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, May 27, 2014

POLL Article, Editorial Policies

If you hop on over to POLL, you can check out and contribute to a discussion of the new article, How Psychiatry Journals Support the Unbiased Translation of Clinical Research. A Cross-Sectional Study of Editorial Policies
by Hannes Kn├╝ppel, Courtney Metz, Joerg J. Meerpohl, and Daniel Strech.

The authors looked at 123 Psychiatry journals, and a subset of the "Top Ten" journals, which were unspecified, to determine how frequently/strongly these journals encourage or require authors who submit papers to follow reporting guidelines, and to register their respective trials with registries such as ClinicalTrials.gov, and the WHO's International Clinical Trials Registry Platform (ICTRP).
Actually, according to their site, the ICTRP is not a clinical trials registry. To become registered, trials need to be submitted to one of the Primary Registries in the WHO Registry Network.

The ICTRP site had a nice description of why it's important to register clinical trials:

The registration of all interventional trials is considered to be a scientific, ethical and moral responsibility because:
  • There is a need to ensure that decisions about health care are informed by all of the available evidence
  • It is difficult to make informed decisions if publication bias and selective reporting are present
  • The Declaration of Helsinki states that "Every clinical trial must be registered in a publicly accessible database before recruitment of the first subject".
  • Improving awareness of similar or identical trials will make it possible for researchers and funding agencies to avoid unnecessary duplication
  • Describing clinical trials in progress can make it easier to identify gaps in clinical trials research
  • Making researchers and potential participants aware of recruiting trials may facilitate recruitment
  • Enabling researchers and health care practitioners to identify trials in which they may have an interest could result in more effective collaboration among researchers. The type of collaboration may include prospective meta-analysis
  • Registries checking data as part of the registration process may lead to improvements in the quality of clinical trials by making it possible to identify potential problems (such as problematic randomization methods) early in the research process
Getting back to the original study, they found that 45% (10% of the Top Ten) of the journals made no mention of URM's (Uniform Requirements for Manuscripts, including guidelines and trial registration); 34% (0%) mentioned without specification; 7% (10%) mentioned with the recommendation to adhere; and 14% (80%) mentioned with the requirement to adhere. 

With respect to trial registration, 66% (30%) did not mention; 9% (0%) mentioned with recommendation to adhere; and 25% (70%) mentioned with the requirement to adhere. Furthermore, 70% of the top ten journals did not ask for the specific trial registration number.

The article did not discuss how well the journals that required the use of guidelines and trial registry followed up on compliance. 

What I found most interesting, though, were the reporting guidelines, which I found at the Equator Network. For example, CONSORT (CONsolidated Standards Of Reporting Trials), the guideline for randomized trials, has the following Results excerpt from their checklist:

Participant flow (a diagram is strongly recommended)
For each group, the numbers of participants who were randomly assigned, received intended treatment, and were analysed for the primary outcome
For each group, losses and exclusions after randomisation, together with reasons
Dates defining the periods of recruitment and follow-up
Why the trial ended or was stopped
Baseline data
A table showing baseline demographic and clinical characteristics for each group
Numbers analysed
For each group, number of participants (denominator) included in each analysis and whether the analysis was by original assigned groups
Outcomes and estimation
For each primary and secondary outcome, results for each group, and the estimated effect size and its precision (such as 95% confidence interval)
For binary outcomes, presentation of both absolute and relative effect sizes is recommended
Ancillary analyses
Results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing pre-specified from exploratory
All important harms or unintended effects in each group (for specific guidance see CONSORT for harms)

STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) is the guideline for observational studies, PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for meta-analyses and systematic reviews, etc. 

So different types of studies have different, and apparently clear and explicit guidelines. 

Not much more to say about this right now, except that I like the idea that the authors looked at sources of bias coming from a less common place (as opposed to from greedy pharmaceutical companies, not that they aren't).

Sunday, May 18, 2014

Discovering America

The big news in the NY Times:

Doctors’ Salaries Are Not the Big Cost

"...a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.

That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine."


Another big news item:


Maybe the idea that doctors like to make a living, and some doctors even take advantage of the system, is just juicier news than that business executives like to make a living and often take advantage of the system.

My favorite part of the article?

"Hospitals and insurers maintain that large pay packages are necessary to attract top executives who have the expertise needed to cope with the complex structure of American health care, where hospitals and insurers undertake hundreds of negotiations to set prices."

Translation: "We created lots of unnecessary work to justify our existence, and now we pay ourselves a lot to do that work."

A quick rundown:

$584,000 on average for an insurance chief executive officer, 
$386,000 for a hospital C.E.O. and 
$237,000 for a hospital administrator, compared with 
$306,000 for a surgeon and 
$185,000 for a general doctor.

More importantly, the executive salaries don't reflect full compensation:

"Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million...
Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million."

In all honesty, I wouldn't mind how much money these executives make if they actually did something to improve the state of healthcare. But as far as I'm concerned, they're being paid for destroying it. Maybe we should all go out and mess up some other industry so we can demand huge compensation packages.

Tuesday, May 13, 2014

Identification with the Aggressor

I was thinking that I'd write a post here and there about basic analytic concepts, to refresh everyone's memory, and to force myself to reread things I haven't looked at in a while.

Since I mentioned Dexter in my How to Sit post, I realized that show is a great way to illustrate the concept of "Identification with the Aggressor".

For those unfamiliar with the Dexter series on Showtime, Dexter Morgan is a forensics lab geek who moonlights as a serial killer. The premise is that he watched his mother being hacked to pieces with a chainsaw as a young child, and now he has a need to kill. The man who adopted him, Harry, was a cop, aware of this trauma and Dexter's need, so he trained Dexter to not get caught, and to restrict his killing to people who deserve it, primarily other serial killers who have eluded the criminal justice system.

It's that "need to kill" that's the key. When I first heard about the show, I didn't know about his mother's death, so the premise sounded silly to me. Having watched the show-all 8 seasons-I think a better description is a need not to feel helpless, rather than a need to kill.

The classic example of Identification with the Aggressor is a child who goes to the doctor, gets a shot, and then goes home and pretends to be the doctor giving a shot to a doll or stuffed animal. The child is small, frightened, angry, subjected to pain, and helpless to do anything about it. So the child goes about mastering the fear and helplessness by becoming the powerful doctor who is in control, and who inflicts pain.

If you think about a 3 year old boy watching his mother's murder, you can understand why he would want to become the murderer. This point is even better illustrated in the Dexter books, on which the series is based.

The TV Dexter straps his victims to a table, and then chooses a sharp object from his selection of knives and other pointy things, with which he delivers a swift death. He then chops them up, puts them in plastic bags, and dumps them in the ocean.

The literary Dexter straps his victims down, cuts them into little pieces, and then kills them-a much more powerful imitation of his mother's murderers. And while he's cutting them up, he describes his fascination, and the feeling that he is getting closer and closer to finding something important, which the reader is left to understand as looking for his mother among the body parts.

(Presumably the TV show veered away from the torture in Dexter's killing because they were afraid it would make the character less likable and accessible.)

Identification with the Aggressor was described by Anna Freud in her book, The Ego and the Mechanisms of Defense (ch. 9). She writes, "A child introjects some characteristic of an anxiety object and so assimilates an anxiety experience which he has just undergone. Here, the mechanism of identification or introjection is combined with a second important mechanism. By impersonating the aggressor, assuming his attributes or imitating his aggression, the child transforms himself from the person threatened into the person who makes the threat."

(Anna) Freud takes this transformation one step farther, to revenge, by quoting her father from Beyond the Pleasure Principle (1920):

"If the doctor looks down a child's throat or carries out some small operation, we may be quite sure that these frightening experiences will be the subject of the next game; but we must not in that connection overlook the fact that there is a yield of pleasure from another source. As the child passes over from the passivity of the experience to the activity of the game, he hands on the disagreeable experience to one of his playmates and in this way revenges himself on a substitute." (p. 17).

Anna Freud posits that Identification with the Aggressor, as a defense, is an intermediate step in the development of the superego. She describes several cases in which children identified not with an aggressor who had subjected them to some unpleasant experience, but with a perceived aggressor who would, in the future, punish them or otherwise treat them cruelly. One little boy would furiously ring the bell of the children's home where he lived. When the housemaid opened the door, he would scold her "loudly for being so slow and not listening for the bell. In the interval between pulling the bell and flying into a rage he experienced anxiety lest he should be reproved for his lack of consideration in ringing so loudly...The aggressiveness which he assumed was turned against the actual person from whom he expected aggression and not against some substitute."

In this way, Anna Freud ties the identification (in identification with  the aggressor) with projection of guilt. I am not the aggressor, that other person is. I am the good serial killer, they are the bad serial killers. And thus, Identification with the Aggressor is viewed as a normal, but intermediate step in the development of the superego. "The internalized criticism is not yet immediately transformed into self-criticism." The final step involves the "ego's perception of its own fault."

I'll include one final quote:

"It is possible that a number of people remain arrested at the intermediate stage in the development of the superego and never quite complete the internalization of the critical process. Although perceiving their own guilt, they continue to be particularly aggressive in their attitude to other people. In such cases the behavior of the superego toward others is as ruthless as that of the superego toward the patient's own ego in melancholia."

I find this idea clinically useful- recognizing the extreme guilt in a patient's expression of righteous indignation or intolerance of others, or in the patient's perception of himself as chronically victimized by the world, and in the intolerance of self that is so pronounced in severe depression.

Wednesday, May 7, 2014

How to Sit

In the introduction to his book, How To See, George Nelson remarks that he should have more properly called the book, "How I See". With that in mind, I should have probably entitled this post, "How I Think I Ought to Sit."

But I need to digress here to include this anecdote about the Nelson Ball Clock:

George Nelson recalls the iconic design of the Ball Clock as being a result of a night of drinking with friends and associates, Isamu Noguchi, Bucky Fuller, and Irving Harper.

“And there was one night when the ball clock got developed, which was one of the really funny evenings. Noguchi came by, and Bucky Fuller came by. I’d been seeing a lot of Bucky those days, and here was Irving and here was I, and Noguchi, who can’t keep his hands off anything, you know- it is a marvelous, itchy thing he’s got- he saw we were working on clocks and he started making doodles. Then Bucky sort of brushed Isamu aside. He said, “This is a good way to do a clock,” and he made some utterly absurd thing. Everybody was taking a crack at this,…pushing each other aside and making scribbles.

At some point we left- we were suddenly all tired, and we’d had a little bit too much to drink- and the next morning I came back, and here was this roll (of drafting paper), and Irving and I looked at it, and somewhere in this roll there was a ball clock. I don’t know to this day who cooked it up. I know it wasn’t me. It might have been Irving, but he didn’t think so…(we) both guessed that Isamu had probably done it because (he) has a genius for doing two stupid things and making something extraordinary…out of the combination….(or) it could have been an additive thing, but, anyway, we never knew.”

End of anecdote.

I while back, I wrote a post, Chairs, in which I described some chairs I like, and the problems I have with finding the right chair. I've been working diligently on this problem, by trying out different chairs, but in order to find the right chair, I needed to figure out how to sit.

Ergonomic desk chairs lean back-the proper angle is supposedly 100-110 degrees. And they assume the presence of a desk, so you can lean your forearms on said desk. What I've discovered, and I'm speaking only for myself here, is that leaning back is terrible for my back. Another bad thing for my back? Leaning forward. 

If I stay in either position for too long, I'm asking too much of my paraspinals.

What to do? The obvious answer is, sit straight up. This isn't so easy, and most chairs don't facilitate it. And it's not just sitting straight. I find that in order to keep my lower back (iliocostals, specifically) from going into spasm, I need to sit with my shoulders down and relaxed, and my abs pulled in. 

A recent article in the Washington Post concurs:

This is difficult enough to accomplish with desk work. When I'm facing a patient, trying to listen intently, I tend to lean forward. When I'm sitting behind a patient on the couch, trying to let my mind associate freely in response to the patient's associations, I tend to lean back. 

And I'm fidgety, in general, so I tend to be all over the place. Sitting has become an occupational hazard for me, and I need help. Surprisingly, desk chairs are not that helpful. 

Take a look:

Think Chair
This is the Think Chair by Steelcase. It looks pretty upright, no? But it's springy. As soon as you sit down, it'll lean back, unless you try to lean forward to type at your computer. But that's not what I do when I'm with patients.

The same is true for the Aeron Chair:

Aeron Chair
The lower back support is good, but see how the upper section leans back?

I went to Design Within Reach a few months ago, to try to sit on as many chairs as I could, and see if anything worked. I tried every likely-looking chair in the place, to no avail. I was ready to give up and leave, but I was tired, and it was hot out, and the woman who was working there offered my a bottle of water. So I took it and just for fun, sat down on a chair that I love the look of, but that I always thought would feel torturous to sit in. It's the Cherner Armchair.

Cherner Armchair

Those of you who watch Dexter and pay attention to furniture, like I do, may have noticed that our hero, Dexter Morgan, has this chair in his living room. Appropriate for a fastidious serial killer.

Guess what! It's not springy, and it doesn't lean back! 

And there's something about the way the seat is carved that keeps you from sliding down. Also, even though the arms look awkward, they actually put YOUR arms in a naturally relaxed position. 

Did I buy it? No. In addition to a chair that could save my back, I was looking for a chair with wheels and adjustable height. A task chair. But wait! The Cherner Chair Company MAKES a task chair:

Did I buy it? No. I was a little concerned because the arms aren't curved downward in the same way as the armchair. At least they don't appear to be. I emailed the Cherner Chair Company about this (I'm in earnest about this chair business), and they said that the arms are exactly the same height as those on the armchair. And the real problem is, Design Within Reach doesn't have the task chair in the showroom. So I couldn't do a comparison. 

And these chairs cost the kind of money that I'm willing to invest in if it means I won't be in pain most of the time, but without that guarantee, I'm reluctant to plunk down that kind of change.

In any case, it's impossible to tell from sitting in a chair for a few minutes in a showroom what it's like to sit in that chair all day. 

So I'm still in chair limbo.

Sunday, May 4, 2014

Coming Up Empty

This one surprised me.

I was reading an article in the May 2014 edition of Psychiatric Times, An Update on the Maintenance of Certification Program for Psychiatry, by Patricia Vondrak, MBA, and Larry Faulkner, MD.

Notice, there's no link to the article. That's because I couldn't find it. Surprise #1.

I went to the Psychiatric Times site, and I searched under the title of the article. Nothing (Actually, 3 links to "Update on Opioids"). I put quotes around the title. Nothing. I tried the authors' names. Nothing. I looked under the "topics" heading for "practice management", which this section claimed to be in the print edition I was reading. Nothing. The print edition had a sidebar heading, "Special Report", so I checked the special reports section. Nothing. I did everything again and checked my spelling. Nothing.

This did not bode well.

The article describes:

The 4 components of the MOC process:

  • Professionalism and Professional Standing
  • Lifelong Learning and Self Assessment
  • Assessment of Knowledge, Judgement and Skills
  • Improvement in Medical Practice

It had a bunch of FAQs, number 5 of which was:

Why is CME required for Part 2 of the ABPN MOC program?

CME ensures that professional development activities have been developed according to rigorous standards, including avoidance of conflict of interest. (emphasis mine)

Really? You think Pharma-sponsored CME is rigorous and free of conflict of interest? I mean, no one believes that, and most people are resigned to it, but you really have the Chutzpah to blatantly state it in a publication?

I admit that while I was peeved, I was not surprised by this last.

I was excited about one part, though:

The ABMS provides an evidence library on their Web site that highlights research studies and articles that support the value of board certification and MOC. It reflects an effort to systematically present the empirical evidence in the current peer-reviewed literature.

I was excited because I thought, Okay, I'll check out the evidence library, and maybe I'll be reluctantly convinced that MOC is helpful, or maybe I'll find some article I can fiendishly try to refute, because that's just irresistible given how peeved I am.

I went to the evidence library.

I clicked on "Topics: Validation of Current MOC Programs". 34 hits, including articles on Family medicine, diabetes, lower back pain. I really just glanced. Then I restricted to "2010 to current", because I figured MOC now is very different than MOC in 2000. 14 hits. Then I went to keyword, "psychiatry and neurology", which they had listed-I didn't need to type it in to a search box.

Surprise #2, no hits.

I tried the same sequence, but with years 2000-2010. No hits.

I started over and changed the topic to "Value of Board Certification".  Out of curiosity, I clicked the first link, appropriately entitled, Specialty Board Certification and Clinical Outcomes: The Missing Link, published in 2002. The authors looked at studies from 1966-1999. They started out with 1204 papers, but by the time they pared the list down to good studies that met their criteria, they had 13, from which they identified 33 "separable relevant findings".

Of the 33 findings, 16 demonstrated a significant positive association between certification status and positive clinical outcomes, three revealed worse outcomes for certified physicians, and 14 showed no association... Meta-analytic statistics were not feasible due to variability in outcome measures across studies.

Their conclusion:

Few published studies (5%) used research methods appropriate for the research question, and among the screened studies more than half support an association between board certification status and positive clinical outcomes.

Surprise #3-16 is more than half of 33!

I went back and went through the same timeframe and keyword search, and got no hits.

I went through the same process with the "framework and structure" topic, and again, no hits.

Maybe it's naive of me, but I really expected SOMETHING. I'm kind of disappointed. I was all ready for a fight.

Well, I guess I did find something. I googled the authors' names, and I ended up on the abpn site. Larry Faulkner is the President and CEO. I guess I'm lame for not realizing that to begin with. And Patti Vondrak is Director of Examination Administration.

Did you ever hear the expression, "The patient has GMG?" It's old medical slang for a patient with many complaints but no findings, and it stands for Gornisht Mit Gornisht, which is Yiddish for, "Nothing with Nothing". And as Shakespeare so famously wrote, "Nothing will come of nothing."