed"? What is this "bootstrap analysis"?

IMPACT studied interventions for depression in the elderly, in primary care settings. It found that depression improved over 12 months. That was the stated purpose of the study. Outcome measures assessed depression, depression treatments, satisfaction with care, functional impairment, and quality of life. The study was not designed to test healthcare spending.

They offer a couple more fumpfed examples, but here's the OMG kicker:

The American Medical Association estimates that there are 41,784 psychiatrists practicing patient care as of 2012. The Bureau of Labor Statistics estimates average annual earnings of $174,170 per practicing psychiatrist as of May 2011. This translates to $7.3 billion in psychiatrist wages annually. Comparing this estimate to the projected savings estimate of $26-48 billion means that the potential financial impact of IMBH programs can be up to 3.5 to 6.6 times annual psychiatrist earnings. Stated another way, a 10% gain sharing arrangement for psychiatrists (where they are credited with a certain percentage of actual achieved healthcare cost savings through a contractual arrangement) of savings from integration has the potential to increase annual earnings estimates for psychiatry overall by about 50%. In this example, that leaves the other 90% of savings through collaborative care to be shared with others in the collaborative care teams, to be used to lower healthcare premiums, and to be reinvested in community based care.

APA, I'm so over you.

Saturday, March 29, 2014


The idea for this post came from a reader who prefers to remain anonymous, but I did want to give due credit, so, you know who you are, and thanks.

Silence is very important to me, both professionally, and personally. I'm pretty sure I picked the right profession for myself, because I don't much like talking (I do like listening), and I'm comfortable sitting silently with patients.

As an aside, one of the attendings from my residency did his residency, way back, at Menninger, when the Menninger brothers were there. So he was surrounded by a lot of analysts for 4 years, and he told me, "For people who spend their days listening, when you get them in a room together, they sure do like to talk."

I have found this to be true, but maybe not to the extent I formerly believed. In one of my first analytic classes, we read a paper about choosing patients who are appropriate for analysis. When I walked into the classroom, before class started, the guy teaching the class asked me what I thought of the paper. So I summarized. "You can't be too sick, you can't be too well, and you never know 'til you try." At the time, I thought that was pretty much everything there was to say about the paper, even though we went on to discuss it for 1 1/2 hours.

Now I'm not so sure. Maybe it has something to do with the value analysis places on language-it is, after all, a "talking cure" (Note that the phrase was coined by Bertha Pappenheim, AKA Anna O, while she was being treated by Joseph Breuer for hysteria. Hers is the first case recorded in Studies On Hysteria, by Breuer and Freud). Or maybe it has to do with the fact that the more time you spend listening to a person, the more you discover how much more there is to know about that person. And the same is true for most, if not all subjects. The more you know about a subject, the more complex you realize it is. So if I thought there wasn't much to say about that paper, it was probably a reflection of my ignorance.

What about silence? It's not the therapeutically exclusive provenance of psychoanalysis. It happens often in face-to-face therapy, and it may even be more difficult to tolerate in that setting than in analysis, where both the analyst and analysand are protected by the lack of eye contact.

Silence can take on many meanings in a therapeutic setting. For the patient, it can be withholding and aggressive, as in, "You can't make me talk!" It can be a form of hiding, as in, "I'm ashamed of my thoughts and feelings, so I'm not going to humiliate myself by sharing them." It can be an attempt to level the playing field, "You don't tell me anything about yourself, so I won't tell you anything, and that way I won't feel helpless and inferior."

It can also be an expression of trust, "I'm comfortable enough with you that I don't feel obligated to entertain you or be socially appropriate by babbling or trying to make conversation." And it can represent an attempt to share an experience or idea that is difficult to verbalize.

Patients have feelings and thoughts about the therapist's silence. It may be seen as punitive, humiliating, rejecting, abandoning, empty, containing, comforting, and many other things.

Therapists also have views about their patients' silences. Are they being hostile, or controlling? Are they confused? Are they attempting to sort through some experience that has not existed for them in the verbal sphere? Are they frightened? Am I doing something wrong? Am I doing something helpful? Do they need me to say something? Am I distracted and therefore have nothing to say?

These questions obviously reflect therapists' feelings about their own silences.

One important question is, why is silence often experienced as uncomfortable? The straightforward answer is, because that's not what people do in normal social interactions. But why is that? What's wrong with not talking? It's true, we're social beings, but speech is not the only form of communication.
At parties, people who don't talk much are considered uninteresting. In many educational settings, children who prefer to take in a discussion and not comment frequently are often thought to not be paying attention. And in medical school, when I was in new, complicated settings like the OR, or the ICU, and was asked by residents or attendings if I had any questions, I usually didn't because there was so much new information to absorb, I hadn't yet reached the point of being able to formulate a question. This was sometimes viewed as evidence of lack of interest on my part.

So we can agree, I think, that both silence and speech are complicated. One thing I wonder is, what happens when clinicians not only don't have time to talk with their patients, but don't have time to sit in silence with them, either?

These are some interesting quotes about silence, that I found on PEP-Web:

From the APSaA Winter Meeting, 1948:

CHAIRMAN: President William C. Menninger, M.D.
2:00 P.M. Robert Fliess, M.D. (New York): Silence and Verbalization: On the Theory of the Analytic Rule.
Discussants: Therese Benedek, M.D. (Chicago); Robert C. Bak, M.D. (New York)
Author's Abstract: Verbalization releases regressive affect, collateral to repressed ideation, thus interfering with the maintenance of repression. The speech-apparatus is substituted for different erotogenic zones, whereby speaking becomes excretory instinctual discharge, words excretory product, and silence equivalent to sphincter closure. Technical and theoretical consequences deriving from these “pleasure-physiological” considerations are discussed.

Greenson, R.R. (1961). On the Silence and Sounds of the Analytic Hour. J. Amer. Psychoanal. Assn., 9:79-84

The most frequent silence met with in psychoanalytic practice is the silence of resistance. This silence means that the patient is either consciously or unconsciously unwilling to verbalize. Since the patients in our psychoanalytic practice are attempting to communicate to us in accordance with the basic rule, i.e., attempting to put all their thoughts into words, if they become silent, it means that they are opposing the procedure of psychoanalysis. It is then our task to overcome this obstacle by attempting to find the motives for this resistance. Here, we are often aided in our task by the fact that the patient communicates despite his resistance...
Silence, however, may not only indicate a resistance to a certain content but may itself be the content which the patient is trying to convey. For example, patients may fall silent during an analytic hour when they are unconsciously repeating some historical event in which silence was an important element. Primal scenes and primal auditions often make their first appearance in the analytic hour as a restless, agitated, wide-eyed silence. The patient is repeating in the presence of the analyst the silent excitement and anxiety of the primal experiences.
Silence may indicate an identification with a silent object. This happens frequently in the analysis of candidates, who in this way identify with their silent analyst. This should be kept in mind when the silent patient seems to be not only comfortably silent, but confidently and poisedly silent. Furthermore, silence can represent an identification with an inanimate object, a sleeping object, or a dead object. This reaction, however, I have only seen in extremely disturbed and repressed patients.

Zeligs, M.A. (1961). The Psychology of Silence—Its Role in Transference, Countertransference and the Psychoanalytic Process. J. Amer. Psychoanal. Assn., 9:7-43

Let us first conjecture as to what a state of silence between any two (or more) human beings might signify. Obviously it could reflect many different psychic states and qualities of feeling.2 It might evidence agreement, disagreement, pleasure, displeasure, fear, anger, or tranquility. The silence could be a sign of contentment, mutual understanding, and compassion. Or it might indicate emptiness and complete lack of affect. Human silence can radiate warmth or cast a chill. At one moment it may be laudatory and accepting; in the next it can be cutting and contemptuous. Silence may express poise, smugness, snobbishness, taciturnity, or humility. Silence may mean yes or no. It may be giving or receiving, object-directed or narcissistic. Silence may be the sign of defeat or the mark of mastery. When life-and-death situations are

2 Because of its ubiquity, silence has been thought about in many frames of reference. Poets, dramatists, and philosophers have loosely used the concept "silence" metaphorically and allegorically to symbolize death, eternity, truth, wisdom, strength, etc. Literary references to silence are frequent in the classics from all periods of history...
3 It is interesting that the aphorism, "Silence is golden, " represents what is left of the complete saying, "Speech is silvern, but silence is golden, " the part about speech having since dropped out of popular usage, historically attesting to the transitoriness of speech as compared to the permanence of silence. This derives from an ancient proverb written in Aramaic which first appeared in the Talmud Megillah and Midrash Rabba Esther (Chapter 6) in relation to prayer, as follows: "If a word is worth one selah, silence is worth two. (Silence invokes Thy praise.)"... The later Hebrew equivalent then became, "If a word be worth one shekel, silence is worth two, " pointing to the material advantage of keeping one's own counsel...

being sweated through there is little occasion for words.3 Silence may be discreet or indiscreet. A tactful silence serves to prevent the expression of inappropriate thoughts and feelings. The art of being tactful combines the skilled use of silence in verbalized as well as nonverbalized action. Thus there is a hidden component of silence in every verbalization. When complete silence is inappropriate or impossible, a gesture, grimace, or mimetic expression serves as a compromise between verbal and nonverbal communication.

I'd love to hear about people's experiences with silence, so please comment.

Tuesday, March 25, 2014

Webinar F/U

I mentioned in my last post that I was going to be participating in an MOC Update Webinar sponsored by the AAPS. Let me start off with a disclaimer: I don't agree with a lot of the views of AAPS, but they have some important ideas, and contributions to make, including their suit of the ABMS (American Board of Medical Specialties), so I find them useful.

The webinar didn't cover much new territory. Some highlights:

The main speaker, Paul Kempen, touched on something I'm not sure I agree with, but that I thought was interesting. Namely, the idea that the Performance In Practice (PIP) modules, which involve implementing the use of rating scales, and then following up on patient outcomes, is a form of using patients for research without their specific consent.

There's a lot of corruption-kickbacks, conflicts of interest, among the higher-ups in the ABMS. Even without the corruption, it costs doctors a lot of money to recertify, and even though ABMS is not-for-profit, executive salaries can hover around $1 million a year.

The ABMS is not regulated, and calls itself the sole official monitoring body. In fact, it doesn't do any monitoring of incompetence, in the form of disciplinary actions. And of course, there is no evidence that it improves patient care.

One question pointed out that if you're being judged on the basis of improved outcomes, such as lower blood pressure, and your licensure is riding on that judgement, you might just tend to "round down" a patient's BP.

Those doctors participating in PQRS will be financially penalized if they don't maintain certification.

Even those physicians who are grandfathered in will have to take a recertification exam by 12.31.23, or they will be given the official descriptor, "Certified Without Meeting MOC Requirements".

Exam questions are clinically irrelevant, out of date, or inaccurate.

What scares me is the way Maintenance of Licensure (MOL) is insinuating itself into the picture. If the ABMS is trying to promote itself as the only game in town, what better way to make sure it stays that way than to make licensure dependent on participation in MOC/recertification.

If you'd like to watch it, you can view the webinar in full here.

Saturday, March 22, 2014

S.A., It Aint So

In the hilarious and highly underrated movie, Moving, starring Richard Pryor, the main character (Pryor) loses his engineering job of 15 years. Before he storms out of his boss's office, he gives him the finger, only it's his index finger. He then ruminates for days over his humiliation in using, "The wrong finger!" Ultimately, it becomes a family joke.

You Tube Link

Somehow I was reminded of this scene when I was pondering what to do about my self assessment (SA) MOC credits.

I've been dutifully filling out my CME credit details on the American Board of Psychiatry and Neurology (ABPN) site, and I have more than enough credits to take my recertification exam in 2015.


But I'm short 1 SA credit.

You may recall from my Alphabet Soup post, or you may not but feel free to link to it, that if you were board certified in 2005, you need 40 SA credits.

I got all 39 of my SA credits from The Carlat Report (TCR). And until a couple months ago, I planned to continue using TCR to complete my SA credits. It was simple. Instead of just taking a post-test for CME credit, I would take a pre-test that asked the same questions. Then I'd read the material, and then take the post-test and get my certificate. That way, I had assessed myself, and I could tell that I had learned something.

That's the idea, anyway. In reality, I could have simply taken the pre-test, which gave me all the correct answers, skipped reading the material, and filled in the answers on the post-test.  And then I would have learned nothing.

The SA requirement was really well thought out, don't you think?

Then TCR changed it's SA policy, and now they have a separate, yearly package:

We are now offering a NEW self-assessment CME product that consists of 12 monthly issues of The Carlat Psychiatry Report, plus a bonus 120+ pageMedication Fact Book. This inclusive product is $377 and is worth 18 Category 1 CME credits and 8 ABPN SA credits.
The subscription can be purchased at any time in 2014, but all tests must be taken by December 31, 2014, at which time SA credit will be awarded. 

This happened when I was one credit short, can you believe? And even if I were to switch over to the new product, it's not clear to me from the description if I can get a credit or two at a time, or if I have to take the whole test and get 8 SA credits at the end of the year (I've asked them about it, but the answer was slightly vague, and seemed to corroborate my suspicions). Since I'm taking my exam in 2015, I would like to have my credits out of the way earlier than the end of this year.

What to do?

I checked the ABPN site, and they have a page with a list of all their approved SA products, most of which are day or weekend seminars that cost more than I care to spend.

The one I decided to do was a Mass General Academy online module in general psychiatry. 50 questions, 4 SA credits, 35 bucks.

I was, of course, expecting the same deal: pretest, read, post-test. But there's nothing to read. Just 50 questions to answer. They don't report your score to the ABPN, but they give you feedback on how you did.

This was convenient for me, but the questions were not great. Here's an example:

48. Which one of the following hypnotics is free of daytime sedation and significant memory impairment:

a) diazepam.
b) flurazepam.
c) triazolam.
d) zolpidem.

Now, clearly, they want you to answer "d) zolpidem", which I did. But honestly, if you were prescribing Ambien for someone who'd never taken it before, would you feel okay telling them they'd be free of daytime sedation and significant memory impairment?  Does a period of time when you don't know where you were or what you were doing and later found out you rammed your car into a truck not qualify as "significant memory impairment"? Tell that to Kerry Kennedy.

Point being, MOC is a racket that costs time and money, and takes time away from patient care and from actual learning. Maybe a board recertification exam MIGHT be worthwhile if it asked questions that were accurate, up to date, and relevant to real world practice.

What questions, you ask?

Let's make some up.

With which of the following would you choose Brintellix as first line treatment for depression?

a) United Healthcare
b) Blue Cross/Blue Shield
c) Aetna
d) Medicare

Okay, enough with the sarcasm. What I'm really thinking is that it would be great if every practicing clinician would submit one or two questions to a giant question bank, and then self-assessment CME, or even board exams, could be generated from that bank.

The questions could reflect, for example, practices that are bread and butter for someone working in one specialty, and more obscure and likely forgotten, or never learned, for someone else. Like, I could come up with a Psychoanalysis question, and Jim Amos from The Practical Psychosomaticist could come up with a C/L question, and George Dawson over at Real Psychiatry could come up with an Addiction question.

Alternatively, the questions could be ones that don't have clear answers, and would require a little looking into, and maybe some discussion with colleagues. For instance, I have this theory that when it comes to antidepressants, there are SSRI people, and there are non-SSRI people. Is there a way to tell, a priori, who's who? I think this is a question that David Healy is interested in researching. But without clear research, it would be nice to have that discussion with other psychiatrists who are dealing with the same dilemma. When faced with a new patient, I kind of know how I go about deciding, but it's more of a hunch than anything else, and of course, there's always the business of trial and error.

All I'm saying is that there are so many better and cheaper ways to generate lifelong learning than stupid APA endorsed SA CME. Like POLL (Psychiatry Online Lifelong Learning), our free online journal club. Please check it out.

Tomorrow, I'll be joining a free MOC Update Webinar sponsored by AAPS, We'll see if they have anything to say about the SA business.