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

Friday, April 24, 2015

MOC Survey Results

I've now closed my MOC survey on SurveyMonkey, so let's talk about the responses. There were 11, which is nowhere near as pathetic as previous surveys I've conducted. To those of you who responded, you have my thanks.

To those who didn't, there will always be opportunities down the line, so you didn't miss out too much.

As a reminder, this was a one question survey, and that question is:

Would you be willing to openly boycott the ABPN and refuse to pay the annual C-MOC fee until the Part IV requirement is removed and an effort is made to demonstrate the usefulness of a 10 year exam?

And now, the big reveal:

Most of the people who responded to my survey would be willing to boycott. Since I limited myself to one question, I don't know why the person who wouldn't be willing to boycott feels that way. Or for that matter, why the other 10 feel the way they do.

It might have been interesting to get that information, but my sense is that the shorter the survey, the more likely people are to respond.

What now? I don't know. If the survey is representative of the greater population of C-MOC psychiatrists, then it would be worth trying to organize something. But there's obviously no way to know if it is.

To be honest, I'm a little sad thinking about it. I feel like I don't have the motivation or energy (or time) to push for something organized and bigger, but maybe I would if I thought more people would join me. And I'm guessing that's the way a lot of us feel.

So maybe we stage our own little, individual protests by not paying the annual fee, but we're not formally together as a group, so maybe it doesn't have that much impact. Or maybe money talks regardless of whether the same amount is being withheld by one large collective, or by individuals.

It still feels kind of isolated.

What would you do with this?

Sunday, April 19, 2015

"Shrinks" Review-Introduction

Jeffery Lieberman's, Shrinks: The Untold Story of Psychiatry, has been in the air lately.  There was a piece in the NY Times that claimed Lieberman claims there is no evidence for the effectiveness of psychoanalysis, and in response to that, I wrote a post about some of the supposedly non-existent evidence (Analytic Evidence).

In a series of tweets in reference to my post, @1boringyoungman asked if any groups had commented on "Shrinks". For my own unconscious, narcissistic reasons (more evidence), I read this as something like, Has Dr. Lieberman commented on my post?, to which I responded, "Not to my knowledge."

In turn, @MichaelBDonner tweeted, "Hard to comment without seeming defensive. He doesn't like psychoanalysis." To which @Drjlieberman eventually replied, "Not true."

MBD: What's not true? You do like psychoanalysis?

JAL: Yes.

MBD: You like psychoanalysis. Good to know. Didn't come across to me. I stand corrected. My apologies.

After this exchange, I decided I wanted to read the book. But I didn't want to buy it, because I didn't feel like contributing to Lieberman's income. I tried the NY Public Library, but there were like 30 holds ahead of me (also my card has apparently expired and I have to go to a branch to renew it, which I'm too lazy to do because I don't know where I put the card, since I usually just use their app to check out books).

So I bought it. The $14.99 Kindle version, as opposed to the $21.17 hardcover version.

My plan was to read it in its entirety and then write a review, but I'm finding it hard to get through. It's engaging enough as a read, I'll give it that. But the tone is quite disparaging. I'm trying to keep an open mind while I read it. Maybe he has some valid points to make. Research in psychoanalysis is notoriously complicated and controversial, since it's innately a non-manualized treatment, and it goes on for such a long time, and it's so dependent on the particular dyad, and much of the research doesn't correspond with the kind of controlled studies we're used to seeing for drugs or short-term, manualized treatments. So maybe I can learn something.

But the tone is kind of like, "This is what those silly, misguided shrinks think, but of course, we know better, wink, wink." The thing is, thus far, and I'm about a quarter of the way through, he hasn't explained what's wrong with what those silly, misguided shrinks think, or why we know better. He just states it as fact.

But along with prescient insights, Freud's theories were also full of missteps, oversights, and outright howlers. We shake our heads now at his conviction that young boys want to marry their mothers and kill their fathers, while a girl's natural sexual development drives her to want a penis of her own. As Justice Louis Brandeis so aptly declared, "Sunlight is the best disinfectant," and it seems likely that many of Freud's less credible conjectures would have been scrubbed away by the punctilious process of scientific inquiry if they had been treated as testable hypotheses rather than papal edicts.

The next paragraph goes on to describe the way Freud would megalomaniacally discredit anyone who didn't agree with him, which is true, to the best of my knowledge, but doesn't it sidestep the question of why oedipal theory constitutes a misstep, oversight, or howler? Are readers just supposed to accept that this is so, without an explanation of what's wrong with it? Papal edict, indeed. And frankly, I see oedipal elements at work clinically all the time. The penis-envy I see only rarely, but when it's there, I wouldn't want to be without a theory to help me understand it. So why is this wrong?

The only "evidence" Dr. Lieberman has supplied for why analysis is no good is in descriptions of incidents like Wilhelm Reich's Orgone Accumulator. Somehow, this ridiculous idea of Reich's discredits all of psychoanalysis.

Another problem. The book describes the history of psychoanalysis. I'm not a historian. In fact, I'm kind of the opposite of a historian. If it didn't happen in 1492 or 1776, I don't know anything about it. So I'm willing to assume that this history is accurate. But Lieberman treats the history as though that's all there is to know about analysis. It's analogous to saying, "I've studied the history of Bellevue Hospital, so I know everything there is to know about the care of psychiatric inpatients."

Sure, it's fun to read about what a jerk Freud was, and who he kicked out of his circle when, but that doesn't tell you anything about the practice of psychoanalysis.

Lieberman makes a point of describing the way he cured a patient of his conversion disorder with an Amytal interview. Nice work, Dr. L, but do you think that means you conducted an analysis with the patient? Or do you think that means analysis is useless, since conversion disorders were what Freud initially treated, and they may respond to medication? And does that, in turn, imply that you think today's analysands all sought out psychoanalysis as a treatment for their conversion disorders? Or that conversion disorders are all that can be or should be or are treated by an analysis?

To me it seems like the book is intended to escort the lay reader into the sacred halls of neuropsychiatry and biomarkers, to convince the unwary reader that any psychiatric treatment that doesn't involve medication, or lasts longer than 30 sessions, is bogus. And that the true psychiatry, the kind that Lieberman practices, is scientifically valid and effective. Just like the rest of medicine. That's his agenda, I get it, but I think he's misleading.

And speaking of misleading. I saw the following image in the April 17th edition of Psychiatric News:

There's Dr. Lieberman in his white coat, like all psychiatrists wear, getting ready to lead a discussion on May 18th at the APA meeting, on psychiatry's past, present, and future. And there's his book, Shrinks: The Untold Story of Psychiatry, by Jeffrey A. Lieberman, MD.

That's funny, because the book cover on Amazon, and the one on my Kindle, looks like this:

Same title, same author, but look! Who's Ogi Ogas? I googled him, and it turns out he's not a Dr. Seuss character. He's a computational neuroscientist, science book author, and game show contestant. Dr. Ogas won half a million dollars in 2006 on Who Wants to be a Millionaire.

He co-authored, A Billion Wicked Thoughts: What the World's Largest Experiment Reveals about Human Desire, which was published in 2011. One description stated:

The researchers wrote a computer program to capture sexual queries in publicly listed catalogs of Web searches. They later categorized the searches and did some number crunching. They estimate that their research reflects the online behavior of 100 million people.

Does any of this disqualify Ogi Ogas as a co-author or whatever he was of Shrinks? No, of course not. But why did JL chose him? Surely there must have been someone better suited.

And finally, the hubris. Lieberman offers a comment about the misguided patient who sought out Wilhelm Reich's care:

You use the word, "confidently", you throw in a couple of science-y sounding brain structures, you mention medication by its class, and CBT, the acceptable therapy, and what do you get? Optimistic, normal, symptoms controlled.

That was easy!

And this pretty much says it all:

I really hope the book starts to redeem itself at some point, and I'm not just out $14.99.

Wednesday, April 15, 2015

Follow the Money: A One Question Survey

Check out the update on MOC, recently sent out by the ABPN. In particular:




Okay so wudda we got?

You have to attest to your CME, SA, and PIP activities, and pay a fee annually.

And you only need 1 PIP unit.

Also the PIP requirement has been modified.

Finally, the board MAY waive SA requirements.

To me, it sounds like the ABPN is getting desperate. They want you to pay the annual fee, so they make noises about modifications to requirements. But if you pay the fee anyway, why should they make any changes?

And judging by the financial state of the ABIM, I'm guessing the ABPN is not doing so great money-wise. Plus they're obviously worried about losing diplomates to the NBPAS.

I think doctors as a group are a pretty suck-it-up bunch. We're so used to hard work that if you tell us we need to do something for "patient care" or for "regulatory requirements", we just do it. (See my post, The Culture of Medicine and the Art of K'vetching).

But this seems like a good jumping off point for negotiations. They want us to invest $175/year in them, with the promise of a meaningful exam in 10 years. Okay. What are they going to do for us? How about they remove the Part IV requirements, as a sign of good faith, and while they're at it, lay out a plan for how they're going to demonstrate that taking an exam every 10 years improves patient care. And once they've done that, then, maybe, we'll start paying them.

Seriously, what if everyone who goes into the C-MOC program joins together and refuses to pay a dime until they hold up their end of the bargain. Because it is a bargain. It's just a financial deal. They shouldn't get to make money AND screw us over.

So here's my one question survey. Is anyone up for this fight? Let's follow the money and see where it leads:

Create your own user feedback survey

Friday, April 10, 2015

Some Analytic History: AA Brill

Last night I was in the library of the New York Psychoanalytic Society and Institute (NYPSI), and I couldn't stop myself from taking this photo:

It's Freud v. Abraham Brill, an early influential figure in American psychoanalysis, and the founder of NYPSI in 1911 (Actually, the Institute part, which is the training program, was established in 1932, but Brill founded the Society). The bust of Freud actually sits on a file cabinet perpendicular to the one Brill is on, but I moved him (Freud) over to take the picture.

This is what he looked like from the front:

Here's a description of Brill, from a paper entitled,  Dreams and Responsibilities: Notes on the Making of an Institute, (Jacobs, TJ. (1983) Ann. of Psychoanal., 11:29-49.):

A short, rather stocky figure, with a Van Dyke beard, a thick accent, and enormous vitality, Brill was a truly remarkable individual. Born in Galicia, he had come penniless to the United States as a young adolescent. Through hard physical work, which included the scrubbing of saloon floors, he put himself through college and, ultimately, medical school. After four years of experience on the wards of Central Islip State Hospital, he approached his old professor, Dr. Frederick Peterson of Columbia, for advice as to where in Europe he might continue his education in psychiatry. 
Fortunately for the development of psychoanalysis, Peterson recommended not Kraepelin's clinic, to which Americans often went, but the clinic at Burghölzli in Switzerland where Bleuler and his colleagues were beginning to apply some of Freud's thinking to the seriously disturbed patients under their care. There Brill met Jung, Jones, Rorschach, and Abraham, among others, and through them he was introduced to Freud. Quite rapidly he became the designated spokesman for psychoanalysis in America. Within a few years of his return to this country in 1908, he had become a familiar figure on the New York scene, lecturing to medical and lay groups, translating Freud, publishing articles on clinical and theoretical topics, and discussing with anyone who would listen the enormous potential of the revolutionary new science of psychoanalysis.

On February 12th, 1911, Brill got together with a group of like-minded individuals, and the first Psychoanalytic Society in the United States was born.

NY Psychoanalytic Society 1st meeting. Note Brill's original pen, at the top.

At this meeting, Brill read, A Paper on the Analysis of a Compulsion Neurosis. The text is not available in its original form, but another paper, entitled, Freud’s Theory of Compulsion Neurosis, and published in American Medicine in December of 1911, is probably a modified version, and the one I've read.

The paper presents the case of a young Jewish man obsessed by the idea that Christians are going to kill all the Jews. The published version, which places less emphasis on the case and its process than it does on a didactic explication of Freud’s theories, is clearly intended to introduce its non-analytic, or in Brill’s conception, not-yet-analytic audience, to psychoanalysis.

Revision: Thank you to Dr. George Dawson for suggesting a simple way to set up a link to the paper.

One quote caught my attention:

...what becomes conscious as an obsession and obsessive affect and substitutes the pathogenic memory in the conscious life are compromise formations between the repressed and repressing ideas. 

Those familiar with the work of Charles Brenner will note the early use of the phrase, “compromise formations”, two years before Brenner was born.

I'm often struck by the contrast between Freud and Brill. Freud with his Gymnasium education; Brill cleaning floors to pay for school. Freud with his Viennese gentleman's bearing, Brill the poor Galician. But their lives converged, and they were both passionate about furthering the cause of psychoanalysis. Freud is obviously better known, but he visited this country only once. It was Brill who established psychoanalysis in the United States.

Wednesday, April 8, 2015

Image in Psychiatry

Remember the Collyer Brothers? They were these two bachelor brothers who lived in the family home at 128th street and 5th avenue. One was blind, the other one hoarded, both were paranoid. They cluttered up their brownstone so much that they were relegated to living in little "nests" that they created within the clutter. It was so bad that they died there.

The city demolished the building after their deaths. And the brothers didn't have anyone to inherit the building or the lot, because it's now a park.  Please forgive the picture-it was taken with an iPhone while passing by in a bus.

According to Wikipedia:

Homer Lusk Collyer (November 6, 1881 – March 21, 1947) and Langley Wakeman Collyer (October 3, 1885 – c. March 9, 1947), ...were two American brothers who became famous because of their bizarre natures and compulsive hoarding. For decades, the two lived in seclusion in their Harlem brownstone at 2078 Fifth Avenue (at the corner of 128th Street) where they obsessively collected books, furniture, musical instruments, and many other items, with booby traps set up in corridors and doorways to ensnare intruders. In March 1947, both were found dead in their home surrounded by over 140 tons of collected items that they had amassed over several decades.

They were the children of two first cousins, their father a gynecologist, their mother a former opera singer. The both had degrees from Columbia, and Langley was an accomplished pianist who performed at Carnegie Hall. The parents separated in 1919, and the brothers continued to live with their mother in the brownstone on 128th and 5th. The father died in 1923, and the mother in 1929, after which, the brothers continued to live together.

Homer lost his eyesight in 1933, and Langley quit his job to care for his brother. The two became increasingly withdrawn, fearful, and eccentric. After several attempted burglaries, Langley:

set up booby traps and tunnels among the collection of items and trash that filled the house. The house soon became a maze of boxes, complicated tunnel systems consisting of junk and trash rigged with trip wires. Homer and Langley Collyer lived in "nests" created amongst the debris that was piled to the ceiling.

Langley occasionally ventured out of the house, collecting food and various objects, but Homer was unable to move due to rheumatism, and both brothers refused to seek medical help for him.

The brothers paid no bills or taxes, and in 1938, refused to sell their home for $125,000. They were nearly evicted in 1942 for not paying their mortgage, and when the police tried to break down the door, they found it blocked by a pile of junk. Langley handed them a check for the full mortgage, and the brothers withdrew once more.

On March 21, 1947, an anonymous tipster reported the smell of decomposition. After some difficulty, the police finally broke in to the house through a second story window. Homer's body was found after 5 hours of digging, dead of starvation. Langley was not found until April 8th, 10 feet from where Homer had died, with 19 tons of junk removed from the first floor in the interim, including 3000 books, a horse's jawbone, a Steinway piano, and an X-ray machine. Langley is thought to have inadvertently tripped a booby trap while crawling through a tunnel to bring food to his brother, and died of asphyxiation.

Ultimately, 140 tons of debris and junk were removed from the building. The house was deemed unsafe, and razed in July 1947.

Saturday, April 4, 2015

Wednesday, April 1, 2015


A little while back, I wrote a post, Virtual Care Physician, about HealthTap, the app that lets you post a medical question and get rapid answers from doctors. The way I checked out Healthtap was by signing up under a false name as a patient, and posting a question about club soda. So now I get occasional email updates from them, and they've come up with an interesting feature called, RateRx, in which, "67,000 top U.S. doctors share their experience and expertise to guide millions toward the best indications."

RateRx is a study that surveyed thousands of US doctors about the clinical utility of medications for specified conditions. Doctors are not permitted to see other doctors' ratings and comments until they've submitted their own, although I'm not sure how they could stop me from viewing ratings as a patient, and then signing on as a doctor and submitting my own ratings. Doctors can also comment on other doctors' comments. The study is ongoing, and contributing doctors can also add ratings for new medications not already on the list.

The way you look up ratings is alphabetically, by condition:

Then you click on the number of treatments or the condition, and you'll get a dropdown list of individual drugs, with ratings and a link to reviews:

The drugs are listed from highest to lowest rated. So it turns out, Prozac is the most highly rated antidepressant, with 4.0 out of 5 stars. The lowest rated is Liothyronine or T3, with 2.2 stars.

Prozac seems to be the only SSRI on the list, which also includes, in descending number of stars:

Effexor                      3.9
Wellbutrin                3.9
Remeron                   3.3
Imipramine               3.0
Desipramine             3.0
Nortriptyline             3.0
Tranylcypromine      2.9
Isocarboxazid           2.8
Phenelzine                2.8
Protriptyline             2.8
Trazadone                 2.7
Trimipramine           2.6
Amoxapine               2.5
Maprotiline              2.5
Chlordiazepoxide     2.2
   & Amitriptyline
Liothyronine            2.2

One nice feature is that when you click on the reviews, you can see each doctor who submitted a rating, and link to his or her profile. Not everyone comments. For instance, in the case of Prozac, there were three comments up at the top, and none below. These are the comments, and all three commenters are psychiatrists:

Actually, I counted, and 23 of the 47 raters of Prozac are psychiatrists. A bunch of the others are neurologists. Then there are a few family medicine docs, as well as some internists. A couple of OB/Gyns, a pediatrician, a couple nephrologists, 1 pharmacologist, 3 clinical psychologists, and 1 labeled, "American Board of Phlebology". Personally, I'm not comfortable having people who can't prescribe or don't see patients comment on how patients respond to medications.

The drug that was most frequently rated, 103 to be exact, was desipramine. The comments were mainly about side effects. One comment I thought was useful was, "If the side effects can be tolerated, it can work. Usually, the prescribed dose is too low."

Most of the comments about Phenelzine were about dietary concerns, with some good general descriptions:

Phenelzine or Nardil is an antidepressant in the group called MAO Inhibitors. These older medications have the highest response rate, which is about 80%. They also require dietary restrictions to prevent a high blood pressire reaction to foods containing tyramine (cheese, processed meat, red wine, soy and some others). Other side effects: insomnia, dizziness.


Useful for atypical depression. People with atypical depression tend to feel better during enjoyable activities, have increased appetite and sleep a couple hours more each day than when not depressed, have a feeling that their arms & legs are heavy, & have an ongoing fear of rejection. Problem with this med: dangerous interactions with MULTIPLE other meds and SEVERAL foods.

So here's my assessment:

It's not a bad idea to have a large survey of doctor ratings and comments. The comments are probably more useful than the ratings, and can be very informative for patients.

It would be helpful to have more statistics listed, like how many of the raters of cardiac medications are cardiologists. I mean, it's not like I know nothing about cardiology, but I wouldn't presume to comment on how well those meds work in the clinical setting, because that's not what I do. By the way, the American Board of Phlebologist also put in his two cents about Amlodipine/HCTZ/Valsartan. I suspect he pops up in most ratings, and gets his name out there that way.

The main drawback is that the setup can be misleading. It seems like a gross oversight to have ratings for lots of MAOI's and Tricyclics, but only one SSRI. I think that would confuse a patient who is looking for advice about commonly prescribed antidepressants. I don't know if RateRx just expects doctors to add the most commonly prescribed meds, but it seems to me the people running the survey should encourage ratings of those drugs. It's not like it's hard to get prescribing information. Drug companies certainly know which meds are most popular.

So check out RateRx, and let me know what you think.