Good Manners

[YOOOUK09]

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Over the Thanksgiving weekend I had a chance to see my cousin who I grew up with (and who has schizophrenia) and aunt. I later emailed my aunt asking for some feedback about good/bad psychiatrists they have dealt with over the years (it's been a really long road for them). Here's what she said:​

(oddly, it closely parallels this article from the ny times today)​

"I have a lot of complaints about psych docs. Most of them are common sense things:​

1. docs not listening and not answering questions in simple terms, such as why can't you give a diagnosis now? It was explained very clearly to me and I knew that the label didn't matter because the symptoms were the things being treated no matter what its called. Some people, especially nervous loved ones, want to wrap their brains around something.
2. being released from a facility without any help, advice, or list of resources. Be prepared with a packet of information of resources including web sites, books and organizations like NAMI. All physical conditions are sent home with a sheet of instructions and danger signs etc. If you think about what physical illnesses need emotionally, its the same for mental illness. I have never had any advice except if he gets violent, call the police. that's it. not good, valid but not enough. so scary This was the biggest complaint. It doesn't happen in physical medicine.
3. do everything to involve the family or support system. They are your biggest source of information and support for the consumer, assuming that they are good of course.
4. advise them to get a second opinion. I heard a lecture at "BMS" and loved hearing a psychiatrist say get a second opinion.
5. Tell the family or loved ones to educate themselves about the illness whether its through books, or organizations. It is a huge benefit to your patient.​

They need to learn how to communicate with their loved ones, and why they are acting the way they do and the fact that its no one's fault. Education is huge."​

Thanks Aunt Betty!​

 

[michaelrack]

Who is going to pay for this 2nd opinion that you are recommending? A truly valuable 2nd opinion will take at least several hours, often over several visits, and cost $500-$1000 (in most cases closer to $500). It's hard enough to get an insurance company to pay for the "1st opinion".

 

[YOOOUK09]

Who is going to pay for this 2nd opinion that you are recommending? A truly valuable 2nd opinion will take at least several hours, often over several visits, and cost $500-$1000 (in most cases closer to $500). It's hard enough to get an insurance company to pay for the "1st opinion".

It's a very good point. My cousin's family is upper-middle-class and could afford to do so.

I think the spirit of her comment was "don't pretend you (meaning me her nephew) know everything."

 

[Anasazi23]

"I have a lot of complaints about psych docs. Most of them are common sense things:


2. being released from a facility without any help, advice, or list of resources. Be prepared with a packet of information of resources including web sites, books and organizations like NAMI. All physical conditions are sent home with a sheet of instructions and danger signs etc. If you think about what physical illnesses need emotionally, its the same for mental illness. I have never had any advice except if he gets violent, call the police. that's it. not good, valid but not enough. so scary This was the biggest complaint. It doesn't happen in physical medicine.​

This is illegal. Even jails by law have discharge and aftercare plans. They had discharge plans and aftercare plans as well. They might not have loved them, or found them fruitless since he sounds like a difficult chronic patient, but he got a discharge plan.

I hate to by cynical, but the other items mentioned by Aunt Betty might be more complicated than it sounds. Giving a diagnosis, for example, is often fodder for more fighting and destructiveness than witholding one. As an aside, I always provide a diagnosis when asked, but there have been times when giving a diagnosis adds little to the clinical progress other than grief.

The other points of advice are generally good medical advice for any patient, not just a psychiatric patient (i.e. #'s 3, 4, 5).​

 

[Doc Samson]

There's also the fairly frequent occurence of the patient being given a very detailed and stringent follow-up plan which they happen not to like - so they tell the family "nope, no appointments." The inpatient service cannot communicate with the family without the patient's permission, which is often refused.

The NYT and NEJM articles by Michael Kahn, Longwood attending BTW (yes, that's a shameless plug for my alma mater), address how we interact with our patients. Our primary duty lies with them, not their families. It's often frustrating to not be able to tell the family something important ("hey, maybe if he stays off the weed, the meds might control his paranoia a little better"), but our commitment to our patient must come first. I get that this frustrates the family, but I really don't see a way around it.

 

[nancysinatra]

Who is going to pay for this 2nd opinion that you are recommending? A truly valuable 2nd opinion will take at least several hours, often over several visits, and cost $500-$1000 (in most cases closer to $500). It's hard enough to get an insurance company to pay for the "1st opinion".

Ok, but what if the diagnosis is something truly debatable, like pediatric bipolar?

Does anyone know--is the misdiagnosis rate in psychiatry officially tracked anywhere? Is it tracked in other branches of medicine? It seems to me that the "value" of a 2nd opinion can only be known if we first calculate how often patients are misdiagnosed, and then, if we also calculate whether they are more often correctly diagnosed by a first doctor vs. a second or a third doctor--i.e. are there diminishing returns or increasing returns? Or is it all doctor-dependent?

I would think with the Diagnostic and STATISTICAL Manual in use by everyone, we'd be all set up to keep an eye on these things, wouldn't we? So we could say to patients, you have, say, a 65% chance of getting the right diagnosis by your first doctor, a 75% chance of getting the right diagnosis by your second doctor, and an 45% chance of getting the right diagnosis by your third doctor...

(Or maybe it's all patient dependent. Doctor shoppers and all...)

I guess what I'm saying is that going to the doctor is a "test" just like getting an HIV test or a hematocrit test or any other medical test. It should have a reproducible specificity and sensitivity over time. Ideally they should be high, but what with human beings being what they are, and psychiatry relying as it does on word of mouth and human judgement, I'm guessing the rates aren't the HIGHEST in all of medicine... No, I'm not saying they're the lowest either. Just that there must be times when a second opinion really, statistically, IS warranted?

 

[michaelrack]

Ok, but what if the diagnosis is something truly debatable, like pediatric bipolar?



I would think with the Diagnostic and STATISTICAL Manual in use by everyone, we'd be all set up to keep an eye on these things, wouldn't we? diagnosis by your second doctor, and an 45% chance of getting the right diagnosis by your third doctor...

(Or maybe it's all patient dependent. Doctor shoppers and all...)

?

A one-line 2nd opinion diagnosis like "pediatric bipolar" or "adhd" isn't really helpful at all.
When I was a resident in Morgantown WV, occasionally children would go to Western Psych (Pittsburgh) for a 2nd opinion. We would get back a very detailed evaluation -very detailed H+P, 5 axis diagnosis, full biopsychosocial formulation, and detailed recs for tx and/or further evaluation. That was helpful, but also took a lot of resources- several hours by the attending psychiatrist, evals by child psychologist, social worker gather data and talking to the child's teachers, resident/fellow psychiatrist, etc. If a patient has that type of 2nd opinion available to them, I say go for it. A 2nd opinion in which a psychiatrist spends 30 minutes with the patient and writes a report barely detailed enough to justify a 90801 billing code won't really help.

 

[BobA]

. . .

 

[howelljolly]

This is really interesting.

One of the that I disliked most about my psych core rotation was that patients would not be reliably diagnosed, but treated anyway.
I had a few patients who's diagnosis I strongly disagreed with, but my attending wouldnt even entertain the idea.

Guess I should have just rolled with it.

 

[YOOOUK09]

This is really interesting.

One of the that I disliked most about my psych core rotation was that patients would not be reliably diagnosed, but treated anyway.
I had a few patients who's diagnosis I strongly disagreed with, but my attending wouldnt even entertain the idea.

Guess I should have just rolled with it.

I have had similar experiences where I've doubted the diagnosis, but I'll defer to the experienced attendings on it usually. That being said, I'm hoping to choose a residency where the attendings have better diagnostic rigor than the ones at my home institution.

But I just got off ID consults, and got to see how the medicine folks were treating all sorts of bogus infections (usually drug fevers from the Abx) - as a consult team (with the benefit of a birds-eye view and an ID attending) we stopped Abx more than continued or started them. My point is just that diagnostic uncertainty is very common in many medical fields. However, the lack of a clearly defined "fixable" defect than can be tested for and treated is a somewhat unsavory aspect of psych I'm having to learn to live with. It'd be great to have an anti-schizophrenia serum but until it comes out I'll take psych for what it is.

What's more bothersome, however, is the inability of many of my attendings to admit to the lack of certainty. It seems to come from a place of insecurity.

Sure, treat the psychosis, but why the need to nail a diagnosis right away while the patient is still coming down from their meth and LSD binge? I hope I'm more comfortable with a wait-and-see approach when I'm all grown up. . . . Just tell the family "it could be X, Y, or Z" and only time will tell.

 

[Doc Samson]

Just tell the family "it could be X, Y, or Z" and only time will tell.

There are really people who DON'T do this???

 

[howelljolly]

Id normally defer to an experienced attending as well, unfortunately, my rotation was a mess.

Its not that they couldn't nail down a diagnosis, its that they never attempted.

Anybody, even a 4 year old child, can figure out of a patient is sad or happy. If a patient came in feeling sad, they got and antidepressant. If they were happy, they got a mood stabilizer. If they were strange, they got and antipsychotic. The dose would be increased until the patient couldnt feel ANYthing anymore. That was it.

It was bad. I met criteria for atypical depression by the end of my rotation.

 

[PeeWee137]

i think alot of misdiagnosing comes from the natural instinct to want to figure things out, and tell a patient they have *something*. sometimes they pressure you for an answer, sometimes the family does, whatever. as a student especially, its been really hard for me to not always have an answer for a patient, i feel like i failed them and that i dont know what im doing.

 

[howelljolly]

Yep, that was a bit of a suprise to me, but in one sense I adjusted pretty quickly...

I saw how the other members of the treatment team, like the psychologist and social worker really measured outcome success by "quality of life" or something similar... rather than figuring things out. I thought kind of mindset could do me some good.

But in another sense, I guess not...

 

[YOOOUK09]

There are really people who DON'T do this???

It was frightening - especially the one attending who told everyone they were bipolar no matter what was wrong with them.

Like I said, I'm hoping to find more diagnostic rigor where ever I end up for residency.

 

[YOOOUK09]

i think alot of misdiagnosing comes from the natural instinct to want to figure things out, and tell a patient they have *something*. sometimes they pressure you for an answer, sometimes the family does, whatever. as a student especially, its been really hard for me to not always have an answer for a patient, i feel like i failed them and that i dont know what im doing.

I think that's the insecurity part.

(As a student I never diagnose anything without talking with my team first) But I think you can show the family you know what you're doing by actually being correct over time.

 

[howelljolly]

It was frightening - especially the one attending who told everyone they were bipolar no matter what was wrong with them.

Like I said, I'm hoping to find more diagnostic rigor where ever I end up for residency.

Oh the agony
My attending would write anyone who had a substance abuse history off, as have substance induced whatever, regardless of how remote.

If it was recent, then the substance abuse was the cause, and abstenence was the treatment. When I suggested that since a particular patient was not withdrawing at all in the first few weeks of admission (yes weeks), and this was only one of the factors to show that the Hx was questionable in the first place... maybe that acute substance use wasnt the etiology... I was written off.

 

[PeeWee137]

well of course my little ms4 self doesnt go around diagnosing everyone

but i think this kind of attitude persists beyond the student years. people go to the doctor for answers, not more questions. its very very tempting to give someone that answer.

 

[nancysinatra]

A one-line 2nd opinion diagnosis like "pediatric bipolar" or "adhd" isn't really helpful at all.
When I was a resident in Morgantown WV, occasionally children would go to Western Psych (Pittsburgh) for a 2nd opinion. We would get back a very detailed evaluation -very detailed H+P, 5 axis diagnosis, full biopsychosocial formulation, and detailed recs for tx and/or further evaluation. That was helpful, but also took a lot of resources- several hours by the attending psychiatrist, evals by child psychologist, social worker gather data and talking to the child's teachers, resident/fellow psychiatrist, etc. If a patient has that type of 2nd opinion available to them, I say go for it. A 2nd opinion in which a psychiatrist spends 30 minutes with the patient and writes a report barely detailed enough to justify a 90801 billing code won't really help.

I see what you mean. It seems very frustrating, though, that not all patients have access to the same diagnostic resources. So then, if someone wanted to do retrospective or epidemiological research, how could they trust the data? America is not exactly a trustworthy laboratory of statistical data for the psychiatric illnesses from what I can tell. And then on top of that we're still just beginning to learn the basic brain science behind the diseases.

 

[whopper]

It was frightening - especially the one attending who told everyone they were bipolar no matter what was wrong with them.

I hate saying this but I've seen a number of medical professionals bungle up. I sometimes wished there were some type of medical police officer to nab these people.

Several medical authorities & organizations such as the AMA reccomends that the allowable number of doctors graduating be of a number that allows doctors to get a large pay. While that's great for us, when there's a deficiency of doctors, especially in a specialized field such as psychiatry--it allows bad doctors to get away with their bad practice because hospitals can't get rid of someone when they're hard to replace.

I've had to tell some of my friends & family to let their doctor know that their (son-in-law, best friend, husband--whatever my relationship is to them) will be checking up on their case, which immediately makes them practice standard of care. My father in law got bitten by a cat--his hand got inflamed & he was getting what was apparently compartment syndrome--the ER doctor gave him the wrong antibiotics & didn't check his blood sugars (the guy is diabetic). He had to go back to the same ER, and when he told the ER doc that his son-in-law was concerned & was going to check up on this--the ER doc actually started giving decent quality care--checked his blood sugars which were over 400, & gave antibiotics that could actually cover cat-bite fever. The ER doctor would've blown him off otherwise.

Some doctors know that their patients do not know the standard of care & will exploit that.