RxNT in Progress

I thought I'd follow up my previous EPCS post to let you know how things are going with RxNT.

I had a bit of a problem setting up the soft token, which is generated by an app called, Safenet Mobilepass. In order to get started, you need to send in an activation code, which shows up on your phone screen. The instructions tell you to take a screenshot so you don't lose the code. My iPhone takes screenshots by pressing the little round button and the top right button simultaneously. My timing was a little off on my first attempt, and I lost the screen. I tried to go back one step, but it wouldn't let me, and I had to get out and start over. It worked the second time, but gave me a new ID. I still can't get rid of the original ID, "Token 1", but I can't use it, either.

My first attempt at sending in a prescription for a controlled substance didn't work. It seemed to go through fine on my end, but then the pharmacy called and said they were getting a message that I wasn't set up for controlled substances. So I emailed support at RxNT, etc. Turns out, the problem was on the pharmacy's end.

Support got back to me the next morning-so that was good. they suggested I delete the "Token 1" ID, but didn't tell me how. I wrote back that I had already tried, and there's no obvious way to do it. Haven't heard back from them on that point yet.

Suffice it to say, all beginnings are difficult.

Other topics of interest:

There's no way to pay RxNT online. No PayPal or anything like that. You have to email or fax a credit card form. That seems like a pretty easy thing to rectify. I mean, I even take PayPal in my office.

There's a "recent rx" tab that lists recent prescriptions (duh) if you click on it. But I can't figure out how to set a date range for how recent I want it. It seems to default to the 4 most recent. You can generate a Rx Report, where you can set the date range as you see fit. But that's just for a reportnot the "recent rx" page.

Similarly, I can't find a screen that simply lists my patients alphabetically. I don't have the EHR set up, so that may be the reason.

Refill requests don't have a direct link to editing. I had to go through the patient link to edit. Maybe I need to practice more, here, and there's something I'm not noticing.

I get a "data could not be loaded" message a lot. But then the data seems to load normally, so I'm just ignoring it.

Finally, this is my silly hangup, but the app icon for the soft token:

Reminds me uncomfortably of the logo for Panera Bread:

I don't know why this bothers me. Something about the relationship between a big, mediocre food chain, and the company that allows me to prescribe controlled substances.

Ziprasidone and DRESS

In case you haven't seen it, the FDA released a safety communication about Ziprasidone (Geodon) induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). The FDA reviewed 6 worldwide cases of DRESS temporally associated with initiation of Ziprasidone, specifically, within 11 and 30 days of initiation of treatment. There were no fatalities. In 3 of the cases, Ziprasidone was initiated, the patients developed DRESS, Ziprasidone was discontinued and later restarted, at which point, the patients re-developed DRESS, only faster than the first time around. 3 cases reported concomitant use of other drugs associated with DRESS. (I believe, based on the ambiguous FDA description, that) all 6 cases were hospitalized.

To review, mostly from UpToDate, DRESS is rare-anywhere from 1-5/10,000 in patients taking carbamazepine and phenytoin, and 1/300 adults or 1/100 children taking lamotrigine. Mortality is 10%. The most common associated agents are carbamazepine, phenytoin, lamotrigine, phenobarbital, and allopurinol. Etiology is unclear. Reactivation of Herpesvirus or EBV infection concurrent with drug hypersensitivity is common.

DRESS usually begins within 2-6 weeks of drug initiation, and most commonly presents with fever, malaise, lymphadenopathy, and skin eruption. There is liver involvement in 60-80% of patients. Kidney and lung are also frequently involved. Hematologic abnormalities include leukocytosis with eosinophilia and/or atypical lymphocytosis.

Treatment consists primarily of withdrawing the offending agent, with systemic corticosteroids for severe cases of tubulointerstitial nephritis or interstitial pneumonitis. Skin eruption and visceral involvement resolve gradually, within 6-9 weeks. In up to 20% of cases, the disease persists for several months, with a succession of remissions and relapses. The long-term, natural course consists of spontaneous flares.

One more thing to discuss with patients before starting them on ziprasidone.

App Review: NbNomenclature

A while back, I wrote a post called, What's In A Name?, about a proposed 5-Axis drug nomenclature system. The idea was that our current system of describing psychoactive medication involves terms like "Antidepressant" and "Antipsychotic", even though antidepressants are sometimes prescribed for anxiety, and antipsychotics for depression, and this is confusing, especially to patients.

Instead, the new system has a different way of describing drug class, along with mechanism of action,  indications uses, and relevant side effects, as well as neurobiology.

I had some concerns about how this system would be used, and by whom. There was talk of a future merge with DSM, whatever that would mean. It was created by people with strong ties to industry. The claim is that it would be a collaborative model, and I wondered what the charge for that collaboration would be. And I also wondered if reporting off-label uses as part of the drug description would influence future drug indication.

This was over a year ago.

More recently, Clinical Psychiatry News reported the launch of the drug terminology overhaul. The launch was accompanied by the release of a paperback book, as well as a new app, NbNomenclature, available for free download on iTunes App store and google play.  See also Nigella's comments on The Practical Psychosomaticist.

Not sure why Nigella had difficulty downloading it. Maybe because she was using an ipad. I put it on my iphone, and it does work. I haven't attempted an ipad yet.

So  I thought I'd share some of my thoughts. The home screen looks like this:

If I type in say, nortriptyline, I get this (the screen shot is missing the neurobiology section, down at the bottom, but I'll get to that):

It gives the official indication as Major Depressive Disorder, under the check mark (or tick, if you're British), but the + sign gives you the conditions it's used for.

Common and serious side effects under the - sign, that's useful.

What it doesn't give you is what you do get on something like Epocrates, dosing:

(Yes, I get crappy signal. Thanks, Verizon)

This lack of further information is strange in light of what I read in the app's stated mission:

"This proposed nomenclature aims to reflect the current pharmacological knowledge base and cannot necessarily represent the ultimate scientific truth...we feel that it's better to present a cutting-edge scientific interpretation than to wait for the definitive conclusion. We need to treat our patients now, and we cannot postpone treatment until all the facts are known.

Therefore this nomenclature is based on:

1. The need to treat now.

2. Updated neuroscience insights.

3. The judgement of the members of the task force." (italics mine)


With all this emphasis on the need to treat NOW, it would be nice to know how to dose the patient sitting in front of me, and what dosing forms are available for writing a prescription.

Maybe the Nb people didn't think that was important since we'll all be using electronic prescribing software that will tell us dosing options and forms. But for me, it keeps the app from being really useful, except perhaps to medical students who don't prescribe anything and don't need to know dosages. (Don't freak. I do remember most dosage forms, but there are some meds I don't prescribe very often, and I look those up just to be sure. Also, when titrating or tapering, sometimes you need weird, in-between dosage strengths.)


One nice feature is that if you're looking at a drug, and you swipe left, you get a similar drug. One left swipe from nortriptyline takes me to amoxapine.

Curious about this feature, I looked up Strattera, which it lists as a norepinephrine reuptake inhibitor (NE-RI in the app's abbreviation system). One left swipe takes me to desipramine, another NE-RI, then to lofepramine, maprotiline, and reboxetine, all indicated for Major Depression, unlike Strattera. So the new classification system is based strictly on mode of action.

Again, my question-who is going to use this? If I'm looking up Strattera, then presumably I want a medication for ADHD. If I'm looking for an alternative, I don't want to end up with an antidepressant. As an experienced clinician, I already know what other ADHD meds are out there. For an inexperienced clinician, this could cause a lot of problems. Or maybe the idea is for doctors to experiment based on mode of action.

Okay, so I couldn't find another ADHD med by swiping. I went back to the home page, clicked on "approved indication", and looked up ADHD. I got two hits: amphetamine and lisdexamfetamine. Aren't they missing a few? It turns out, they have several categories of ADHD. The one I checked was just ADHD. ADHD in children in Canada gives me guanfacine, ADHD in children >6y in the US gives me clonidine, and ADHD in children >6y and adults gives me methylphenidate and atomoxetine, right back where I started. Those are all the ADHDs they had.

In contrast, looking up ADHD in Epocrates gives me a list of 31 drugs, from Adderall to Zenzedi. Kinda easier to find alternatives.

As for the neurobiology section, nortriptyline looks like this:

Those highlighted phrases don't link to anything. Maybe they will down the line.

Bottom line: I can't think why this would be useful to anyone who already prescribes medications. And I'm not sure what the long term implications of a system like this are.

If an app rating consists of "A", "AP", and "APP", from worst to best, I rate it a "A".

Behind the Violence

(Note: This post was written a week earlier than published, but did not save properly so I had to rewrite it. Sorry for the delay)

There was an article in the NY Times last week entitled, Adam Lanza's Mental Problems 'Completely Untreated' Before Newtown Shootings, Report Says. It linked to a report released by the Connecticut Office of the Child Advocate (OCA) on November 21st of this year, Shooting at Sandy Hook Elementary School. This is a 114 page report produced by the OCA to, "...focus on Adam Lanza (hereinafter referred to as AL)  and [to] include a review of the circumstances that pre-dated his commission of mass murder...The charge was to develop any recommendations for public health system improvement that emanated from the review. Authors of this report focused on AL's developmental, educational, and mental health profile over time, the services he received from various community providers, and ultimately his condition prior to his actions on December 14, 2012."

It's a pretty extensive review, written by six main reviewers, 8 additional contributors, and with the assistance of the Connecticut State Police, the FBI, and the US Attorney's Office, among others.

Typically, the Times goes for the sensational, "Completely Untreated". To me, that conjures up an image of a child who is visibly deteriorating, and ignored by everyone in his life. And that is so not what happened.

I read the report, and before I describe my impressions, let me convey what prompted me to bother reading the whole thing. As you probably know, on November 18th, two armed Palestinian men entered a synagogue in Jerusalem, and murdered 4 of the men who were praying there. A fifth man, a police officer, later died of his wounds. The two Palestinian men were killed at the scene.

One of the men murdered while praying was a cousin of mine. Not a first cousin, but not a very distant cousin, either. I probably hadn't seen him since I was a child, so I don't mourn for him personally, although my heart goes out to those of his family and friends who do. But the killing does feel personal to me.
This blog is not a forum for discussion of politics in the Middle East, and I will refrain from sharing any of my opinions on that subject. But my professional life involves trying to understand why people feel what they feel, think what they think, and do what they do. Since I never expect to have access to that information about the men who murdered my cousin, I find it helpful to know that many people took the time to try to understand AL and the horror in Newtown, CT.

The authors of the study were very good about emphasizing the fact that no one incident or condition or lapse in treatment has a direct line to the outcome of a mass shooting. They stressed this repeatedly, in boldface. Unsurprisingly, one of their main conclusions was that guns are dangerous.

There is no clear evidence of bullying. The closest anything came to a history of bullying is the comment by someone who knew him and was interviewed that to his knowledge, AL was not bullied, but he wouldn't be surprised to learn that he had been. There are indications that many people, including fellow students, were kind to him.

It was clear from very early on that AL had difficulties with communication. In the early years of elementary school, he received speech and language tutoring to help with articulation. The report noted that this tutoring did not focus on AL's other communication difficulties, i.e. the social ones. So once he mastered the articulation issues, the tutoring stopped.

This type of help is characteristic of one of the difficulties in what happened with AL. He had problems. People in his life knew about these problems and tried to help with them. The school was involved. Bits and pieces of the problems got addressed, with a notable focus on helping AL navigate his academic requirements. No one regularly involved with AL had a grip on, or was able to address the bigger picture.

Overall, AL did okay in elementary school. He was a decent student, if odd. But there was one red flag noted in the report. In 5th grade, AL had a school assignment that involved writing some sort of comic book. He collaborated with a classmate, and they wrote, The Big Book of Granny, about a female caregiver and her grandchild. According to the report, the book was extremely violent, way out of proportion to what would be expected of a 5th grade boy. They didn't include any details.

I think this is a red flag in retrospect. If you're a 5th grade teacher, and one of your students hands in something like The Big Book of Granny, you might be concerned. You might even show it to the school psychologist. Or, you might just say, "Well, that's a bit extreme, but he's not a violent child. He doesn't get into fights. He's not disruptive in class. He's a good student. So what if he has a violent imagination?"

Even if you were quite concerned, what would you do? Insist that he be in therapy because of a homework assignment? And in the absence of other evidence of violence? I can't imagine that every 11 year old boy with violent fantasies goes on to become a mass murderer. And in fact, the boy who co-authored the book now has some serious psychiatric illness, but he's never killed anyone.

Middle school was more difficult for AL, given the changing social environment for early adolescents. He switched to a different school, and later stopped going to school entirely. His anxiety levels had skyrocketed.

At this point, his mother took him to an ER in Danbury, ostensibly to get a note excusing him from attending school due to his anxiety. The hospital suggested further testing and evaluation, but Mrs. Lanza declined, stating the experience was too stressful for AL ("torture" was the word she used), and in any case, he was to begin seeing a community psychiatrist in a couple weeks. The ER wrote a note indicating that AL should stay home from school for 3 days.

AL did begin working with a community psychiatrist, who wrote a note to the school stating that AL could not return to school at that point, and might never be able to return to school.

This is where AL's life really begins to unravel, and we start to see the other characteristic problem in attempts to help him begin to unfold. Mrs. Lanza, who no doubt had her own troubles with anxiety, tried to fit the world to AL, rather than to help AL adjust to the world. She seems to have gotten the community psychiatrist to collude with her. This man is no longer in practice, due to allegations about sexual misconduct with patients, but nowhere in the report is there any indication that AL was one of his victims. However, one wonders about his ability to maintain boundaries with his patients, and their families.
The school classified AL as "homebound" rather than "homeschooled". "Homeschooling" is what it sounds like. But "homebound" means that the student is expected to return to school, and there is a specific plan, with a timeframe, for getting him back to school. This is one of the places the school dropped the ball. Any plan that existed was vague. And as far as I could tell, there was no real discussion of moving AL to a therapeutic school, or any other kind of school setting.

Another point that came up in the report is Mrs. Lanza's ideas about her own health. She believed she had MS and was dying, but there was no evidence to support this conclusion.

During this period, the pediatrician's notes indicate obsessive compulsive behaviors, including hand-washing leading to excoriated skin. There is no documentation of the reasons for the behaviors being explored. He was prescribed an ointment for his skin. Again, a small, easily treatable problem is addressed, and the larger, more difficult problem is ignored.

High School was a little better for AL, at least at first. He managed to return to school, and took some high level classes. He even joined the Tech Club, and functioned well enough in it to host one of their events at his house. But by the end of 10th grade, his mother decided he'd be better off at home. He had increasingly severe OCD symptoms, would not touch anything handed to him directly, but would pull his sleeves over his hands to accept it. He also began influencing his mother in compulsive ways, such as insisting she stand a certain way.

Shortly after he started high school, his father sought an evaluation for him by the Yale Child Study Center, for his OCD and Asperger's symptoms. This evaluation expressed deep concern about the way his mother, in particular, shielded him from anything that might produce anxiety. Previously, when Mr. Lanza sought help for AL's social difficulties, Mrs. Lanza wrote (note? email?) that she had not focused on this aspect of AL's difficulties, and was, "More concerned with keeping [AL] as comfortable as possible and just getting through each day." The evaluation brought up the possibility of a therapeutic school, and made several other suggestions, including continued treatment at the Child Study Center, and intense parental guidance. AL had several sessions, but ultimately, Mrs. Lanza rejected their suggestions, defaulting to the community psychiatrist, who she felt knew him better. She also felt that their recommendations would be too great a strain on AL.

Mr. Lanza has stated that he was a "weekend father", even before he and Mrs. Lanza separated when AL was 9. He was concerned, and tried to get the school on board with the Yale recommendations, but there is no record that the school even had a copy of the evaluation. This is yet another instance of the limitations in the help AL received. His father was aware of difficulties, and tried to help in a constructive way, but was much less involved than his mother, and in any case, Mr. Lanza's attempts to get care coordinated with AL's school were thwarted.

There was a brief trial of medication, during which Mrs. Lanza reported that AL had complained of various side effects. AL or Mrs. Lanza or both decided to stop taking it.

The school misclassified AL's difficulties. He could have been classified as autistic, or having "emotional problems"-both of these classifications would have entitled AL to more extensive services  that addressed his social and emotional difficulties than he received. Instead, he was classified as Other health Impaired (OHI), a category that is intended for students with chronic or acute health problems impacting their education, and received 10 hours per week of tutoring. In general, the documentation by the school is terrible, and communication with other people involved in AL's care was, at best, fragmented. In addition, the community psychiatrist lost his records, but apparently treated AL for two years (based on payment records).

In 11th grade, AL left high school, but took classes at a local state college for high school credit, so he could graduate early, which he did, in 2009. AL's IEP (Individualized Education Program) stated that his "transition skills" were "age appropriate", while also noting his significant mental health disabilities, and without any plan to address these.

AL was severely isolated by this point. Mrs. Lanza attempted to adjust the world to fit him, rather than the other way around. In her defense, she was intensely involved in his care, anxious in her own right, and was attempting to support a son with very complicated problems. Her interchanges with the school indicate that both parties were trying to get AL through school, as he expressed a wish to be in school and treated normally. In the midst of this Herculean task, it must have been difficult to make room for considerations of his social/emotional disabilities. Mr. Lanza deferred educational decisions to Mrs. Lanza.

After high school, AL retreated even further. Towards the end of his life, he rarely left his room. He obsessively played hours of Dance Dance Revolution, becoming emaciated. His adult medical record notes nothing remarkable about his presentation, despite weighing 120 lbs. at 5'10". He refused any contact with his father. His mother appears not to have communicated the level of AL's deterioration to Mr. Lanza. He spent increasing time with an online community obsessed with mass murder.

It remains unclear what made him choose the particular day of his rampage. It was very carefully planned out, so he didn't just "snap". He was not considered psychotic by those who reviewed his records. His mother had recently informed him of her plan to move from Newtown, and had gone away to New Hampshire for several days, 2-3 days before the shooting. Prior to her trip, AL sustained a head injury, described by Mrs. Lanza as "bloody, bloody, bloody."

That's all we know.

This is a lot to take in. I don't feel like it's clear what led to the mass murder. AL's lifelong trajectory was poor, but I don't see anything about it that implies a direct line to the shooting. There could have been other outcomes. Maybe not towards the end of his life, but it seems like the Sandy Hook shooting was already being planned, then.

What can we learn? Maybe that various providers of care need to talk to each other clearly. That access to firearms is dangerous. That it's not only the whole child who needs to be considered, it's the child and his whole family. How fitting that poor communication between care providers took such a toll on a child who suffered from an inability to communicate.

RxNT in More Detail

I just finished my training session to use RxNT's e-prescribing software, so I thought I'd give readers a rundown of what it looks like and how it works.

The home page looks like this:

But you have the option of switching your startup page to Patient History, Scheduler, or Prescription Watch. Since I'm not using the EHR or scheduling software, I chose the Prescription Watch, which looks like this:

The Prescription Watch also has a patient search box (not shown) in the upper right hand corner.

When you enter a new patient, the only required information is name, DOB, address, and gender. But it offers all kinds of demographic options, which are helpful if you're using the program for charting. There's also the option to import all your patient information if you already have it in some suitable electronic form. And if you have multiple sources for a single patient, you can merge them.

I successfully sent off my first prescription with almost no difficulty. Almost, because it got stuck when I didn't enter the type of thing I was prescribing, namely, a tablet. I didn't notice that I was supposed to enter this, at first, and I wouldn't have thought it was necessary because the medication was listed as lexapro 10mg tablet, but apparently it needed that. Beyond that mild glitch, it was easy.

The trainer was pleasant and helpful and knowledgable, but it's really quite an intuitive system.

The other problem I was warned about, but didn't end up being a problem because I was warned about it, was that the various pharmacies that populate the list when you're looking for your patient's pharmacy each have a little check box to the left. It looks like, if you want to send the prescription, you just click on the box and it goes off to that pharmacy. But the box is just to add that pharmacy to your favorites. You need to click on the pharmacy's name to choose it and have the rx sent to it.

According to the trainer, you have to enter all the drugs you want on your "favorites" list individually, and there's no option to prescribe a drug and then click "add to favorites". The latter seems to be true, i.e. no click option, but I tried writing a new rx for a different patient (my dog), and instead of entering a medication, I clicked on "favorites", which should have been empty, but the search turned up lexapro, so I think the drug is added to favorites automatically. Same deal for the pharmacy-it was already entered as one of my favorites, with the option to remove it. I think, in general, there's a fair amount of redundancy in the system, which I consider a good thing.

Here's how lexapro comes up:

the little "?" on the left means the formulary status is unknown. There's a legend for the symbols:

The bottom of that same screen has several sections. The drug info:

Clicking on the blue highlighted phrase brings you to a screen with all drugs in that class.

Sig builder lets you create any administration method you like. Reference gives you a patient education monograph, patient counseling messages, and warnings, all of which can be printed out for the patient. Interactions gives you the obvious, but you set your level of interaction tolerance to mild, moderate or severe, depending on how many messages you can stand. It includes drug-drug warnings based on the patient's other meds, food interactions, and age- and diagnosis-based warnings. If you want to override an interaction, you don't need to justify it with a reason, like some other systems require. It just checks a second time to make sure you want to prescribe it, and then lets you do so.

The drug info also gives you recommended sigs:

And the option to create a new sig.

At the lower right, there's a list of alternatives-the same as the drug class list, I believe, with formulary information, I suppose based on whatever you've entered about the patient's insurance.

When I clicked on one of these drugs, it highlighted the drug, but didn't substitute it for lexapro, so I guess that has to be entered separately.

Oh, and there's an "add drug" button, if you want to send more than one prescription without starting from scratch.

I really like the delayed Rx feature:

You can do a one time rx, but schedule it for some time in the future. And then you can specify whether you want it placed in your "pending" queue that day so you can check it before sending it off-necessary with controlled substances, or you can just approve and transmit it without ever looking at it. Whoosh! And you can do the same with repeated prescriptions.

This feature is incredibly convenient. It also makes it easy not to see your patients very often, if that's how you want to manage your practice.

Some drawbacks to the system:

-If you send in a prescription, and then realize it was the wrong one, and you delete it, you need to call the pharmacy to tell them, because it doesn't automatically get deleted from their system, only yours.

-You can use the claims history to find other meds the patient is taking, with the patient's permission:

And you can add those meds to the patient's active list. You can also manually enter other meds you know the patient is taking. But if you delete a medication you didn't prescribe, it's completely lost to the system, unlike ones you did prescribe, which are retained in a list of deleted meds, and can be re-prescribed without having to enter the whole thing from the beginning. So if the patient is taking, say, prilosec, and has some adverse reaction to it, you can delete it from the system so you know the patient isn't taking it anymore, but the only way to record the fact that the patient took prilosec and can't tolerate it is if you write a little note to yourself. And there's a "notes"section that's independent of the chart notes, which you may or may not choose to use.

-There doesn't seem to be a screen that simply lists your patients, but I may just need to play around with it longer to find that, or it may be there only if you're using the EHR system.

-There's a "status" column in the list of recent rx's. If an entry is highlighted in green, that means the rx went through. Yellow means it's pending, and the system will keep trying as long as it's yellow, and red if it didn't go through. But there's no flashing light or message to let you know that a rx didn't go through, so if you take care of your prescribing first thing in the morning, you might not find out that a prescription didn't go through until the next day. You also can't sort the list of recently prescribed meds by field, it's just chronological. So you can't request that all the red statuses get lumped together where you can see them easily.

-I'm a little confused about the sig builder. I tried to create a new sig, which was lexapro 10mg 1 po 5 times per day. And it let me do that without any comment about maximum dosage. Since I just entered the sig, but didn't try to prescribe it, I'm not sure if it would have questioned me if I did try to prescribe it.

-This one is on the state of NY, not on RxNT, but when you prescribe a controlled substance, which I haven't done yet, you go through a screen that asks for your hard or soft token, so that's already a pain. But then, in addition, you have to complete the whole I-STOP business, which seems like big time overkill. I think the company is trying to hammer out this issue with the state, but I'm not holding my breath.

I haven't yet attempted to go through the identity proofing/two factor authentication process, so I'll post again to let you know how it goes.

Chocolate, Again

About 2 months ago, I posted about my chocolate addiction, and the potential mental health benefits of chocolate.

It seems I was more right than I knew.

In a recent study, Enhancing dentate gyrus function with dietary flavanols improves cognition in older adults, published in Nature Neuroscience,

A team led by researchers at Columbia University Medical Center randomly assigned 37 healthy volunteers aged 50 to 69 to receive either a high-flavanol (900 mg) or a low-flavanol (10 mg) cocoa drink, developed by candymaker Mars Inc., once a day for three months...
After three months, the researchers found noticeable improvements in both the health of the dentate gyrus and cognitive test performance among those who consumed the high-flavanol drink.... “If a participant had the memory of a typical 60-year-old at the beginning of the study, after three months that person on average had the memory of a typical 30- or 40-year-old.” (From Psychiatric News Alerts)

Unfortunately, 900mg of flavanol is more chocolate than most people can consume in a day (MOST people, not me), so it's unrealistic to expect chocolate to improve your memory. But it made me wonder if candy makers like Mars are planning to branch out into chocolate as health food.

Mars manufactures all of these chocolate products:

I checked out the Mars website, and sure enough, they have a department called, "Symbioscience", "a technology-based health and life sciences business focused on evidence-based product development."

One of their products is CocoaVia:

CocoaVia® is daily cocoa extract supplement that helps support healthy circulation, which contributes to healthy aging by promoting cardiovascular health. †CocoaVia® supplement is made with our patented Cocoapro™ cocoa extract and delivers 250mg of cocoa flavanols per serving – guaranteeing the highest concentration of cocoa flavanols in a dietary supplement. The cocoa flavanols in CocoaVia® are scientifically proven to help support healthy circulation, important for cardiovascular health, cognitive health, exercise performance, blood flow, heart health, and skin health. 

†This statement has not been evaluated by the Food and Drug Administration.
This product is not intended to diagnose, treat, cure or prevent any disease.

Here's a link to their research publications, so you can check out their "scientifically proven-ness". I don't know what to make of any of it. It's industry-does that make it bad science? Maybe I should suggest they look into marketing the cannabinoid components of chocolate. No matter what, though, it's gluten free.

The Evil Emperor MOC-Or My Review of a Review Course

I seem to have strayed from my Lord of the Rings metaphor for my Board Recertification journey. But I signed up for the Beat the Boards online course, and I decided to do something I've never done before-use flashcards. I'm not sure why I made that decision, but maybe it was because I wanted to try out flashcard apps.

But before I move on, here's a picture of Charles Middleton as the Evil Emperor Ming the Merciless from the Flash Gordon (hence the "flash" cards) series of 1936.

I used to love that show, even though the special effects were laughable-you could see the strings holding up the spaceships.

And here's Max von Sydow as the Evil Emperor Ming in the 1980 Flash Gordon Movie:

And finally, here's the incomparable Ben Kingsley playing the evil Nizam in 2010's Prince of Persia movie, which, as far as I know, has nothing to do with Flash Gordon or MOC:

Turns out, there's a reason I've never used flashcards. I guess I've never understood why I should bother to write bits and pieces of information down on some index cards when someone else has gone to the trouble of writing down the same information in whatever text or source I'm trying to copy it from. Cut out the middleman, I say! I thought I might be inspired to try it this once using smartphone apps, just for the tech-y coolness appeal. But it's at least as much trouble to type things out on my phone as it is to write them on an index card. Well, so much for Flash Gordon.

However, I HAVE been attempting to study for boards. I have a three-pronged approach.

1. Meet every two weeks with the same friend who I studied for Step 3 and the first round of boards with, to go over questions.

2. Watch the Beat the Boards videos and follow along with the written materials on a regular basis. Once in a while when I feel like it seems pretty regular, right?

3. Review the Med-Quick guide from Beat the Boards.

Here's how Beat the Boards is measuring up.

1. The question bank is probably the best learning source, assuming, as they claim, that it accurately reflects the content of the boards. There are supposed to be "100's" of questions, but there have been some repeats, so far. There's a flashcard mode and a test mode. I've only done the flashcard mode, which tells you if you're correct, gives an explanation, and allows you to save the question for later review. I believe the test mode is supposed to simulate testing conditions, and is also the part that gives you CME credit.
    I find I don't agree with some of the answers, so again, I'm taking it on faith that these are the answers the ABPN wants. There are also some questions that don't seem to belong there, like the one about the most effective form of contraception. I would feel remiss if I didn't encourage my patient to have that discussion with her gynecologist.

2. The videos are of varying quality. The ones given by Jack Krasuski, who runs the company, are decent. He doesn't simply repeat what's in the written material, and he has a good way of organizing what he's trying to convey. He does have, well, it's not quite risus sardonicus, but an unnervingly permanent smile glued to his face, that's a little off-putting. Besides his videos, I've only watched those by one other guy, and he is soporific. It's that poor use of power point, where if you're just going to repeat the written material I have in my hand, why should I bother listening to you babble on.
   The presentations are done in such a way that they start off with a multiple choice question, and use that as a jumping off point for the discussion. There's nothing earth-shattering about this approach, but it isn't bad, either.

3. The Med-Quick guide is a pdf in 4 parts. Part 1 is a list of FDA-approved medications 2009-2013. Part 2 is a list of psychiatric disorders with their respective FDA-approved meds. Part 3 is a review of individual medications. And part 4 includes additional board-pertinent information, like drugs to use during pregnancy.
   I sort of remember the site offering the Med-Quick guide for free, when I was first checking it out , but when I tried to access it, the link didn't work. I can understand why. I think if I can memorize this guide, I'm pretty much set. the non-med questions in the question bank are easy and intuitive, except for the statistical ones (what percentage of pedophiles self-identify as heterosexual? 20-40%, 40-60%, 60-80%, 80-100%?) I tend to err on the side of moderation if I don't know the specific number, but that's clearly the wrong approach. But there aren't that many of those, so if I have the meds down, I think I'll pass.

(It just occurred to me that, having documented this process publicly, it'll be really embarrassing if I fail).

Overall, on a scale of 1 to 10, I give Beat the Boards an average thumbs up. Since it's effectively the only game in town, though, I can't complain.

Electronic Prescribing of Controlled Substances

Calling all New York State prescribers!

On March 27, 2015, all NY State doctors and other prescribers will be required to use electronic prescriptions, rather than paper, except under very extenuating circumstances, like a power outage. This includes controlled substances.

You may recall, I signed up for Practice Fusion EMR a while back, solely so I could use their free electronic prescribing. I did this, largely, because I didn't want a last minute scramble to set up e-prescribing. Unfortunately, they're only just now gearing up to set up prescribing of controlled substances. That's supposed to happen for them in January, and it'll still be free, but I'm a little nervous about waiting til that close to the deadline.

This is what you have to do to set up Electronic Prescribing of Controlled Substances (EPCS):

First, the software you currently use must meet all the federal security requirements for EPCS, which can be found on the Drug Enforcement Agency’s (DEA) web page.

     Note that federal security requirements include a third party audit or DEA certification of the software.

Second, you must complete the identity proofing process as defined in the federal
requirements.

Third, you must obtain a two-factor authentication as defined in the federal requirements.

Fourth, you must register your DEA certified EPCS software with the Bureau of Narcotic Enforcement (BNE) (Form)


So what is this two-factor authentication?

Individual practitioners will be required to apply to certain Federally approved credential service providers (CSPs) or certification authorities (CAs) to obtain their two-factor authentication credential or digital certificate. The CSP or CA will be required to conduct identity proofing that meets National Institute of Standards and Technology Special Publication 800-63-1 Assurance Level 3. Both in person and remote identity proofing will be acceptable.

 You need 2 out of 3 factors:

Under the interim final rule, DEA is allowing the use of two of the following – something you know (a knowledge factor), something you have (a hard token stored separately from the computer being accessed), and something you are (biometric information). The hard token, if used, must be a cryptographic device or a one-time password device that meets Federal Information Processing Standard 140-2 Security Level 1.

Hard Token?

A hard token is a cryptographic key stored on a hardware device (e.g., a PDA, cell phone, smart card, USB drive, one-time password device) rather than on a general purpose computer. A hard token is a tangible, physical object possessed by an individual practitioner.

I wasn't sure what a biometric was, but according to Wikipedia, it's something like a fingerprint, face recognition, retina scan, or voice recognition. Personally, I'd prefer fingerprint to retina scan, because I'd rather that someone desperate to use my prescribing privileges cut off my finger, rather than cutting out my eye. I've seen that in movies, so I know it can happen.

I've found some companies that do EPCS, and their fees and services vary. The NY State Psychiatric Association had a fair with these vendors this past weekend, but I didn't go, so I checked out their respective websites:


RxNT has an option for e-prescribing only, without an associated EMR. That appeals to me. They charge $650 per year plus $50 one time token fee, plus $25 annual maintenance after the first year. A colleague spoke with them, and they are willing to do group rates, if you have a bunch of people.

They have a video you can watch, but it's not very informative. You can, however, arrange a live demo, or schedule a live webinar, to learn more.

There's also DrFirst. They don't specify price, but will also arrange a demo.

Stratus EMR is  mainly designed for addiction psychiatry.

And ScriptRx, which claims to improve patient outcomes while conserving 24,000 trees each year. They also offer a demo. To their credit, they had the most aesthetically appealing site.

Allscripts was not included in the vendor fair, but they charge $20 per month for their basic E-Rx plan, and and additional $5 per month for the Deluxe plan, without which you can't prescribe controlled substances. I have a feeling there are more hidden charges, but it was hard to tell from the site.

This has been a public service announcement.

My Bad

I messed up in my past post, Let's Talk about the ACA. I cut and pasted pieces of various drafts, and the part about CoMeBeh, The University of Iowa's program that provides primary care to patients who are already in psychiatric care, makes no sense. The Practical Psychosomaticist called me on it, and rightfully so.

Let me state that my intention in including CoMeBeh in the article, to begin with, was to introduce it to people who might not know about it, as a more sensible approach to integrated care than the Katon model, which refers primary care patients to very limited psychiatric care. At least, I think it's more sensible. I've certainly treated patients who would have benefited immensely from such a program, and it's unfortunate that they didn't have access to it.

The following is closer to what I was trying to get at, and I will change the Let's Talk about the ACA post to include it:

Other models of integrated care exist, such as the Collaborative Medicine and Behavioral Health (CoMeBeh) project at the University of Iowa, in which primary care is provided by physicians rotating through the psychiatry clinic, rather than the other way around. This excellent model is, unfortunately, limited by the fact that it targets a smaller population than the Katon model—those patients already in psychiatric care. 

Let's Talk about the ACA

I got a lot of responses to my recent post, Reinvention. I have to say, I was really touched by the concern people expressed, and I appreciate the suggestions for augmenting my soon-to-be-depleted income. I want to assure everyone that I am not on the verge of starvation.

One of the commenters focused on the Affordable Care Act (ACA), or Obamacare, and remarked, correctly, that not all the problems with healthcare can be blamed on the ACA. There was also a question of whether or not any of the NY exchanges covers out of network providers, because apparently, there's at least one that does in Massachusetts. Well, I checked, and there is no out of network coverage in the NY Exchange, except for immediate, emergent care.

Back in January, The Carlat Report published an article entitled, An Ethical Perspective on the Affordable Care Act, which I wrote. The contract I signed with them indicates that once 6 months has passed since the publication, I'm allowed to publish or use it myself, and since it's been that long, I thought I'd includea version of it here:

An Ethical Perspective on the Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA), commonly referred to as the “ACA” or “Obamacare”, was signed into law on March 23, 2010. It’s mission: to secure health care for all US citizens, irrespective of age, gender, race, medical history, or socioeconomic status. This article will present a brief review of the ACA, and then discuss its ethical considerations, especially as they pertain to psychiatry.

First, An Ethics Refresher:

There are generally considered to be four principles of medical ethics:
Autonomy, which implies respect for a patient’s ability to make decisions for himself or herself; Justice, which allows for equal treatment of all, including fair allocation of scarce resources; Beneficence, or acting for the good of the patient; and Non-Maleficence which is the principle of primum non nocere, first, do no harm.

Ideally, any interaction with or treatment of a patient obeys all four principles, but in reality this is often not possible. For instance, the tension between autonomy and beneficence comes into question when determining patient capacity.

Provisions of the ACA are set to take effect by 2020, and generally fall into two categories: increasing access to healthcare (by mandating insurance coverage), and improving the quality and efficiency of health care delivery. Table 1 lists all the provisions scheduled through 2015, divided roughly into these two categories.

Table 1

For the most part, potential ethical dilemmas for psychiatrists will occur in the quality and efficiency improvement category. Particular areas of concern are new innovations to improve quality and bring down costs, integrated health systems, linking payments to quality outcomes, payment bundling, and paying physicians based on value rather than outcome.

The Collaborative Care Model:

The Collaborative Care Model, developed by Wayne Katon, M.D., and Jürgen Unützer, M.D., at The University of Washington, is a type of integrated health system. Its implementation highlights many of the ethical pitfalls of the ACA, particularly as they pertain to psychiatrists.  In this model, primary care clinic patients are screened for psychiatric illness using simple rating scales. If the screen is positive, they are referred to a care manager, usually a MSW or other behavioral health provider, who oversees their psychiatric care. The care manager is, in turn, supervised by a psychiatrist, who reviews cases at regular intervals, but does not see the patients, except under unusual circumstances. Patient progress is measured by rating scales, until clinical goals are achieved. And providers are reimbursed based on clinical outcomes. (Link)

There have been some reports of success with this model. A study by Katon, et. al examined 214 participants with poorly controlled diabetes, coronary heart disease, or both and coexisting depression, randomized to usual care or collaborative care management by a medically supervised nurse. The intervention combined support for self-care using motivational and encouraging coaching, with pharmacotherapy, either citalopram or buproprion. At 12 months, patients in the intervention group had significantly greater overall improvement compared to controls. There was a significant difference in scores on the SCL-20 depression scale alone, but non-significant differences in the other individual outcome measures (HgbA1C, LDL, systolic BP).

The collaborative care model raises numerous ethical questions. It provides access to psychiatric care to many more patients than could be seen individually by psychiatrists, particularly in remote rural areas, thus allowing for the just distribution of scarce resources. At the same time, beneficence, and even non-maleficence, need to be considered, because care is being provided by people with limited training-in the Katon study, nurses attended a 2 day training course on depression management and behavioral strategies. And in a 2006 meta-analysis of collaborative care for depression, Gilbody, et. al found that, “...effect size was directly related to ...the professional background and method of supervision of case managers.”

In addition, types of treatment may be limited to medication, and follow-up to screening questionnaires, often conducted via telephone. 

What are the ethical implications of overseeing care for many patients who will never be interviewed in person? As a psychiatrist, would you be comfortable signing off on such care?

There is the question of putting an additional burden on primary care providers.

And there is the broader question of wasting resources by not utilizing the psychiatrist’s hard-earned skills. Which psychiatrists will find this work appealing, and will the model influence which medical students chose to pursue careers in psychiatry?

Other models of integrated care exist, such as the Collaborative Medicine and Behavioral Health (CoMeBeh) project at the University of Iowa, in which primary care is provided by physicians rotating through the psychiatry clinic, rather than the other way around. This excellent model is, unfortunately, limited by the fact that it targets a smaller population than the Katon model—those patients already in psychiatric care.

Value vs. Volume:

There are several innovations of the ACA which are intended to encourage not only better quality care, but better quality care at equal or lesser cost. In other words, greater value. 

The motivation for this idea seems clear. It acknowledges that a high volume of patients does not allow for much individual time or attention, so it attempts to incentivize physicians to provide better quality care for each patient.

Given that a goal of the ACA is to ensure coverage for all, it is paradoxical to expect doctors to spend more time with and provide better care for each patient, and to simultaneously reduce cost, when there are more patients to be cared for. But even assuming it is possible to get more for less, how does one go about implementing these innovations? How is value measured? And what ethical quagmires does one encounter in the process? 

PQRS:

The Physician Quality Reporting System (PQRS) was designed by the Centers for Medicare and Medicaid Services (CMS) as a way to improve the quality of care of Medicare beneficiaries by tracking practice patterns and providing incentive payments. It was implemented on a voluntary basis in 2007, for Medicare Part B Fee For Service (FFS) beneficiaries. But beginning in 2015, there will be payment adjustments for Medicare providers who do not satisfactorily report data. 

The PQRS is ponderous. Providers can report via one of five methods, some of which require a vendor. Beginning in 2014, providers are required to report at least 9 measures within at least 3 domains (e.g. Patient Safety, Person and Caregiver-Centered Experience and Outcomes, Communication and Care Coordination, Effective Clinical Care, Community/Population Health, Efficiency and Cost Reduction), at a certain frequency. 

One example of a measure pertinent to psychiatry is PQRS #9, Anti-depressant Medication Management: 

Percentage of patients 18 years of age and older who were diagnosed with major depression, and who remained on antidepressant medication treatment. Two rates are reported

Effective Acute Phase Treatment: Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) 

Effective Continuation Phase Treatment: Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) 

Clearly, this "measure of quality" has nothing to do with how well the patient is doing, and everything to do with coming up with something that can be easily measured-how long the patient has been taking medication. What if the patient is responding poorly, or taking an ineffective dose, or should be tapered off meds? Is that an example of "ineffective treatment"?

Value Based Purchasing

Similarly, “value-based purchasing holds providers of health care accountable for both cost and quality of care... [It involves]: measuring and reporting comparative performance; paying providers differentially based on performance; and designing health benefit strategies and incentives to encourage individuals to select high value services and providers and better manage their own health and health care.”

But how is performance determined, and will the patient's role be considered in this determination? Patients sometimes make poor choices. Should the physician’s income be adversely affected by those choices? Will doctors “cherry-pick” patients they think will be “good”? And is the patient’s autonomy diminished if the doctor is held responsible for his or her decisions?

ACO’s: 

Accountable Care Organizations (ACO’s) are groups of doctors, hospitals, and other providers who have agreed to work together to improve care and reduce costs. ACO’s that successfully demonstrate quality care and reduced costs “share in the savings” they create for Medicare. In addition, selected ACO’s can participate in the advance payment model , which provides upfront and monthly payments that can be invested in the ACO infrastructure. 

Ethical considerations for all the value measurement provisions include who is being served by these measures of value, and whether they truly measure value, or simply take up time and energy better spent with patients.

Payment Bundling: 

The Bundled Payments for Care Initiative involves paying a lump sum, rather than individually, for an “episode of care”. For example, if a patient is admitted for a course of ECT, rather than separately reimbursing the hospital, anesthesiologist, and psychiatrist who performs the ECT, all three will be reimbursed in one lump sum, presumably to be divided in a mutually agreed upon way. The intention seems to be to encourage collaboration between providers, and limiting of costs and overhead. But the effect may be limiting who is willing to participate, and "turfing" of work.

Coverage vs. Care:

Leaving aside questions about quality and efficiency, the ACA’s goal of health coverage for all presents its own ethical dilemma.  An expectation of medical care goes along with insurance coverage, but there is a discrepancy between the number of patients seeking treatment that will be paid for by their insurance, and the number of practitioners who will accept their insurance. In this respect, psychiatrists in private practice are in an unusual position. A study by Bishop et. al, published in JAMA Psychiatry Online on December 11, 2013, notes that psychiatrists are significantly less likely than physicians in other specialties to accept private noncapitated insurance (55.3% v. 88.7%, respectively, p<.001), Medicare (54.8% v. 86.1%, p<.001), and Medicaid (43.1% v. 73.0%, p<.001). 

The reasons for the discrepancy are unclear. One possibility suggested by the article is that while reimbursement rates for office-based psychiatric treatment are similar to those for office-based medical evaluation/management, psychiatrists don’t see as many patients per day as physicians from other specialties, resulting in less income for those who accept insurance. 

Another possibility is the fact that there are more psychiatrists than doctors from other specialties in solo practice (60.1% v. 33.1%), and solo practices require less infrastructure than larger practices, so there is less motivation to hire staff to interact with insurance companies, which is necessary to dispute claims and ensure reimbursement.

The article also cites a 14% decline in the number of graduates of psychiatry training programs between 2000 and 2008, and an aging workforce, as reasons the demand for psychiatrists exceeds the supply, and allows psychiatrists to not accept insurance. 

This is an ethical conundrum. Do we, as physicians, have a moral obligation to accept insurance, even if we lose income as a result? Or to provide care for patients who are unable to pay our full fees? Should we donate some percentage of our services, free of charge, to those who could not otherwise afford care? Or is it more ethical to treat patients who are free of the session limits and formulary restrictions that come with insurance coverage, even at greater financial cost to the patient? 

In regard to the doctor’s need to make a living, Freud writes, “It seems to me more respectable and ethically less objectionable to acknowledge one's actual claims and needs rather than...to act the part of the disinterested philanthropist—a position which one is not, in fact, able to fill, with the result that one is secretly aggrieved, or complains aloud, at the lack of consideration and the desire for exploitation evinced by ones patients.” (On Beginning the Treatment (Further Recommendations on the Technique of Psycho-Analysis I). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, Pp. 131-132

The ACA has taken on the challenge of guaranteeing affordable and quality health care for all Americans. This is a noble undertaking, with vast challenges, and unpredictable ramifications, including ethical dilemmas for doctors. What are the moral implications of refusing to accept insurance? Does that harm or help our patients? Is it possible to provide better care at lesser expense, and will we or our patients suffer as a consequence? How do we know what constitutes better care, and are measures of care helpful, or simply time-consuming? Is it more ethical to provide full care for the few, or limited care for the many? Perhaps we can view these dilemmas as opportunities to re-examine our values, and the reasons we chose to become doctors in the first place.

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.

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.

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.