Post X-mas

I'm Jewish down to my toenails, and I don't celebrate Christmas. But I happen to think it's a lovely holiday. Colorful lights, shiny ornaments, lots of red, flying fat men, indoor foliage, good will, peace on earth, presents. Sounds nice.

And I have a special fondness for Christmas carols. Not Christmas songs. Please no. Not even Springsteen. Well, maybe a little Springsteen. But I love decking halls and wassailing and gentlemen resting merry and Wenceslas walking in snow.

So this is my 12 countdown for 2013. Yeh, 12 and 11 are lame, but I'll re-post if someone comes up with better ones. Feel free to sing along.

12 Cranial Nerves
11 Brodman Frontal
10 ICD soon
9 ICD now
8 an I-STOP sign
7 RDoC Columns
6-9083
DSM-5
4 P-Q-R-S
3 Glaxo billions
2 Janssen billions
And god send you a happy new year!

E-Rx Update and Review

A few months ago I wrote a post (ERx Me) about e-prescribing. Now that I've been using Practice Fusion for a while, I thought I'd write an update.

The program, itself, has some problems. Ads for more training in Practice Fusion pop up a lot, along with dialog boxes that take up enough of the screen that I have trouble seeing what I need to see. On my work computer, an old MacBook, I couldn't see at all until I switched to presentation view, and I had to figure that out by trial and error. There was no, "If you have difficulty viewing..." message. I suspect the visual difficulties would go away if I paid for an upgrade, which I'm not willing to do.

There was a 6 month time limit for sending in my first e-prescription. After that, I think I wouldn't have been able to use the system without reapplying for eRx privileges, which may have been delayed due to my failure to demonstrate an interest in using the system. But I did "write" an eRx within the time limit. Weirdly, after that, I started getting emails and phone calls from Practice Fusion encouraging me to contact them for training so I could get started using the system. I thought I had already started.

I tried setting up a dummy chart for patient, Joe Cool. There doesn't seem to be a direct way to create a new chart. Instead, you enter the patient's name, and click on a button to search for an existing patient. Then, when it doesn't find the patient, it asks you if you want to add this as a new patient.  Seems silly.

The notes feature is comprehensive. Too comprehensive. There are all kinds of variations, and most aren’t useful for my needs. You can customize notes, but the process of doing so is prolonged and cumbersome. You can also upload a note template, which I did. It’s there now, but I haven’t figured out how to incorporate it into a chart.

I can’t really complain about the charting features, though, because that’s not why I use it. I use it only to send eRx’s to pharmacies, since I’m going to be required to do that in the not so distant future, and I don’t want to end up rushing to set up a system last minute.

I’m still not comfortable with storing patient information in the cloud. I’m not worried about HIPAA. As I found out (What, Exactly, Is HIPAA?), HIPAA allows me to take my patients’ histories and do everything  short of publishing them in a full page ad in the Times.

But according to my last malpractice tutorial, it’s a no-no, because if it’s in the cloud,  it’s not clear who owns it. I’d like that to be straightened out before I send patient data off into the stratosphere. I also wonder what the story is with personal clouds, or Network Attached Storage, or whatever.. If I have one of those, can I use Practice Fusion’s  EHR but store the data myself?

I only need minimal data for e-prescribing on Practice Fusion. The patient’s name, date of birth, and phone number. I don’t even include a diagnosis in the chart. And I always check with patients before I e-prescribe for them.

I’ve run into some problems with the actual eRx’ing, but I don’t believe they’re specific to Practice Fusion. The first issue is that you pick the medication and strength from a drop-down list. It’s VERY easy-I’ve already done it-to pick the wrong strength or formulation, even if it’s just because your hand moved when you clicked. E-prescribing is supposed to do away with prescription errors. NOT!

Also, I guess writing one eRx puts you into “the system”, because I’ve gotten refill requests for patients for whom I’ve never e-prescribed. This is a particular problem because until I realized this, I wasn’t even checking in on Practice Fusion. I found out when I logged in one day, and there was a list of erx’s I “needed” to write. This seems to be an extension of something I find incredibly annoying. I get calls from the pharmacy, asking me to call in refills for a patient, because the prescription is about to run out. Or sometimes I get faxes. But it’s automatic. There is no accounting for the fact that the dosage may have been changed, or the patient has enough 25’s left over from when we were titrating to cover for a week or two more. I end up having to call the patient to check, and there’s almost always no need to call in a Rx. But it creates extra work for me.

Refills are another thing. I initially tried checking the box for “refill as needed”, for patients I thought were reliable enough to keep track of their meds. I thought this meant that when the patient ran out and called the pharmacy, they would just refill it. Apparently, what it means is they have to call me to authorize a refill. So now I enter a specific number of refills instead.

The automatic thing is a real problem. I saw a refill request on my Erx list. The patient had already called me to let me know she was running out. So I just approved the refill request. Later that day, the patient called me again to let me know that the pharmacy wouldn’t fill it in the requested dosage form, and then I had to call the pharmacy anyway with the change in dosage form, even though they were the ones who requested I refill it in the other dosage form.

I feel about e-prescribing the way I feel about technology in general. When it works, it’s wonderful, and when it doesn’t work, you’re so much better off with paper and pen. Everyone gets all excited about a technological improvement, as though it’s a panacea, and doesn’t come with side effects of its own.

Trials R Us

Here's a link to Randomise Me, Ben Goldacre's new site that allows anyone to create his or her very own randomized clinical trial.

There are several things I love about it. The fact that you can easily create your own trial, for one. And that it's a great learning tool, especially for kids.
I love the fact that "randomise" is spelled the British way, with an "s". I love that the tutorial includes a suggestion for studying "the number of wees you have in 24 hours".
Yes, I love Britishisms, and I try to introduce them into my speech as often as possible, in the hope that they'll catch on in the States. But we'd probably just make them sound flat and nasal. Nevertheless, I have started calling things I don't like rubbish, as in, "That place makes a rubbish bagel! You should just tip it into the bin. I'm more keen on Zabars."

Back to Randomise Me. You decide what you want to study, say the number of cockroaches in NYC apartments. No, I don't think so.

Instead, I set up a study of magnesium supplements for initial insomnia. 15 nights on, and 15 nights off, with time to sleep measured by a sleep app called, Sleep Cycle, which measures sleep by movement.

The site walks you through setting it up, asks you whether you want to conduct a trial on yourself or others, randomises you to different arms, and asks if your study will be private or public (defaults to private).

Well, here goes.

And don't forget to check out the new article on POLL.

Values

I've been thinking about the connection between deadlines and values. There's nothing like a good, looming deadline to help establish priorities. I guess that's the principle behind triage. But I'm thinking about less life-threatening choices.

I'm writing another article for The Carlat Report. Not sure if I'm allowed to discuss details, so I won't (until it's published). It's due at the end of the month, and obviously, I'm making it a priority, especially since it requires a fair bit of research.

This week has been a little rough. My mom died a year ago Friday, and the anniversary of her death hit me harder than I expected. I suppose that's what got me thinking about setting priorities.

So what's important? Obviously, meeting an article deadline.

But what about other responsibilities and projects I've taken on? I co-teach a class on technique once a week-that'll run until March.

I feel very strongly about continuing POLL, the free online journal club I started together with Jim Amos of The Practical Psychosomaticist, and George Dawson of Real Psychiatry, although it's been hard to get people to comment. But I don't want to give up, because I truly believe that in the long run, that kind of format will be more important for lifelong learning and professional collaboration than any MOC requirement.

What about this blog? It's been a challenge and a pleasure to come up with things to write about. It forces me to read a lot of professional material, to stay current, and to think critically. It also forces me to write, which has always been an outlet for me.

Oh yeah, I also have a day job. I like working with patients, but I hate the paperwork, especially since the notes no longer have anything to do with treatment.

And then there's family. And friends. And the pain-in-the-butt dog:

Almost forgot: health, exercise, cooking, reading, movies, Cable Series, art, music, theater, chocolate, exploring NYC, crocheting:

There are other things I'd like to learn, like how to play guitar, and paint with watercolors, and  knit, and hem a pair of pants, and fold a fitted sheet, and html, and photoshop. When am I ever gonna find the time to become an architect and design and build a summer home? When am I ever gonna be able to afford a summer home? Will I get to visit the Galapagos before they're polluted to the point of not being worth seeing? What about the screenplay I want to write on The Controversial Discussions (more on that in another post)? And the coffee-table book on architectural ironwork:

And since I'm nowhere near having them yet, I don't need to make time for grandchildren. But I want them big-time, and I suspect most other things will fall by the wayside if I'm fortunate enough to ever get them.

Life is short. You give up some paths to pursue others. It's rare that you need to make life-and-death decisions. But you're always making this-life vs. that-life decisions.

How do you prioritize?

Shrink Rap Survey-Who Are the Mentally Ill?

Shrink Rap is conducting a survey about who qualifies as mentally ill. It's interesting, important, and probably hasn't been done before. So please click

HERE

to link to the post, and take the survey.

Clinical Trials Article

This week's POLL article for discussion is:

Timing and Completeness of Trial Results Posted at ClinicalTrials.gov and Published in Journals, by Riveros et al.

The authors searched clinicaltrials.gov for trials with posted results. They then tracked down the published articles corresponding with these trials.

They looked at a random sample of 600 trials with results. 50% had no published article.
Of the 202 that did, "...the median time between primary completion date and first results publicly posted was 19 months." The corresponding time to journal publication was 21 months.

As for what was reported, "Reporting was significantly more complete at ClinicalTrials.gov than in the published article for the flow of participants (64% versus 48% of trials, p<0.001), efficacy results (79% versus 69%, p = 0.02), adverse events (73% versus 45%, p<0.001), and serious adverse events (99% versus 63%, p<0.001)."

85% of the trials were industry funded.

My thoughts:

They know what percentage of the trials they looked at posted results/adverse events/serious adverse events. They don't know what percentage of results/adverse events/serious adverse events were actually reported, even in the trials they looked at. In other words, all the data they have to go on was what the trials voluntarily reported.

Why more complete reporting at Clinicaltrials.gov? Is the expectation that fewer people will check it than the literature, especially since the results often don't agree, and look more favorable in publications than on clinicaltrials.gov?

Serious adverse events reported in only 63% of publications? Oy vey.

My experience with clinicaltrials.gov has been that results are rarely reported at all.  What percentage of trials reported any results?
This wasn't what the above article was about, so I replicated the search terms they used to find the trials they considered. They searched for "'Closed study' in the Recruitment field, 'with results' for Study Results, 'Interventional studies' for Study Type, and 'Phase III and IV' for Phase." Then they excluded certain studies.
First, I used the same search terms,  except I used, "all studies" rather than "with results", and I got 29,261 such studies. Then I searched again, using "with results" for Study Results, and I got 4885 such studies. That means that 17% of registered trials reported results.

This despite the fact that:

"Section 801 of the Food and Drug Administration Amendments Act (FDAAA 801) requires Responsible Parties to register and submit summary results of clinical trials with ClinicalTrials.gov."

In addition:

"The International Committee of Medical Journal Editors (ICMJE) requires trial registration as a condition for the publication of research results generated by a clinical trial."

This means that the vast majority of registered trials aren't bothering to post results on clinicaltrials.gov, despite the fact that they are required by law to do so. And when they do post results, it's generally after the one year time limit. So the clinicaltrials.gov people are not reinforcing their own rules.

Furthermore, the ICMJE requires trial registration to publish articles, but also doesn't generally check up on whether results have been posted, and if they have, whether they agree with the results in the articles they're about to publish.

If you read the Riveros article, and I encourage you to do so and comment on POLL, you'll see that there are a lot more problems than the ones I've just cited.

What a mess.

Use the Couch, Luke

First off, I want to state that my post, The Couch, First Session, got more hits on its first couple days than any post I've ever written, and I don't know why.  Is it that in questioning the validity of the DSM-5, and the efficacy and safety of psychotropic meds, people want something deeper? Is it the freak show effect-who are these weirdos? Is it a general interest in something you've heard of but didn't know much about? I'd very much like to know, so if you have any thoughts about it, please share them.

This is meant to be a follow-up post, where I write about what it's like for me to be an analyst. In later posts, I'll go into more detail about what it's like to work as an analyst. Appropriately, I'm going to free-associate.

One admittedly small way my training has helped me-and this is mainly from my own analysis-is in finding things. You know when you misplace something, and you look all over for it, and you can't find it? That doesn't happen so much anymore. Instead of trying to figure out where it could or should be, or methodically rooting through drawers and cupboards for hours, I free associate. I just relax and wait for the first thought to pop into my head, and then I go wherever that thought seems to indicate, and most of the time, I find what I'm looking for. If that were all analytic training had done for me, I'd eat my hat, but it is a perk.

Another change I've noticed in myself is what I call "The Vampire Effect".  As a medical student and resident, I found myself looking at people's veins. Not just patients, mind you. Friends, family, the new acquaintance who was wearing short sleeves when he shook my hand. My eyes would wander, surreptitiously, I hope, to the antecubital fossa, and I'd think, "Hm, that's a pretty nice vein. I could get blood out of that." No doubt this habit was related to the fact that the better I was at drawing blood, the more sleep I could potentially get on call. And I'm grateful that it seems to have faded.

But something similar happened with my analytic training. Something related to a skill I needed to develop to become an analyst. Something that is experienced by other analysts and analytic candidates, but less so or not at all by most others. ( I really hope the random Joe walking down the street doesn't spend time thinking about getting blood from people's veins). It's a way of thinking analytically, which sounds pretty obvious. But you get in the habit of listening for latent content, and for recognizing that there are underlying unconscious processes going on all the time, and that manifest content is not always what it seems, and that unacceptable thoughts and feelings often appear in other guises.

All well and good, but try telling the friend who believes he's never had an irrational thought in his life that he chose his profession not because he "just happened to like it", but because he feels competitive with his (father, mother, spouse, sibling, cat, take your choice). Or telling the friend who "forgot" he had a meeting with his boss that he has conflicts about his aggression towards authority figures.

The responses you get, if you're foolish enough to say things out loud, are along the lines of, "Oh, please, don't give me that psychobabble, I just forgot." And you respond with, "Okay."

But meanwhile you're thinking, "A repressed memory is a forgotten one from the subjective point of view of the individual in whom repression has taken place. Indeed, we may remark parenthetically that we don't know for sure whether there is any type of forgetting other than repression." (Brenner, Charles; An Elementary Textbook of Psychoanalysis; New York: Doubleday, 1974, p.81).

I hope I'm not arrogant enough to think I always know what's really going on with everyone. In fact, if I did think that, I'd be pretty crappy at my job, because I wouldn't be able to listen for anything I didn't expect. But in the same way that medical training allows you to recognize certain constellations of symptoms and signs as a particular disease entity, one that someone untrained might miss, analytic training allows you to recognize certain basic ideas about conflict and the unconscious.

The point is, it can make you a little nuts if you see stuff that other people don't, especially family members, and I think it makes you gravitate more towards being around other analysts, or people who are trained to think analytically.

The first class I took as a candidate was, not surprisingly, Introduction to Psychoanalysis. One of the readings for that class (I can't seem to find it), described qualities necessary to practice psychoanalysis. There were things like, patience, selflessness, comfort with silence, openness, lack of judgement. It made Psychoanalysis sound like a monastic order. I think that's pretty close to how it feels. There's a definite religious quality-the institute I'm affiliated with is like a shrine to Freud:

But I've come to think that it's more like being a Jedi. You're involved in this archaic practice that requires years of training and apprenticeship. Most people think it's useless or non-existent, but you and your fellow Jedis recognize that there's a powerful, universal force, the unconscious, that affects everything and everyone. As I understand it, George Lucas underwent a Jungian analysis, so the analogy may not be that far off the mark. And sometimes, a lightsaber is just a lightsaber.