Who Controls the Future of Medical Knowledge? Part I

The recent discontent amongst physicians regarding the process of maintaining board certification in various specialties got me thinking about a broader question: how do doctors acquire new medical knowledge, especially after medical school? Which brings me to an even more critical question: who controls said knowledge?

I would argue that next to our ability to listen to and empathize with patients, the other most valuable aspect of the medical profession is our knowledge. Ever since the days of Hippocrates, medical knowledge has been transmitted from one doctor to another in essentially the same way. In medical school and residency, we attend lectures, read textbooks, study cases, answer Socratic questions posed by more experienced clinicians, and most importantly, learn by seeing numerous patients and accumulating experience. After graduating medical school, it seems that most doctors learn by conferring with one another, reading journals, and attending conferences.

But the more information there is, the more time it takes to access and acquire new knowledge, and the harder it becomes for individual physicians to keep up.

You can be sure that corporations are well aware of this. On the patient side, of course, Dr. Google already provides incredible ease of access to knowledge and profits handsomely from selling ads to consumers. Pharmaceutical companies know more about my prescribing practices than I do, which fuels their targeted marketing efforts. More ambitiously, IBM's Watson Health Cloud promises to "bring together clinical, research and social data from a diverse range of health sources, creating a secure, cloud-based data sharing hub, powered by the most advanced cognitive and analytic technologies." And as much as I panned athenahealth's advertising in an earlier post, the electronic medical record companies will certainly find clever ways of profiting from the vast troves of health care data that they accumulate. And doctors are paying for the privilege of providing that information to them!

At least SERMO ("the most trusted and preferred social network for doctors") pays doctors for completing surveys, but you can be sure that they're in the same game. They keep their service free by monetizing the attention and knowledge of doctors: "Organizations seeking physician expertise, such as pharmaceutical companies, medical device firms, and biotechs, underwrite the market research and sponsorship opportunities within our site."

So what options are available for doctors who want to share their knowledge with each other free from the confines of a data mining operation? Of course, we can still consult with colleagues the old fashioned way, either in person or by phone. But after having these conversations, the knowledge still resides in the brains of people, not easily accessible to future doctors who may run into similar situations. Our professional associations post practice guidelines that hardly anyone reads, and at annual meetings, there are opportunities to meet with expert clinicians to discuss cases, which seems terribly inefficient. What about higher-tech options? There are numerous subscription services that provide summaries of research studies, but I believe that the patients doctors see do not necessarily resemble those who sign up for clinical trials. There are electronic mailing lists in which doctors can discuss cases, and which allow members to search through previous conversations. And there's wikidoc, a free wikipedia for doctors. However, these options are used by very few doctors and are paltry efforts next to the commercial ambitions of Big Data.

With all these business interests aiming to aggregate and profit from the knowledge of doctors, is there anything that the medical profession can do to avoid having our knowledge become some company's proprietary intellectual property?

I don't claim to have the answers, but I will explore some ideas in Part II. Stay tuned…

Why I Love Wall-E (and Question the ACA)

Spoiler warning: If you haven't seen Wall-E yet, why not? See it first before reading this post if you don't want certain aspects of the plot revealed.

Let me tell you why Wall-E is my favorite Pixar move. The title protagonist begins the movie as a humble robot, programmed with a very specific purpose: to pick up garbage, compress it, and stack it in neat, towering piles. In Wall-E's world, man-made trash overwhelmed the earth generations ago, smothering all plant life. The humans escaped in giant spaceships, leaving robots behind to clean up the mess. Over time, all of the other robots broke down, with Wall-E the sole survivor living a repetitive, lonely existence. Yet Wall-E somehow transcends his programming and develops a sense of curiosity about the world. What were those humans like? What are these relics that they left behind? What's that green thing growing amongst the trash?

After a series of improbable but exciting events, Wall-E finds himself on board one of those giant spaceships. There, he encounters real, live humans and the robots that serve their needs. The people were uniformly plump with adiposity, reclining comfortably on mobility chairs while sipping futuristic Big Gulps™ and fixated on screens. Wall-E was aghast, eventually discovering that the villainous AI of the ship was trying to keep the humans confined to their blissful but vacuous existence. Wall-E finds a way to rally the other robots and spread the news that plant life was growing on earth once again. The movie ends on a hopeful note, with the ship returning home and the humans taking small, earthbound steps that feel like giant leaps. I love that Wall-E acted in humanity's long term interests instead of either rejecting these disappointing humans or attending only to their short term comfort.

Recently, I was reminded of Wall-E when I attended a session at AACAP's Annual Meeting in San Diego titled: "The Affordable Care Act [ACA] and How We Think About Systems, Care, Quality, and Ethics." The discussants covered various aspects of the ACA (for an overview of the ACA, see this recent post from Psych Practice). What interested me most was the talk by Dr. Michael Houston on how the ACA relates to child and adolescent psychiatrists. Dr. Houston discussed the ethical underpinnings of the ACA, namely how it seeks to institute a more egalitarian and less libertarian health care system. The law lays the groundwork for transitioning us from a fee-for-service system in which doctors have a financial incentive to do lots of procedures to a system in which both patients and doctors have a responsibility to society to contain costs.

Clearly, one of the goals of the ACA is to make doctors provide more efficient care. One of the justifications for why we need this is the chart above (from this HuffPo article) showing how, despite spending way more than any other country on health care per capita, the U.S. trails most other developed nations in life expectancy. The logic seems to be that since we're not getting good bang for our buck, the health care delivery system must be streamlined.

This focus on efficiency would have an especially high impact on child psychiatrists, given how relatively few of us there are compared to the high numbers of patients. Here's an old article from 2006 about the shortage, and not much has changed since, except that even more children are being diagnosed with conditions like ADHD and taking multiple medications, putting further strains on the health care system. Last year, AACAP published a document describing how the ACA will impact the practice of child and adolescent psychiatry. More mental health care will be delivered by pediatricians and care managers, with psychiatrists overseeing cases but not seeing patients directly unless they were especially complicated.

To me, this seems like a herculean effort to create ever more efficient Wall-Es, without trying to address why there was so much for Wall-E to clean up in the first place. Instead of just focusing on the shortage of child psychiatrists, why are we not doing more about the over-abundance of patients? After the session, I asked one of the speakers this very question. Her answer was sobering: she had thought about this issue herself, but when she tried to a submit a paper on the prevention of mental disorders in children, no child psychiatry journal would accept it. She thinks that is just not our mindset, just not what we are trained or paid to do. It reminded me of the old adage by Upton Sinclair, "It is difficult to get a man to understand something, when his salary depends on his not understanding it."

Don't get me wrong, I believe in universal health care. I just don't think that the ACA is going to successfully address the mental health issues of children in this country, just as it won't address the obesity epidemic by making obesity treatment more streamlined. For example, today's NYTimes article that I linked to earlier profiled a California mother who has a child with ADHD and severe behavioral issues. Here's the crucial paragraph:

Some would consider Matthias a textbook candidate for combined treatment. His rages have overwhelmed schools and child care programs for years, and he is already struggling in first grade. He and his mother — a medical technician whose typical workday drawing blood lasts from 7 in the morning until 4 p.m. — share a cramped and clamorous three-bedroom ranch house with her sister and brother-in-law and their spirited children, ages 3 and 6 months. Matthias is having nightmares and bladder-control issues.

I'm not sure that any amount of meds or access to a child psychiatrist would help this child as much as having a less stressful home environment. I don't claim to know what the best solution for our society as a whole would be, but I do think we need to put more effort into investigating what can be done to better support children and families, and not just from a medical/health care system point of view.

I hope that more of us in the child psychiatry field can be a bit more like Wall-E: a bit more curious about the world we find ourselves in and how it became that way, a bit more willing to ponder what can change things for the better. Let's not continue to just put our heads down in order to squeeze ever more efficiency and productivity out of our days.

The Limits of Big Data in Psychiatry

While browsing The Atlantic earlier this week, I came across this:

Yes, I was tempted to click on the article involving electric shocks, but it was the ad "Rising Mental Health Issues Facing Our Children, in Five Charts" that caught my attention. The colorful charts show some alarming-looking numbers that most readers of this blog are probably used to seeing by now: that there is a large increase in children receiving mental health diagnoses, that ADHD is diagnosed at very high rates (especially in the South), that children on Medicaid are more likely to receive a mental health diagnosis than children with commercial insurance, etc. The data for the charts were gathered from pediatrician visits across the country by athenahealth (apparently they're too cool for capital letters), the electronic health record (EHR) company who paid for the ad.

They helpfully included a video at the bottom of the ad so we can get "perspectives on these trends from top health care leaders." Take a look:



Watching this video, I was struck by the words of Kurt Newman, M.D., President and CEO of Children's National Medical Center:

"These graphs are just probably the tip of the iceberg. The directional trend is very disturbing, but also the magnitude is disturbing, and these pediatricians are swamped.
[…]
That's why we need to do more research, we need to have a better system in terms of more providers, we need to be able to pay the providers a reasonable amount for the care they're giving. But I think if we do all that, we're going to have a huge impact for these kids and families."

Classic. There's an epidemic on, doctors are swamped—we need more funding so we can provide more treatment! No wonder he's the CEO. And like many other CEOs, he oversells when talking about the future:

"We're on the cusp of something really huge there. It's kind of like big data and big analytics that are gonna really revolutionize how we can identify these trends or get specific about certain diseases […] Autism might be a hundred different rare diseases that are all rolled up into one. We won't figure that out unless we have the analytics, all of the the really sophisticated capability of probing into: is that patient like that patient, is that child like that child, what made them more similar?"

Perhaps I'm too dumb to comprehend big data/analytics, but I fail to see how information mined from an EHR is going to shed light on the etiology of autism. Also featured in the video is Angela Diaz, M.D., Director of the Mt. Sinai Adolescent Health Center, who seems to have a more common sense take on the data:

"We need to figure out what is leading to these kids…30% of U.S. students to feel sad and hopeless for the last 12 months, and of those, 40% of the girls? What is going on? So we need to get to the root causes of these things, and try to identify and then figure out, how to prevent?"

I certainly agree with Dr. Diaz on the importance of trying to determine the root causes of the rising rates of these conditions. However, having the raw data and figuring out causality are two very different things. I would argue that in psychiatry we already have access to tons of data, but unfortunately much of it is interpreted through a very narrow, biologically-oriented lens. Having faster access to bigger pools of data is not going to help. Example in point: the January 2014 JAACAP article that described rising rates of ADHD in the US, which I had previously blogged about. That article was accompanied by an editorial by Drs. Walkup, Stossel, and Rendleman that essentially heralded the findings as good news and a sign that ADHD is being increasingly recognized and treated, which is desirable from a "public health" point of view.

In the June 2014 issue of JAACAP, Dr. Jonathan Posner wrote a very reasonable letter to the editor (subscription required), pointing out that other, more rigorous studies (relying on both parent and teacher report instead of parent report only) have found rates of ADHD closer to 5-7% instead of the 11% reported in the JAACAP article. He concludes that the reason for the rapidly increasing rates of ADHD diagnosis in the community may be "that a substandard approach to diagnosing ADHD has become the norm." Drs. Walkup and Rendleman wrote a reply (subscription required); here's the first paragraph of their response:

Thank you very much for your comments. Your position is one that we believe is shared by many, which is why we wrote the piece. Although we respect your and others’ opinions, we find it difficult to support the statement that rising rates are due largely to substandard assessment of ADHD—it is just too simplistic an explanation. The solution that you allude to is likely not tenable for a high-prevalence condition such as ADHD, because there just aren’t enough child psychiatrist providers to do it all. We are not advocating poor-quality diagnosis or inappropriate treatment; rather, the goal of the editorial was to understand the role of advocacy and education in rising rates, the importance of a public health approach to high-prevalence conditions, and to help child and adolescent psychiatrists come to terms with the fact that our traditional model of care, which is time intensive and highly personalized, is not likely to be able to address the public health burden of ADHD. We certainly do not want to inhibit the pediatric prescriber from taking on the challenge. They need our support to do it well.

So the assumption they make is that cases of ADHD reflect a biological disorder and that increasing awareness of the condition amongst the population, diagnosing it, and treating it with medications is good and proper.

Imagine, for moment, something like this happening with the obesity epidemic. The maps of child obesity in the U.S. look suspiciously like those of the ADHD epidemic, with the highest rates in the deep South. Sure, there are drugs to treat obesity, but would anyone talk with a straight face about a "public health" approach to obesity consisting of identifying the cases and then treating them with medications? Wouldn't a better (and true) public health approach be to ensure that children can get adequate exercise, good nutrition, and that people aren't incentivized to buy the cheap calories and processed "foods" that are making them obese?

Thus, as long as the prevailing view of psychiatric conditions is a narrow one, the data will be used for narrow purposes, such as academic leaders/CEOs arguing for more resources, or to justify the high rates of psychiatric medication prescribing. Here, I'm not even going to get into some other questions I had about the athenahealth ad, including who its intended audience is and what it is trying to achieve. Most doctors recognize that EHRs do not help them care for patients. These systems mostly appeal to large clinics and hospital organizations, for reasons that I will let Dr. George Dawson's recent blog post explain.

Psychiatry's Low-Tech Advantage

The other day, I received this in the mail:

It's a 57-page booklet/brochure ("bookchure"?) filled with professional photos designed to tug at the heartstrings, minimalist typography, and colorful charts highlighting the awesomeness of Akron Children's Hospital. All I could think of was, "How much money did they waste on this?" Living nowhere near Ohio, I will never have the chance to refer a patient to them. Pages 51-53 list 6 names on their Board of Directors, 26 Directors, 3 Directors Emeritus, and 5 Honorary Directors. This many Directors, I presume, are needed to oversee the 4751 employees and 703 medical staff (p. 50), as well as $1.06 billion in gross patient services revenue (p. 56).

And this wasn't the first such bookchure I've received. I've gotten similar mailings from the Mayo Clinic, the Cleveland Clinic, and probably other places that I've since forgotten. This is what our health care industry has become: Specialty centers who vie for clientele by boasting about the high-tech procedures and treatments that they offer. It reflects a system where about 20% of the population take up 80% of the costs (and even more damning, 5% of people account for 49% of spending).

At its core, Psychiatry is a very low-tech specialty, perhaps the one least reliant upon machines and specialized equipment. That's not to say there's no technology in the field, since knowledge constructs such as CBT are also forms of technology (and let's not forget Big Pharma), but psychiatry today is generally not what anyone would call "high-tech."

The leaders of academic psychiatry and the director of NIMH certainly view the low-tech nature of psychiatry as a huge disadvantage, a travesty that they are doing everything in their power to try to rectify. Hence the ever-greater emphasis on higher-tech ways of studying and manipulating the brain, whether it's optogenetics or connectomes.

However, I view psychiatry's low-tech nature as a huge advantage, at least when that advantage is embraced. A psychiatrist can easily start a practice due to low capital costs and enjoy low overhead since there is no need for a huge support staff. This keeps the focus on the relationship between the doctor and the patient, rather than having some other intermediary like an insurance company or a managed care organization extracting profit. Patients get to spend more time with their psychiatrist, and the psychiatrist has to see fewer patients, resulting in a win-win scenario. Especially if you believe, as I do, that a good therapeutic relationship can lead to positive changes.

Rather than embrace these advantages, the leaders of our profession have done all they can to minimize them, by advancing and supporting a biomedical model of psychiatry where psychiatrists are turned into prescribers doing brief med checks (or into consultants to other doctors). Since drugs are one of the few high-tech (and expensive) things in psychiatry, this of course serves the interests of pharmaceutical companies and the researchers that they support.

Last week, 1 Boring Old Man wrote about new APA President Paul Summergrad's plea for psychiatrists "to put aside internecine battles":

What [Summergrad's] predecessors have failed to notice is that a growing number of psychiatrists refuse to operate in the world created for them by Managed Care and insurance reimbursement, and that’s not all about money. […] A lot of it has to do with being unwilling to have practice dictated by excel spreadsheets in the offices of bureaucrats, the marketing departments of a corrupt industry, or the moguls of the APA and NIMH. Many avoid the APA like a plague. And many who still work in that system would be glad for a chance to change it into something more compatible with the real reasons they chose this specialty in the first place.

I really like the above paragraph from 1BOM since it captures the essence of the problems within our profession, but I would say that it's very hard to be a part of "that system" without being subject to general economic trends affecting all of healthcare. Most other specialities are not quite as low-tech as psychiatry, but the ones that rely on talking to patients and examining them using very basic equipment, such as internal medicine and pediatrics, certainly have similar dynamics.

With all that said, I am by no means anti-technology, as long as the technology is serving the patient. For example, a recent San Francisco Chronicle article highlights one entrepreneur's efforts to create "a website for a health care model in which members pay monthly fees for primary care." If that works, it would help remove primary care physicians from the grind of being in the current insurance reimbursement-based system, which has led to high rates of burnout. Also promising are the health initiatives of companies like Apple, which have the potential to empower individuals to keep better track of their own health (and allow doctors easier access to that information), which hopefully will someday decrease society's reliance on the high-tech specialty hospitals with their fancy publicity materials.

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.

On Integrated Mental Health Care

The American Psychiatric Association sure seems to be pushing hard for integrated (a.k.a. "collaborative") care these days. They even commissioned a report on how integrated care would save the system billions, which the Psych Practice blog recently dissected. APA president Dr. Jeffrey Lieberman, who is nearing the end of his term, recently published this piece in Psychiatric News. The attitude is one of "change is coming, so we'd best prepare." In this post, I'd like to take a critical look at various aspects of integrated care, based on my own (admittedly limited) experience.

First, why is integrated care a good idea? Where I work now, many psychiatrists do not accept insurance, and it can take patients months to get in to see a psychiatrist. When they do see a psychiatrist, the psychiatrist and referring physician are often too busy to communicate with one another. In some places, primary care doctors are forced to handle psychiatric patients with severe illnesses like schizophrenia, as highlighted in this post by Dr. Maria Yang. With children, pediatricians with very little psychiatric training often end up counseling parents about behavioral issues and prescribing medications, due partly to the severe shortage of child and adolescent psychiatrists.

Just as the American health care system is not just one system, but a patchwork mostly local systems, integrated/collaborative mental health care is not one thing; it can be done in many different ways. Several years ago, I experienced integrated care first-hand when I worked as a consulting psychiatrist in several primary care clinics that mainly provided care for underserved populations. Not surprisingly, most patients I saw were over 40 and had multiple medical problems. Most were referred to me because of depression or anxiety, though a significant number had a personality disorder, bipolar disorder, or schizophrenia. I got to spend an hour for each new patient visit and 30 minutes for each follow-up. In some of the clinics, I was told I should try to refer the patient back to their primary care physician (PCP) after 6 visits with me, though they were generally flexible about that.

I have to say, it was overall a good experience for me. I got to focus on providing patient care and did not have to deal with insurance companies or pharmacy benefit managers, since the clinics mostly used a generic formulary for medications. I was also glad that I helped not only the patient, but fellow physicians as well. The primary care doctors were uniformly and sincerely appreciative of having a psychiatrist that they could quickly refer patients to, or quickly consult with on a "curbside" basis. The patients tended to show up consistently for their appointments and liked having more time to talk with me compared to their brief PCP appointments. In one of the clinics, where the patients were mostly refugees and immigrants, few of them would have sought out a therapist or psychiatrist on their own, but they were more comfortable going to their doctor's office to meet with me. This all seems to concur with the APA's view of things.

That being said, my experience with integrated care was far from perfect. I thought that the vast majority of patients I saw would have benefitted from psychotherapy, yet very few of the clinics employed therapists, and none had access to more intensive treatments like dialectical behavior therapy. Even in the clinics that did have therapists (usually LCSWs), they were usually full and could not readily see new referrals. Because of the therapist shortage, I often ended up prescribing a medication by default. And of course, other forms of integrated care may be much more compromised than what I experienced. For example, managed care organizations seem to focus much more on cost containment, screening using rating scales, and then using medications to get those numbers down. To quote Sandra Steingard's comment last month on the 1Boring Old Man blog:

I was at a conference where a psychiatrist enthusiastically described her experience with collaborative care. Every morning, the treatment team would get together (the “huddle”). She gave an example of why this was so helpful. One day, someone mentioned that someone’s PHQ-9 had gone up by a few points (this is a nine item screening for depression). The presenter said something like, "So we agreed to increase the fluoxetine from 20 to 40 mg and we were all set to go!"

I also get quite concerned when I read things like Dr. Lieberman's article, which reflects the thinking of the APA leadership. From his closing paragraphs:

The difference between challenge and opportunity is often one of perception. Psychiatrists can view health care reform as leading to an inevitable change from the status quo and worrisome loss of autonomy. Alternatively, they can recognize that psychiatrists are well positioned to participate in and direct new health care initiatives—to become leaders of change, rather than siloed providers outside the mainstream of modern health care. We are the most highly trained, knowledgeable, and best positioned of all health care specialists to determine and provide (or at least oversee) the care of people with mental disorders. We are also mental health advocates who can identify gaps in service, educate others on the role of psychiatry, and offer concrete ways to better serve those within our communities.

There is a historic and exciting opportunity for psychiatrists to influence the future of medical care and occupy our rightful position in the field of medicine. Our nation is still at the beginning of the reform process, and we have the ability to influence its direction, but not if we choose to sit on the sidelines. It is important for psychiatrists to stay involved, not only in practice settings, but as APA members at the local and district branch levels. Step up and make your thoughts known to health care and government leaders; most are willing to listen if we offer ideas and solutions.

Is the focus on improving patient care, or something else? I believe that most psychiatrists are secure with their professional identities, and it is the more biologically-oriented psychiatrists who feel that we must claim our rightful place amongst other medical professionals. It's clear that they fear that psychiatrists would just opt out of the system entirely and remain in solo practice or collaborate mostly with independent psychologists and therapists. This would open the door for people like prescribing psychologists or nurse practitioners to fill the unmet need of psychiatric prescribers in medical settings. So on some level, this is a political battle as the APA fights to retain the mantle of mental health leadership. Why else do you think they have prominent politicians like Bill Clinton and Joe Biden opening the APA annual meetings?

In my mind, the biggest unmet need in mental health right now for the insured population is increasing the numbers of providers of effective therapies like CBT, DBT, PCIT, and so on. Of course, the APA does not address this at all. Instead, what the biological psychiatrists tend to emphasize is that primary care doctors don't diagnose enough, don't use the right dosage of medication, and patients do not stay on medications for long enough. Thus, the relentless push for diagnostic inflation, mass screening so cases are not missed, medication algorithms so that doses are optimized, and tracking patients like they're widgets in a factory. If psychiatry changes in accord with this vision, it would profoundly alter who enters this profession (if it continues to exist at all). Most psychiatrists I know went into this field because of a desire to treat the whole person rather than just symptoms, not to "or at least oversee" treatment provided by someone else. This type of system would favor those whose interests lie primarily in numbers, charts, "huddling" with a team. Is this really what anyone other than the APA wants business interests of managed care want the future psychiatrist to be?

This post was edited to more accurately reflect what I meant to say. Thanks, Dr. Dawson!

Book Review: Slow Getting Up

Over the weekend, I read Nate Jackson's Slow Getting Up: A Story of NFL Survival from the Bottom of the Pile in almost one sitting, a rare thing these days with my attention span getting ever shorter. Jackson was an unlikely success story, someone who beat the odds by making it to the NFL and playing for six seasons despite not being drafted after playing for a Division III college.

Jackson very vividly captures the bravado of the professional athlete: the pride in his extraordinary physical prowess, the adrenaline rush of stepping onto the field, the agony of being in the purgatory of NFL Europe, the fear of appearing weak, the drunken cash-burning Vegas partying, the frenzied testosterone-fueled cracking of helmets.

The book is wickedly funny in parts, such as when Jackson described having to be at practice early because he was part of the special teams unit:

Forty-five minutes later the rest of the team shows up. Starters don't come to special teams meetings. They're happy not to play during the ritual sacrifice of kickoffs and punts, but maybe they're also a bit envious. We're a tight-knit group. We know things the other guys don't. We know about fifty-yard dead-spring head-on collisions. We know about snot bubbles. We look at the game differently. [p. 101]

The gallows humor pervades much of the book, but the most jarring passages are when Jackson quotes from his own extensive medical record. The dry technical language belies the horrible ravaging that his body has suffered. From one of his later injuries:

MRI findings:

High-grade complete tear and stripping of proximal left adductor longus and brevis, with distal retraction and about 5cm tear defect gap with intervening edema and hemorrhage. Strain of the adjacent pectineus and obturator externus and gracilis muscles and attachments.

Moderate proximal hamstring tendinosis and/or strain and scarring are seen, with longitudinal thinning and possible tearing of the proximal deep margins at the ischial tuberosity attachments bilaterally. [p. 185]

From my viewpoint, Jackson's interactions with the team doctors take on a surreal quality. They ostensibly warn him of the risks and benefits of procedures such as steroid or NSAID injections, but it's a foregone conclusion that he would do whatever might get him back onto the field the fastest. Of course, the doctors were serving the team more than the players: one passage describes how Jackson's injuries were first reported to the team's management and the coach before he himself found out what was going on. The long-term health of the player did not factor much into the equation.

Ultimately, what I got out of the book is that the NFL is a profit-generating industry, which like all others, seeks to maximize its profits. It treats the players as replaceable cogs in a machine, parts that can easily be replaced when broken. Sure, coaches and general managers are frequently hired and fired as well, but it is the bodies and minds of the players that pay the ultimate price for our entertainment. Yet at the same time, players enter into this arrangement willingly (at least in the beginning), attracted by the money, the glory, the desire to be compete with the best in the world.

And that brings me to perhaps why I wrote this post today. There was an article in The Daily Beast making the rounds: How Being a Doctor Became the Most Miserable Profession. The article highlights a litany of woes, including the high suicide rate amongst doctors, the fact that 9 out of 10 doctors would discourage others from joining the profession, and how doctors have to see so many patients now that "the average face-to-face clinic visit lasts about 12 minutes."

Just as the NFL uses its players for profit maximization with little regard for their well-being, the healthcare system uses doctors in the same way. I tend to believe that what keeps most doctors in the profession is not the quest for money or status, but a sense of duty, of wanting to help patients and not abandon them. So in this way, doctors might actually be worse off than NFL players. There's no collective bargaining agreement. Doctors – in the U.S., at least – don't go on strike. The associations that are supposed to represent doctors often seem to collude with the business forces of medicine rather than look out for the interests of practicing clinicians. Doctors are not so easily replaced, and since there's already a big doctor shortage in the U.S., we've been sucking up physicians from the rest of the world's supply.

Compared to primary care, psychiatrists have it relatively good. Many are still in solo private practices, not on insurance panels and seeing a manageable number of patients per day. Others work in public-sector roles. Yet with every passing year, the system creeps closer to requiring psychiatrists to participate, ostensibly to help contain costs with measures like integrated care. What can be done to change it for the better? The current path is clearly not sustainable. Cost containment is clearly being targeted at the wrong level. How about containing costs here, or here? Now that would be a great start!

How to Combat Stigma, Part 2

This is part of of a series of posts on how to reduce stigma around mental health. Part 1 is here.

I'm working my way through Anthony Beevor's The Second World War, a one-volume history covering the major military events of World War II. To me, one of the most interesting aspects of the book is how much the author repeatedly describes the psychological effects of stress from war, which affected everyone involved from civilians to front-line soldiers to generals. One particularly striking passage described an infamous incident that occurred in Sicily in August 1943 when General George Patton was visiting hospitalized soldiers [page 498]:

Patton asked a soldier from the 1st Division, a young carpet-layer from Indiana suffering from battle-shock, what his problem was. 'I guess I can't take it,' the soldier replied helplessly. Patton flew into a blind rage, slapped him with his gloves and dragged him out of the tent. He booted him in the rear, shouting: 'You hear me, you gutless bastard. You're going back to the front!' A week later, Patton had another explosion when visiting the 93rd Evacuation Hospital. He even drew his pistol on the victim, threatening to shoot him for cowardice. A British reporter, who happened to be present, heard him say immediately afterwards: 'There's no such thing as shellshock. It's an invention of the Jews!'

I thought about this passage a lot as I was writing this post. In many ways, it does seem that the stigma of having a condition like post-traumatic stress disorder has greatly decreased. No general today would claim that PTSD does not exist or publicly berate a soldier suffering from it. However, the silence and shame surrounding mental conditions continues to be pervasive. There have been numerous articles and reports about the difficulties returning soldiers have in readjusting to civilian life or having access to appropriate treatment. Suicide rates, which used to be lower in the military than in civilian life, are now higher among members of the military.

I have not come across any good studies about evidence-based ways of decreasing stigma related to mental health, so what follows is my own intuition and opinion. I personally do not believe that talking about how common mental illnesses are would do anything to decrease stigma. Just look at the example of obesity, which despite skyrocketing rates, is still something that leads to kids being teased and bullied at school. Likewise, emphasizing that mental illnesses are biologically-based is unlikely to help. Everyone knows that those with intellectual disability have a brain-based condition. However, that did nothing to stop previous terms like "mentally retarded" and "idiot" from becoming pejorative. Below I'll discuss two broad areas that I think can help decrease stigma.

Normalizing the Expression of Emotion

In the U.S., when someone asks "How are you?", the answer is almost always some variation of "I'm okay," no matter what the truth may be. I believe that this cultural taboo against honestly discussing one's emotional states is one of the root causes of stigma. I have had countless patients apologize to me for crying as they describe the stress or trauma in their lives. The perception that it is somehow a weakness to be emotional or to talk about such difficulties leads to shame, which perpetuates stigma. When I ask about a family history of mental illness, one of the most common things I hear is: "I think my ___________ may have _____________, but my family never talked about it." Needless to say, those family members probably never got any sort of treatment for their suffering.

However, in some cultures, the more open expression of emotion seems to help people be more willing to seek treatment, as this CNN report on psychotherapy in Argentina shows. Even in the U.S., there are starting to be efforts to teach children emotional skills, which are increasingly recognized to be as important as intellectual or social skills. I believe that if children (and adults, but it's certainly easier with children) learn that it's acceptable to acknowledge and discuss their own feelings of sadness, anger, frustration, anxiety, etc., then they will have more compassion for others who are in emotional distress.

Of course, this does not address the stigma surrounding serious and chronic mental illnesses. Tellingly, the CNN article linked above contains the following:

One of the soon-to-be psychology graduates is Agustina, 31, who did not want her last name used because her future patients may Google her name.

Every member of Agustina's family goes to some kind of therapy, but, she's quick to add, "It's not that we are completely crazy or something. Nobody has big issues."

So what can be done for those with "big issues"?

Access to Care/Quality Treatments

I believe that as with other conditions like HIV/AIDS or Hansen's disease (a.k.a. leprosy), nothing stigmatizes more than having a group of suffers treated as outcasts and isolated from the rest of society. Having hundreds of thousands of chronically mentally ill people living homeless in the streets and millions more locked up in jails and prisons is terribly stigmatizing. Similarly, having managed care erect roadblocks to patients getting quality psychiatric care is stigmatizing, as it reinforces the idea that mental conditions are second-class citizens compared to purely physical ones. Despite passage of the Mental Health Parity and Addiction Equity Act in 2008, insurers are still unwilling to pay for many treatments.

Unfortunately, this is not going to get better until we as a society come to our senses and implement a better model for mental health treatment. As fellow blogger Dr. George Dawson has pointed out many times on his blog, managed care's focus on cost containment over quality has had a horrendous effect on the ability of clinicians to provide adequate care. Likewise, taxpayers are paying billions to keep mentally ill people locked up, when the same money could be used to much better effect to provide interventions such as stable housing, assertive community treatment, and vocational training.

It does not help that the NIMH continues to emphasize basic biological research above all else, or that the APA does little to challenge the managed care system, accepting it as fait accompli. But hopefully, with enough awareness and activism around these issues, meaningful change will eventually take place, and we as a society will make a bigger dent in the stigma related to mental health.

A Psychiatrist's Favorite Breaking Bad Moments

I came upon Breaking Bad very late in the game. I have only been watching for the past few weeks, and I still have 8 episodes left. But since watching Season 2, I have decided it's my favorite show since The Wire. While I'm obviously not unique in feeling that way, I wanted to share some of the things I've enjoyed most about the show, from my perspective as a psychiatrist and doctor.

What impresses me most about Breaking Bad is how it portrayed the interactions of its characters with the healthcare system. Just as The Wire showed how individuals were entangled with dysfunctional inner-city institutions, Breaking Bad showed the absurd hoops people have to jump through for good health care in America. This has been written about extensively elsewhere, but what I found most fascinating and revealing was how the characters – like most people in real life – had no recourse but to work with the system as is, since the system is too colossal for any individual to fight.

Moreover, every single "medical drama" I have ever seen has made me cringe because they just felt off. The doctors and patients were overly dramatic, acting too angry, or too serious, or too witty. They always brought out the paddles when they were trying to revive someone, even if the patient was in asystole. There were too many aha moments, too many exciting procedures, too little quiet suffering. I could go on forever. Breaking Bad made few of those mistakes and got lots of little details right. In particular, I think that the way the characters reacted to being poked and prodded, the look in their eyes as they had to accept the indignity of using a bedpan or stripping down for a PET/CT, and how the doctors and patients talked to each other, all seemed true to life. After seeing the episode in which Walt and Skyler met his new oncologist Dr. Delcavoli for the first time, I had the unprecedented urge to google the name of the actor who played Dr. Delcavoli to see if he was a doctor in real life.

Other details that I loved about the show:

Walt's Family Dynamics

It was clear to me early on that Walt's father was not around when he was growing up, though the show did not reveal why until late in Season 4. I have witnessed numerous patients who grew up in abusive or neglectful homes, who vow to be better parents to their own children, but then inadvertently create a dysfunctional situation of their own. In Walt's case, his justification for starting a meth lab was so he could provide for his family after his death. He likely grew up poor, so his ideal image of a father was someone who could make sure his family did not have to scrape by. However, in embarking on his quest for money, he deprived Skyler and his son Walter Jr. of his presence, driving him apart from the rest of this family. Thinking that he only had months to live, he never seemed to consider whether his family would prefer to have $700,000 or some meaningful time with him. He tries to make it up to his son later by buying Junior a muscle car, but that's no substitute for being a good parent.

My favorite moment of the entire series came in Season 4, Episode 10, when Walt, after the stress of a huge fight with his partner Jesse, broke down crying in front of Junior, who comforted him and helped him to bed. The next morning, Walt talked about how when he was a child, he saw his own father die from Hungtingon's disease, growing weaker physically and mentally, and how he did not want his son remembering him that way. Junior forcefully told Walt that he had no need to feel ashamed, and that unlike how he had behaved for the past year, at least last night "you were real!"

Hank's Post-Traumatic Stress

After Hank's shootout with Tuco Salamaca and then nearly being killed by a Mexican cartel's IED-planted-in-a-decapitated-head-on-a-tortoise in Season 2, he was clearly suffering from post-traumatic stress. The show did not try to get fancy by showing what was going on inside his head from his point of view, but the viewer can clearly see all the external signs of fear and hyperarousal, whether triggered by intrusive recollections/flashbacks or misinterpreting popping noises at night for gunfire. Then, Hank suffered even more trauma when he survived an attempt by the Salamaca brothers to kill him in Season 3. He grew angry and terse with his wife and nearly withdrew completely from life. Even though his emotional recovery from those traumatic events seemed to happen a bit too smoothly and quickly, it felt true to me that what helped him most was having a purpose in life again when he put his energy into going after Gustavo Fring's meth operation.

Jesse's Misinterpretation of Acceptance

While Jesse was in rehab at the start of Season 3, the show did a good job of illustrating the concept of acceptance when the therapy group leader talked about accidentally killing his own daughter, and how beating himself up for it only led to more drug use. Acceptance, as I understand it, does not mean thinking that something is ok. It's an acknowledgement of fact, that something unpleasant or terrible has happened and that one is imperfect, but also acknowledging that one cannot change the past, but can only control how one acts in the present moment. However, Jesse seemed to interpret acceptance somewhat differently, because after he left rehab, he told Walt that he had learned to accept the fact that "I'm the bad guy." Later in Season 4, after killing a man, Jesse berated the same group leader at a 12-step meeting, asking if he is supposed to accept himself no matter what he does. Given Jesse's emotional turmoil and the extent of his grief and guilt, it is not surprising that this was a difficult concept for him to, well, accept.

Walt's "Fugue State"

In Season 2, Walt went missing from his family because he was stuck in his mobile meth lab out in the desert. Upon hitchhiking back to civilization, he stripped naked in a convenience store and made up a story about being in a fugue state. What I love about this scenario is that it fits my experience (admittedly based on a very small n) that most of the time, when someone is found far from home claiming to have forgotten everything, it's B.S. made up by a somewhat sociopathic person to get out of trouble of some sort. And just like in real life, first Walt was seen by his medical providers, who ordered various tests and called a neurology consult. Then, when no answers were forthcoming, they brought in the shrink. I got a good laugh when Walt told the consulting psychiatrist the truth about how he made up the fugue state after the psychiatrist explained the rules of confidentiality. This, unfortunately, is not something I've had the fortune of seeing yet in real life.

I'm impressed if you've never seen Breaking Bad but managed to read this far. What are you waiting for? In addition to being thrilling entertainment, Breaking Bad is an incisive examination of the follies of our society, with some of the finest acting and thorniest moral questions that I have seen.