tag:blogger.com,1999:blog-40537708664542961902024-03-17T02:24:52.140-04:00Psych PracticePsychpracticehttp://www.blogger.com/profile/04066923364269302930noreply@blogger.comBlogger270125tag:blogger.com,1999:blog-4053770866454296190.post-56278516945048142062018-02-25T20:29:00.002-05:002018-02-25T20:29:40.255-05:00Addendum to "A Modest Proposal": Guns ARE the problem.In reference to my most recent post, <a href="https://psychpracticemd.blogspot.com/2018/02/a-modest-proposal.html" target="_blank">A Modest Proposal</a>, it has come to my attention that many readers are not aware that I was being facetious, and that I am in fact appalled by a government that values the weapons industry over children's lives. It is jaw-droppingly disturbing that the idea of training up child soldiers was not immediately recognized as unthinkable. What a terrible state of the world.<br />
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So let me state it for the record: The problem is not mental illness, or even irrational hatred. The problem is guns. Other countries have figured this out, I don't understand why we haven't.<br />
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For those interested, this is a remarkably coherent argument made by James Corden about the impact of gun control laws in other countries, including Japan, where not only are there no mass shootings, but there are almost no gun-related deaths.<br />
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And this is a link to the original, <a href="http://www.readwritethink.org/files/resources/30827_modestproposal.pdf" target="_blank">A Modest Proposal</a>, written by Jonathan Swift in 1729, on which my post was modeled. In it, he suggests reducing poverty and overpopulation in Dublin by eating the babies of the poor. His arguments are so convincing and so skillfully presented that there is an inevitable head-shaking moment when the reader, having been carried along in the wake of his reasoning, suddenly realizes she is witnessing satire, and that Swift is viciously commenting on the appalling dehumanization of the poor.</div>
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PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-44363789249639905532018-02-25T03:15:00.001-05:002018-02-25T19:46:54.512-05:00A Modest Proposal<h2 style="text-align: center;">
<span style="font-weight: normal;"><i><br /></i></span></h2>
<h2 style="text-align: center;">
<span style="font-weight: normal;"><i>A Modest Proposal</i></span></h2>
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<i>For the prevention of mass shootings in schools and other vulnerable locations.</i></div>
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It is a melancholy object to those who live in this great country when they watch or read the news, only to be confronted with the repeated slaying of children in schools by deranged killers who have been failed by the mental health system.<br />
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I think it is agreed by all parties that this prodigious number of murdered children is, in the present deplorable state of the union, a very great grievance. And therefore, whoever could find out a fair, cheap, and easy method of keeping these children safe, would deserve so well of the public, as to have his statue set up for a preserver of the nation.<br />
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As to my own part, having turned my thoughts for many weeks upon this important subject and maturely weighted the several schemes of our projectors, I have found them grossly mistaken in their computation. It is true, a child may attend school, from ages four through eighteen, without violent incident, and it is exactly at this latter age that I propose to provide for them in such a manner, as instead of being a charge upon their schools or communities, or wanting protection from their teachers or security personel, they shall, on the contrary, contribute to the protection and safety of their fellow students, and ultimately, of their country.<br />
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The number of souls in a US high school being reckoned, on average, 750, of these I calculate that there may be 180 in each senior class, of which a few begin the school year having attained the age of majority, perhaps ninety by mid year, and virtually all as the year concludes.The question therefore is, How this number shall be gainfully utilized to the betterment of all? which, as I have already said, under the present situation of affairs, is utterly impossible by all the methods hitherto proposed. For they can neither be adequately protected by armed guards or teachers, their numbers being insufficient to the task. Nor by the mental health system, which has failed to identify those creatures likely to embark on nefarious endeavors. Nor can this proud nation violate the rights of its people to bear arms, those rights having been attained through great struggle, by preventing access to firearms.<br />
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I shall now therefore humbly propose my own thoughts, which I hope will not be liable to the least objection. That each student be presented with a weapon on his or her eighteenth birhday, either handgun or shotgun, semiautomatic, or automatic, according to preference, each having pursued and concluded a course of study in preparation for the receipt of the chosen fierarm, and the assumption of responsibility for pretecting the school from those who may try to perpetrate violence upon its pupils.<br />
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I think the advantages by the proposal which I have made are obvious and many, as well as of the highest importance.<br />
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For first, our government has already made provision for the purchase and use of firearms by those citizens eighteen and older, so that no new statutes need be passed to allow for such a process.<br />
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Secondly, by the time of their receipt, students will have been well trained in the use of these weapons, as such training will begin in early childhood, and continue throughout the course of standard education.<br />
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Thirdly, the usual requirements of Physical Education will be replaced by classes in martial arts and weaponry, so no additional strain need be placed on school budgets, while still maintaining fitness standards for all children.<br />
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Fourthly, this training will yield other educational advantages, such as study of the history of warfare, and understanding of tactical approaches in battle, and strategy for outwitting the enemy. In fact, most of the knoweldge and skills ordinarily sought via a traditional education can readily be obtained by a shift of educational focus to that of military training.<br />
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Fifthly, weapons maufacturers and overseeing organizations such as the NRA will be eager to invest in this system, and to contribute materials and skilled military teachers, as children raised in this envoronment will naturally develop a love of guns and weaponry, along with a reverence for the country they serve, and will go on to become large scale purchasers of such commodities, supporting the industry that so generously contirbuted to their enriched childhoods.<br />
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Sixthly, the mastery of skills needed for protection of the school environment will instill in each child a sense of pride in his or her achievements. Furthermore, incentives can be created for those who show special aptitude in fighting or sharpshooting, such as advanced training, early receipt of their weapons, and participation in reconnaissance missions to seek out those with the potential to do violence to others, and thereby prevent killing sprees at their points of origin.<br />
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I profess, in the sincerity of my heart, that I have not the least personal interest in endeavoring to promote this necessary work, having no other motive than the public good of my country, by advancing our trade and protecting our children.<br />
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PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-89538797298308368492017-04-26T18:42:00.001-04:002017-04-26T18:42:07.973-04:00Opioid Training RequirementNew York State recently decided that in order to address the problem of opioid abuse, all physicians (and non-physician prescribers) with a DEA number need to be trained in pain management, palliative care, and addiction. By July 1st of this year. I found out about it in the middle of March.<br />
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And it needs to be repeated once every 3 years.<br />
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The required course work covers the following eight topics:<br />
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(1) NYS and federal requirements for prescribing controlled substances;<br />
(2) Pain management;<br />
(3) Appropriate prescribing;<br />
(4) Managing acute pain;<br />
(5) Palliative medicine;<br />
(6) Prevention, screening and signs of addiction;<br />
(7) Responses to abuse and addiction; and<br />
(8) End of life care.<br />
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I. Don't. Prescribe. Opioids. Period.<br />
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What I'm saying is, this training has no relevance for me, and is another example, aside from MOC, of taking time away from educational or clinical experiences that are useful to me, to do someone else's busywork.<br />
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I think whoever came up with this idea is trying to create the impression that something is being done about the opioid problem, without thinking it through. A more reasonable, and respectful approach would have been to say, "If this is relevant to your practice or work setting, then you must get this training. And if you don't have the training and you do prescribe opioids, you're in big trouble."<br />
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Here's an indication of just how poorly thought out this program was:<br />
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<i>Providers will be required to attest to completion of the required course work or training. The Department of Health has not yet released instructions for submitting an attestation, but has indicated that more information is coming soon. </i><br />
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As I mentioned, this was back in March. There is now a way to attest, by going to the HCS portal, then "My content" --> "All Applications" --> "N" --> "Narcotic Education Attestation Tracker (NEAT)". <a href="https://www.health.ny.gov/professionals/narcotic/mandatory_prescriber_education/docs/neat_instructions_prescriber.pdf" target="_blank">This</a> is where the directions come from.<br />
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And for reference, <a href="http://files.constantcontact.com/0a9fb977be/afee7897-8ef7-483f-a696-6ffb1078c402.pdf" target="_blank">this</a> is the actual announcement.<br />
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There are two currently available courses that satisfy the training requirements (that I know of):<br />
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The New York Chapter of the American College of Physicians offers a three-hour online course on the required eight topics in conjunction with the Boston University School of Medicine. This course is available free of charge to all providers. You can view the course announcement by clicking <a href="http://www.nyacp.org/i4a/pages/index.cfm?pageid=3831" target="_blank">here</a>.<br />
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The Medical Society of the State of New York is also offering three 1-hour online courses covering the required eight topics. The courses are free to MSSNY members and will be made available to non-members for a fee of $50 per module. <br />
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I couldn't figure out how to access this course without paying dues and logging in to the MSSNY site. But why would I want to pay $150 for a course I can take for free elsewhere?<br />
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The <a href="https://www.health.ny.gov/professionals/narcotic/mandatory_prescriber_education/docs/faq.pdf" target="_blank">statute does provide an exemption</a> from the course work or training requirement for DEA registered providers, but it's not clear to me under what circumstances, or how it can be done:<br />
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<i>...The DOH may grant an exemption to the required course work or</i><br />
<i>training to an individual prescriber who clearly demonstrates to the DOH that there is no need to </i><i>complete such training. Exemptions shall not be based solely upon economic hardship, technological </i><i>limitations, prescribing volume, practice area, specialty, or board certification.</i><br />
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When I was making my attestation, there was a button you could press to ask for an exemption, but I didn't press it since I wasn't asking for one, so I don't know what happens when you do.<br />
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Now about the course. This is an aside, but one thing that pissed me off is that while the course provides CME credit for everyone who takes it, those certified by the ABIM can use it as SA credit, while those certified by the ABPN cannot. If that's not a scam on the ABPN's part, I don't know what is.<br />
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The first two modules were completely useless to my practice, although I found the content interesting. They cover how to:<br />
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Determine when opioid analgesics are indicated<br />
Assess for opioid misuse risk<br />
Talk to patients about opioid risks and benefits<br />
Monitor and manage patients on long-term opioid therapy<br />
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One thing that struck me is that the course seems to be intended mainly for primary care providers, and it's hard to imagine when someone who is responsible for everything involved in primary care would have time to deal with pain management and potential for misuse.<br />
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The third module was useless as well as boring. It was basically just someone rattling off NY State laws governing the safe prescribing of opioids, and how to, "Appropriately document communication with patients about health care proxies and advance directives and describe the appropriate use of advance care planning CPT codes."<br />
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I dozed off several times. I still managed to pass.<br />
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So if the topic is relevant to your practice, or you're looking for some free CME credits, or if neither of these is the case but you have a DEA number in NY State, then by all means, take these classes.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-14323289318627326022017-04-17T16:41:00.001-04:002017-04-17T16:41:34.835-04:00House CallsThe other day, I was scooting around a Google map of Manhattan, trying to find <a href="http://doughnutplant.com/" target="_blank">The Doughnut Plant</a>, which makes the best coconut cream yeasted doughnut ever. And as I was virtually strolling along 23rd street, I saw this:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8BRVy_Dzq0Ei1nkFjwki2a24QAgobqG8JDnx6MrTU6mjh15sflS1XRnXmBNFHVKjfwFfDK1y7DbjcUjbDEi8iQy2KaFUVHz4uhEXBRncDTOVsU5EougXCcYFVv4zsAjYcUfGgfQAGUxs/s1600/Screen+Shot+2017-04-17+at+2.43.51+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8BRVy_Dzq0Ei1nkFjwki2a24QAgobqG8JDnx6MrTU6mjh15sflS1XRnXmBNFHVKjfwFfDK1y7DbjcUjbDEi8iQy2KaFUVHz4uhEXBRncDTOVsU5EougXCcYFVv4zsAjYcUfGgfQAGUxs/s640/Screen+Shot+2017-04-17+at+2.43.51+PM.png" width="640" /></a></div>
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<a href="http://housecallpsychiatrists.com/" target="_blank">House Call Psychiatrists</a>. Hmm. I couldn't help checking out their website.<br />
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From their home page:<br />
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">House Call Psychiatrists is a network of board certified and licensed psychiatrists with extensive experience making psychiatric home visits. They are available 24 hours a day, 7 days a week for convenient and private house calls within Manhattan, Brooklyn, Queens and North Jersey.</span></div>
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">House Call Psychiatrists offer a unique and high level service in the convenience of your home, office or hotel room. They are able to address most psychiatric issues in a timely and private manner avoiding other urgent care centers and hospital emergency rooms.</span></div>
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There's an interesting idea. It's a bit different from <a href="https://psychpracticemd.blogspot.com/2015/03/talkspace.html" target="_blank">TalkSpace</a>, a texting therapy service which I posted about previously. Some of the things I didn't like about TalkSpace were that it's not in-person treatment, and there's no delayed gratification like there is when you have to wait for your appointment.<br />
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But these are house calls. So you do have to make an appointment, even if it happens to be in the middle of the night. And it is in-person.<br />
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Here's some more information.<br />
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There are 7 psychiatrists on the team, all men. A general psychiatrist, two addiction psychiatrists, a bipolar specialist, a geriatric specialist (who doesn't seem to be board certified in gero-psych, so I guess that's why they don't call him a geropsychiatrist), a community psychiatrist, and an anxiety specialist.<br />
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Thinking about the "extensive experience making psychiatric home visits," I'm skeptical. How would they get that extensive experience? I can remember my pediatrician coming to my house, but nothing since then-who makes house calls anymore?<br />
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"Our psychiatrists have been making house calls for many years on Assertive Community Treatment (ACT) teams which are home-based psychiatric outreach programs. They are also psychiatric emergency room physicians with admitting privileges to..."<br />
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ACT house calls seem very different to me than the house calls they're talking about here. For one thing, ACT is a team, and sees patients as such. Here, my impression is that this is 1 to 1 care. For another, most patients in ACT treatment can't afford the $500 fee that House Call Psychiatrists charge. Or $1000 from 8pm to 8am.<br />
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I'm trying to understand the model. I assume they cover for each other, and that someone is always on call.<br />
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All the the psychiatrists seem to have separate private practices that provide more typical office visits. Some of their websites indicate that they will also make house calls, but at the $500 rate, rather than their regular rates, which are less. Does this mean that the House Call Psychiatrists only see established patients? I don't get that impression.<br />
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They also offer to see patients in their hotel rooms, which implies that they may be visiting NYC, and therefore not established patients.<br />
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The house call services provided are:<br />
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This makes me wonder about liability. If they provide crisis intervention and safety checks, then they may end up seeing a patient they don't know who is suicidal. What if that patient needs to be hospitalized but refuses to go? One of the individual psychiatrist's websites states that he does make house calls, but that, "A home visit should not replace calling 911 if you are having an emergency." That confuses me.<br />
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My fantasy about this model is that some wealthy person feels like he needs to see a psychiatrist, but he is either visiting NYC, or lives here but doesn't want to go to anyone's office. I imagine this as happening in the middle of the night, with patients who suffer from insomnia (they state they treat sleeping difficulties), or who are having panic attacks. Or maybe it's during the day, but it's some CEO who wants his shrink to come to him.<br />
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I'm really not sure what to think about this model. I know I wouldn't make house calls with my patients, but my practice has a certain nature that doesn't lend itself to this model. Also, I don't fancy wandering into a stranger's hotel room in the middle of the night, knowing that there's a psychiatric problem.<br />
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Home visits are a great idea for patients who function poorly and would be lost to care if they weren't followed by an ACT team, for example. But patients who can afford $500 fees presumably function fairly well. (Incidentally, no insurance is accepted, and the fee is prepaid at each visit via credit card.)<br />
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I think that for one-off panic attacks, home visits are probably not a good idea, because they maintain the message that the patient can't manage on his own and tolerate some delayed gratification, similar to TalkSpace.<br />
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For naltrexone injection or genetic testing, maybe it does make sense for the shrink to come to your office.<br />
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For ongoing therapy, I don't know. Is there some benefit to making time during the day to travel to the shrink's office? Is there a power struggle that gets settled by default when the shrink comes to you? Does it violate the important frame of a treatment to have it in your home, or does it just create a different frame?<br />
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I have a lot more questions than answers. What do you think?<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-35102197321630391182017-03-13T02:01:00.000-04:002017-03-13T02:01:06.367-04:00Manualized Treatments<div class="separator" style="clear: both; text-align: center;">
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I'm sorry I've been gone so long. There, I got that out of the way. I have been exquisitely busy, with mostly good things, so no complaining. But really no time to blog. I have missed it, though, and I've also felt strangely guilty, as though having embarked on this journey, I need to see it through, whatever that might mean.<br />
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I assumed no one would be reading the blog, once I stopped posting regularly. I haven't even checked in much to see the stats. But when I did, recently, I was shocked to discover how many hits the site is getting on a regular basis. It's a nice feeling.<br />
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So now that I'm back, there's the question of what to post about. I've decided, at least for this return post, to ignore the Republican in the room. With my apologies to those who voted for Trump, I find the current political situation in this country very disturbing. And that's all I'm going to say on the subject, for now.<br />
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Why manualized treatments? Lately I've been involved in some committees that are debating the nature of an analytic curriculum, and whether it should include psychotherapy training. This goes to the question of what the difference is between psychodynamic psychotherapy and psychoanalysis (these days, I believe the therapy is referred to as psychoanalytic psychotherapy). That's a very tough question, with lots of controversy about a spectrum of treatment, the use of the couch, the frequency of sessions, goals of the treatment, whether analytic training makes for better therapists, the theoretical bases, overlap in technique, the list goes on.<br />
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At a recent meeting, one suggestion was to include courses in Transference Focused Psychotherapy (TFP) and Panic Focused Psychodynamic Psychotherapy (PFPP), both manualized treatments, in the first year of training, and the point was made that it may be helpful early on in ones training to have this kind of framework for thinking about what one is doing, rather than just learning to sit with the chaos and confusion.<br />
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Oh, this was funny. I got to that meeting a couple minutes late, and everyone was sitting around in a big circle, and it was crowded, so I went and grabbed a chair from a stack and just plunked it down in the outermost circle. Then I started to look around for my analyst so I could figure out how uncomfortable I should feel. At first I didn't see her, then I realized I was sitting directly behind her. About five minutes later I started to laugh because I thought, "Well this is backwards."<br />
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I disagree with the framework point for several reasons. First, it's not the only way to create a framework. The current trend in teaching psychotherapy is to use a book by Cabaniss, <i><a href="https://www.amazon.com/Psychodynamic-Psychotherapy-Clinical-Deborah-Cabaniss/dp/0470684712" target="_blank">Psychodynamic Psychotherapy: A Clinical Manual</a></i>. The idea behind it is that there are now core competencies in psychotherapy that residents have to meet, and it's structured in a way that fulfills those competencies. It's brilliant in the way it breaks things down into simple pieces, but it's very algorithmic, and in my opinion, it infantilizes the residents for whom it's intended.<br />
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I've been teaching in a psychotherapy program for several years, and we don't use that book. Instead, we use Rosemary Balsam's, <i><a href="https://www.amazon.com/Becoming-Psychotherapist-Rosemary-Marshall-Balsam/dp/0226036367/ref=sr_1_2?s=books&ie=UTF8&qid=1488995785&sr=1-2&keywords=becoming+a+psychotherapist" target="_blank">Becoming a Psychotherapist: A Clinical Primer</a></i>. It's a bit outdated (it includes a section about whether you should have an ashtray in your office), but when it comes to teaching newbies how to work with patients, it's brilliant. Completely non-algorithmic, it still manages to create a solid framework for how to think about what one is doing in terms of technique. Every time I read it I think, "I wish I had had this when I was a resident."<br />
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Second, teaching beginning psychodynamic psychotherapy with manualized treatments is analogous, for me, to using a GPS to get someplace new. This happens to me all the time. I use the GPS, I have no problem getting where I'm going, and I have no idea where I am. Not a chance that I could get home without the GPS. I just did as I was told, (drive 158 miles, then turn left) but I'm clueless. Whereas back in the days before GPS's, I had to look at a map, and maybe I got a little lost and had to pull over and look at a map again. It was more of a struggle, but by the time I reached my destination, I could get home on my own.<br />
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That said, I think manualized psychotherapy treatments are good things. I just don't think they're the first way one should learn to do psychodynamic psychotherapy. So let's go over the two I mentioned above. Please note that I'm writing about manualized <i>psychodynamic</i> psychotherapy treatments, which is why CBT is not included in the discussion.<br />
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<b>Transference Focused Psychotherapy (TFP):</b><br />
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<i>TFP is a manualized evidence-based treatment for borderline and other severe personality disorders. It is based on psychoanalytic concepts and techniques that have been modified and organized into a systematic approach to address severe personality pathology. TFP posits that the specific symptoms of borderline personality disorder (BPD) stem from a lack of identity integration, corresponding with a lack of coherence in the individual’s experience and understanding of both self and others. This unintegrated psychological state, referred to as “identity diffusion,” is associated with reliance on defensive strategies involving dissociation of conscious aspects of experience that are in </i><i>conflict (“splitting-based defenses”) and with a vulnerability to experiencing cognitive distortions in the setting of affect activation. </i>(<a href="file:///Users/rivkee/Downloads/Yeomans,%20Levy,%20Caligor%20-%202013%20-%20Transference%20focused%20psychotherapy.pdf" target="_blank">Yoemans, et al</a>)<br />
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TFP meets twice weekly for an indefinite period. Its objectives include improved behavioral control, and an increase in reflection and affect regulation, both of which ultimately promote identity integration. The success of TFP rests on three central tasks for the therapist: setting and maintaining the frame; containing and making use of the therapist's own affective responses (countertransference); and interpretation.<br />
<br />
<i>Frame:</i><br />
The frame is set via a collaborative negotiation of a treatment contract-how frequently they will meet and why that's important, what happens if sessions are missed, etc. The therapist needs to be flexible and open, and to address any concerns the patient might have. This creates a safe environment for the patient, and allows for later discussion and exploration of deviations from the contract.<br />
<br />
<i>Countertransference:</i><br />
Work with Borderline patients can produce intense affective reactions in the therapist. The goal is for the therapist to recognize and accept those affects, rather than denying their presence, and to use them to help understand what the patient is feeling. For example, Borderline patients can project a lot of their own negative and aggressive feelings onto others, so the therapist's awareness of his own affective reaction can help him recognize an affective state which the patient may be experiencing, but unable to recognize in herself.<br />
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Interpretation:<br />
The interpretive process includes the triad of clarification, confrontation, and interpretation, itself.<br />
<br />
"Clarification involves drawing attention to an area of psychological conflict by tactfully and specifically exploring the patient’s conscious experience."<br />
<br />
Confrontation calls attention to the, "...patient’s verbal and nonverbal communications that are in contradiction with each other and that represent internal states that are segregated from each other." An example would be pointing out her own aggressive behavior to a patient who frequently feels mistreated by others.<br />
<br />
As for interpretation, itself, "In the advanced phases of the interpretive process, the TFP<br />
therapist continues to support reflection, while calling attention to the dissociation of positively and negatively colored aspects of affective experience and ultimately exploring the patient’s motivations<br />
for keeping them apart. In the process of interpretation, TFP emphasizes a persistent focus on the here-and-now and an empathy with the total internal experience of the patient, which is to say, with the patient’s identifications with both the persecutory as well as the persecuted object, and with the idealized as well as idealizing object." Much of this work takes place in the transference, i.e. in the therapist's interpretation of the patient's reactions to the therapist, whether idealizing or demeaning.<br />
<br />
Empirical studies of TFP have shown decreased suicide attempts, ER visits, and hospitalizations, as well as increases in global functioning. (<a href="https://en.wikipedia.org/wiki/Transference_focused_psychotherapy#Empirical_support" target="_blank">all significant, see this summary</a>)<br />
<br />
<a href="https://www.ncbi.nlm.nih.gov/pubmed/17541052" target="_blank">One study comparing TFP with DBT and supportive treatment</a> found significant improvements in depression, anxiety, global functioning, and social adjustment in all three groups, at one year. TFP and DBT showed significant improvement in suicidality. TFP and supportive treatment were associated with improvements in anger and impulsivity. Only TFP was significantly predictive of change in irritability and verbal/direct assault.<br />
<br />
The difference in approach of TFP vs. DBT seems to be that DBT is good at getting Borderline patients to function, despite their affective and cognitive tendencies, while TFP tries to shift those tendencies.<br />
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<br />
<b>Panic Focused Psychodynamic Psychotherapy (PFPP):</b><br />
<br />
I actually wrote a post about PFPP a couple years ago, <a href="https://psychpracticemd.blogspot.com/2013/10/panic-disorder-study.html" target="_blank">Panic Disorder Study</a>. Unfortunately, the link I used to the article doesn't seem to work anymore, so <a href="http://ajp.psychiatryonline.org/doi/full/10.1176/ajp.2007.164.2.265" target="_blank">here's a new link</a>, with the full text.<br />
<br />
As a quick recap, PFPP is a manualized treatment for Panic Disorder that runs for 24 sessions over the course of 12 weeks (2/week). It assumes that panic symptoms have psychological meaning, often related to conflicts surrounding separation, autonomy, and anger. There are three phases of treatment.<br />
<br />
In phase 1, the meanings behind the panic symptoms are explored, with the goal of some initial symptom relief. Phase II involves addressing transference to examine the way the conflicts causing the panic can play out in real time. Phase III addresses termination, including the reliving of central separation and anger themes in the transference.<br />
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One of the impressive things about PFPP is that it managed to develop a manual for doing psychoanalytic psychotherapy. I haven't seen <a href="https://books.google.com/books?hl=en&lr=&id=oJzTTxrHMbsC&oi=fnd&pg=PA1&dq=panic+focused+psychodynamic+psychotherapy&ots=Pq3R0kt3hC&sig=DJFISd0Z2fcSf5JYmEYq3FyOPnE#v=onepage&q=panic%20focused%20psychodynamic%20psychotherapy&f=false" target="_blank">the actual manual</a>, but presumably, it was able, "... to maintain the essential features of a psychoanalytic treatment (free association, elucidating unconscious meanings and conflict, developmental exploration, interpretation, use of the transference) with adequate flexibility, while focusing on the specific underlying meanings of symptoms of panic disorder." (<a href="http://www.pep-web.org/document.php?id=apa.057.0131a" target="_blank">Discussed Here</a>).<br />
<br />
I couldn't find a trial testing PFPP against CBT, since the original, 2007 study, which tested PFPP against something called, Applied Relaxation Training. <a href="https://weillcornell.org/bmilrod" target="_blank">There does seem to be a trial in progress</a>, as well as one about PFPP in adolescents. I guess they were satisfied enough with the results of the original trial that they continue to offer training in PFPP.<br />
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<br />
That's about it for my return post. Hope to post again soon.<br />
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<div style="text-align: center;">
<span style="font-size: x-small;">Published on Psych Practice March 13, 2017</span></div>
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-87373534320751177512016-10-18T22:04:00.000-04:002016-10-18T22:04:05.448-04:00Finally! Building a Website-The WebsiteI know, I know, I started writing about building my practice website months ago, and I've completely dropped the ball. But only the blog ball. I've actually been working very hard on my own website, as well as that of my analytic institute, and on other tech-y advances we're adopting. More on that later.<br />
<br />
For now, I have finally chosen SquareSpace as my site host, and I'm diligently shoveling away at everything I need to do to get the site up and running.<br />
<br />
Why SquareSpace? I know that in <a href="https://psychpracticemd.blogspot.com/2016/04/building-website-pricing.html" target="_blank">my last post on this matter,</a> it looked like I was going to go with Duda. Since then, I've traveled further along the convoluted paths of website-building research, and one of the things I discovered is that SquareSpace is a solid company in many ways, including staying power. I really wasn't sure I could say that about Duda-that a couple years from now, they'll still be around.<br />
<br />
In the end, it was a competition between Squarespace, and a hosted site using Wordpress. I'll tell you a little bit about that.<br />
<br />
I like Instagram. My interests fall into a few main categories: dogs, crochet/yarn, design, food, and museums. They have targeted ads, which I sometimes look at. One day, an ad came up for <a href="http://skillshare.com/" target="_blank">SkillShare</a>, where you can take mini-courses taught by whoever. Some are free. Some require a premium subscription. I found a premium class called, Mastering Wordpress: Build the Ultimate Professional Website. So I paid the 99 cent three month trial fee, and started taking the class. It was pretty bad. It was boring, and the guy was describing how to make his EXACT site. But it did make it clear to me that I could do this.<br />
<br />
Then I found another course, How to Properly Make a Website with Wordpress-Beginner's Tutorial. This one was helpful. You can check it out on SkillShare, but the guy has his own site called, <a href="http://websitesmadeeasy.tv/" target="_blank">Websites Made Easy</a>.<br />
<br />
Basically, you use HostGator.com to host your site. You can also buy a domain name through them.<br />
<br />
To review briefly, the domain name is the name of your site, i.e. its address, like alfredeneumanmd.com. (I actually got a .org domain name). The hosting site is where your site "lives" online. Hosting sites usually have several pricing plans that vary by what's offered.<br />
<br />
Once you buy your domain name and pick your hosting plan, you hook up Wordpress to it, and you build your Wordpress site. Wordpress has a ton of plugins, which are little extra functions that someone else wrote the code for, and which do great things for your site.<br />
<br />
I didn't go this route because I actually tried to go this route, and something happened with the billing, and then it somehow got canceled. The problem wasn't on my end, so I started reading reviews of HostGator, and apparently they used to be pretty good, but not so much anymore. So I gave up on it.<br />
<br />
It's also not clear to me why this is a better way to go than simply hosting your site through Wordpress.<br />
<br />
But here's what it came down to with SquareSpace. It's a one-stop shop. You can buy a domain name through them, and host on their site, and use their software to build your site.<br />
<br />
The domain name has an annual fee (no matter where you get it), and SquareSpace charges $20/year, which is more than many of the other hosting sites. But they lock you in at your initial rate. Other sites don't tell you what they'll charge after the first year.<br />
<br />
SquareSpace also doesn't give you a hard time about transferring your domain name, if you decide you don't want them to host anymore, as long as you've had your site for at least two months. According to reviews, other hosting sites do give you a hard time. I think it's indicative of SquareSpace's trust that you'll like their product, and want to continue with them.<br />
<br />
The pricing is middle of the road. I got the "personal" plan, as opposed to the business plan. It boasts:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgO-fFVwV8q8gzVuXvnYF_Ik2hIRXyOOMtl88kRl8dVaA__LM09Ha11U5f9DIZGl2RLIiMOY9_Uc3TBjodOE1nZlDeoRA6ghtdodvuAM-2E07k8qlM37GknAj9BX4tnp1srHzDDrhdfijE/s1600/Screen+Shot+2016-10-18+at+9.14.24+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgO-fFVwV8q8gzVuXvnYF_Ik2hIRXyOOMtl88kRl8dVaA__LM09Ha11U5f9DIZGl2RLIiMOY9_Uc3TBjodOE1nZlDeoRA6ghtdodvuAM-2E07k8qlM37GknAj9BX4tnp1srHzDDrhdfijE/s400/Screen+Shot+2016-10-18+at+9.14.24+PM.png" width="350" /></a></div>
<br />
and costs $16/month, or $12/month if I pay annually. It includes Domain Privacy, which removes your personal contact information from the public WhoIs internet record of your domain name, which can be crawled by spam marketers for your email address.<br />
<br />
The business plan has a few more items that I don't need right now. But you can switch between plans whenever you like. They also require a 14 day free trial, so you're sure SquareSpace is what you want.<br />
<br />
The design software took a little getting used to, but it's powerful, and really quite beautiful. They have excellent online tutorials, and lots of them.<br />
<br />
In case you're interested, I chose the Keene template:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsz8raTIC3yKmSZoUU2eUIo1bDwQqjcgBNOAKSROV0QxAMfmCllxha8_Q_CJZOvMm_1lCyD_JsX8BBXo_lOWTuvhRPmjPFHEG5k-YIv6xKDlAt2VBzUVbt43QmUBEnw7NUtCP4hAsyMUo/s1600/Screen+Shot+2016-10-18+at+9.18.38+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="460" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsz8raTIC3yKmSZoUU2eUIo1bDwQqjcgBNOAKSROV0QxAMfmCllxha8_Q_CJZOvMm_1lCyD_JsX8BBXo_lOWTuvhRPmjPFHEG5k-YIv6xKDlAt2VBzUVbt43QmUBEnw7NUtCP4hAsyMUo/s640/Screen+Shot+2016-10-18+at+9.18.38+PM.png" width="640" /></a></div>
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<br />
I changed the font and ditched the toothbrush, and I really like it. It's clean, uncluttered, and attractive.<br />
<br />
The new font looks like this:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuW04cyZlWqwAhKceafil4WmtNYN16VwATkdGjnTDcDCV75n1JyCZlzHwzQw0ILfiGiv3ADhke853KfLG0gIrTVqK40yZQBnhi7FByPJkgF0Ovf5QDHFJ3KC69TUrj4RHmdatl4gXj8JY/s1600/Screen+Shot+2016-10-18+at+9.45.33+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="371" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuW04cyZlWqwAhKceafil4WmtNYN16VwATkdGjnTDcDCV75n1JyCZlzHwzQw0ILfiGiv3ADhke853KfLG0gIrTVqK40yZQBnhi7FByPJkgF0Ovf5QDHFJ3KC69TUrj4RHmdatl4gXj8JY/s640/Screen+Shot+2016-10-18+at+9.45.33+PM.png" width="640" /></a></div>
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<br />
Finally, SquareSpace has exceptional customer service, which I came to realize is very important when you're DIY'ing your own site. Every review I read about SquareSpace was impressed by the customer service. I've already made use of it, and the turnaround time was faster than I expected, and they were genuinely helpful.<br />
<br />
Next up, the ACTUAL building of the site, or, "How do I introduce myself to the world and describe what I do? What DO I do? Why do I do it that way?" I never realized how philosophical building a website can be.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-62052910171726354882016-10-02T21:00:00.000-04:002016-10-02T21:00:16.349-04:00Rosh Hashanah 5777Tonight is the start of the year 5777, on the Jewish calendar. Regardless of when you mark the beginning of the year, whether it's tonight, or January 1st, or some other day, the new year is a time for reflection on the past, and hope for the future. May it be a year of happiness, health, and peace.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBn8_NBVKtFB9gt3wC8EX82pZoAmgj4Cl7Xlb8AhKxtXIk-J6towvwhoPdBdCM2dU1vnxFkST0v1_eOLKrv8aDT4384i5xTaJniYJoT_Z3fPvlRoGVVlt1dPbu2mjMArKrmNP08aRBjVo/s1600/Screen+Shot+2016-10-02+at+10.09.57+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBn8_NBVKtFB9gt3wC8EX82pZoAmgj4Cl7Xlb8AhKxtXIk-J6towvwhoPdBdCM2dU1vnxFkST0v1_eOLKrv8aDT4384i5xTaJniYJoT_Z3fPvlRoGVVlt1dPbu2mjMArKrmNP08aRBjVo/s400/Screen+Shot+2016-10-02+at+10.09.57+AM.png" width="380" /></a></div>
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<span style="font-size: x-small;">(It's traditional to celebrate Rosh Hashanah by eating an apple dipped in honey, to symbolize a sweet new year). </span><br />
<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-9140379825772529752016-10-01T17:00:00.000-04:002016-10-01T17:00:24.249-04:00There IS Something You Can Do<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRxeL7M4FVApCMZWeIRRscGVNI-0p_ZS6bOZYZoGGyNj5FSLQ6OO24SiKYXGnvGxCbAkr5l5yaPFAJEAzw9l6BsKFpMnhMhcEUIqFZK4KlWd_KUBUxJYE8F968QR9PYOBPsYrBdnMzANc/s1600/petition.chart1_.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="321" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRxeL7M4FVApCMZWeIRRscGVNI-0p_ZS6bOZYZoGGyNj5FSLQ6OO24SiKYXGnvGxCbAkr5l5yaPFAJEAzw9l6BsKFpMnhMhcEUIqFZK4KlWd_KUBUxJYE8F968QR9PYOBPsYrBdnMzANc/s640/petition.chart1_.jpg" width="640" /></a></div>
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<br />
<a href="https://www.nih.gov/news-events/summary-hhs-nih-initiatives-enhance-availability-clinical-trial-information" target="_blank">On September 16th</a>, The Department of Health and Human Services (HHS) released a final regulation about clinical trials submitted to the FDA, and the National Institute of Health (NIH)issued a new policy regarding the same subject. These are the basics:<br />
<br />
<br />
The HHS regulation, also called the "Final Rule", states that a responsible party, such as a pharmaceutical company submitting a phase 2, 3, or 4 clinical trial for review by the FDA, with the purpose of getting a new drug approved, or a new indication for an existing drug, must register the trial at clinicaltrials.gov within 21 days of enrolling the first participant. Registration involves providing, "1) descriptive information, 2) recruitment information, 3) location and contact information, and 4) administrative information."<br />
<br />
In addition, "The Final Rule requires a responsible party to submit summary results information to ClinicalTrials.gov for any applicable clinical trial that is required to be registered, regardless of whether the drug, biological, or device products under study have been approved, licensed, or cleared for marketing by the FDA."<br />
<br />
The, "...results information must be submitted no later than one year after...the date that the final subject was examined or received an intervention for the purpose of collecting the data for the primary outcome measure. Results information submission may be delayed for as long as two additional years...," for a few complicated reasons we won't get into here.<br />
<br />
Results need to include, "1) participant flow information, 2) demographics and baseline characteristics of the enrolled participants, 3) primary and secondary outcomes, including results of any scientifically appropriate statistical tests, and 4) adverse events."<br />
<br />
Importantly, "The Final Rule also adds a requirement to submit the clinical trial protocol and statistical analysis plan at the time of results information submission."<br />
<br />
Information needs to be updated on clinicaltrials.gov at least once a year. And any errors, deficiencies, or inconsistencies that the NIH (which runs clinicaltrials.gov) identifies need to be addressed by the responsible party.<br />
<br />
That's the HHS final rule. Trials need to be registered on clinicaltrials.gov, information needs to be kept relatively current, and results have to be posted.<br />
<br />
The NIH policy broadens the scope of which trials they consider subject to these requirements.<br />
<br />
These are good things for trial transparency and honesty. We'll get to the catches in a bit.<br />
<br />
Let me backtrack and try to explain why I'm writing about this. Currently, pharmaceutical companies submit drug trials to the FDA, to get approval. They're supposed to register these trials on clincialtrials.gov, but they often don't, it's not policed, and the data they do submit isn't checked. Note that clincialtrials.gov is run by the NIH, not the FDA, so there's a built in disconnect right from the start.<br />
<br />
While a study is being reviewed by the FDA, the pharmaceutical company can publish anything they want about that study in peer reviewed journals. They can do this even if the drug ends up not being approved. They often mis-report data and results. And there is no way of knowing if they are staying true to their original study protocol, or if they're messing around with the stats in ways that benefit them. The journals have no way of knowing what's true and what isn't. The whole "peer review" part is also a sham, because the "peers" are given whatever information the pharmaceutical company feels like giving them.<br />
<br />
And the FDA does nothing to prevent any of this from happening.<br />
<br />
This is not me being paranoid. Here's an article that describes a disturbing example:<br />
<br />
<i><a href="http://content.iospress.com/download/international-journal-of-risk-and-safety-in-medicine/jrs717?id=international-journal-of-risk-and-safety-in-medicine%2Fjrs717" target="_blank">The citalopram CIT-MD-18 pediatric</a></i><br />
<i><a href="http://content.iospress.com/download/international-journal-of-risk-and-safety-in-medicine/jrs717?id=international-journal-of-risk-and-safety-in-medicine%2Fjrs717" target="_blank">depression trial: Deconstruction of medical</a></i><br />
<i><a href="http://content.iospress.com/download/international-journal-of-risk-and-safety-in-medicine/jrs717?id=international-journal-of-risk-and-safety-in-medicine%2Fjrs717" target="_blank">ghostwriting, data mischaracterisation and</a></i><br />
<i><a href="http://content.iospress.com/download/international-journal-of-risk-and-safety-in-medicine/jrs717?id=international-journal-of-risk-and-safety-in-medicine%2Fjrs717" target="_blank">academic malfeasance</a></i><br />
<br />
Jureidini, et al.<br />
<br />
Abstract.<br />
<b>OBJECTIVE</b>: Deconstruction of a ghostwritten report of a randomized, double-blind, placebo-controlled efficacy and safety trial of citalopram in depressed children and adolescents conducted in the United States.<br />
<b>METHODS</b>: Approximately 750 documents from the Celexa and Lexapro Marketing and Sales Practices Litigation: Master Docket 09-MD-2067-(NMG) were deconstructed.<br />
<b>RESULTS</b>: The published article contained efficacy and safety data inconsistent with the protocol criteria. Procedural deviations went unreported imparting statistical significance to the primary outcome, and an implausible effect size was claimed; positive post hoc measures were introduced and negative secondary outcomes were not reported; and adverse events were misleadingly analysed. Manuscript drafts were prepared by company employees and outside ghostwriters with academic<br />
researchers solicited as ‘authors’.<br />
<b>CONCLUSION</b>: Deconstruction of court documents revealed that protocol-specified outcome measures showed no statistically significant difference between citalopram and placebo. However, the published article concluded that citalopram wassafe and significantly more efficacious than placebo for children and adolescents, with possible adverse effects on patient safety.<br />
<br />
<i>International Journal of Risk & Safety in Medicine 28 (2016) 33–43</i><br />
<i>DOI 10.3233/JRS-160671</i><br />
<br />
<br />
And this is the abstract from the original article, for comparison:<br />
<br />
<i><a href="http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.161.6.1079" target="_blank">A randomized, placebo-controlled trial of citalopram for the treatment of major depression in children and adolescents.</a></i><br />
<i><br /></i>
Wagner KD1, Robb AS, Findling RL, Jin J, Gutierrez MM, Heydorn WE.<br />
<br />
Abstract<br />
<b>OBJECTIVE</b>:<br />
Open-label trials with the selective serotonin reuptake inhibitor citalopram suggest that this agent is effective and safe for the treatment of depressive symptoms in children and adolescents. The current study investigated the efficacy and safety of citalopram compared with placebo in the treatment of pediatric patients with major depression.<br />
<b>METHOD</b>:<br />
An 8-week, randomized, double-blind, placebo-controlled study compared the safety and efficacy of citalopram with placebo in the treatment of children (ages 7-11) and adolescents (ages 12-17) with major depressive disorder. Diagnosis was established with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version. Patients (N=174) were treated initially with placebo or 20 mg/day of citalopram, with an option to increase the dose to 40 mg/day at week 4 if clinically indicated. The primary outcome measure was score on the Children's Depression Rating Scale-Revised; the response criterion was defined as a score of < or =28.<br />
<b>RESULTS</b>:<br />
The overall mean citalopram dose was approximately 24 mg/day. Mean Children's Depression Rating Scale-Revised scores decreased significantly more from baseline in the citalopram treatment group than in the placebo treatment group, beginning at week 1 and continuing at every observation point to the end of the study (effect size=2.9). The difference in response rate at week 8 between placebo (24%) and citalopram (36%) also was statistically significant. Citalopram treatment was well tolerated. Rates of discontinuation due to adverse events were comparable in the placebo and citalopram groups (5.9% versus 5.6%, respectively). Rhinitis, nausea, and abdominal pain were the only adverse events to occur with a frequency exceeding 10% in either treatment group.<br />
<b>CONCLUSIONS</b>:<br />
In this population of children and adolescents, treatment with citalopram reduced depressive symptoms to a significantly greater extent than placebo treatment and was well tolerated.<br />
<br />
<i>Am J Psych. 2004;161(6):1079-83</i><br />
<br />
In the end, the FDA did not approve citalopram for use in children. But the study has been cited over 160 times, putting it in the top 5% of cited articles in medicine from 2004. Between 2005 and 2010, nearly 160,000 children under age 12 received escitalopram, despite the FDA's lack of approval. (There was a switch at some point from off-patent citalopram to on-patent escitalopram, in this time period.) It's hard not to conclude that the published study had impact on prescribing practices.<br />
<br />
There's a much fuller description of this <a href="http://hcrenewal.blogspot.com/2016/06/corruption-of-clinical-trials-reports.html" target="_blank">here</a>, by Bernard Carroll. And a lot more about this whole topic on <a href="http://1boringoldman.com/">1BoringOldMan.com</a>.<br />
<br />
Getting back to the Final Rule, there are some problematic loopholes. There are allowances for delays in reporting. There is also the crazy idea that the study protocol doesn't have to be reported until the results are submitted. This leaves room for dinking around with the protocol, changing outcome measures after the trial has started, etc.<br />
<br />
Here's what you can do. Take a look at <a href="https://www.change.org/p/congress-congress-stop-false-reporting-of-drug-benefits-harms-by-making-fda-nih-work-together" target="_blank">this petition</a>, and if you're on board, sign it. It's entitled, "<i>Stop False Reporting of Drug Benefits & Harms by Making FDA & NIH Work Together</i>". The main point is this:<br />
<br />
<span style="color: #363135; font-family: "Change Calibre", "Helvetica Neue", Helvetica, Arial, Tahoma, sans-serif;"><i>We now petition Congress to require the FDA and NIH to coordinate their monitoring and sharing of key information through ClinicalTrials.gov. Working together, the two agencies could enable stakeholders to verify whether purported scientific claims are faithful to the a priori protocols and plans of analysis originally registered with the FDA. Publication of analyses for which such fidelity cannot be verified shall be prohibited unless the deviations are positively identified (as in openly declared unplanned, secondary analyses). This prohibition shall include scientific claims for on-label or off-label uses made in medical journals, archival conference abstracts, continuing education materials, brochures distributed by sales representatives, direct-to-consumer advertising, and press releases issued by companies or their academic partners. It shall extend to FDA Phase 2, Phase 3, and Phase 4 clinical trials. By acting on this petition, Congress will create a mechanism for stakeholders independently to verify whether inferences about clinical use suggested by the unregulated corporate statistical analyses can be trusted.</i></span><br />
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Please think about it. Thanks.PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-55236465243757512122016-09-30T05:30:00.000-04:002016-09-30T05:30:20.221-04:00PA Victory?I know everyone has problems with prior authorizations. The Byzantine bureaucracy and obscure explanations for denials are maddening.<br />
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I'm suddenly reminded of the DMV scene in Zootopia, except I think insurance companies do it on purpose.<br />
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Today I had a minor and unexpected victory, and I think I might know why it worked, so I thought I'd share it.<br />
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Unfortunately, I have to mask any clinical information, so you'll have to take my word on a number of points. Some things may sound peculiar or not-thought-out, but like most cross-sectional views of a patient's medication regimen, if you knew the full history, it would make sense.<br />
<br />
Here's what happened. I needed to get a PA for a new medication, M. The patient had had trials of multiple <strike>cheaper</strike> covered medications, and had either failed them, or had been unable to tolerate them. The insurance company's criteria seemed to be having failed a 4 week trial of, or been unable to tolerate, two medications.<br />
<br />
A number of months ago, I had tried to get a PA for a new med for this patient, and the application was rejected, despite the fact that the criteria were obviously met. I didn't have the energy to pursue it then, and there were one or two more covered meds left to try.<br />
<br />
The difference now seems to be that I've since had a Genesight test done on this patient. As I've described in the past, I have my doubts about the whole <a href="https://psychpracticemd.blogspot.com/2016/06/in-genes.html" target="_blank">genetic testing business</a>, but I used the test results as documentation to support my rationale. M was in the "Green Column", and the other meds in that column had already been tried.<br />
<br />
It worked! Who knew? I'm only guessing that that's the reason, but I can't think of any other difference. Same patient, same insurance company.<br />
<br />
It wasn't a pure victory, though. This medication has a starter pack that's used to titrate gently. THAT wasn't approved. And using a single dose form, starting lower, and then increasing the number of pills per day, well, that wasn't covered, either, because it involved too many pills. What I needed to do was skip the recommended titration, and go straight to the next dose up. Not dangerous, but possibly hard to tolerate.<br />
<br />
To me, it feels like a punishment for asking the insurance company to cover the medication.<br />
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I guess with insurance companies, you take what you can get.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-23589724252675436642016-09-27T12:13:00.000-04:002016-09-27T12:13:09.899-04:00ICD-10 ChangesI know it's been forever. I have actually been super busy. I still am, but since this is timely and important, I thought I'd post something.<br />
<br />
There are ICD-10 changes that go into effect on October 1st. These are intended to correspond to recent changes in DSM-5. I suppose it should now be called DSM-5.1.<br />
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These are the changes:<br />
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I hope this is helpful.PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-17308049918858623172016-08-05T00:01:00.000-04:002016-08-05T00:01:02.466-04:00Laziness<br />
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I'm very curious about the idea of laziness. "Lazy" is one of those words we throw around as though everyone understands what it means and agrees on its definition. Kind of like, "Love". But I don't think anyone honestly knows what lazy means. I'm not sure it even has a meaning. I think what is really meant by, "He's so lazy," is, "I don't understand why he's not doing the things I think he should be motivated to do, or that I would be doing in his position."<br />
<br />
I'm hard pressed to think of an instance in which the word lazy is used in a non-pejorative way. At least in reference to a person or an animal. Rivers and summer days are exempt from this criticism.<br />
<br />
I searched Pep-Web to see if the concept is addressed in the analytic literature, and there were a lot of hits for "laziness" (343) and "lazy" (806), but none in a title, and while I didn't go through every one, the ones I did look at all seemed to be either quoting someone speaking about himself or someone else, or describing someone, and all with the assumption that no elaboration was needed as to what was meant by "laziness" or "lazy".<br />
<br />
I'll share a multilayered thought I just had. I generally make an effort to write correctly, which means that there's a comma before quotes, and the first word of a quote is capitalized, and the ending punctuation is within the quotes, even though that's weird. Or, "That's weird." Not, "that's weird". But it's not always clear to me what to do when I'm referring to an individual term. Do I place a comma before, "Lazy?" Do I always need to put quotes around, "Lazy?" Do I capitalize , "Lazy," if I use it over and over again? Do I place the punctuation within the quotes if it's just a word I'm defining, like, "Lazy"?<br />
<br />
I assume I should do the same thing with "lazy" that I do with longer quotes, but I don't always do so. And my thought was, I'm just too lazy to bother.<br />
<br />
Then I thought about Frank McCourt in Angela's Ashes, where he doesn't bother to use quotes, but he manages to write in such a way that you're never confused about who's saying what. Presumably, he's mimicking Joyce. So who cares whether I get the punctuation right or not? The whole purpose of punctuation is to make yourself understood, and if readers know what I mean, what difference does it make?<br />
<br />
I'm impressed by how easily I fell into using the catchall term, "Lazy," to explain why I don't always punctuate correctly. But I'll get back to this.<br />
<br />
I Googled, "What is Laziness?" and after the definition: <i>the quality of being unwilling to work or use energy; idleness</i>, I linked to an article by Neel Burton, MD, in Psychology Today, <a href="https://www.psychologytoday.com/blog/hide-and-seek/201505/the-causes-laziness" target="_blank">The Causes of Laziness</a>.<br />
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It's not a bad article, but the explanations are a bit simplistic: We haven't evolved enough past our ancestral need to conserve energy and to assume life will be short so why plan for the future; We prefer immediate gratification to long-term goals; We can't see the purpose of our work; We're afraid of success; We're afraid of failure so we don't try.<br />
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Now back to my previous point. I don't think anyone knows much about why she does what she does. Even less about why someone else does what he does. You can get at some unconscious content in analysis, but there will always be mysterious actions and thoughts.<br />
<br />
What I do notice is that when I have to make a decision about how to punctuate, it causes a slight twinge of anxiety. Am I doing this right? Is my meaning clear if I don't do it right? Why do I care? Do I care?<br />
<br />
Clearly, I do.<br />
<br />
I'm reminded of Otto Fenichel's paper, <a href="https://static1.squarespace.com/static/53a79084e4b01786c921de45/t/53a86478e4b009ec07711b38/1403544696336/On+the+Psychology+of+Boredom+%28Fenichel%2C+1951%29.pdf" target="_blank"><i>On the Psychology of Boredom</i></a>. Fenichel describes a particular kind of boredom, a sort of ennui, in which the bored person can never settle into any particular activity. Fenichel's understanding of this is that it reflects a warded off, unacceptable wish. So the bored person wants something, but is unable to allow himself to know what it is he wants, because he's conflicted about it, and it makes him anxious. So instead, he searches for something to satisfy the wish, but of course, nothing does, because he doesn't consciously know what he's wishing for.<br />
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Laziness is not directly related to boredom, though obviously it can be, in some instances. The common thread here is anxiety generated by unconscious content-likely conflict. And it's hard to assess motivation when there's all sorts of unconscious fermentation going on.<br />
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My final association: I read a story when I was a kid, and I still don't quite understand it. It was a Chinese fable about a lazy boy who never did anything his mother asked. He never helped out at home. He never did any kind of work. He was just a lazy good-for-nothing. Then one day, there was some kind of threat to his family, and the boy got up and deftly handled the situation, and saved the day.<br />
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The End.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-78725637135769501202016-07-27T22:59:00.001-04:002016-07-27T22:59:08.638-04:00Good and Bad IdeasToday, NY State sent <a href="https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/InsuranceCircularLetter4.pdf" target="_blank">a letter</a> to insurance companies, telling them they better comply with parity laws, and that they'll be checking up to make sure the insurers are keeping in line. Specifically, the letter was written to "remind" insurers that<br />
<br />
<i>MHPAEA (Mental Health Parity and Addiction Equity Act) prohibits issuers whose</i><br />
<i>policies or contracts provide medical and surgical benefits and MH/SUD benefits from applying</i><br />
<i>financial requirements, quantitative treatment limitations (“QTLs”), and NQTLs to MH/SUD</i><br />
<i>benefits that are more restrictive than the predominant financial requirements or treatment</i><br />
<i>limitations that are applied to substantially all medical and surgical benefits covered by the plan...</i><br />
<br />
<i>...state regulators [will] further review the processes, strategies, evidentiary standards, or other factors used inapplying the NQTL to both MH/SUD and medical and surgical benefits to determine parity </i><i>compliance:</i><br />
<i><br /></i>
<i>• preauthorization and pre-service notice requirements;</i><br />
<i>• fail-first protocols;</i><br />
<i>• probability of improvement requirements;</i><br />
<i>• written treatment plan requirement; and</i><br />
<i>• other requirements, such as patient non-compliance rules, residential treatment limits,</i><br />
<i>geographical limitations, and licensure requirements.</i><br />
<i><br /></i>
<i>Accordingly, issuers are advised that the Department of Financial Services will be reviewing</i><br />
<i>issuers’ NQTLs and QTLs to ensure that issuers fully comply with MHPAEA and will take</i><br />
<i>necessary action in the event of any non-compliance.</i><br />
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Some <a href="http://lac.org/wp-content/uploads/2014/12/November_2013_Parity_FAQs_copy.pdf" target="_blank">additional NQTLs</a> are:<br />
<br />
"...treatment limitations based on geography, facility type, provider specialty, and the criteria limiting the scope or duration of benefits or services."<br />
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This is a good idea, enforcing rules for insurance companies. But I worry about certain bad ideas. In fact, I have a sneaking suspicion that insurance companies pay lawyers or others so inclined large sums of money to sit around all day and come up with new bad ideas by finding ways to comply with parity laws, but still hinder or delay reimbursement.<br />
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I've written <a href="https://psychpracticemd.blogspot.com/2014/01/a-new-low.html" target="_blank">previously</a> about one of these bad ideas, namely, an insurance company's demand that I provide proof that my patient requires out of network services. I almost fell for this and started researching articles on continuity of treatment, etc., until Dinah from <a href="http://psychiatrist-blog.blogspot.com/" target="_blank">Shrink Rap</a> pointed out that the insurance company doesn't need to cover out of network services, but if they do cover out of network, the patient doesn't need to justify not using in-network care.<br />
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Other egregious examples are stalling and finally informing the patient that the claims were never submitted, or that they were lost, and then sometimes even more egregiously, when the claims are resubmitted, the insurance company comes back and says it's too late to submit.<br />
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Or prior authorization. I tried to get Brintellix, now Trintellix (because Brintellix sounds too much like some other drug) approved, got rejected, appealed by filling out a long form that met every criterion for approval, got rejected again, and finally decided it's a crappy drug anyway, and not worth the effort.<br />
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A recent gem involved asking the patient's spouse, who is the primary insured, to call the insurance company to verify or "prove" that the patient has no other insurance (Doesn't, never did).<br />
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And I'm quite convinced that these stalling tactics are effective overall, because some percentage of them will not be pursued by patients. That percentage is a gold mine for insurance companies. And mental health patients are perhaps more susceptible than most to this hindrance, since things like depression, psychosis, and anxiety can get in the way of accomplishing tiresome, long, and frustrating tasks like talking to insurance companies.<br />
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Anyone else have insurance horror stories?PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-20181529038417164522016-07-21T17:10:00.003-04:002016-07-21T17:10:58.989-04:00The Gene GenieIn response to my recent post, <a href="https://psychpracticemd.blogspot.com/2016/06/in-genes.html" target="_blank">In the Genes?</a>, I got the following email message:<br />
<br />
<i>Dear PsychPractice,</i><br />
<i>I am a genetic counselor for Assurex Health, the company behind GeneSight. We read your recent blog post comparing <a href="http://genesight.com/" target="_blank">Genesight</a>, the Genecept Assay, and Genelex with interest, and I wanted to reach out to you concerning a couple items that you may not have run across in your search of GeneSight. While much of what you wrote about GeneSight is accurate, some of it is outdated. For example, GeneSight Psychotropic now includes 12 genes, not 5. Based on the images of the report in your blog, I wonder if perhaps you pulled the images from our Pine Rest (Winner et al, 2013) study? This study was published in 2013, at a time when GeneSight had 5 genes. GeneSight has since been updated and currently includes 12 genes. Additionally, 4 other studies on GeneSight have been published, as well as 2 meta-analyses of these data, all of which were statistically significant. </i><br />
<i><br /></i>
<i>If you are interested in receiving any of these studies, please let me know and I will send them to you. You may also be interested in white papers on GeneSight genes that outline all current research in the context of psychiatric pharmacogenomics. We have also created white papers on genes we choose not to add to GeneSight due to lack of clinical utility. </i><br />
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Somehow, I thought I had gotten the image I used, with the list of genes, from the Genesight site. So I went there to look for it again, and I couldn't find it. So then I tracked down where I found the image, by scrolling through my browser history, and it was here:<br />
<br />
<a href="http://www.discoverymedicine.com/Joel-G-Winner/2013/11/08/a-prospective-randomized-double-blind-study-assessing-the-clinical-impact-of-integrated-pharmacogenomic-testing-for-major-depressive-disorder/" target="_blank">Winner, Joel G; <i>A prospective, Randomized, Double-Blind Study Assessing the Clinical Impact of Integrated Pharmacogenomic Testing for Major Depressive Disorder; Discovery Medicine</i>; ISSN: 1539-6509; Discov Med 16(89):219-227, November 2013</a>.<br />
<br />
I guess it was from the Pine Rest study, and yes, I suppose it is outdated. And I'm pretty sure I looked up the paper because I couldn't find much information about which genes Genesight uses on their site.<br />
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I checked again just now, and it took a while for me to find it, but they do have <a href="https://genesight.com/new/" target="_blank">a description of all the genes they're testing</a>, including four new ones.<br />
<br />
Pharmacokinetic:<br />
<br />
UGT2B15<br />
CYP2D6<br />
CYP2C19<br />
CYP2C9<br />
UGT1A4<br />
CYP3A4<br />
CYP2B6<br />
CYP1A2<br />
<br />
Pharmacodynamic:<br />
<br />
HLA-A*3101<br />
HLA-B*1502<br />
HTR2A<br />
SLC6A4<br />
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The UGTs and HLAs are the new ones.<br />
<br />
So now we've got that straightened out. My apologies to Genesight for propagating outdated information.<br />
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That said, since publishing that last post, I have used Genesight. Yes, I have. I chose it partially for reasons having to do with insurance coverage.<br />
<br />
I had to meet with a rep. I tried to tell him, via email, that all I needed was a test kit. He insisted that we had to meet in person, and that it would only take 15 minutes. We scheduled and rescheduled, mostly because I was annoyed about the waste of my time so I didn't prioritize the time slot. Maybe that sounds obnoxious, but I felt I was giving up my time, and therefore money, so he and his company could make more money. I was paying to make him money.<br />
<br />
He asked if he should just bring along a lunch. I flat out said no. When he got to my office, he had a bag with lunch, from Panera. I refused it, and I'm really proud of this fact because I was super hungry.<br />
<br />
The meeting took closer to 40 minutes, with most of my time spent sitting quietly and waiting while the rep talked on the phone to his IT people, to figure out the new tablet system they were using. When the rep did talk to me, there was emphasis on the fact that the tests are covered by medicare. Maybe that makes them more respectable. I don't know. I was also told I'd be receiving 10 more kits in the mail shortly. I was encouraged to use them on new patients, and asked about when I do my chart review, in the mornings or evenings. I tried to explain that I don't have a high volume practice, and it doesn't work that way. He also mentioned something about my EMR, and looked a bit nonplussed when I nodded towards my file cabinet and said, "I don't use one."<br />
<br />
I did the test on a Monday. You do two buccal swabs-1 per cheek, 10 seconds each. Then you put the swabs in an envelope and seal it. You add a consent form and the swab envelope to a larger envelope, seal that, and send it out via Fedex-it's already labeled and paid for overnight shipment. This sounded easy, but I wanted it sent off that day, my doorman wasn't sure when or whether Fedex would be in the building, and the closest Fedex drop box had been shut down some time ago. So I wandered around a bit til I found a place. More lost time and money. I had tried to contact Fedex to come pick it up, but their site didn't work properly, so I had to wander.<br />
<br />
Also, it was a little confusing, because you don't include an order form. Instead, you login to your Genesight account and order the test there (You can print out and use an order form, but only if you don't use the online system). They give you an order number, but there's nowhere to record it on anything you mail in. I wrote it on the swab envelope, anyway.<br />
<br />
The results came in at 10pm on Wednesday night, which is probably within the 36 hour turnover time. I can't get into the clinical details, but the test results were about as helpful as I expected. The pharmacokinetic stuff was fair. They suggested some dose adjustments that might be helpful. They also yellow-boxed, meaning use, but with caution, a couple meds that have caused serious side effects in this patient, in the past.<br />
<br />
The pharmacodynamic stuff was not particularly good. Meds were recommended that have been of little or no use in the past, or have actually had deleterious effects. I didn't expect much of this aspect, so I wasn't too disappointed. I already knew that genetic testing that's supposed to predict which drugs will be helpful is not ready for prime time, yet.<br />
<br />
The best I can say for Genesight, so far, is that it made one potentially useful suggestion, and it seems to be covered by insurance, or if it isn't, it has a decent financial assistance plan, with patients who make less than $50K per year paying $20 for testing. Will I use it again? Hard to say.<br />
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<b><span style="font-size: large;">David Bowie: The Jean Genie</span></b></div>
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-27834103242698239092016-07-06T16:41:00.001-04:002016-07-06T16:41:32.277-04:00Keeping Mum<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfogJeZji7M6oo8BTv3o2arKr7XQkz3mKREd8_FzfxhAJ1XbtfKKSsgc2godP1fMjYR1xMbsxTZoI6bZqGbsxKlhJrg1GEpVexnwJCVNgtNmqUGDKkfIUY2Wgz76Q9P3MTtCklTplPGm4/s1600/Hippocrates.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfogJeZji7M6oo8BTv3o2arKr7XQkz3mKREd8_FzfxhAJ1XbtfKKSsgc2godP1fMjYR1xMbsxTZoI6bZqGbsxKlhJrg1GEpVexnwJCVNgtNmqUGDKkfIUY2Wgz76Q9P3MTtCklTplPGm4/s400/Hippocrates.jpg" width="271" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Hippocrates</td></tr>
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This post was prompted by an article written by <a href="http://www.badscience.net/" target="_blank">Ben Goldacre</a> in The Guardian, <i><a href="https://www.theguardian.com/commentisfree/2014/feb/28/care-data-is-in-chaos" target="_blank">Care.Data is in Chaos. It Breaks My Heart</a></i>. The article is about the Health and Social Care Information Centre (HSCIC, in the UK), which, "admitted giving the insurance industry the coded hospital records of millions of patients." These records, according to Goldacre, were line for line, and could be decoded by anyone with an inclination to do so. The purpose of this "gift", by the way, was for the insurance companies' actuaries to figure out premiums, based on likelihood of death (or illness, I assume).<br />
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<i>Useless Fun Fact: Years ago, in another professional trajectory, I passed the first of the however many actuarial exams.</i><br />
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Anyway, then the HSCIC said it couldn't share documentation on this release of information, presumably because it's more important to protect insurance company privacy than patient privacy.<br />
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Summarily, in Goldacre's words, "...a government body handed over parts of my medical records to people I've never met, outside the NHS and medical research community, but it is refusing to tell me what it handed over, or who it gave it to, and the minister is now incorrectly claiming that it never happened anyway."<br />
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So I started to think about patient privacy, including a long-ago post, <a href="https://psychpracticemd.blogspot.com/2013/06/what-exactly-is-hipaa.html" target="_blank">What, Exactly, Is HIPAA?</a>, where I wrote that I would follow-up with more information about privacy, and I never did. Incidentally, I've looked, and I still haven't found any contradictory information about what constitutes a HIPAA covered entity, and I'm still convinced that I'm not one, because I don't bill patients electronically.<br />
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So I was wondering, what is the difference between privacy and confidentiality, as they relate to patients? And I found <a href="http://healthinformatics.uic.edu/resources/articles/confidentiality-privacy-and-security-of-health-information-balancing-interests/" target="_blank">this article</a> (Prater), which was helpful.<br />
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Basically, <b>confidentiality</b> is the, "...obligation of professionals who have access to patient records or communication to hold that information in confidence," while <b>privacy</b> is the, "...right of the individual client or patient to be let alone and to make decisions about how personal information is shared."<br />
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In other words, confidentiality is my professional, or at least ethical obligation to my patients, while privacy is a patient right I need to respect. From this I infer that technically, my patients do not have a right to confidentiality, and I don't have an obligation to protect patient privacy.<br />
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Here are some more details.<br />
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<b>Confidentiality</b><br />
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Confidentiality goes back, at least, to the Hippocratic Oath:<br />
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<i>And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.</i><br />
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It is a cornerstone of professional association codes of ethics. The <a href="http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion505.page?" target="_blank">AMA's code of Ethics, Opinion 5.05</a>, states:<br />
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<i>The information disclosed to a physician by a patient should be held in confidence. The patient should feel free to make a full disclosure of information to the physician in order that the physician may most effectively provide needed services. The patient should be able to make this disclosure with the knowledge that the physician will respect the confidential nature of the communication. The physician should not reveal confidential information without the express consent of the patient, subject to certain exceptions which are ethically justified because of overriding considerations.</i><br />
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And don't forget about <a href="http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion5051.page?" target="_blank">postmortem confidentiality</a>:<br />
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<i>All medically related confidences disclosed by a patient to a physician and information contained within a deceased patient’s medical record, including information entered postmortem, should be kept confidential to the greatest possible degree...At their strongest, confidentiality protections after death would be equal to those in force during a patient’s life. Thus, if information about a patient may be ethically disclosed during life, it likewise may be disclosed after the patient has died.</i><br />
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In reading this stuff, I also found that the AMA has a slightly different slant on the <a href="http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion5059.page?" target="_blank">definitions of privacy and confidentiality:</a><br />
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<i>In the context of health care, emphasis has been given to confidentiality, which is defined as information told in confidence or imparted in secret. However, physicians also should be mindful of patient privacy, which encompasses information that is concealed from others outside of the patient-physician relationship.</i><br />
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An example of support for the legal status of confidentiality, as the privileged communication between patient and doctor, can be found in <a href="https://scholar.google.com/scholar_case?case=365976032268433131&hl=en&as_sdt=6&as_vis=1&oi=scholarr" target="_blank">Jaffee v. Redmond</a>, where the, "...U.S. Supreme Court upheld a therapist’s refusal to disclose sensitive client information during trial." (Prater)<br />
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<i>Effective psychotherapy...depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories, and fears. Because of the sensitive nature of the problems for which individuals consult psychotherapists, disclosure of confidential communications made during counseling sessions may cause embarrassment or disgrace. For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment. </i>(p.10, Jaffee v. Redmond)<br />
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<b>Privacy</b><br />
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There is no constitutional right to medical privacy. Rather, healthcare privacy rights, "...have been outlined in court decisions, in federal and state statutes, accrediting organization guidelines and professional codes of ethics." (Prater)<br />
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The big example is HIPAA. Subject to HIPAA, "Individuals are provided some elements of control, such as the right to access their own health information in most cases and the right to request amendment of inaccurate health information...However, in [the] attempt to strike a balance, the Rule provides numerous exceptions to use and disclosure of protected health information without patient authorization, including for treatment, payment, health organization operations and for certain public health activities..."(Prater)<br />
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I've been trying to read through the relevant parts of <a href="https://www.gpo.gov/fdsys/pkg/CFR-2007-title45-vol1/pdf/CFR-2007-title45-vol1.pdf" target="_blank">this ponderous document about HIPAA</a>, and on pages 757 and following, in part Squiggle164.512, <b>Uses or Disclosures for which an Authorization or Opportunity to Agree or Object is not Required</b>, I found what appear to be a number of these exceptions to the "privacy" provided by HIPAA. I think. I'm not a lawyer. Such as:<br />
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a) required by law<br />
b) public health activities<br />
c) victims of abuse, neglect, or domestic violence<br />
d) health oversight activities<br />
e) judicial and administrative proceedings<br />
f) law enforcement purposes<br />
g) about decedents, i.e. coroners, ME's, funeral directors<br />
h) cadaveric organ, eye, or tissue donation purposes<br />
i) research purposes<br />
j) aversion to serious threat to health or safety<br />
k) specialized government functions<br />
j) worker's compensation<br />
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There are many specifics, including disclosing information to a patient's employer, but I'll leave those as an exercise for the reader.<br />
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Point being, HIPAA does little to protect patient privacy. I think the value of HIPAA is that it attempts to delineate what patient privacy rights are, and that it has succeeded in making people aware that the privacy of their medical information is vulnerable. It does not solve this difficulty, which becomes hugely magnified by the use of electronic health records. This leads to consideration of one more important term, <b>security</b>, or the means by which patient information is protected, such as a locked filing cabinet, or encrypted data.<br />
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What I glean from all this is that there is at least a notion of a patient's right to privacy, which I should try to respect. But that my standards for protecting patient information are much higher than anything HIPAA has to say.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-77572984361904236902016-06-29T15:40:00.000-04:002016-06-29T15:40:19.192-04:00In the genes?<br />
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I'm starting to look into genetic testing to help my work with patients who have not responded well to multiple psychotropic medications. It feels like a desperate bid, but I'm not sure what other help I can offer.<br />
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There are three main testing products, that I could find:<br />
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<a href="http://genesight.com/" target="_blank">Genesight</a><br />
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<a href="http://genomind.com/" target="_blank">Genecept Assay</a><br />
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and<br />
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<a href="http://genelex.com/" target="_blank">Genelex</a><br />
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I have three main questions about these products:<br />
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1. What do they tell me?<br />
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2. How accurate/helpful are they?<br />
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3. How easy are they to use?<br />
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Genesight<br />
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Genesight seems to be the one mentioned most by people I asked. Practically speaking, it involves a buccal swab sent to Genesight via prepaid FedEx, with access to results online 36 hours after the sample is received. They are covered by some insurance plans, and have a financial assistance program. And it looks like, in order to try out the test, you need to speak with one of their representatives-there's no way to order online.<br />
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In terms of how well it works, their claim is, "Patients with uncontrolled symptoms who switch off of genetically discordant medications show the greatest reduction in depressive symptoms."<br />
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They also claim that, "70% of patients who have failed at least one medication are currently taking a genetically sub-optimal medication," and that, "GeneSight testing may help avoid drug-drug interactions and compounding side effects."<br />
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Finally, for patients younger than 18, Genesight can help in decisions about efficacy, tolerability, and dosing.<br />
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They site a paper, <i><a href="http://www.discoverymedicine.com/Joel-G-Winner/2013/11/08/a-prospective-randomized-double-blind-study-assessing-the-clinical-impact-of-integrated-pharmacogenomic-testing-for-major-depressive-disorder/" target="_blank">A prospective, randomized, double-blind study assessing the clinical impact of integrated pharmacogenomic testing for major depressive disorder</a>, </i>the results of which were:<br />
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<i>Between-group trends were observed with greater than double the likelihood of response and remission in the GeneSight group measured by HAMD-17 at week 10. Mean percent improvement in depressive symptoms on HAMD-17 was higher for the GeneSight group over TAU (30.8% vs 20.7%; p=0.28). TAU subjects who had been prescribed medications at baseline that were contraindicated based on the individual subject's genotype (i.e., red bin) had almost no improvement (0.8%) in depressive symptoms measured by HAMD-17 at week 10, which was far less than the 33.1% improvement (p=0.06) in the pharmacogenomic guided subjects who started on a red bin medication and the 26.4% improvement in GeneSight subjects overall (p=0.08).</i><br />
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You'll notice that they talk about "trends" without any statistics, and mean percent improvement showed no significant difference (p=0.28), even though they point out that improvement in the Genesight group was higher. Recall that p=0.28 means there is a 28% chance that the differences they found were due to chance alone.<br />
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The "red bin" is a reference to the way Genesight presents its results, which I find easy to understand, if not entirely illuminating. This is an example:<br />
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I don't get the impression that the results give me information about which drugs will be helpful, as much as which drugs won't be harmful.<br />
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How does the test work? Genesight measures polymorphisms among 5 genes, CYP2D6; CYP2C19; CYP1A2; the serotonin transporter gene, SLC6A4; and the serotonin 2A receptor gene, HTR2A.<br />
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The CYP genes are clearly measures of rates of metabolism. A repeat length polymorphism in the promoter of SLC6A4 has been shown to affect the rate of serotonin uptake. The implications of this fact are not clear to me, but according to <a href="https://en.wikipedia.org/wiki/Serotonin_transporter#Genetics" target="_blank">Wikipedia</a>, genetic variations in the SLC6A4 gene have resulted in phenotypic changes in mice, including increased anxiety. HTR2A influences serotonin transporter binding potential, and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1474035/" target="_blank">variations in the gene have been associated with variations in outcome in treatment with citalopram</a>.<br />
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So the answers to my three questions, for Genesight, are:<br />
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1. It tells me which drugs are more and less safe and tolerable to use. And if I accept their conclusion that patients switched off red bin drugs improved significantly, then perhaps it tells me which drugs will be effective, but I'm skeptical about this part.<br />
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2. The results are less impressive than they'd like me to think.<br />
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3. Results are clear and easy to read. Turnover time is good. Getting hold of a test is not that easy.<br />
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Genecept Assay<br />
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The <a href="https://genomind.com/clinician-faq/" target="_blank">genecept FAQ page</a> is much more informative than the Genesight pages. The test can be ordered online or by phone. It's covered by most insurance and they have a patient assistance program. Turnaround time is 3-5 business days from receipt of the sample, also a buccal swab, and they provide expert staff to help interpret results.<br />
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The online order form also gives you the option of becoming a "Preferred Provider", which means they'll send patients who are looking for genetic testing to you.<br />
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As for function:<br />
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<i>The Genecept Assay® report is intended to aid clinicians in making personalized treatment decisions tailored to a patient’s genetic background and helps to inform psychiatric treatments that:</i><br />
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<i>Are more likely to be effective</i><br />
<i>Have lower risk for side effects and adverse events</i><br />
<i>Are dosed appropriately</i><br />
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The report consists of two pages, and looks like this:<br />
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So they look at more genes than Genesight, and they provide one report about what's safe to use, and another about what's potentially helpful. And in all honesty, I don't have the energy right now to look up how believable their first page markers are in terms of efficacy, and I think I would need their help to interpret these results, but they do provide more information than Genesight.<br />
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Answers:<br />
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1. Safety, tolerability, and efficacy<br />
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2. I'm too tired to check<br />
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3. Easy to get the test, harder to interpret results<br />
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Genelex<br />
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Genelex allows you to order tests online, too. They claim there is some insurance coverage (See *, below), they have some fancy software that's supposed to be helpful, in addition to their report, and they have a 3-5 day turnaround time.<br />
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Genelex restricts itself to CYP450 genes, but it includes three that Genesight doesn't, 3A4, 3A5, and 2C9, but doesn't include 1A2. <a href="http://genelex.com/wp-content/uploads/2014/11/YouScript_2015_Primary_Care_Personalized_Prescribing_Sample_Report.pdf" target="_blank">This is a link</a> to a sample result, which is too long to include as an image. And like Genesight, it's mainly about what is and isn't safe or tolerable to take.*<br />
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*Actually, I just learned on the FAQ page that Genelex also includes CYP1A2; NAT2;DPD Enzyme; UGT1A1; 5HTT; and HLA-B*5701, but that these are generally not covered by insurance. I also couldn't figure out what data these additional tests provide.<br />
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Answers:<br />
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1. Safety, tolerability, maybe efficacy?<br />
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2. For the CYP tests, same as above, for others, I don't know<br />
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3. The software seems like overkill. The report is clear and moderately informative. You can order the test online.<br />
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That's it for this topic, for now, for me. I have yet to decide whether I'm going to use any testing.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-57576308567002573382016-06-23T13:25:00.000-04:002016-06-23T13:25:24.494-04:00Virtually CertifiedA while back, I wrote about <a href="https://psychpracticemd.blogspot.com/2014/07/virtual-care-physician.html" target="_blank">HealthTap</a>, a platform that allows people to ask doctors questions in almost real time. The company was also developing a system for virtual care, and I recently received an email suggesting I take <a href="https://www.cmeuniversity.com/course/content/112629" target="_blank">an online course</a>, worth 2 CME credits, to be certified in said virtual care.<br />
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I was curious about the progress in this field, so I did take the course, and am now officially certified. I also accidentally clicked an "okay" button, thinking it would allow me to print out my certificates. But it was the wrong button. The button I wanted said, "certificate only", but I didn't see it in time. The "okay" button indicated that I was allowing myself to be part of the HealthTap network of physicians. I didn't really want that, but I suppose it doesn't matter since I'm not going to do anything with it. So watch out for this if you decide to try it.<br />
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What I was mainly interested in, in the course, were the legal and regulatory issues related to virtual care. And I did learn a couple things. For instance, you do need to be licensed in your patient's state in order to provide virtual care. I don't know if that means the state where the patient resides, or just the state the patient is in when seeing you. I would guess the latter, since I can treat patients, in person, who live in neighboring New Jersey or Connecticut for example, where I'm not licensed, as long as they see me in my New York office.<br />
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Incidentally, you don't need to be licensed in any particular state to virtually treat patients outside the US.<br />
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The course referenced the <a href="http://www.licenseportability.org/" target="_blank">Interstate Medical Licensure Compact</a>, which, "Creates a new pathway to expedite the licensing of physicians seeking to practice medicine in multiple states. States participating in the Compact agree to share information with each other and work together in new ways to significantly streamline the licensing process."<br />
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A number of states have already enacted legislature that will allow this expedited pathway to proceed, and other states have introduced such legislation. Still others, such as New York, have done neither. One interesting point I noted is that in order to use this expedited system, you need to be primarily licensed in a state that has already enacted the legislature. So if I want to virtually care for patients in Montana, which has enacted this legislature, I can't, because I'm licensed in New York, which hasn't.<br />
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That point is irrelevant, though, since there is currently no administrative process for applying for this pathway, although they state that there, "...will be soon."<br />
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The video mentioned that there are CPT codes for virtual care, ranging from 99441 for a 5-10 minute telephone Eval/Management consultation, to a 99444 for an online E/M, to a 99446 inter-professional 5-10 minute consult, to a 99490 <u>></u> 20 minutes of chronic care management. But most virtual care billing is done using the same CPT codes that would be used for a regular office visit, with a GT modifier, e.g. 99213 GT.<br />
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Most importantly, 25 states with parity laws, plus Washington DC, have enacted "...legislation requiring private insurers to pay for Virtual Care at the same level as equivalent in-person services, provided the care is deemed medically necessary."<br />
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According to <a href="http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf" target="_blank">this document</a>, in New York, "The law
requires telehealth parity under
private insurance, Medicaid, and state
employee health plans. The law does
restrict the patient setting as a
condition of payment."<br />
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This image depicts which states make it easy to provide virtual care (A is best), and which make it difficult (I'm not sure what the * means):<br />
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Aside from that, the course touts the virtues of virtual care, claiming that in some ways, it's superior to in-person care, and giving examples, such as the fact that patients have quicker access to virtual care. They also claim that many, if not most, common complaints can be treated virtually, and a lot of monitoring can be done at a distance, e.g. glucose. In addition, they mention the use of wearable devices for tracking activity, etc., and the up and coming virtual examination tools, like <a href="https://www.clinicloud.com/" target="_blank">stethoscopes</a>.<br />
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The video is careful to note situations which require in-person treatment, such as a wheezing infant, or chest and jaw pain in a 68 year old man.<br />
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A bit comical were the presentations. For a company that's promoting care via video-conferencing, they should probably have gotten better people to present in their video. One guy had shifty eyes, another had drooping eyelids and looked like he was falling asleep and forgetting what he needed to say, yet another guy looked like his shoulders were hiked up to the point of having no neck.<br />
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While I definitely prefer in-person work, I can see where psychiatry, and especially psychotherapy, are amenable to virtual care, probably more-so than specialties that require a physical examination. But given the regulatory and legal limitations, I'm not ready to go there, yet.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-55239491223611468932016-06-13T11:49:00.001-04:002016-06-13T11:49:52.549-04:00OrlandoThe mass shooting in Florida has left me nearly speechless. But I want to post something because silence is the wrong response. <div><br></div><div>Maybe I could write something useful about hate crimes or terrorism or psychotic enactments, but that would imply I have some understanding of this tragedy, and I don't. </div><div><br></div><div>All I have is sadness, and my heart goes out to the victims and their loved ones. </div>PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-23327299657476730072016-06-07T16:42:00.001-04:002016-06-07T18:21:37.089-04:00Film Review-In A Town This SizeI recently learned about a documentary, <i><a href="http://www.inatownthissize.com/filmmaker--film-bios.html" target="_blank">In a Town this Size</a></i>, by photographer and filmmaker Patrick V Brown. It tells the story of the wealthy, Oklahoma oil town, Bartlesville, in which the pediatrician sexually abused many children over the course of many years. Brown, himself, was one of the victims.<br>
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I'm not really going to make this a review, as in, what did I like, what didn't I like, whether it's worth seeing. It <b>is</b> worth seeing, so please do. (That I know of, <i>In a Town this Size</i> is available on iTunes, on DVD from Netflix, and on Amazon Prime.) It addresses very important issues, aside from the obvious one of pedophilia. It addresses what it means to move from being a victim to being a survivor, to finding support, both within oneself and externally. It's also extremely well made, although quite simple-just interviews with a few interspersed pieces of footage and photographs. Mainly, I'm going to relate what it made me think about.<br>
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Dr. Bill Dougherty was a pediatrician and a prominent citizen in Bartlesville. He was friendly with the families of many of his patients, and was welcomed into their homes, and joined them on family vacations. Many of the adults considered him an "odd duck", because he had never married. Some assumed he was gay, but in that time and place, this was not a topic for discussion.<br>
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In the film, Brown interviews people who, as children, were abused by "Dr. Bill". He also interviews their family members, including his own parents, as well as a few lawyers and therapists. Everyone who was interviewed was articulate and thoughtful. In part, this is a product of Brown's skillful interviewing-sensitive but appropriately direct. But I suspect it's also a product of the innate selection bias in who volunteers to be interviewed for a film like this, and what parts of the interviews made the final cut.<br>
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But the interviews did hit home the point for me that Bartlesville is a wealthy, educated town. There is footage of the Price Tower, the only skyscraper designed by Frank Lloyd Wright, and commissioned by Harold C. Price, of the H. C. Price oil company. There is also footage of the home of Harold Price, Jr., which looks like a Lloyd Wright structure to me. And Harold Price, Jr. is one of the interviewed parents.<br>
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The status of the town is what, perhaps, informed the title of the film. I couldn't tell if the idea was, "Who would believe something like this could happen in such a small town with so much money and power?" or, "Who would believe everyone didn't know about what was happening?" I suspect the ambiguity is intentional.<br>
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Which brings me to the topic of denial. Brown, himself, told his parents about the abuse after it had happened several times, starting when he was around 6 years old. But a child that young has neither the language nor the emotional wherewithal to describe sexual abuse, and the most he could come up with was, "He leaves his hands down there too long."<br>
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In their interviews, Brown's parents comment on their reactions. His father seemed to think he was talking about a normal genital exam, which is uncomfortable and embarrassing for everyone. His mother said that strange as it sounds now, maybe she'd heard of the word, "pedophile", but she couldn't imagine it applied to her family.<br>
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I was a bit outraged by their responses. I realize this is anachronistic of me, and their reactions to Brown's revelation were typical for the time, but even if you don't believe your child, don't you wonder? Aren't you at least a little suspicious? Don't you watch to see what your child's reaction is after the next pediatrician visit, or don't you insist on being present for the exam?<br>
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In fact, all but one of the parents interviewed say something along the lines of, "This sounds stupid now, but..."<br>
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Upon hearing that Dougherty had been accused of sexually abusing children, several of the parents went and comforted him. One ex-marine said he thought, "He's my friend. He'd never do that to me or my children. Besides, he knows I'd kill him."<br>
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Years later, after this man's sons revealed the abuse, his wife spent countless hours looking at photographs of her children from that period. The younger son's eyes are haunted. In retrospect, she says, she knew.<br>
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By all appearances in the film, Brown has a good relationship with his parents, and is working with his father, who is a lawyer, on changing the laws about the statute of limitations for reporting this kind of abuse. But I found myself outraged once more when he asked his father, "What made you finally believe me?"<br>
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The father's answer was that, as an attorney, he had gotten letters from other survivors of Dr. Bill's abuse, asking for legal help. He had to hear it from someone else in order to believe it.<br>
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Several of the survivors note that they don't feel angry at Dougherty. Some posit that this is because they don't have the self esteem to generate the anger. I wondered if their anger is threatening to them because it's not just towards Dougherty, it's towards their families, for not protecting them.<br>
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Based on the families interviewed, it seems like once it became clear, years after the fact, that the accusations of sexual abuse by Dr. Bill were true, the families did become very supportive of their children and of each other. The film, itself, is a testament to that.<br>
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My own reaction to Dougherty was interesting. Generally, after I get over the initial horror of a story like this, my mind goes to, "What could possibly have happened to this man to have turned him into such a monster?" There's some sympathy involved, even if the crimes are inexcusable.<br>
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But I really don't have that much sympathy for Dougherty. There's something terribly opportunistic and psychopathic about him. Some of the survivors suggested that there was premeditation in his choice of pediatrics. My first thought about that was skeptical. I thought he probably felt an irresistible pull towards pediatrics, even though he knew this was a problem for him, and then rationalized the choice by convincing himself that he understood children, and that that would make him a good doctor. Apparently, when he wasn't abusing his patients, he was a good pediatrician.<br>
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As the film proceeded, I was less convinced by my argument. Atypically for a pedophile, he abused both boys and girls, although it seemed like there was a predilection for boys. His patterns of abuse also varied, and the choice of behavior seemed to vary with what he thought he could get away with. Several men report having been masturbated by him on the examining table. One woman reports having him take her on his lap and try to get her to masturbate him, while on vacation. On that same vacation he paraded in front of her and her sister in his underwear, showing his penis. It also seems that he sodomized a boy he knew to have psychiatric problems, and to me, that sounds like he thought the boy's story wouldn't be credible.<br>
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When Harold Price, who I mentioned above, visited him to offer support after he had been accused of the sodomy, Dougherty said something like, "That's absurd. I would never do that. Besides, he was ugly."<br>
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Such was Dougherty's power over these children that Brown seems to be in a minority in telling his parents about the abuse. Most of the kids didn't say anything to anyone. They didn't feel threatened, and they weren't told not to say anything, they just didn't.<br>
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Incidentally, after the truth about his abuse had come out, while the statute of limitations for criminal charges had run out, he did lose his medical license. However, he is still alive and living in Bartlesville, leaving his home only in disguise. He recently got married, for the first time, to a woman, at age 81.<br>
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The final point that struck me was about forgiveness, and its different meanings. The ex-marine father, who is a religious Christian, was torn for a long time between killing Dougherty and forgiving him. After reading a lot of scripture, and a lot of soul searching, he decided to forgive him. He says it is easier said than done. What puzzled me was the man's description of seeing Dougherty at a church with a woman and her sons, and thinking, There go those kids down the tubes. Does his forgiveness preclude speaking out against Dougherty to protect those children?<br>
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Brown's mother says she can't forgive him because he's shown no remorse. She and other's have written him many letters, and he has never responded. And Brown, himself, says he's not interested in forgiving Dougherty. It made me think about whether forgiveness is more for the one being forgiven, or the one forgiving.<br>
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<i>In a Town this Size</i> tells a horrifying story in a sensitive way. I think this approach has a further reach than a film that was more graphic and less forward-looking would have. The real strength of the film lies in the question Brown asks all the survivors, "How has the abuse impacted your life?" This simple question places the emphasis on where the survivors are now, and where they're headed, which is why this is a film about survivors, not victims.<br>
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One of the most powerful scenes takes place towards the end, where Brown goes to Bill Dougherty's house to confront him. He knocks on the door -forcefully, not timidly-, we hear a dog bark, but no one answers. Brown paces back and forth with his hands on his hips and knocks again. Still, no answer.<br>
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There is tremendous pathos in witnessing the courage it must have taken Brown to try to confront his abuser, only to be disappointed. But even if Brown didn't succeed in confronting the external version of Dougherty, I hope that <i>In a Town this Size</i> did succeed in helping him confront the internal version of the monster that is Dr. Bill.<br>
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<br>PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-8178359758628836682016-06-01T11:58:00.002-04:002016-06-01T11:58:38.729-04:00A Tale of Two HospitalsThis is the story of two New York city hospitals, Mount Sinai, and Beth Israel.<br />
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According to Wikipedia. Mount Sinai was founded in 1852 as the Jews' Hospital, in response to discrimination against Jews by other hospitals, which would not treat or hire them. It is one of the oldest teaching hospitals in the US.<br />
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Also according to Wikipedia:<br />
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<span style="background-color: white; color: #252525; font-family: sans-serif; font-size: 14px; line-height: 22.4px;"><a href="https://en.wikipedia.org/wiki/Mount_Sinai_Beth_Israel" target="_blank">Beth Israel</a> was incorporated in 1890 by a group of 40 </span><a class="mw-redirect" href="https://en.wikipedia.org/wiki/Orthodox_Jew" style="background: none rgb(255, 255, 255); color: #0b0080; font-family: sans-serif; font-size: 14px; line-height: 22.4px; text-decoration: none;" title="Orthodox Jew">Orthodox Jews</a><span style="background-color: white; color: #252525; font-family: sans-serif; font-size: 14px; line-height: 22.4px;"> on the</span><a href="https://en.wikipedia.org/wiki/Lower_East_Side" style="background: none rgb(255, 255, 255); color: #0b0080; font-family: sans-serif; font-size: 14px; line-height: 22.4px; text-decoration: none;" title="Lower East Side">Lower East Side</a><span style="background-color: white; color: #252525; font-family: sans-serif; font-size: 14px; line-height: 22.4px;"> each of whom paid 25 cents to set up a hospital serving New York's Jewish immigrants, particularly newcomers. At the time New York's hospitals would not treat patients who had been in the city less than a year. It initially opened a </span><a href="https://en.wikipedia.org/wiki/Dispensary" style="background: none rgb(255, 255, 255); color: #0b0080; font-family: sans-serif; font-size: 14px; line-height: 22.4px; text-decoration: none;" title="Dispensary">dispensary</a><span style="background-color: white; color: #252525; font-family: sans-serif; font-size: 14px; line-height: 22.4px;"> on the Lower East Side. In 1891 it opened a 20-bed hospital and in 1892 expanded again and moved into a 115-bed hospital in 1902.</span><sup class="reference" id="cite_ref-findarticles.com_2-0" style="background-color: white; color: #252525; font-family: sans-serif; font-size: 11.2px; line-height: 1; unicode-bidi: isolate; white-space: nowrap;"><a href="https://en.wikipedia.org/wiki/Mount_Sinai_Beth_Israel#cite_note-findarticles.com-2" style="background: none; color: #0b0080; text-decoration: none;">[2]</a></sup><span style="background-color: white; color: #252525; font-family: sans-serif; font-size: 14px; line-height: 22.4px;"> In 1929 it moved into a 13-story, 500-bed building at its current location at the corner of </span><a href="https://en.wikipedia.org/wiki/Stuyvesant_Square" style="background: none rgb(255, 255, 255); color: #0b0080; font-family: sans-serif; font-size: 14px; line-height: 22.4px; text-decoration: none;" title="Stuyvesant Square">Stuyvesant Square</a><span style="background-color: white; color: #252525; font-family: sans-serif; font-size: 14px; line-height: 22.4px;">. It purchased its neighbor the Manhattan General Hospital in 1964 and renamed the complex Beth Israel Medical Center, located at First Avenue and 16th Street in Manhattan.</span><br />
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According to other verbal sources I've encountered, Beth Israel Hospital was founded in response to discrimination by Mount Sinai against poor Jewish immigrants on the lower east side. Mount Sinai would not treat them, but restricted its Jewish patients to middle- and higher-class Jewish immigrants from Germany.<br />
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I like to believe that this is the reason for the inscription on the entrance to the original Stuyvesant Square building:<br />
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It's a little hard to see, and it's in Hebrew, but roughly translated (by me) it reads:<br />
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<i>Welcome! Welcome! From far and near. So says the Lord and his Healers. </i>(Isaiah 57:19)<br />
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Hospitals in NYC are like 7th graders. They merge, split up, merge again with a different hospital, move around. For a while, Beth Israel belonged to a group of hospitals known as "Continuum," which included Albert Einstein Hospital, from which Beth Israel got its medical school affiliation. A few years back, Columbia Presbyterian joined up with New York Hospital Cornell, and became New York Presbyterian. These two hospitals are in very different parts of Manhattan, so the merger gave them access to a huge group of patients from diverse neighborhoods. My guess is that this was done for financial reasons. Then Mount Sinai decided to be even bigger, and subsumed Beth Israel, as well as St. Luke's/ Roosevelt (these two had merged years previously, and were formerly affiliated with Columbia).<br />
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For a little orientation, this is a map:<br />
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This gives you an idea of the current relationship statuses, which I've color coded. Mt. Sinai is the white star. Beth Israel, now called Mt. Sinai Beth Israel, is all the way downtown in red. It is the southern-most hospital in Manhattan.<br />
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Well, in case you didn't read it in the NY Times, <i><a href="http://www.nytimes.com/2016/05/26/nyregion/mount-sinai-beth-israel-hospital-in-lower-manhattan-will-close-to-rebuild-smaller.html?_r=0" target="_blank">Mt. Sinai Beth Israel Hospital in Manhattan Will Close to Rebuild Smaller.</a></i><br />
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The 825-bed Beth Israel will be closed over the next four years, to be replaced by a 70-bed hospital somewhere nearby, with an ER a few blocks away. Residents will be dispersed to other Mt. Sinai hospitals, union employees will be found new jobs. And according to an email I got from Mt. Sinai, where I'm affiliated, everyone else will be assisted in finding new employment. I suspect that's not precisely what will happen.<br />
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Ken Davis, President and CEO of the Mt. Sinai Health System (and former chair of psychiatry) explained that health care is too expensive, that Beth Israel lost $115 million last year and stood to lose $2 billion in the next 10 years, that hospitals are no longer the most efficient vehicles for delivering care, etc.<br />
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They plan to have 16 outpatient practice locations and 35 stand alone operating and procedure rooms.<br />
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Interestingly, from what I can tell, they plan to keep the psychiatry building, and expand its services. I assume the department actually makes some money, although I thought that was because of the rapid turnover on the Dual Diagnosis unit.<br />
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I worry about the impact on the community. There used to be 3 hospitals in Beth Israel's area, Beth Israel, itself, Cabrini, and St. Vincent's. Cabrini closed in 2008. St. Vincent's, much larger, and beloved by the community, closed in 2010. It's been replaced by some pretty fancy condos. Beth Israel is also situated in an extremely desirable neighborhood.<br />
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Going from 825 beds to 70? It may look like, what's the big deal, there are dozens of hospitals throughout NYC. But there are 8.5 million people living in NYC, plus people come in for treatment regularly from neighboring New Jersey and Connecticut.<br />
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Dr. Davis may be correct in stating that hospitals are not the future of medicine. But I don't believe 70 inpatient beds are adequate to the needs of all of lower Manhattan. We seem to have come full circle since 1890.<br />
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The word I translated above as "Welcome!" is Shalom, and the Hebrew word has multiple meanings. It can mean welcome, peace, and hello. It can also mean, "Goodbye."<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-33950494445285827452016-05-24T18:01:00.001-04:002016-05-24T18:01:45.948-04:00ODD Clinical TrialThis post is a sort of advertisement, except that no one's getting paid anything. A colleague of mine and his group just got a 2 year grant to conduct a trial of Regulation Focused Psychotherapy (RFP) for the treatment of Oppositional Defiant Disorder in children ages 5-12. This is the flyer:<br />
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That's the advertisement part. I think it's a great idea. But just to be clear, not only am I not being paid, I'm not involved in the study in any way except feeling pleased about it, and writing this post.<br />
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Why do I think it's a great idea? The American Academy of Child and Adolescent Psychiatry has <a href="https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/odd/odd_resource_center_odd_guide.pdf" target="_blank">a brochure</a> about ODD. It describes treatment for ODD, which includes a combination of Parent-Management Training Programs and Family Therapy, Cognitive Problem-Solving Skills Training, Social-Skills Programs and School-Based Programs, plus or minus medication.<br />
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These are all useful tools, but none of them addresses the underlying affects, and difficulty in regulating these affects, that children with ODD experience. That's where RFP comes in.<br />
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The group conducting the study recently published the <a href="https://www.routledge.com/Manual-of-Regulation-Focused-Psychotherapy-for-Children-RFP-C-with-Externalizing/Hoffman-Rice-Prout-Pacella-Parent-Child-Centre/p/book/9781138823747" target="_blank">Manual of Regulation-Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Psychodynamic Approach</a>.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRLlNI4JY6Hy7FlnZqEY19cu0m6gGDpbQZUxWWJOL0t20cQoBgHaxSsb03BWoMQhVWRlmb8wF0jY0fwzvtDi3A5i0_thGt1HkgYkNIXX_myveW7pwAafxOcATSAI1dtEO2T6i2vtzm164/s1600/9781138823747.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRLlNI4JY6Hy7FlnZqEY19cu0m6gGDpbQZUxWWJOL0t20cQoBgHaxSsb03BWoMQhVWRlmb8wF0jY0fwzvtDi3A5i0_thGt1HkgYkNIXX_myveW7pwAafxOcATSAI1dtEO2T6i2vtzm164/s400/9781138823747.jpg" width="263" /></a></div>
<br />
<br />
<br />
In it, they describe the way, "RFP-C enables clinicians to help by addressing and detailing how the child’s externalizing behaviors have meaning which they can convey to the child," and more specifically, that RFP-C can:<br />
<ul style="background-color: white; box-sizing: border-box; color: #333333; font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-size: 15px; line-height: 21.4286px; margin-bottom: 10px; margin-top: 0px;"><div style="box-sizing: border-box; margin-bottom: 16px; max-width: 680px;">
</div>
<li style="box-sizing: border-box;">Achieve symptomatic improvement and developmental maturation as a result of gains in the ability to tolerate and metabolize painful emotions, by addressing the crucial underlying emotional component.</li>
<div style="box-sizing: border-box; margin-bottom: 16px; max-width: 680px;">
</div>
<li style="box-sizing: border-box;">Diminish the child’s use of aggression as the main coping device by allowing painful emotions to be mastered more effectively.</li>
<div style="box-sizing: border-box; margin-bottom: 16px; max-width: 680px;">
</div>
<li style="box-sizing: border-box;">Help to systematically address avoidance mechanisms, talking to the child about how their disruptive behavior helps them avoid painful emotions.</li>
<div style="box-sizing: border-box; margin-bottom: 16px; max-width: 680px;">
</div>
<li style="box-sizing: border-box;">Facilitate development of an awareness that painful emotions do not have to be so vigorously warded off, allowing the child to reach this implicit awareness within the relationship with the clinician, which can then be expanded to life situations at home and at school.</li>
</ul>
<br />
That's my pitch. So if you know anyone in the New York City area who could benefit from this trial, whether child, parent, educator or clinician, please get this information to them.<br />
<br />
Thanks.<br />
<br />
<br />
<br />
<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-51057625608008259912016-05-08T20:47:00.002-04:002016-05-08T20:47:37.944-04:00Outside InIn the context of my working on <a href="http://psychpracticemd.blogspot.com/2016/04/building-website-template.html" target="_blank">building my own practice website</a>, I found a NY Times article, <a href="http://www.nytimes.com/2016/05/07/world/dalai-lama-website-atlas-of-emotions.html?emc=edit_tnt_20160507&nlid=22449895&tntemail0=y" target="_blank"><i>Inner Peace? The Dalai Lama Made a Website for That</i></a>, compelling to read.<br />
<br />
The website is, <a href="http://atlasofemotions.com/" target="_blank">Atlas of Emotions</a>, and it's not really about inner peace. It's more about the Dalai Lama's notion of emotions as reactive internal events that prevent inner peace, combined with information about the five emotions considered universal by the 149 experts <a href="http://pps.sagepub.com/content/11/1/31.abstract" target="_blank">surveyed</a> for this purpose.<br />
<br />
The emotions are:<br />
<br />
Anger<br />
Fear<br />
Disgust<br />
Sadness<br />
Enjoyment<br />
<br />
The site was conceived by the Dalai Lama as a "map of the mind", and developed by Dr. Paul Ekman (for $750,000), who conducted the survey, and has done pioneering work in nonverbal behaviors, especially facial expressions. He now has a company called the <a href="http://paulekmangroup.com/" target="_blank">Paul Ekman Group, or PEG</a>, which will teach you, for a fee, to read people's expressions and determine if, for example, they are lying. He was a major consultant for Inside Out, the Pixar movie that illustrates the emotional life of a girl named, Riley (I assume based on the expression, "Living the life of Riley," meaning the good life). He was also consultant and inspiration for the main character on the TV series, "Lie to Me", which I know nothing about.<br />
<br />
The site is primarily visual, with the imagery designed by a company called, <a href="http://stamen.com/" target="_blank">Stamen</a>, that creates data visualizations. It's interesting that the colors used to depict the five emotions on the site:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjH_d5K6D0oYrNB17FJuvNJGTyljA8wOYDYy5lglR2RsrhzhDMcU51uoRJYDVlilCd-N2-qFNd-4bp0pq9nwaoaReHSFqMJLw4pJLW9xL8NZXeWr3IAgIH6btZmyQre0_GpwoeFgpDgoR0/s1600/Screen+Shot+2016-05-07+at+10.27.54+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="363" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjH_d5K6D0oYrNB17FJuvNJGTyljA8wOYDYy5lglR2RsrhzhDMcU51uoRJYDVlilCd-N2-qFNd-4bp0pq9nwaoaReHSFqMJLw4pJLW9xL8NZXeWr3IAgIH6btZmyQre0_GpwoeFgpDgoR0/s640/Screen+Shot+2016-05-07+at+10.27.54+AM.png" width="640" /></a></div>
<br />
match the colors of the corresponding characters in Inside Out:<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirFSMd7dzG7Tx3BD6lT0m8bB5Rpt6_m8ApXjGLw0n8aMEogwb2Q0Gkx8YskSdESfyB8OtcTU83gkfKNjuuexqz1WnfZvLN4FyilRl2u_nbOW-pzlDnu1O-o1rcCuNzB8h-rvmKGhipKyg/s1600/Screen+Shot+2016-05-07+at+10.28.13+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="274" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirFSMd7dzG7Tx3BD6lT0m8bB5Rpt6_m8ApXjGLw0n8aMEogwb2Q0Gkx8YskSdESfyB8OtcTU83gkfKNjuuexqz1WnfZvLN4FyilRl2u_nbOW-pzlDnu1O-o1rcCuNzB8h-rvmKGhipKyg/s320/Screen+Shot+2016-05-07+at+10.28.13+AM.png" width="320" /></a></div>
I probably shouldn't be including either of these images without permission, but the Disney-fication was just so striking. Then again, we do associate colors with feelings, like red with anger, blue with sadness, and green with disgust, and red and green, at least, are related to changes in skin color that occur with their associated emotions. I don't know about purple with fear or yellow/orange with enjoyment.<br />
<br />
<br />
The way the site works is you land on the home page, with those five circles of emotion, which are called, "continents". Remember, this is supposed to be a map. If you click on a continent, you get a brief description. For example, Sadness brings up, "We're saddened by loss."<br />
<br />
You also get a menu to the right which lists, Continents, States, Actions, Triggers, Moods, and Calm. If you go to States, after you've clicked on Sadness, you get a graph of various states related to sadness, with overlaps, from least intense to most. The least intense for Sadness is Disappointment, "A feeling that expectations are not being met." The most intense is Anguish, "Intense agitated sadness."<br />
<br />
There are left and right arrows to switch to other basic emotions, but also a down arrow, corresponding to the menu on the right, with more about the emotion you're looking at. The next one down is Actions, with another visual including a range of possible actions for each given state. For anguish, you can seek comfort, which is considered a constructive action. You can mourn, which is ambiguous. And you can withdraw, which is destructive.<br />
<br />
This is a good illustration of one of the main limitations of the site-that it oversimplifies, but that probably makes it more widely accessible.<br />
<br />
The next down is Triggers, which are either universal, like losing a loved one, or learned, like perceiving a loss of status.<br />
<br />
And next down is Moods, the "longer lasting cousins" of emotions. For Sadness, the corresponding mood is Dysphoria.<br />
<br />
That's as deep as the graphics go. The only thing left is calm, which you access from the right hand menu. It has nothing but a short description:<br />
<br />
<i>Experiencing Calm</i><br />
<i><br /></i>
<i>A calm, balanced frame of mind is necessary to evaluate and understand our changing emotions. Calmness ideally is a baseline state, unlike emotions, which arise when triggered and then recede.</i><br />
<br />
The only other feature of the site is a link to the "Annex", where you can find the scientific basis for the work, some more complicated definitions, the signals of emotional display, and a page of "Psychopathology", which lists various DSM diagnoses related to each emotion.<br />
<br />
I wasn't thrilled with this page. For one thing, I disagreed with some of the categorization. For example, as an anxiety disorder, OCD was listed under Fear. But etiologically, at least from an analytic standpoint, OCD is more about a way of dealing with aggression, so I would have listed it under Anger. It also lists Mania under enjoyment, with a qualification about it being pathological enjoyment. But I don't think this is what's actually meant by the term, Enjoyment.<br />
<br />
And this page doesn't mention the DSM, even though it includes diagnoses like Disruptive Mood Dysregulation Disorder (DMDD).<br />
<br />
<br />
Overall, I have mixed feelings about the Atlas of Emotions. On the one hand, it recognizes that we usually don't know why we feel what we feel, or do what we do, and that's useful to know. To quote the NY Times quoting the Dalai Lama:<br />
<br />
<span style="background-color: white; color: #333333; font-family: "georgia" , "times new roman" , "times" , serif; font-size: 17px; line-height: 26px;">“We have, by nature or biologically, this destructive emotion, also constructive emotion,” the Dalai Lama said. “This innerness, people should pay more attention to, from kindergarten level up to university level. This is not just for knowledge, but in order to create a happy human being. Happy family, happy community and, finally, happy humanity.”</span><br />
<br />
On the other hand, the goal is a calm state:<br />
<br />
<span style="background-color: white; color: #333333; font-family: "georgia" , "times new roman" , "times" , serif; font-size: 17px; line-height: 26px;">“When we wanted to get to the New World, we needed a map. So make a map of emotions so we can get to a calm state.”</span><br />
<br />
I think this calm state is supposed to be an absence of emotion, either good-feeling or bad-feeling, a Buddhist ideal, so emotion is viewed as the enemy:<br />
<br />
<span style="background-color: white; color: #333333; font-family: "georgia" , "times new roman" , "times" , serif; font-size: 17px; line-height: 26px;">“Ultimately, our emotion is the real troublemaker,” he said. “We have to know the nature of that enemy.”</span><br />
<br />
When I read this, I was reminded of the talk I attended, that I wrote about in <a href="http://psychpracticemd.blogspot.com/2016/02/laughing-rats.html" target="_blank">Laughing Rats</a>, where Jaak Panksepp noted that, "Most learning takes place through affective shifts." So if we contain our emotions, do we prevent ourselves from learning new things?<br />
<br />
And in that same talk, Jean Roiphe noted that, "Ego functioning often involves "taming" certain affects, especially through thought and language, but it also involves intensifying some affects, so that people can feel truly alive. A full human life can't be reduced to an all or nothing switch of feeling in response to external events."<br />
<br />
Also, I'm not sure "calm" isn't an emotion.<br />
<br />
Maybe I just have trouble with this because I'm so steeped in a culture of neurotically exaggerated emotions, so the ideal of inner peace isn't just unattainable, it's laughably unapproachable, which, for me, quickly turns into undesirable.<br />
<br />
<br />
<br />
<br />
<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-50791434189796184382016-05-06T17:00:00.000-04:002016-05-06T17:00:19.747-04:00NACI've been hearing a lot about N-Acetylcysteine (NAC) in the treatment of psychiatric disorders, so I thought it would be worth looking into.<br />
<br />
<a href="http://www.sciencedirect.com/science/article/pii/S0149763415001190" target="_blank">A 2015 systematic review in Neuroscience and Biobehavioral Reviews</a> has the following abstract:<br />
<br />
<i>N-acetylcysteine (NAC) is recognized for its role in acetaminophen overdose and as a mucolytic. Over the past decade, there has been growing evidence for the use of NAC in treating psychiatric and neurological disorders, considering its role in attenuating pathophysiological processes associated with these disorders, including oxidative stress, apoptosis, mitochondrial dysfunction, neuroinflammation and glutamate and dopamine dysregulation. In this systematic review we find favorable evidence for the use of NAC in several psychiatric and neurological disorders, particularly autism, Alzheimer's disease, cocaine and cannabis addiction, bipolar disorder, depression, trichotillomania, nail biting, skin picking, obsessive-compulsive disorder, schizophrenia, drug-induced neuropathy and progressive myoclonic epilepsy. Disorders such as anxiety, attention deficit hyperactivity disorder and mild traumatic brain injury have preliminary evidence and require larger confirmatory studies while current evidence does not support the use of NAC in gambling, methamphetamine and nicotine addictions and amyotrophic lateral sclerosis. Overall, NAC treatment appears to be safe and tolerable. Further well designed, larger controlled trials are needed for specific psychiatric and neurological disorders where the evidence is favorable.</i><br />
<br />
<br />
I'm not sure how they drew their conclusions. They have a rating system called, Grade of Recommendation (GOR), from A-best, to D-worst, and N-no studies identified. They also state, at least for some disorders, whether they recommend NAC for treatment, from Yes to No, with Mixed in between.<br />
<br />
They found only 1 GOR of A, for Bipolar disorder, and even that they recommended as Mixed.<br />
<br />
The B/Mixed were:<br />
<br />
Addiction-Cannabis<br />
Addiction-Cocaine<br />
Autism<br />
Depressive Disorder<br />
Impulse Control-Trichotillomania<br />
Schizophrenia.<br />
<br />
Specifically:<br />
<br />
-In one study of NAC in treating and preventing symptoms during the maintenance phase of Bipolar Disorder, when compared to placebo, the NAC group demonstrated a significant improvement on the Montgomery–Asberg Depression Scale (MADRS), Bipolar Depression Rating Scale (BDRS).<br />
<br />
-Cannabis-dependent adolescents and young adults given NAC and counseling had significantly fewer positive urine cannabinoid tests than those given placebo and counseling.<br />
<br />
-There may or may not have been a reduction in cravings for Cocaine.<br />
<br />
-Children with Autism had less irritability.<br />
<br />
-A large randomized controlled trial in individuals with major depressive disorder (MDD) and MADRS score ≥ 18 showed improvement in multiple outcome measures – in the NAC group when compared to placebo add on treatment to usual treatment for 12 weeks.<br />
<br />
-In a medium sized trial, significant improvements were found on the Massachusetts General Hospital Hair Pulling Scale, the Psychiatric Institute Trichotillomania Scale and the CGI in participants who received NAC as compared to the placebo group.<br />
<br />
- I can't figure out from the paper what NAC did for patients with Schizophrenia.<br />
<br />
<br />
Everything else was worse.<br />
<br />
However, NAC was pretty well-tolerated, with no serious side effects, so it's probably worth a try in conditions not responding well to other treatments. At least, I think that's their conclusion. Also, other than the IV form used in acetaminophen overdose, and the Sub-Q form used in ALS studies, NAC is sold over the counter as an oral medication, with doses ranging from 2-2.4g/day.<br />
<br />
Posited mechanisms of action for NAC include effects on:<br />
<br />
Oxidative Stress<br />
Mitochondrial Dysfunction<br />
Inflammatory Mediators<br />
Glutamate Neurotransmission<br />
Long Term Neuroadaptation<br />
Dopamine Neurotransmission<br />
Serotonergic Neurotransmission<br />
<br />
Check out this visual:<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjX_Snsi_a65NKTCtYmh-y2c4nxNKcSLQj2vq1Wl3R3d8btusYZObaM2bfewy3yjFP3PiduDLdsHl62gkR0is_ZN8p-mNnWhUQLWnaoKhcFdVcCSqIzA6uklJ5QaV0LRlbOF7ENd1JzcZY/s1600/NAC.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="609" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjX_Snsi_a65NKTCtYmh-y2c4nxNKcSLQj2vq1Wl3R3d8btusYZObaM2bfewy3yjFP3PiduDLdsHl62gkR0is_ZN8p-mNnWhUQLWnaoKhcFdVcCSqIzA6uklJ5QaV0LRlbOF7ENd1JzcZY/s640/NAC.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">http://www.cell.com/trends/pharmacological-sciences/fulltext/S0165-6147(13)00002-3</td></tr>
</tbody></table>
<br />
<br />
To get into a little more clinical nitty-gritty, there are a number of trials posted on clinicaltrials.gov, most without results.<br />
<br />
<a href="https://clinicaltrials.gov/ct2/show/results/NCT00568087?term=n-acetylcysteine&rank=19&sect=X01256#all" target="_blank">One</a> that did have results looked at NAC in alcohol dependence, with the primary outcome measure Alcohol consumption in percentage of heavy drinking days:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguUz-GXll4qCVMxsf8ooN2QmEkGIDtkWboNMqNnyfAMSuLHKpURg_jORe2UhUGMRb2IO0V3TRRO9N0pP_7dHzY7iSyykf7c0kcs85FXEMECzqBAgfOxWx6YFklHAzn-XS8LTBuSuKXC1M/s1600/Screen+Shot+2016-05-05+at+4.41.41+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguUz-GXll4qCVMxsf8ooN2QmEkGIDtkWboNMqNnyfAMSuLHKpURg_jORe2UhUGMRb2IO0V3TRRO9N0pP_7dHzY7iSyykf7c0kcs85FXEMECzqBAgfOxWx6YFklHAzn-XS8LTBuSuKXC1M/s640/Screen+Shot+2016-05-05+at+4.41.41+PM.png" width="640" /></a></div>
<br />
No statistical analysis was provided.<br />
<br />
<a href="https://clinicaltrials.gov/ct2/show/results/NCT00993265?term=n-acetylcysteine&rank=38&sect=X01256#all" target="_blank">Another</a> was NAC in pediatric trichotillomania:<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlZorIY-s7dLFsH1idmFIWdoL524RIdT80dxI0aDIDSU9WFPiExg6u_S_sAMYXveFOEukiop741zlb8TM6e0vwz3Jm81v9Bu-FbwmhJveMS7EXIFSPKGV0crSwU4zBEShjpj80sZCnAb0/s1600/Screen+Shot+2016-05-05+at+4.44.18+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="142" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlZorIY-s7dLFsH1idmFIWdoL524RIdT80dxI0aDIDSU9WFPiExg6u_S_sAMYXveFOEukiop741zlb8TM6e0vwz3Jm81v9Bu-FbwmhJveMS7EXIFSPKGV0crSwU4zBEShjpj80sZCnAb0/s640/Screen+Shot+2016-05-05+at+4.44.18+PM.png" width="640" /></a></div>
<br />
Again, no statistical analysis.<br />
<br />
However, when I plug the raw data into <a href="http://1boringoldman.com/index.php/2016/01/05/john-henrys-hammer-continuous-variables-i/" target="_blank">1 Boring Old Man's table,</a> (see also <a href="http://psychpracticemd.blogspot.com/2016/01/diy-study-evaluation.html" target="_blank">DIY Study Evaluation</a>) I get:<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeOauyKMGiuAWW3-J1aWq9pJynWs1ozhZz0Yu1Uut8fENw2SCJGugh28XiBFU2Vc3qIjC1flSFz4EMIyxbQLRyjteKRtw7-xoHbh5yoU85lt7wzG89A2u09fdXIvOJW8kzd46_ITitUD4/s1600/Screen+Shot+2016-05-05+at+11.33.41+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="156" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeOauyKMGiuAWW3-J1aWq9pJynWs1ozhZz0Yu1Uut8fENw2SCJGugh28XiBFU2Vc3qIjC1flSFz4EMIyxbQLRyjteKRtw7-xoHbh5yoU85lt7wzG89A2u09fdXIvOJW8kzd46_ITitUD4/s640/Screen+Shot+2016-05-05+at+11.33.41+PM.png" width="640" /></a></div>
<br />
<br />
<br />
The trichotillomania study had a p value of 0.185, a Cohen's D effect size of 0.433, and a 95% CI of -0.202 to 1.068 (In case it's too hard to read). So there's no statistically significant difference.<br />
<br />
The Alcohol study's data was weird, with no calculable p value, and negative Cohen's D's, so then I tried change in means, which was negative, and that got p=0.533; Cohen's D=0.190; CI (-0.403-0.782). I'm not sure if that's a legitimate calculation on my part.<br />
<br />
Basically, the numbers are bad, and I only decided to include the spreadsheet as practice at evaluating a study.<br />
<br />
So now I ask myself, "Would I prescribe or recommend NAC?" Based on this post, I'd have to say maybe. I'd probably stick to the conditions I listed above. Maybe I'd use it as an add-on for depressive symptoms in between bipolar episodes, or in unipolar depressed patients stable on medication but with some residual symptoms. I might suggest it to patients trying to stop using cannabis or cocaine. I don't treat children, but I think if I did, I'd feel more comfortable prescribing NAC for irritability than risperdal. If I ever had a patient with trichotillomania, I'd be willing to try it. And maybe as an adjunct for anxiety or something in schizophrenia.<br />
<br />
The bottom line is probably that it won't hurt, and it might help.<br />
<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-42715538484788971422016-04-29T14:00:00.000-04:002016-05-05T22:40:32.974-04:00Building a Website-The PricingFirst, I want to thank people who read my <a href="http://psychpracticemd.blogspot.com/2016/04/building-website-template.html" target="_blank">first website post</a> and made suggestions about using Blogger, <span style="background-color: white;">Wordpress,</span> and Google for my website. I'll incorporate those into my research.<br />
<br />
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, <a href="http://thesitewizard.com/" target="_blank">The Site Wizard</a>, 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.<br />
<br />
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.<br />
<br />
But let's discuss basics.<br />
<br />
What is a Web Host?<br />
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.<br />
<br />
What is a Domain Name?<br />
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.<br />
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You register your domain name, for an annual fee, with an organization called, <a href="https://www.icann.org/registrar-reports/accredited-list.html" target="_blank">ICANN</a>, 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.<br />
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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.<br />
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Domains also come in different suffixes, like .com, .org, .company, .biz, .education, and respective costs depend on something called, "TLD", or Top Level Demand.<br />
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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.<br />
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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.<br />
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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.<br />
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<a href="https://domains.google/" target="_blank">Google</a> 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.<br />
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<a href="https://www.squarespace.com/" target="_blank">Squarespace</a> 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.<br />
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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.<br />
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<a href="https://wordpress.com/start/delta-site/plans" target="_blank">Wordpress</a>:<br />
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This is Wordpress' price chart for website plans. It doesn't say anything about an annual fee for a domain name.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQDzEVI6q9QAEw0tefFARIPCvutpUZ8vmNXr5CzqQwQuEUaxEHYYCDYdfk9LX6c5Yh4N6oKYh_CzgrXBW5GJrtqTVrgpTYtExuPJ5nSIKNEM_RP0I7Vk9BHY5VTjcRd8OF3F-uMPA7jFE/s1600/Screen+Shot+2016-04-28+at+1.05.04+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="432" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQDzEVI6q9QAEw0tefFARIPCvutpUZ8vmNXr5CzqQwQuEUaxEHYYCDYdfk9LX6c5Yh4N6oKYh_CzgrXBW5GJrtqTVrgpTYtExuPJ5nSIKNEM_RP0I7Vk9BHY5VTjcRd8OF3F-uMPA7jFE/s640/Screen+Shot+2016-04-28+at+1.05.04+PM.png" width="640" /></a></div>
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<a href="https://www.dudamobile.com/" target="_blank">Duda</a> does not sell custom domain names. The'll set up a subdomain on their free plan, which would be <i>mypsychiatry.dudaone.com</i>. 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. <a href="https://www.hover.com/domain_pricing" target="_blank">Hover's</a> .com pricing is $12.99 the first year, then $14.99 for annual renewals.<br />
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This is Duda's pricing:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4xMULuO7WixRLF2uVQ5XuNkd2WuKIRHLNPRfIuX6t0GCvqVhdlRZ_coJj-aIcOX-R6KgQvDyPb6R_9rE4GN_nHST6yLzV-w2kcf_XNIPq6WnPvOtR0XYH9v2ARcQ78OZgXgXWuAni8sI/s1600/Screen+Shot+2016-04-28+at+2.08.28+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="363" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4xMULuO7WixRLF2uVQ5XuNkd2WuKIRHLNPRfIuX6t0GCvqVhdlRZ_coJj-aIcOX-R6KgQvDyPb6R_9rE4GN_nHST6yLzV-w2kcf_XNIPq6WnPvOtR0XYH9v2ARcQ78OZgXgXWuAni8sI/s640/Screen+Shot+2016-04-28+at+2.08.28+PM.png" width="640" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4sAIP8CN6iAvS_uK7sFwGLKimBrUW8R5AfIfKGbi1ZpgDIr3p5-YafhND70S1vGsB5aoYxHgmiTab40m4h5n7ST6KSKqmt-oUWMWoYMWu6zrTy7TejwxM6q60BghnSAi-dMtSFz9HIeE/s1600/Screen+Shot+2016-04-28+at+2.10.44+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="132" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4sAIP8CN6iAvS_uK7sFwGLKimBrUW8R5AfIfKGbi1ZpgDIr3p5-YafhND70S1vGsB5aoYxHgmiTab40m4h5n7ST6KSKqmt-oUWMWoYMWu6zrTy7TejwxM6q60BghnSAi-dMtSFz9HIeE/s640/Screen+Shot+2016-04-28+at+2.10.44+PM.png" width="640" /></a></div>
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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.<br />
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<a href="http://blogger.com/" target="_blank">Blogger</a> 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 <a href="http://www.sylvialiuland.com/2012/01/7-ways-to-get-blogger-blog-to-look-and.html" target="_blank">this article</a> and <a href="http://www.confluentforms.com/2011/07/you-can-do-some-amazing-things-with.html" target="_blank">this o</a>ne 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.<br />
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<a href="http://weebly.com/" target="_blank">Weebly</a> has a pretty good deal:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm7tQIL1Lerx9HbCK4N_7Bb_Bo5SXTGPg9NqXxn985DB3mZnrIK4GnWNBLFgAy5ljZ5mbwtbe4bArMrCUCXHVvZ_dSdw1yvE1Fhy2__iJ4Ti65pk40fiWUuL5sF6vbYe7Y5yNKrlrhuGM/s1600/Screen+Shot+2016-04-28+at+3.37.39+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="272" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm7tQIL1Lerx9HbCK4N_7Bb_Bo5SXTGPg9NqXxn985DB3mZnrIK4GnWNBLFgAy5ljZ5mbwtbe4bArMrCUCXHVvZ_dSdw1yvE1Fhy2__iJ4Ti65pk40fiWUuL5sF6vbYe7Y5yNKrlrhuGM/s640/Screen+Shot+2016-04-28+at+3.37.39+PM.png" width="640" /></a></div>
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The domain is free for the first year, and $19.95 each additional year, with discounts for extended terms.<br />
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I really find <a href="http://godaddy.com/" target="_blank">GoDaddy</a> 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.<br />
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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.<br />
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And now for the spreadsheet:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYim6atct5yYN1O5C1h22DuNih3LZwl_sWkKAsbMV53rZMoMqtU9eUx3z4QdF-xLVXN6Oz4kryB53xSLRZCduskXOzl0zEdnPxzUbnPxe7nfIir8xuWS5uRO5UTAv3qp6Be8NKJltrsO4/s1600/Screen+Shot+2016-04-28+at+4.50.10+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="276" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYim6atct5yYN1O5C1h22DuNih3LZwl_sWkKAsbMV53rZMoMqtU9eUx3z4QdF-xLVXN6Oz4kryB53xSLRZCduskXOzl0zEdnPxzUbnPxe7nfIir8xuWS5uRO5UTAv3qp6Be8NKJltrsO4/s640/Screen+Shot+2016-04-28+at+4.50.10+PM.png" width="640" /></a></div>
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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.<br />
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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.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-76110018521287056382016-04-26T16:15:00.001-04:002016-04-26T16:16:33.892-04:00Building A Website-The TemplateI'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.<br />
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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.<br />
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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.<br />
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I finally decided to cave when I was researching my <a href="http://psychpracticemd.blogspot.com/2015/03/analytic-evidence.html" target="_blank">Analytic Evidence post</a>, 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.<br />
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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.<br />
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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. <br />
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A few things I need to figure out before creating my site:<br />
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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.<br />
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I need to decide how much information to provide about myself. Is a CV a good idea? Will that much information interfere with therapy?<br />
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I need some kind of description of what patients can expect from treatment.<br />
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I need to include my practice policies, which I already have written up. And I want to include the <a href="http://psychpracticemd.blogspot.com/2015/03/surprise.html" target="_blank">Surprise Act</a> 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.<br />
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And I'd like patients to be able to pay through the site, but I need to understand how that impacts privacy.<br />
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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:<br />
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<a href="http://weebly.com/" target="_blank">Weebly</a><br />
<a href="http://wix.com/" target="_blank">Wix</a><br />
<a href="http://sitebuilder.com/" target="_blank">Sitebuilder</a><br />
<a href="https://www.dudamobile.com/" target="_blank">Duda</a><br />
<a href="http://squarespace.com/" target="_blank">Squarespace</a><br />
<a href="http://godaddy.com/" target="_blank">GoDaddy</a><br />
<a href="http://web.com/">Web.com</a><br />
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<b>Web.com</b> 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.<br />
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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.<br />
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<b>Sitebuilder</b> 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.<br />
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<b>Weebly's</b> closest business theme was for a law firm, and the next closest theme was a personal one that was basically a large business card.<br />
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Similarly, <b>Wix's</b> closest templates were Dentist and Doula.<br />
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<b>Squarespace</b> had nothing specifically medical, but I thought it had the most aesthetically pleasing themes.<br />
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<b>GoDaddy</b> 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.<br />
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The same was true for <b>web.com</b>-too busy, with only a small sampling of templates, all fairly ugly.<br />
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My favorite was <b>Duda</b>, 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.<br />
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Well, okay, just this one image, since I'm saying it's my favorite:<br />
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Here's a spreadsheet summary of the templates:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBEO-g0UwaL4JKsm8tJy8sii0SBCkcu2CwnFgIEqo35zkC1_bhRn7gcF35FvMlcPhO5R8VGZsvKgXa_ISHY6KVrulI6vzGNeueG5VUJLcz3xjh3OfMxrGxRTa-q8klyeY2WnnJXU-vJ7s/s1600/Screen+Shot+2016-04-26+at+4.09.49+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="226" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBEO-g0UwaL4JKsm8tJy8sii0SBCkcu2CwnFgIEqo35zkC1_bhRn7gcF35FvMlcPhO5R8VGZsvKgXa_ISHY6KVrulI6vzGNeueG5VUJLcz3xjh3OfMxrGxRTa-q8klyeY2WnnJXU-vJ7s/s400/Screen+Shot+2016-04-26+at+4.09.49+PM.png" width="400" /></a></div>
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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.<br />
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<br />PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.comtag:blogger.com,1999:blog-4053770866454296190.post-37571764901371579832016-04-15T20:08:00.000-04:002016-04-15T20:08:11.830-04:00OOOOOOKLAHOMA!Good news for doctors in Oklahoma, also known as the "<a href="https://en.wikipedia.org/wiki/Oklahoma" target="_blank">Sooner State</a>", "...in reference to the non-Native settlers who staked their claims on the choicest pieces of land prior to the official opening date."<br />
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I learned from an email from the <a href="http://nbpas.org/" target="_blank">National Board of Physicians and Surgeons</a> (NBPAS, See, "<a href="http://psychpracticemd.blogspot.com/2015/02/another-board.html" target="_blank">Another Board</a>", and "<a href="http://psychpracticemd.blogspot.com/2015/12/summing-up-2015.html" target="_blank">Summing Up 2015</a>"), 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.<br />
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The link to the bill is <a href="http://www.oklegislature.gov/BillInfo.aspx?Bill=sb1148&Session=1600" target="_blank">here</a>. 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:<br />
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<i>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.</i><br />
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Go, Oklahoma! And because I'm a little giddy about this small but important victory, I'm including this Sesame Street clip:<br />
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PsychPracticehttp://www.blogger.com/profile/07071440888782115503noreply@blogger.com