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.

Friday, April 29, 2016

Building a Website-The Pricing

First, I want to thank people who read my first website post and made suggestions about using Blogger, Wordpress, and Google for my website.  I'll incorporate those into my research.

I'm continuing to figure out which company I'm going to use to build my practice website. As part of my research, I found a wonderfully helpful site called, The Site Wizard, that contains all kinds of information like the definition of a domain name, and html tutorials. The author does not allow his material to be reproduced all or in part, so I'll just have to paraphrase, and you have the link.

The question of pricing is more complicated than I expected, because different website builders or platforms have different features, with different charges. So I've tried to narrow things down to basic costs-the site itself, and the domain name.

But let's discuss basics.

What is a Web Host?
A Web Host is a home for your website. The companies I've been looking at, Weebly, Duda, Squarespace, and Web.com, are all web hosts. They have lots of computers, or access to cloud space, where your website will live. Duda, for example, claims to offer hosting on Amazon Cloud.

What is a Domain Name?
If I want my own site, that I name myself, that doesn't belong to some larger thing like this blog does to blogger, I need a domain name, which is like a business name. As long as I register it and pay the annual fee, it's mine whether or not I choose to have a website associated with it. That makes me the owner of the domain name, and allows me to take it with me if I switch web hosts.

You register your domain name, for an annual fee, with an organization called, ICANN, which has a list of domain name registrar companies that you need to register through. GoDaddy, the website builder I rejected in my last post, is also a domain name registrar, so I may need to reconsider using it. Google is also a registrar.

Some web hosts provide a domain name free for the first year, and then charge the annual fee. Many let you import a domain name you already own for less money than they would charge for getting you the domain name. And reputedly, some dubious web hosts will register your domain under their name, making them the owner. But apparently, those companies are largely gone.

Domains also come in different suffixes, like .com, .org, .company, .biz, .education, and respective costs depend on something called, "TLD", or Top Level Demand.

So let's look at the cost of a website at the various companies, including a domain name, and let's assume I want to call my website, "MyPsychiatry.com," provided that name is available.

Let's also assume I'm not going to use the free sites available via the web hosts I'm considering. They exist, but they have ads, and I can't use my own domain name.

And finally, I'm just considering price in this post. I'm ignoring various features, for now, because it just gets too complicated to look at all at once.

Google would charge me $12/year for that name. Google would also need me to use blogger or squarespace or something as my web host, so that would be additional.

Squarespace charges $20/year for the domain name, including the first year, but that $20 fee doesn't increase in subsequent years, something I haven't seen clearly indicated on other sites. It also includes something called, "WHOIS Privacy" which I don't really understand but seems to protect some information about you, as the domain name owner.

Then there's the website fee. The personal site costs $16/month or $12/month billed annually, and if you get the annual plan, they waive the first year's domain fee. The Business site's corresponding prices are $26 and $18 per month.


This is Wordpress' price chart for website plans. It doesn't say anything about an annual fee for a domain name.

Duda does not sell custom domain names. The'll set up a subdomain on their free plan, which would be mypsychiatry.dudaone.com. But if I want a custom domain name, I have to go elsewhere. They have lists of compatible registrars, including Hover and GoDaddy, but they have a partnership with Hover which allows you to purchase a domain name from Hover while you're setting up your Duda site. Hover's .com pricing is $12.99 the first year, then $14.99 for annual renewals.

This is Duda's pricing:

Duda does have that excellent one-time payment of $299 site for life deal. I checked, and you can switch from a monthly or annual plan to a site for life plan, but they do say they may not have that deal forever.

Blogger is probably the best deal, financially. The web hosting is free, and you can get a custom domain name through them for $10/year. Blogger allows up to 20 standalone pages, so I could include things like the Surprise Act form and my office policies. The main problem with blogger is that sites tend to look like blogs, not websites. Some people have done amazing things with customization, check out this article  and this one to see some impressive sites. But these were customized with html code, so if I knew html, this would be great, but since I don't I'd probably consult someone professional to help me at least get started, adding to the cost.

Weebly has a pretty good deal:

The domain is free for the first year, and $19.95 each additional year, with discounts for extended terms.

I really find GoDaddy unnerving. They have a domain name auction site, where you can purchase a domain name that someone else swept up. For example, mypsychiatry.com isn't available. But mypsychiatrist.com is available for $14.99/year, plus an initial $5700.00 purchase fee. I used the 2 decimal places so you wouldn't think it was $57. On the other hand, mypsychiatry.net and .org are each $11.99/year. As I mentioned in my last post, they also have web hosting, but I find interacting with their site very unpleasant.

Finally, I couldn't find domain name prices on Web.com. Mypsychiatry.xyz was available, as well as .net, but all the "pricing" said was, "Add to cart." So I added .xyz to the cart so I could see the price, and pressed "continue". It was $1.95/month (not year), with a "*" I couldn't find the text to, and an option to keep my information private or not. Then it asked for my information before giving me a real price, and that's where I stopped.

And now for the spreadsheet:

From a strictly monetary perspective, Blogger is the best deal. I'm now quite sure I'm not interested in GoDaddy and Web.com, so I'm ruling those out. Everything else is somewhere in between, and will depend on specific features.

I'm also wondering if the most useful thing I learned in researching this topic is that I should buy up a bunch of domain names and charge exorbitantly for people to purchase them from me.

Tuesday, April 26, 2016

Building A Website-The Template

I've been blogging for a little over three years now, which is hard to believe. I feel like I'm about average on the tech-y scale, and I certainly feel like a web presence is an important thing for any business to have. But I'm just starting to consider setting up a website for my private practice.

The main reason I've delayed this long is that since I don't use email to communicate with patients due to privacy/confidentiality and delay-in-treatment concerns, there didn't seem to be a point to a website where the contact information consists of a phone number.

Also, I knew I'd want an attractive, professional-looking site, but I didn't want to pay a lot of money to a designer for a site, the function of which is to get people to call me. There are some nice mixes of low and high tech, like a wooden iPhone case, or 3D printing a yarn winder, but a website with a phone number didn't seem to qualify as such a mix.

I finally decided to cave when I was researching my Analytic Evidence post, and I checked out the website of John Thor Cornelius, whose YouTube presentation I referenced in the post. I'm not sure how he'd feel about my linking to his site, which is why I haven't done so.

It's a thoughtful site, not glitzy, not overwhelming, but with all the information prospective and current patients might need about his practice, in addition to the ability to pay bills via PayPal, and I thought, yeah, this can be done well.

There are companies out there that design websites just for doctors, but they're expensive, and I don't need or want all the EMR integration stuff. So I've pretty much decided that, at least initially, I'll design my own site, for free, or for as little money as possible, and then see how it goes.

A few things I need to figure out before creating my site:

I need to decide what information to include on it. I'll need a decent headshot, contact info with a map feature, and a brief paragraph describing myself and my practice philosophy, which means I need to figure out what my practice philosophy is. I'm pretty sure I have one, I've just never articulated it. And I need to articulate it in a way that feels confident and inviting, but not exhibitionistic.

I need to decide how much information to provide about myself. Is a CV a good idea? Will that much information interfere with therapy?

I need some kind of description of what patients can expect from treatment.

I need to include my practice policies, which I already have written up. And I want to include the Surprise Act forms indicating that I don't accept insurance, and what my fees are, because that way I don't need to hand the stupid forms to my patients.

And I'd like patients to be able to pay through the site, but I need to understand how that impacts privacy.

I also need to pick a free or cheap website builder. I did several online searches including "build your own website free", "website builder for physicians,", and "best website builder for doctors". After googling around, I found a few I want to look into:


Web.com seems to have the highest rating when I looked up reviews, but my first concern was the template. Specifically, I wanted to find a template that looks like it's professional for a doctor, not professional for a lawyer, or a restaurant, or a dog-walker. My theory is that if such a template exists, then the company has probably had a number of doctors design sites through it, which feels like a "safer" bet to me. I don't want my site to look amateurish, but I also don't want it to look like I'm a graphic designer or the APA.

Note that contrary to my inclination, I'm not including images because I assume these sites are pretty proprietary with their stuff. Or maybe I'm wrong and they want the advertising.

Sitebuilder has a template category specifically for professional services, and it includes a physician page which is a little slick for my taste, but usable. What I didn't like about it was that it was the only site for which I had to register before I was allowed to see the available templates.

Weebly's closest business theme was for a law firm, and the next closest theme was a personal one that was basically a large business card.

Similarly, Wix's closest templates were Dentist and Doula.

Squarespace had nothing specifically medical, but I thought it had the most aesthetically pleasing themes.

GoDaddy has what I think of as a "jittery" site, where there's too much information thrown at you at once, and you just want to close the page. I don't think that bodes well for my own site. I did briefly look at their templates though, and I didn't much care for them.

The same was true for web.com-too busy, with only a small sampling of templates, all fairly ugly.

My favorite was Duda, which allowed access to templates, and had a specific medical template that looks about right to me. Also, their templates are responsive, which means they adjust themselves to whatever device the user is on, and can be customized for specific devices, i.e. you can make your smartphone page a bit different from your laptop page.

Well, okay, just this one image, since I'm saying it's my favorite:

Here's a spreadsheet summary of the templates:

Based on this information, I'm going to rule out GoDaddy, Sitebuilder, and Wix. I'm not crazy about Web.com but I'm going to keep it in the running because it gets consistently high ratings, so maybe there's more to it than I've seen thus far.

Friday, April 15, 2016


Good news for doctors in Oklahoma, also known as the "Sooner State", "...in reference to the non-Native settlers who staked their claims on the choicest pieces of land prior to the official opening date."

I learned from an email from the National Board of Physicians and Surgeons (NBPAS, See, "Another Board", and "Summing Up 2015"), that in response to pressure from physician groups like NBPAS, the Oklahoma state legislature has passed a bill stating that Maintenance of Certification (MOC) cannot be required as a condition of licensure, reimbursement, employment or admitting privileges. The bill was approved by the governor on April 11, 2016.

The link to the bill is here. You need to click on "SB1148" in the upper left-hand corner to view the actual bill. The relevant language is the following, with an otherwise identical clause included further on for osteopathic doctors:

G.  Nothing in the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act shall be construed as to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment or admitting privileges at a hospital in this state.  For the purposes of this subsection, "Maintenance of Certification (MOC)" shall mean a continuing education program measuring core competencies in the practice of medicine and surgery and approved by a nationally-recognized accrediting organization.

Go, Oklahoma! And because I'm a little giddy about this small but important victory, I'm including this Sesame Street clip:

Wednesday, April 13, 2016

Investing in Mental Health

According to the NY Times, which does not lie, while mental health care is scarce in parts of the US, it's virtually non-existent in most of the world, with one mental health professional per 1 million people in developing countries.

This is the push behind the World Health Organization's (WHO's) goal to, "...move mental health to the forefront of the international development agenda," and the focus of a conference in Washington this week.

In support of this goal is a paper published yesterday in the Lancet Psychiatry, Scaling-up treatment of depression and anxiety: a global return on investment analysis, by Chisholm, et al. The study was funded by Grand Challenges Canada, which supports, "Bold Ideas with Big Impact in global health," and is, itself, funded by the Canadian government.

I was curious about the study, in particular, how they went about assessing something huge like economic impact of mental illness, and what interventions they think would be helpful. They used the OneHealth tool, which you can download here, to estimate the number of people with depression and anxiety disorders living in 36 large countries, constituting 80% of the world's population, and 80% of the global burden of depression and anxiety disorders. The countries were a mix of low-, middle-, and high-income. Incidentally, I didn't download the OneHealth tool even though it looks really interesting because it's designed for Windows, feh, and I would have to do funny things to my precious Mac to use it. But there's an introductory tutorial on YouTube, and boy does OneHealth have a lot of fascinating data for countries, and powerful functionality.

Quite reasonably, in my opinion, they excluded prevention as a type of treatment, because the evidence for it is weak, and not easily generalizable. Interventions included, "...basic psychosocial treatment for mild cases, and either basic or more intensive psychosocial treatment plus antidepressant drug for moderate to severe cases." The choice of intervention is based on WHO's Mental Health Gap Action Programme (mhGAP), where the recommended treatment for moderate to severe depression is:

Anxiety and mild depression are considered, "Other Significant Emotional or Medically Unexplained Complaints." In those cases, the recommended treatment is:

INT are advanced psychosocial interventions which take, "...more than a few hours of a health-care provider’s time to learn and typically more than a few hours to implement." They include Behavioral Activation, CBT, Contingency Management Therapy, Family Counseling or Therapy, Interpersonal Psychotherapy, Motivational Enhancement Therapy, Parent Skills Training, Problem-Solving Counseling or Therapy, Relaxation Training, and Social Skills Therapy.

I have to say I'm a little skeptical about how effective these interventions will be. However, their computations were based on the assumption that there would be only a 5% improvement in the ability to work, and productivity at work, as a result of treatment. So their expectations were modest-if someone would normally miss 20 days of work per year, how much money would it cost or save if that person only missed 19 days per year. At least, that's how I understand it.

They were looking for the total cost of scaling-up treatment, as well as effects on three categories:

Health Return = increased healthy life years gained as a result of treatment
Value of Health Returns = I don't really understand this
Economic Return = enhanced levels of productivity

One table I initially skimmed over but now realize is quite important is:

Current and target levels of scaled-up treatment coverage for depression and anxiety disorders (all interventions combined), by country income level 

It reflects the idea I pointed out above that their expectations are modest. Currently, 7% of people who need it get treatment in low-income countries. With the scaled-up program, that number will rise to 34%, which means that 2/3 of people who need treatment won't get it.

The article notes that, "...very few studies have assessed the extent to which effective depression treatments get people back into work." So that's an important question to try to answer. They looked at absenteeism, meaning days lost to work, and "presenteeism", meaning partial days of impaired activity while at work. I guess that includes things like staring off into space.

Let's review. They used this powerful, OneHealth tool to see how many people in the world suffer from depression and anxiety. And they also used the tool to determine the economic impact of these illnesses when they're treated, and when they're not treated. Then they figured out how many more people would need treatment in order to get a 5% increase in productivity. They estimated the cost of the additional treatment, and they estimated how much money would be saved (or made, depending on your perspective) by having that many more people back at work.

And this is what they found:

Costs and benefits of scaled up treatment of depression and anxiety disorders, 2016–30

The total investment is $91.5 billion for depression, plus $55.7 billion for anxiety, equals approximately $147 billion.

They claim that, "...scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period [2016-30]." I don't understand how they determined this, but they placed an economic value on these healthy life-years, the "Value of Health Returns".  For depression, it's $258 billion, and for anxiety, $52 billion, for a total of $310 billion.

In terms of economics, they got $230 billion for depression, and $170 billion for anxiety. That's a total of $400 billion.

To summarize, just looking at pure dollar amounts, over a 15 year period, you put in $147 billion, you get out $400 billion, yielding a total benefit to cost ratio of 2.3-3 : 1.

The discussion describes some limitations. For example, it notes that is a modest return on investment. By comparison, in another OneHealth model, the benefit to cost ratio for malaria was 28-40 : 1. But they also mention that they didn't include things like reduction in unemployment- and welfare-benefits in their analysis, so that could change the ratio.

Another limitation is that unlike the prevalence of of depression and anxiety, the prevalence of treated depression and anxiety is unknown. Meaning that even if you invest in and set up programs, they may not be implemented well. Also, treating more people, for example in remote locations, may drive up the cost of treatment.

Plus, the study didn't consider the negative effect of maternal depression on early child development, the health, social, and economic benefits of effective treatment of maternal depression on the cognitive and physical development of newborns, the monetary and non-monetary impact of effective treatment on family and other caregivers, and the effect of depression and its treatment on physical health outcomes.

To these considerations I would add my own concerns about the particular interventions the WHO recommends. However, I will concede that while the whole endeavor is about the bottom line, and may not make that much emotional difference to that many people, some people will be helped, and that's more than are helped now. And, more importantly, if things work out like they want them to, they will have demonstrated that helping more people actually saves money. I hope they're right.

Thursday, April 7, 2016

Making My Comeback

I am very sorry for my long absence. I can come up with excuses, like I was out of the country, then sick, and the whole time working on what is turning out to be a very challenging article for The Carlat Report. All true, but still excuses.

I'm gonna show you some photos from Thailand, anyway:

6 foot shadow puppet

Street Market

Tuk Tuk

Detail from Wall Mural, Temple of the Emerald Buddha

I'm not gonna get into the part where I was sick, except to convey the one important lesson I learned, although it was too late to be of use to me: There are home IV services. You can google them, if you like. They're mainly for hangovers, and they come to your home and hang some lactated ringers, but they also cover the occasional flu and GI bug.  Good to know.

Now for some real content.

You may recall that a few months ago, I went into this rabbit hole about statistics and flu vaccination. I looked at an article by Talbot et al, that the CDC is using to support its recommendation for universal influenza vaccination. First I finagled around for a while trying to figure out how the article obtained its statistics. When I had finally done that, I considered the conclusions from those statistics, and decided they were erroneous-meaning that even if the statistics are accurate, they don't prove what the authors claim they prove, namely, that there is a 71% reduction in flu-related hospitalizations in patients who have been vaccinated against flu, vs. those who haven't. Instead, I believe what they demonstrate is that flu vaccination resulted in a 71% reduction in flu INFECTION, in their study population, which consisted exclusively of patients who were already hospitalized for something that resembled flu. These are very different conclusions, and if you check my post, you can see where I demonstrated that with the study's data, it's possible flu vaccination reduced flu-related hospitalization, but it's also possible it increased it. They don't have the right data to know.

Since I'm not a statistician, I asked a few people who I thought knew more statistics than I if my conclusion was correct, but I couldn't seem to get a clear answer. I even wrote to the Cochrane Review about it, then promptly forgot I had done so.

Well, they responded, and this is en excerpt (most) of their reply:

Our opinion on the Talbot, et al observational study is as follows:

The public health significance of the study is limited for multiple reasons including the inability to estimate absolute treatment effects and number needed to vaccinate. Without this vital information it is difficult to determine the value of the intervention for public health use. Furthermore there is no information on harms reported therefore we have no idea of the balance between positive and negative outcomes. It is well known that observational studies tend to be associated with higher risk of bias compared to randomised clinical trials. Bias introduced by the design usually has the effect of exaggerating the effects of the intervention, in this case influenza vaccines. Coupled with absence of any mention of harms is well within the narrative findings of our reviews.

The assumptions required for validity of the case-positive, control-negative study design are not stated in the paper and no information is provided on whether they have been met. For example, a critical assumption is that the risk of non-influenza ILI needs to be the same in vaccinated and non-vaccinated individuals1. This may not be the case as shown by Cowling et al who reported an increased risk of non-influenza respiratory virus infections associated with receipt of inactivated influenza vaccine2. Stratification by disease severity (apparently not measured in this study) is needed because this is likely to be associated with a person’s probability to seek medical care as well as vaccination status3. If the vaccine modifies the conditional probability of developing symptoms after infection with influenza then the odds ratio may be biased3.

The case-positive, control-negative study design is not recommended for study of patients hospitalised for influenza-related illnesses because hospitalisations may occur due to complications that become manifest after the virus is no longer detectable3. It is notable that only 10% had positive RT-PCR tests; surprisingly low given the participants were selected and recruited during the influenza season. 

Further weaknesses of the study include selection bias as only 169 of 413 eligible participants were included in the analysis. Only 17 had a positive RT-PCR test making estimates from statistical modelling unreliable. 

Given these multiple methodological concerns we consider the study to be at high risk of bias; providing very low quality evidence. 

1Broome, C., Facklam, R., Fraser, D. Pneumococcal Disease after Pneumococcal Vaccination — An Alternative Method to Estimate the Efficacy of Pneumococcal Vaccine. N Engl J Med 1980; 303: 549-552.
2Cowling, B., Fang, V., Nishiura, H., et al. Increased Risk of Noninfluenza Respiratory Virus Infections Associated With Receipt of Inactivated Influenza Vaccine. Clin Infect Dis. 2012 Jun 15; 54(12): 1778–1783.
3Foppaa, I., Haberc, M., Ferdinandsa, J., Shaya, D. The case test-negative design for studies of the effectiveness of influenza vaccine. Vaccine 31 (2013) 3104– 3109. 

Cochrane replied to my inquiry! I feel so important! Sure, they didn't really answer my vanity question of, "Did I catch the CDC in a big statistical boo boo?" But that's probably for the best. What they do seem to be saying is that the the study is poor enough that it's not even worth considering the validity of its conclusions, which still supports my contention that this is a terrible study to use as part of the recommendation for universal flu vaccination.

The Cochrane people also suggested that I post our exchange in PubMed Commons as comments to the Talbot et al study, which I told them I would like to do, but haven't gotten around to yet.

That's my bit for today. I will try to be less neglectful of the blog, going forward.