Sunday, May 11, 2014

Assimilation vs. Independence

Last week, I got the chance to have dinner with a friend who is a businessman and one of his acquaintances, a cardiologist. My friend asked the two of us what we thought of the state of medicine, and what it was like being a doctor these days. It was interesting to hear what the cardiologist had to say. He had been part of an independent medical group, which was recently bought out by a large hospital system. He talked about all the additional rules and regulations that he had to follow and how burdensome they were. Then he had this to say:

"Basically, the problem is that doctors have no power or control over our own profession. The reimbursements rates and policies are determined by the government and private insurers. The doctors who are older can tell themselves they only have to stick with it a few more years before retiring, while younger doctors are too busy trying to establish themselves and pay down medical school debt. Doctors can't unionize or go on strike. It's hard to organize them because it's like herding cats. Therefore, we just have to accept the system and work within it."

I thought it was a very good summary of the present situation facing most medical specialties. It was a nice coincidence that the following day, 1 Boring Old Man wrote wrote this post highlighting some of his reactions to recent articles on psychiatrists & insurance panels, as well as whether psychiatrists who do psychopharmacology vs. psychotherapy will eventually split into different professions. He began:
I went into practice around 1986. If patients used insurance, that was fine with me, but for two simple reasons, it never occurred to me to take insurance. First, I would’ve had to have a staff to file it and keep up with it and I didn’t want to pass on those costs. Second, that would’ve required me to be on insurance panels that would’ve prescribed how I practiced, meaning becoming a psychiatrist who primarily prescribed medications – the kind of psychiatrist people rave about in the blog comments, on Mad in America, or on the steps of the APA Meeting in New York.
Dr. Dawson wrote the following in response to 1BOM's post:
We will all remain in the limbo of politicians telling us we need increased access and insurance companies decreasing access in order to increase their profitability.  And that has nothing to do with the fact that psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy.  Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.
In a comment on 1BOM's post, Dr. Reidbord had this to say:
It appears many of us psychiatrists simply got the memo a little earlier. Psychiatry, like primary care medicine, is fast becoming two-tier: practiced at the level of professional excellence when business does not define it, and something tragically less when it does.
What I wonder is, why don't more psychiatrists speak out about the state of things? The difficulty in spurring practicing clinicians to action is vexing, since I believe that the majority of psychiatrists enjoy spending time with patients and did not go into the profession to become 15-minute med checkers or care team consultants who do not directly see patients.

Of course, I think the cardiologist's explanation above is a good one, but additionally, I believe that ideology and zeal are two primary factors that give psychiatrists of the key opinion leader (KOL) variety a disproportionate amount of power. 1BOM has written before about the dangers of therapeutic zeal, while I've written about the NIMH's techno-utopian vision. The problem here is that ideology and zeal are unifying forces that rally people to a cause, allowing them to dictate the course of events even when they are in the minority. It is much harder to get people to rally around the banner of multi-disciplinary thought ("psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy") or the biopsychosocial model. As David Brooks wrote in a recent column on threats to the international system of liberal pluralism:
It was barely possible [to defend the system] when we were facing an obviously menacing foe like the Soviet Union. But it’s harder when the system is being gouged by a hundred sub-threshold threats. […]

Moreover, people will die for Mother Russia or Allah. But it is harder to get people to die for a set of pluralistic procedures to protect faraway places. It’s been pulling teeth to get people to accept commercial pain and impose sanctions.
Can there possibly be a solution? Well, it is fortuitous that at least for psychiatrists, independence is still an option. Unlike many other medical specialities, we don't have to buy expensive equipment or hire an extensive support staff. Solo office-based practice is still possible. In certain parts of the country, people are willing to pay $250 per hour for a psychiatrist who is good with both medications and therapy, though if you're like 1BOM and don't care about income maximization, you can probably work anywhere.

And perhaps some day, enough doctors will tire of the "long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism," and declare independence en masse. That'll be an interesting day.

Monday, May 5, 2014

What It Will Take to Decrease ADHD Rates, Part 2

In my last post, I enumerated some of the reasons why I thought the high rates of ADHD diagnosis and treatment were not about to fade. Here, I will discuss several steps that I think would need to take place in order to quell the ADHD "epidemic" in America.

Education Reform

Back in October, the New York Times published a very interesting article examining possible causes behind the rising rates of ADHD diagnosis:
Hinshaw, as well as sociologists like Rafalovich and Peter Conrad of Brandeis University, argues that such numbers are evidence of sociological influences on the rise in A.D.H.D. diagnoses. In trying to narrow down what those influences might be, Hinshaw evaluated differences between diagnostic tools, types of health insurance, cultural values and public perceptions of mental illness. Nothing seemed to explain the difference — until he looked at educational policies.

The No Child Left Behind Act, signed into law by President George W. Bush, was the first federal effort to link school financing to standardized-test performance. But various states had been slowly rolling out similar policies for the last three decades. North Carolina was one of the first to adopt such a program; California was one of the last. The correlations between the implementation of these laws and the rates of A.D.H.D. diagnosis matched on a regional scale as well. When Hinshaw compared the rollout of these school policies with incidences of A.D.H.D., he found that when a state passed laws punishing or rewarding schools for their standardized-test scores, A.D.H.D. diagnoses in that state would increase not long afterward. Nationwide, the rates of A.D.H.D. diagnosis increased by 22 percent in the first four years after No Child Left Behind was implemented.
And now, with the implementation of the Common Core, things may get even worse. As the philosopher-comedian Louis C.K. tweeted:

I am no education specialist, but it's fairly obvious that our education system is not working, and things like NCLB and the Common Core do not address the most pressing need, which is better teachers. This is a problem that is parallel to the emphasis in my profession on useless things like "quality of care", maintenance of certification, and patient satisfaction surveys, rather than increasing professionalism and training better clinicians.

Changes in Professional Training/Culture

Speaking of training better clinicians, blindly applying diagnostic criteria without regard to context is one of the biggest problems in American psychiatry. It leads to situations like this one noted by Dr. Allen Frances on Twitter:
In that study, parents completed a structured interview, designed to cover all of the ADHD diagnostic criteria. This approach is the gold standard in research, yet if you look at the document I linked to, there is no mention of the word "sleep" at all in there. So if a teenager is up all night playing video games and then struggles with focusing at school and doing homework, this approach would flag that teen as having ADHD. Sadly, many doctors, especially those with limited time to spend with patients, use a similar approach when they give parents a questionnaire like the Vanderbilt and then diagnose the child with ADHD if enough 2's and 3's were circled.

If a child does get diagnosed with ADHD, both the American Academic of Pediatrics and the American Academy of Child and Adolescent Psychiatry have published guidelines that say first-line treatment is medication "and/or" behavior therapy. Yet it is very hard for most families to actually find someone who offers this type of therapy; plus, behavioral therapy is much more demanding of parents' time and effort than simply medicating a child, a point I'll address in the next section. Still, increasing access to behavioral therapy can potentially help reduce the reliance on meds. I'm not sure how this is going to happen, but obviously we as a society would have to make it a priority to increase the numbers and the quality of training of those therapists.

As another example of the lack of holistic thinking, there are multiple studies showing a link between certain artificial food colorings and hyperactive behavior in school-aged children. During my child psychiatry training, I heard about these studies from a lecturer who emphasized that the effect size was small. However, a small average effect can mask large effects in individuals who are susceptible to certain insults. Or it may slowly lead to larger effects over long periods of time. In Europe, foods containing those dyes are required to have a warning label that they "may have an adverse effect on activity and attention in children," so most manufacturers have switched to using natural colors so they don't have to show the warning label. Not surprisingly, the FDA decided not to act, citing the need for more research.

Societal/Demographic Changes

One of my previous posts examined the geographical differences in the distribution of ADHD in the U.S. Clearly, societal factors like higher rates of single parenthood, lower social mobility, etc. have an impact on which children get diagnosed with ADHD.

One of the biggest issues I come across is how everyone is super-busy all the time, especially parents with young children who have to juggle their jobs and child-raising responsibilities. Not surprisingly, given how exhausted many American parents are, it is easy to give in to the temptation of having television or an iPad be a babysitter/pacifier. This of course comes at a huge cost to the relationship between parents and their children. Child in Mind is an excellent blog that has many posts on how parent-child interactions are critically important for the development of self-regulation skills in children, which significantly impact emotions, behaviors, and the ability to concentrate. There is also evidence that parents and schools can effectively teach self-control to children in ways that do not require harsh treatment or bribery.

Thus, measures that take stress off parents and increase the time that they can spend with their children is something that our society needs to invest in. Universal daycare/preschool is just one example. According to this article, "the U.S. ranks third to last among OECD countries on public spending on family benefits." If you don't think that has anything to do with why we lead the world in ADHD, then I'd love to hear your explanation.

In conclusion, there are no easy fixes to the problem of ADHD over-diagnosis/treatment in America, because it is in large part a reflection of some thorny societal/cultural problems. But that doesn't mean there are no solutions. The problem does require addressing issues on multiple levels, and not simply prescribing more pills.