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 24, 2013


I seem to have a lot of random thoughts floating around in my head. In no particular order:

1. The Practical Psychosomaticist has a new article up for our fledgeling online journal club, entitled

Competency-Based Education, Entrustable Professional Activities, and the Power of Language

It's about new and improved ways to judge progress in residents. You can read my full comment over on the site, but the gist of it (my comment) is that it's an attempt to quantify things that may not be easily quantifiable. So I'm skeptical. But then, I don't trust checklists, in general. Here's me quoting myself (and mixing four different metaphors):

To my way of thinking, it comes down to a mode of teaching and learning. The traditional approach in residency has been an apprenticeship, starting as a scut-monkey PGY1 who just does what she’s told, and progressing to journeyman on graduation. And the entire arc is supervised, hopefully by supervisors who know when to be heavily involved, and when the resident can solo. This is in contrast to a style that involves rigid quantification. I agree that it’s an excellent idea to have specific expectations, and it’s also a great exercise to sit down and think about what makes a good doctor a good doctor. But it’s similar to using checklists to evaluate patients. Checklists have their role. They can be useful for tracking progress. But appropriate use of checklists, like in the Ham-D article, involves the ability to interview the patient. It’s about people getting to know people.

2. I'd really like to continue this journal club idea. But the logistics are more complicated than I anticipated. I was thinking about doing it as a LinkedIn group. Other possibilities include a Facebook page, Google+ Circle,  and a separate blog. I'm sure there are other ways to go about it. I'd appreciate suggestions.

3. I read an article in Wired magazine, How Successful Networks Nurture Good Ideas. In it, Clive Thompson writes about the power of collective thinking. He claims that writing for an audience clarifies ideas because "the effort of communicating to someone else forces you to pay more attention and learn more." He then cites several convincing studies and examples.

This has implications for so many things. An online journal club, for example, can reach out to many more people than can be gathered in one room. Think of the possibilities for exchange of ideas! Things like allowing the public access to drug research data, so safety and efficacy can be independently judged. Sites like Change.org, for worldwide petitions, and Fundly.com, for raising money for causes.

There's the flip side. You could conceptualize another article entitled, How Successful Networks Nurture Bad Ideas. Imagine if Hitler had written, Mein Blogge. (Sorry if that offended anyone, it wasn't my intention.)

But on a deeper level, communicating with an audience is what allows me to do my job. A patient comes into my office and somehow manages to articulate scary, icky thoughts and feelings that have been pent up and festering and unshared for years to an audience that includes myself and all the significant figures in the patient's life, as transferred onto me. And then those thoughts and feelings become less scary. And ideas start to congeal. And something in the patient shifts, and his life improves. Just by communicating with an audience. That's real learning.

4. I'm thinking about A Randomized Controlled Clinical Trial of Psychoanalytic Psychotherapy for Panic Disorder, by Milrod et al,  as my next journal article. Here's the abstract:

Objective: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors’ knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. Method: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18–55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. Results: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. Conclusions: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.

It's an interesting study because it successfully manualized a type of treatment not previously believed to be manualizable.  Anyone game?