Welcome!

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.


Monday, October 20, 2014

NY Times: Why Doctors Need Stories

I just want to link to an article by Peter Kramer, published today in the NY Times:

Why Doctors Need Stories

It's about the role of the case vignette, and how it shouldn't be discounted in the face of evidence based medicine. It also reflects my personal opinion about the significant limits of CBT, despite all its hype.

I submitted this comment:

As a psychiatrist and psychoanalyst, I applaud Dr. Kramer's embrace of "the story". But I don't think case vignettes need to be limited to the role of adjunct to evidence based medicine. Case vignettes actually do supply statistical evidence. A research group from the University of Ghent, in Belgium, specializes in Meta-Synthesis (as opposed to meta-analysis), in which they mine the data generated by a large collection of single case vignettes. You can check out their website: singlecasearchive.com, where you can search for different parameters within papers that have already been published.

You may recall my mention of this topic in a post from last January, The Rest of the Meeting. Feel free to recommend my comment (under the name, Physician NYC-not sure how that happened) from 2:14pm on Sunday the 19th.

Saturday, October 18, 2014

Reinvention

Hello. Sorry for the prolonged absence. I've been pretty busy with a number of things. I've started studying for Boards in earnest. It's unpleasant, and I don't feel like I'm getting anything useful out of the experience, but it does take up time.

I've also been dealing with family stuff of the happy variety. I do feel like I'm getting something useful out of that, but it does take up time.

My husband and I are both self-employed, so we get our medical insurance from Freelancer's Union. I'm not sure if that exists everywhere, but we have it here, in NYC, and it's a great idea because you don't have to buy individual coverage at skyscraper prices if you don't work for some company. We've had it for several years and the coverage has been decent, if not stupendous.

But in keeping with all the plans under Obamacare, starting in January, Freelancer's is no longer going to offer any plans with out of network coverage. And this is a big deal. Not so much because I won't have out of network coverage, myself, although that's important. But because some of my patients are also insured through Freelancer's, and will be losing their out of network coverage. And I don't accept any kind of insurance. I'm guessing that in the not-too-distant future, employer-sponsored plans with out of network benefits will also go the way of the dodo. Why should companies pay for that, right?

Not all my patients pay my full fee. But those who do can often afford it only because they have reasonable reimbursement. And even those who don't pay my full fee use their insurance to help cover whatever I'm charging them.

So what's gonna happen in January? I'll either have to charge less per session, or my patient's will have to see me less frequently, or not at all. I'm anticipating a significant drop in my income. So significant, in fact, that if I don't find a way to make up the difference, in a couple years, I won't be able to afford to run my practice.

This is not an exaggeration. NYC real estate prices are ridiculous. As a reference point, the cheapest studio apartments in Manhattan rent for about $1250 a month-and those aren't even professional offices, and they're in a neighborhood where it's not worth having an office if you want patients. Add to that all the other costs of running a practice, plus food, clothing, shelter, and family expenses, and I'm toast.

My practice is not atypical for NYC. Most psychiatrists in private practice, the ones I know and whose work I respect, anyway, don't take insurance. And these days, it's not just psychiatrists who are completely out of network-other MD's have stopped, too. And I happen to know that my full fee is way on the low side for NYC.

It seems like it's time to reinvent myself. Do I refuse to see patients who can't pay me in full? Do I increase my full fee so those patients who still have out of network coverage can help compensate for those who don't? Do I figure out a way to market myself to that portion of the population who can afford my fee? Do I start accepting Groupons? Do I go concierge style? Do I accept whatever patients can pay me, and take a second job as a barista? Do I play the lottery on a regular basis? Do I develop a clever psych app? Do I monetize my blog? Do I find some other way to offset my losses? Gambling? Home pornography? Airbnb?

You may have noticed that I didn't include accepting insurance as one of my options. I don't consider it a viable option. If I were to sell out that way, I'd be bogged down in all kinds of extra scutwork, the insurance companies would do everything in their power to avoid paying me (United still owes me a couple thousand from back when I accepted medicare), and even when they did pay me, it wouldn't be enough to allow me to maintain my practice.

Or maybe I close my practice completely and find a new profession, after pouring a good percentage of my life, and enough money to feed a small third world country for a year, into medical school, residency, and analytic training.

When I was getting ready to leave my inpatient job and open my practice, I spoke to a friend/colleague who had started her practice two years earlier. She told me that she had written herself a script, which she memorized, of how to tell patients what her fee was. She did this because after accepting $5 per session fees in the clinic, as a resident, she thought it would be hard to keep a straight face when she quoted her fee as $250 a session (this was maybe a dozen years ago).

I'm finally getting to the point where I feel like I deserve my fee. Like I have the knowledge, skill, expertise, and experience to warrant what I charge. I've noticed feeling that way lately. It's been a nice change. And now it's not going to matter.

I can't honestly say I'm surprised by any of this. It's just an extension of what I wrote about in Coverage vs. Care:

1. Everyone has health coverage.
2. Doctors will stop accepting that coverage because they can't afford to practice with those reimbursement rates.
3. Patients will stop going to the doctors who don't accept their coverage.
4. Doctors who don't accept coverage will lose all their patients.
5. Doctors who don't accept coverage will be forced to start accepting insurance or close their practices.
6. Goto 2.






Tuesday, September 30, 2014

New App-Pager

I saw an ad on the subway today for a new app called, "Pager". You download the app, input your info, and then you can report any symptoms you might be having, and get a doctor to make a house call within 2 hours.

That's right! The new innovation in medicine is house calls.

The app was designed by the same people who brought you Uber, the taxi summoning app. Which makes sense. In case you're interested, and I must say I'm intensely interested in this, here's a Wall Street Journal article about Pager from back in May.

But today was the first ad I'd seen for it, and I ride the subway every day.

I did the instant chat thing with Michelle from Pager when I checked out the site, because I was curious about a few things. Here are the screen shots:





Okay, so it's not foolproof, but they do have some way of addressing safety concerns.

I asked about safety because I remember my doctor making house calls when I was a kid, but this was someone with whom my family and I had a long-established relationship. Not a stranger.

I asked about Gyn just to be challenging. And I asked about Psych to see what they would say, and if I could potentially work there one day. Not that that's my current plan, but I do think this is a much more promising venue than telemedicine. These are real medical visits, with real physical exams. Wounds can be sutured, school physicals dealt with, flu shots given, labs ordered and followed up, prescriptions written.

I was thinking about this in comparison with Urgent Care centers, and for reasons I  can't really justify, I prefer this system. I somehow have the sense that if I walk into an urgent care center, I'll end up dealing with someone who has less training and knowledge than I do, and I'll be frustrated and walk out. I'm not sure why a doctor working for Pager would be any different, except that, at least according to the WSJ article, doctors do this to supplement their incomes, and to avoid the frustration of working at insurance based clinics. Somehow that seems more reasonable, or at least more in line with my approach. But I'd be interested to hear other people's thoughts.

Pager is $50 for a call or text that does not require in-person follow up, $199 for a weekday house call, and $299 for a weekend/evening house call. I believe it's only available in Manhattan, currently. I'm also not sure what the time limit is for a house call. Pager will provide you with appropriate bills to submit to insurance.

The site seemed reasonably responsible in weeding out emergencies, which was reassuring. It also seemed really suitable for someone visiting NYC and staying in a hotel.

Is this the future of medicine? Surely not the future of Psychiatry-house calls are kinda off limits for the way I practice. But Pager has an option for telemedicine, so maybe it could be tele-psychiatry, with an option for in-person follow-up if necessary. Sounds confusing, but better than run-of-the-mill distance psychiatry.

I did download the app. It required my name (false), email, cell number, and photograph, which it claims to need. It requires a credit card to set up an appointment, but not for plain old registration. I entered my office location, but I couldn't figure out how to access a list of local doctors without entering my current symptoms. Maybe I'll try that out.

Wednesday, September 24, 2014

Happy New Year

For those who celebrate the Jewish New Year, have a good and a sweet year. For those who don't celebrate the Jewish New year, also have a good and a sweet year.

Shannah Tovah!


Monday, September 22, 2014

Prozac "News"

This article was in the NYTimes.

It includes a retro report video which describes, in essence, Prozac's celebrity. The video leaves me kind of unsatisfied. It alludes to the unproven suspicion that Prozac increases suicidality, but drops the subject. It focuses more on the marketing of Prozac: "PRO" as in professional. "AC" as in action. And "Z" that sounds powerful, or techy, according to the article. They have quick videos of Elizabeth Wurtzel (author of Prozac Nation, also see this ghastly piece by her in yesterday's Times), and Peter Kramer (author of Listening to Prozac-check out the "before and after" of him with brown hair and with grey hair, and of the computers he uses). And it references the controversy of what Prozac is treating-is it "cosmetic"?, what is illness?, etc. All in 9 minutes.

I guess I expect a media video to be more interested in the controversies. There's a lot that could be said about the suppression of data. And the marketing guy they interviewed is satisfyingly slimy, so I can't really complain. Basically, it's a small capsule.


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

Chocolate



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