stimulants, benzos, and outpt private practice psychiatry......

a. they were in their (similar) shoes when everyone decided what kind of psychiatrist they wanted to be, setting they wanted to practice in, etc.

b. i find that a very interesting use of the word "need" (particularly with asterix) and wonder how to justify putting such a "need" above their patients' (and society's) best interests medically, psychologically, psychiatricly

c. I would hope that most of psychiatry doesn't oscillate between solely mere thoughtless following of algorithms and consumer-satisfaction, poorly-practiced distribution of addictive/abuse-able medications; there is a lot more nuance than that, no?

d. I don't think the picture you're painting can't happen on a case by case basis but to seek to or feel okay with running a practice like that seems out of line with what psychiatrists - as medical doctors - should be seeking to do.

I have a cash pay private practice that is steadily growing and I prescribe zero benzo's or stimulants, and make that clear up front.

Vistaril, your posts seem to have a provocative flavor, contrary to your medication namesake.

vistaril said:

And let's be honest, if someone with GAD, depression, whatever is coming to see you, most are going to expect a benzo.

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No

nitemagi said:

I have a cash pay private practice that is steadily growing and I prescribe zero benzo's or stimulants, and make that clear up front.

Vistaril, your posts seem to have a provocative flavor, contrary to your medication namesake.

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Interesting. I never say never and think flexibility is key to a good practice but clearly there are more than enough psychiatry patients to have a practice without using benzo's or stimulants. Don't you think there is a role for appropriate benzo use?

I won't lie, once you are out doing a cash only practice, you think twice at some requests that you would have normally scorned the patient for. However at the end of the day I remember michael jackson and always stand my ground. With that said I have the luxury of being selective so I have turned down many patients wanting stimulants up front. I speak to every patient on the phone before seeing them so I don't waste their time or money and do not waste my own time. There are however people that come along that I feel it is appropriate for stimulants. Quite rare for me as I really do not enjoy treating ADHD.

Benzo's are a different story. I use these a lot in agoraphobics and severe panic which I seem to see a lot of. I use them for 3-6 months if they are too anxious to participate in good CBT. It helps them embrace CBT and allow an SSRI to take effect and then wean off the benzo. I also use it with bipolar patients for insomnia sometimes.

Personally saying "never" is not a good quality for a doctor to have but that is just my opinion.

At the end of the day your patients respect you much more if you hold your ground and do what is best from your medical opinion. They lose respect for you if you become someone who just does whatever they say. I have heard this over and over since I see only higher-end patients who have had many "high-end" psychiatrists who would do whatever they wanted. They had no respect for them as a physician and appreciate someone (myself) who does not take B.S and instead does what is in their best medical interest.

It's a very tempting way to practice. Easy and profitable. I'm sure there are plenty of psychiatrists out there that do this. Like the saying goes: "psychiatry is easy to practice poorly, but hard to practice well"... or something like that

I have less than 5 patients on BDZs for treatment refractory panic disorder. About 3-4 on stimulants for adhd after failing strattera and wellbutrin.

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vistaril said:

ummm...I've stated I dont want to do outpt med mgt. Well except suboxone part time.

The point was that it is delusional for us to believe many/most outpt pp high volume med mgt psychs dont practice this way. Anyone who has spent time on an inpt unit and sees pts coming in knows this.......

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You're presuming your individual experience at your individual hospital generalizes to all outpatient practices all over the country. You have no data to support that.

I am the first to point out that I disagree with many outpatient provider's strategies, but I also know I don't know everything and don't need to judge everyone else to feel confident that I can do a good job.

It's ok to work hard and do quality work without pissing on everyone else. I don't buy ADHD as a dx in most cases, but I don't judge those that do treat it. That's their call. I just respectfully disagree. Vistaril seems to be missing the respect portion of that last sentence.

nitemagi said:

You're presuming your individual experience at your individual hospital generalizes to all outpatient practices all over the country. You have no data to support that.

I am the first to point out that I disagree with many outpatient provider's strategies, but I also know I don't know everything and don't need to judge everyone else to feel confident that I can do a good job.

It's ok to work hard and do quality work without pissing on everyone else. I don't buy ADHD as a dx in most cases, but I don't judge those that do treat it. That's their call. I just respectfully disagree. Vistaril seems to be missing the respect portion of that last sentence.

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Here here! I don't like to comment often on this but I also do not believe in adult ADHD especially in 9 out of 10 cases anyway!

.

That's just the business realities imo. If you're a mostly med mgt outpt psychiatrist that isn't salaried through a CMHC type place, you *need* paying patients

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I don't see any business "reality" in working as a drug dealer. Forgive me if I'm taking your words out of context and if so, please explain what you meant because I'm getting the impression that you're justifying meds that are not considered the better treatment in the name of giving patients a quick fix and making more money.

I've done private practice and I hardly gave out benzos. Out of hundreds of patients, I haven't done an exact count but I'd guestimate around 600, I only chronically gave benzos to about 3 that didn't have panic disorder, and only gave it to those with panic disorder as PRN to prevent panic attacks that I already stabilized as much as I could with an SSRI with our without buspirone or gabapentin for augmentation.

Those panic disorder patients only took benzos on the order of a few times a month (e.g. about 3-5x a month), and I monitored their benzo use so that if they tell me they still had panic attacks 3x a month and I gave them 30 pills, I expected them to last about 10 months. Even those patients were on the order of about a few dozen (about 20-30). Most of the patients either didn't want a benzo when I explained to them it was addictive, or they stabilized to the point where they did not need benzos at all.

The point was that it is delusional for us to believe many/most outpt pp high volume med mgt psychs dont practice this way. Anyone who has spent time on an inpt unit and sees pts coming in knows this.......

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I see plenty of doctors prescribe this way, and I think they're wrong, and the data suggets they are wrong too. Benzo dependence, per studies, starts within weeks of treatment, not months or years. One doc being an idiot, or even a group of idiots doesn't strengthen the argument to follow their example.

vistaril said:

I'm simply trying to understand the VERY LARGE number of outpt high volume med mgt psychiatrists who do it.

People who do therapy, people who are salaried, people who work on contract, people who do part time CL in addition, people who treat SMI population, etc don't really fall into this category because the pressures and reality of running a successful practice are different.

If I derive 1/3 of my salary from a C-L contract, 1/3 from a CMHC 15 hrs a week, and the other 1/3 from private med mgt patients, the financial concerns of running a successful business are different because I don't depend on self pay/privately insured pts as much.....

A person who goes to a cmhc has non leverage to expent/want/demand benzos from their psychiatrist or else. The psychiatrist can just shrug, state "sorry not standard of care" and that's that...the pt isn't going somewhere else because they can't. But private and self pay patients do have more leverage when they are paying money for the service of a 10 minute med mgt outpt with no therapy and no other useful services......there is no shortage of people(pcp pr psychiatrist) who can do that, and eventually they know if they have a payer source they will find someone who will give it to them.

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I thought it was kinda weird when I got an intake at the University from a lady that was self-pay. Turns out she was not interested in a diagnostic evaluation. She just wanted Xanax. Tapered her off with Valium. She then left the state to see her original doctor that was prescribing her Xanax. Psychoeducation, frequent follows, and empathic statements can only go so far in someone who has no motivation to stop their addiction. Just in understanding the relapsing and remitting nature of addiction, should alone help you feel assured that if they don't get benzo's from you, they will from someone else. No sense in feeding into their addiction if that's the problem you're trying to fix. I disagree that these patients have more leverage. If I had to choose between harming a patient and not getting paid, I'd choose not getting paid.

Simply just trying to understand? Sounds like you were more on the order of justifying it.

Some of it is pure idiocy. Some docs just seem to have forgotten everything in medical school, or at least the important things. The others don't care.

I've made plenty of money in private practice without selling out, and I don't see how anyone could want to go in that direction unless they're intentionally going into a model where they're just acting as drug dealer and not trying to actually get the patient better. I don't see a "pressure" either. There is a shortage of psychiatrists across the country, I don't see a problem with a person filling up unless they did cash-only and charged extremely high fees. I've never had any pressures in private practice to get new patients. Quite the opposite, I had too many patients trying to get in and not enough time to give to them.

I don't know if it'll make any difference, but if I had ample evidence to believe a doctor was giving out benzos or opioids like candy, and I've seen patients suffer from this, I encourage patients to report this to the state medical board and tell them how to do so. At least where I am, you simply go to the state medical board's website, click on the complaint form, and viola.

vistaril said:

I'm simply trying to understand the VERY LARGE number of outpt high volume med mgt psychiatrists who do it.

People who do therapy, people who are salaried, people who work on contract, people who do part time CL in addition, people who treat SMI population, etc don't really fall into this category because the pressures and reality of running a successful practice are different.

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First of all, i seriously doubt that most managed care psychiatrists are not aware of the abusive potentials of these medications. But let's also not forget the very serious risk of not giving meds to people who need it and please do not confuse the basic difference between tolerance, withdrawal symptoms and addiction. Patients come for meds because meds help them. This is NOT the same thing as them being addicted to meds.

Let's assume that you aren't trolling, based on the type of cases you've seen, you actually have no idea how cash only private practices work. First of all, they only exist in very few markets, which I'm assuming you don't actually see. Secondly, it's actually rare to have "large volume" psychopharm for private patients, because it behooves you to spend the actual time to treat someone who's going to pay you $300 an hour. Thirdly, when you are paid that much to treat generally high functioning individuals in severe episodic illness, the stakes are much higher than you think, because while they don't become SPMI, if they really become an addict, they can lose their jobs, get divorced and become completely dysfunctional.

I would argue very few patients who can afford private treatment actually need/want a private drug dealer. Even in private substance dependent patients, the main issue is for them to get off the substance that they are on, not to get more dependent on something new. Private patients want treatment to get them BETTER so they become MORE functional, not so that they can get high and sit around.

High end boutique psychiatry which I happen to be familiar with, and from what appears you aren't, is a very different animal compared to the high throughput cattle managed care style psychopharm practice that you delineate and, apparently devalue, and let's just not confuse the two from the get go. These small, highly exclusive, often part time faculty practices are truly designed to be a sort of luxury mental health services combining the best psychopharm with the best psychotherapy. Is it more efficacious? Likely no. Do people need it? No. Is it more luxurious to have an MD who's an expert in your field be your private retainer doctor? HELLZ YES. Do rich people pay a lot of money for it? Yes. It's your brain on meds, wouldn't you want the best of the best to do it if you can afford it? It's much more similar to a high end derm or plastic surgery practice than a HMO 50 visit a day psychopharm practice.

On that note, I've treated very wealthy patients who want top services for top dollar fees. I've treated the son of a wealthy former corporate officer of a major corporation, a hedge fund manager that made dozens of millions of dollars a year, a professional athlete, a few people in one of America's most wealthiest families to name a few.

You screw up, you're disappointing powerful and well-connected people who have very high expectations of your work.

I had a talk with another doctor in a similar position, and we both vented that sometimes the family members expected us to pull a rabbit out of the hat that was not medically possible and this was frustrating to both of us and how it was a relief to talk to someone else who understood this because most docs are not in this position.

And I believe I only got to that position to begin with because I was treating patients consistently without resorting to benzos, listening to them, and earning a rep. Before I joined the University, the local private institution started referring me patients that were willing to pay out of pocket because they told me I had developed a good record from what they heard from others. That actually led me to want to leave the private practice because it was not MY private practice but I was the one really bringing in all the money. It motivated me to leave because the more I succeeded in it, the more it made me think I'm just working for another guy when I should be thinking more about myself.

I started working at that private institution after I joined the University, and the social workers had a good idea of who the quacks were vs the good doctors that gave a damn.

whopper said:

You screw up, you're disappointing powerful and well-connected people who have very high expectations of your work.

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EXACTLY! excellent case demonstrating my point. Thx whooper.

In that private practice I mentioned, I was doing high-output after I put in about 6 months of work. How this happened was that several of the patients that were stabilized just needed med refills and/or their 3 month labs for Depakote or lithium.

Those patients were stable and just wanted their meds refilled, but to get them to that point, I had to spend good time with the patient to diagnose correctly and then get them the correct med. At first it was mostly patients that needed a lot of time, but as a few months rolled on, the ratio of people who just needed a med refill became the majority even though I was only seeing them every 4-6 months.

And for the overwhelming majority of them, I didn't have to give out a benzo. Most of them actually came to me on a benzo and I weaned them off of it.

vistaril said:

I've noticed that the tendency for salaried psychiatrists is to condemn these people when benzos and schedule2 stimulants are prescribed without very clear indications.

The fact of the matter is that a very substantial % of mood d/o/anxiety pts are on benzos, many on stimulants, and some on both. And most of these pts are on these meds chronically, and most don't suffer from real panic d/o. Some even have past hxs of possible susbtance issues.

That's just the business realities imo. If you're a mostly med mgt outpt psychiatrist that isn't salaried through a CMHC type place, you *need* paying patients. Either self-pay cash or the insured pts with the highest reimbursing insurance. And let's be honest, if someone with GAD, depression, whatever is coming to see you, most are going to expect a benzo. Or take that money to another psych who will give it to them. Let's be honest- following StarD or some otherwell established protocol or algorithm isnt brain surgery. If they wanted to be treated with Celexa and then augmented with Buspar or whatever later, they could get their pcp to do that.

I don't think it is unreasonable for the typical med mgt outpt psychiatrist in private practice to say: "yeah, I know this pt has run of the mill GAD and is drug seeking on some level. And maybe ideal standard of care is to not have them on Klonopin forever. But you know what.....they aren't a bad guy and seem somewhat reliable, and at least this way I can monitor them. And I'll try to set reasonable limits in terms of refusing to keep increasing it over time"........

that's what happens in the real world. I don't think it's fair for a salaried CMHC person or a C-L psych to judge these people, because they aren't in there shoes......

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FACT: You could choose to actually treat their anxiety, panic disorder, PTSD, depression with empirically validated psychotherapies, but you choose not to for the sake of money (high volume= more money, no?).

This is your choice. Do not blame it on the system and do not justify only using half your skill set as a psychiatrist because the "guy is an overall good guy" and could probably get it from someone else. I find that pretty disgusting.

I also find it pretty insulting that you basically view your patients as drug/med seekers only. All patients presenting with these disrorders "expect a benzo?" 1.) Obvioulsy, that is a gross and inappopriate generalization that has developed due to your biased sample of patients and your "practice model." 2.) What the hell does it matter what someone expects anyway?! You're the Dr. The best advice/therapy/help a person can get is often something that they dont want to hear. To tell them that benzos are not appopriate for long-term tx of these condition and thus avoiding iatrogenic illness/addictions would be following the hippocratic oath, no?

So it's 'Some other doc will give them substandard care, so I might as well be the one giving them substandard care.' ? Cool deal. I'm glad you can deliver care you know is substandard while secretly being very competent.

vistaril said:

I don't find being practical disgusting. Again, I'm not interested in outpt med mgt, but if I was I think there is some value in saying "this pt is going to get benzos from somewhere. Considering that there are pill mill doctors out there, it's far better for them to get a more reasonable dose that can be monitored here than going to one of those physicians".

As for patient populations, in the most drug seeking patient populations(people without a true SMI who somehow snuck into CMHC's), that's a no brainer. Just tell those patients "nope. not going to do it. find someone else if you want".

for my outpts, I have some people with GAD who are on benzos chronically. And I have some people with GAD who are not on benzos chronically but would like to be. It's a decision I make on an individual basis. But with all the sketchy prescribing going on in medicine I see, including a non-trivial % of psychiatrists, I certainly won't lose any sleep at night doing what I believe to be best for my pts.

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Um, So.... "best for your patients" is enablement of addiction and/or to continue to Rx medications that have NO demonstrated efficacy in the literature for treating the diagnoses you mentioned (GAD, PTSD, panic, mood disorder), all while maintaining that you don't do the efficacious treatments because that's a different "practice model?"

Then seriously pal, what actual benefit are you providing here?

vistaril said:

well I don't know what you are leaning in psychology school, but many of these pts don't qualify as addicts, being addicted, etc......in fact, part of the reason some outpt psychs probably feel comfortable with doing it is because they feel they may be able to manage and monitor the pt such thing they can reduce the likelihood of addiction.

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I said "and/or." Anyway, it is VERY clear that you know darn well what I mean in my points and because you dont have alot of clinical justification for your pratices, you fall back on the "others are doing it too/worse than me" thing.

vistaril said:

But let's be real.....any review of the most prescribed medications in the US has klonopin in particular renked *very high*. The % of the benzos being prescribed out there being used for actual indications many in this forum would publically state(acutely/temporarily only with the addition of blah blah) is like 1-2% of all the benzos being prescribed out there. Knowing that, a practical risk reduction strategy may not be a bad idea........

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This is irrelvant...

vistaril said:

sorry if I came off a little abrupt here, but quite frankly I don't have a lot of patience or respect for psychology students drawing such lines in the sand when it comes to clinical practices with medications.

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Again, this is irrelevant. We are both qualified to treat anxiety disorders. You, are choosing not to.

vistaril said:

As for my own personal rx habits in the outpt setting, I write for less benzos than most outpt pp people who have completed residency and are out there.

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You have not really answered the questions I have asked and have not provided any real clinical justification for the practice that you are doing. I can tell that you dont like the way you are practicing. Thus, all you have to do is change it. You are your own boss, no?

I think it is a bit naive to think that systemic effects do not have a role in governing what an individual practitioner does. Obviously there is some level of choice, but our decisions are determined by wider factors. I trained in a system where benzos were generally seen as 'evil' - xanax is not even available. There is no possibility of even prescribing drugs like xanax or halcion because they are not covered. In primary care, physicians actually lose money if they prescribe too many benzodiazepines (due to the way physicians are paid) so prescribing them for longer than 2-4 weeks, even prescribing them at all is disincentivized. (not always for the better- i much prefer rx temazepam short term than zopiclone for example). I would mainly use benzodiazepines for alcohol withdrawal and palliative care (end of life anxiety etc). The only patients I had on chronic benzodiazepines were those who had been on them for many years (often 30 or 40 years when they were just dished out to everyone) and had unsuccessfully cross-tapered and weaned off diazepam. I do like using benzos for sedation in mania though, as opposed to using crazy high doses of antipsychotics to sedate.

I probably would never have rx benzos for panic d/o. we shall we what will happen now...

vistaril - maybe you should do some training in negotiations? you will learn there are differences between positions ('i want benzos' 'i will not prescribe benzos') and interests and that for many patients you will actually be able to help them without giving them benzos and convincing them this is not what they want. Obviously there are patients who are simply drug-seeking but many of these are not immutable.

the clinical justification is some pts benefit from them, and some of these don't experience negative long term effects. Again, that's where physicians must use clinical judgement

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Yes but the only way to find out is to put the patient on a medication regimen that is riskier than the safer routes before those safer routes are tried.

Listen, I hate doing this as a moderator, but the arguments are repeating themselves and are going in a circle. If that continues, this thread is not worth furthering and it'll just devolve into a flame war. I'll leave it alone for now and see what happens in the name of libertarianism, but if it continues I'm considering locking it. I'm only going to allow it to continue if something new is introduced.

I do agree that benzos should not be out of the question in every single case, but I do think Vistaril's opinions on giving it out are more liberal than my own. I have seen other doctors that I respect that have given it out more liberally than I do.

But here's my bottom line. The argument that other doctors give it out worse in no way justifies we give it out inappropriately. Further to argue to give it out based on practicality and not what's the best decision given the situation is without argument wrong and there is no way to wiggle yourself out of it. To even suggest those as justifications are either an accidental and forgivable slip of the tongue (and I've done that) but the problem here is it's being repeatedly used. Even I'm not thick-headed enough to have repeated that enough times on this thread without realizing I made a mistake. In a perfect-world, anyone in the residency level of medical training not understanding that should not have progressed to that level IMHO, though I've seen plenty of attendings do far worse. We're talking ethics that people should have developed in high school.

Vistaril, if you're a resident have you talked to attendings in your program about this? Actually I wouldn't be surprised if you found one that actually agreed with you. I had an attending saying a patient dying due to his lack of care would be a great teaching experience for a resident while I was a chief when I confronted him on his lack of performing even minimal standards with resident support and supervision, and the program didn't get rid of him and basically gave him a slap on the hand.

but patients come to people saying they've already been on x.y,z and done cbt in many cases. again, pts are more sophisticated than we give them credit for a lot of the times. It's probably worth it to get the records and check if one has time though.

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A problem here is several are manipulating the clinician. I had a guy come in and tell me he had bad anxiety but was allergic to everything reasonable, even Klonopin, and said the only things he wasn't allergic to was Xanax and Ativan. Yeah right.

Kinda like those violent patients that say they're allergic to Haldol. I've yet to see anyone allergic to it. They just didn't want to get injected with it when they started throwing chairs.

There are patients that are outside the norm and could be telling the truth. I've seen that too. What a doc should do in this case is get collateral information. Get previous records, call pharmacies, and, well at least in Ohio, I can look up every single prescription the patient has filled out in the last several years. Unfortunately there are patients who have gotten prescriptions for prior SSRIs but really haven't given them a real try (take them consistently for one month). People with poor coping skills often-times just want the quick fix and we shouldn't enable that. Such people are usually also the same ones that would abuse a benzo.

I have had patients that were tried on several SSRIs, SNRIs, and TCAs with no improvement and I actually did believe they were telling me the truth. One of those patients had to go inpatient because each time he tried Lexapro his BP shot out of control (I'm not joking and he was the only case where I've seen this happen). His BP had to be monitored closely while he was tried on SSRIs. He was one of the only people I allowed chronic benzo use with and I couldn't get him better. I believed the guy's sincerity because he kept telling me he was sick of benzos, felt drunk on them, but nothing else was getting his anxiety under control including gabapentin, vistaril, zyprexa (yes that's how desperate I was), Trazodone, what have you. This was a guy who kept a detailed list of every single med he ever tried.

The fortunate thing was these patients were about 1% or less of all the patients I've seen. Virtually all the patients I've seen demanding benzos were doing so inappropriately.

vistaril said:

well as for the first, yeah.......but patients come to people saying they've already been on x.y,z and done cbt in many cases. again, pts are more sophisticated than we give them credit for a lot of the times. It's probably worth it to get the records and check if one has time though.

As for talking to attendings about it, well like I said it's not something I think about because Im not interested in that sort of practice and I don't start benzos on an inpatient unit for chronic use, but judging by what is done in the community(from pp med mgt psychs), I'm definately on the conservative spectrum of things......

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I understand where you may be coming from as a physician, I do. I just dont agree with it, AT ALL.

I think you guys have MUCH more pressure than we do to eradicate ALL distressing or displeasure emotions from a person's life. Personally, I like to think that I "treat" pathology, not the occurrence of all distressing emotion. I think we can all agree that distressing emotion doesn't automatically=pathology. However, the idea of "normal" (ie., happy, free of anxiety, etc) as the homostatic state that all must be in (or returned to if they deviate) at all times is quite unique to western medicine and western ideas of mental health. However, in reality, negative emotions are an important and meaningful experience. I am happy that I am in a position where I feel able to do more than tx a symptom of a much larger psychic struggle.

vistaril said:

I've noticed that the tendency for salaried psychiatrists is to condemn these people when benzos and schedule2 stimulants are prescribed without very clear indications.

The fact of the matter is that a very substantial % of mood d/o/anxiety pts are on benzos, many on stimulants, and some on both. And most of these pts are on these meds chronically, and most don't suffer from real panic d/o. Some even have past hxs of possible susbtance issues.

That's just the business realities imo. If you're a mostly med mgt outpt psychiatrist that isn't salaried through a CMHC type place, you *need* paying patients. Either self-pay cash or the insured pts with the highest reimbursing insurance. And let's be honest, if someone with GAD, depression, whatever is coming to see you, most are going to expect a benzo. Or take that money to another psych who will give it to them. Let's be honest- following StarD or some otherwell established protocol or algorithm isnt brain surgery. If they wanted to be treated with Celexa and then augmented with Buspar or whatever later, they could get their pcp to do that.

I don't think it is unreasonable for the typical med mgt outpt psychiatrist in private practice to say: "yeah, I know this pt has run of the mill GAD and is drug seeking on some level. And maybe ideal standard of care is to not have them on Klonopin forever. But you know what.....they aren't a bad guy and seem somewhat reliable, and at least this way I can monitor them. And I'll try to set reasonable limits in terms of refusing to keep increasing it over time"........

that's what happens in the real world. I don't think it's fair for a salaried CMHC person or a C-L psych to judge these people, because they aren't in there shoes......

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As a chronic pain clinic medical director , I despise the above statements with every fibre of my being.

You thesis stament is pretty much legalized drug dealing, is it not ?

I see folks on daily large doses of benzos for generalized anxiety disorder, whether prescribed by psychiatry or their family doctor. Once a person is prescribed this medication for a prolonged period of time, it is very difficult to get them off it. Your financial based mindset is not reassuring.

Your mindset reminds me of opioid based " pill mill " behavior. You would do well to see where this type of conduct leads physicians.

Your peers have spoken, and spoken well. Such behavior is not the standard of care.