Not feeling comfortable prescribing Benzo's?

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They do, and I have agreed with that for the most part. But, that is not how they are used in many cases. In many cases, people will pull the trigger on benzos with little hesitation or thought of first trying behavioral methods, without any real thought of this person becoming dependent and now on this medication for a life time. There is a cost-benefit analysis, and regarding long-term use, the costs are demonstrably very high compared to the benefits. Especially when we have other ways of treating these things.

Or, "in many cases," the prescriber has weighed the risk/benefit and decided this is the proper course of action for now. You can't presume to know what prescribers are thinking or not thinking and assuming that "in many cases" they're practicing bad medicine with "little hesitation" and "without any real thought of this person becoming dependent."

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Or, "in many cases," the prescriber has weighed the risk/benefit and decided this is the proper course of action for now. You can't presume to know what prescribers are thinking or not thinking and assuming that "in many cases" they're practicing bad medicine with "little hesitation" and "without any real thought of this person becoming dependent."

Given the prevalence levels, particularly as patients age, we can safely assume that a significant number of prescribers do not know the risks, or do not care. Ignorance is no excuse for negligence.
 
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Several posters have mentioned how logical it is for X situation to cause anxiety (e.g., medical procedure, MRI, etc). The resulting anxiety is the stated reason for the benzodiazepine prescription. The DSM5 says that being anxious in bad situations is not an adjustment disorder. So what are you diagnosing people with in such situations?
 
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Several posters have mentioned how logical it is for X situation to cause anxiety (e.g., medical procedure, MRI, etc). The resulting anxiety is the stated reason for the benzodiazepine prescription. The DSM5 says that being anxious in bad situations is not an adjustment disorder. So what are you diagnosing people with in such situations?

Is this a joke? This is the nit-picky, not relevant stuff that makes psychiatrists roll their eyes at psychologists sometimes. Does it matter what you call it? Call it “anxiety”, unspecified anxiety, pre procedural sedation, who cares??? Just do what you need to do to get them in the scanner.

I refer to salt bae guidelines for pre procedural dosing considerations.

 
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Several posters have mentioned how logical it is for X situation to cause anxiety (e.g., medical procedure, MRI, etc). The resulting anxiety is the stated reason for the benzodiazepine prescription. The DSM5 says that being anxious in bad situations is not an adjustment disorder. So what are you diagnosing people with in such situations?

And having pain when someone pokes you with a scalpel is not a disorder at all. What do you suppose surgeons are diagnosing people with to justify administering a local anesthetic like lidocaine during a procedure? What does an anesthesiologist diagnose someone with to justify administering sevoflurane?

This is a silly argument. We have medications that allow people to get necessary tests and procedures with minimal distress, so we use them when indicated.
 
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Is this a joke? This is the nit-picky, not relevant stuff that makes psychiatrists roll their eyes at psychologists sometimes. Does it matter what you call it? Call it “anxiety”, unspecified anxiety, pre procedural sedation, who cares??? Just do what you need to do to get them in the scanner.

I refer to salt bae guidelines for pre procedural dosing considerations.




And having pain when someone pokes you with a scalpel is not a disorder at all. What do you suppose surgeons are diagnosing people with to justify administering a local anesthetic like lidocaine during a procedure? What does an anesthesiologist diagnose someone with to justify administering sevoflurane?

This is a silly argument. We have medications that allow people to get necessary tests and procedures with minimal distress, so we use them when indicated.

I think that certain triers of fact are interested in deviations from the professional standard of care.
 
I think that certain triers of fact are interested in deviations from the professional standard of care.

I’m not sure what this means?

It is absolutely the standard of care to provide either sedation or anxiolysis to the degree required to accurately and safely perform a medical procedure or test. For pediatric dentists this may mean hydroxyzine and laughing gas, for adult getting an MRI it may be PO benzo, for a kid getting MRI it may be general anesthesia and for some of my intellectually disabled patients it means benzos before blood draws.
 
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I think that certain triers of fact are interested in deviations from the professional standard of care.

You're out of your mind if you think that prescribing Ativan for an MRI is outside of the standard of care.

To be frank, people who refuse the medical imaging necessary to evaluate a dangerous medical condition they would otherwise want treated on the basis that they're "scared to go in the machine" or whatever are not making a rational decision and one could easily argue that they don't actually have the capacity to make that decision in that state. Honestly, the question of capacity in such patients probably doesn't come up as often precisely because most physicians, sensibly, are going to do whatever they reasonably can to get these people the imaging they need. In the majority of these cases, mild sedation overcomes the barrier of their anxiety and makes them amenable. I've arranged to put incapacitated schizophrenics under general anesthesia to get necessary imaging they were refusing, so really some Ativan (especially taken voluntarily) is no big deal.
 
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I get that neither of you understand.

1) In very general terms, a medical malpractice tort is comprised of a duty owed, a deviation from the community standard of care, and a resulting injury.
2) Almost all of common law recognizes that diagnosis precedes intervention.
3) Most federal and state law enforcement agencies recognize that intervention must be appropriate for the diagnosis. See FDA indications for medications. See DEA enforcement actions. See state boards actions.
4) There is a professional standard of care for diagnosis in mental illness, termed the DSM5.
5) Within the DSM5, there are diagnostic criteria.
6) The DSM5 specifically indicates that normative stress reactions are not diagnosable.

My question remains: In instances where the anxiety is understandable, what diagnosis are you giving to justify the prescription of benzodiazepines?

Because right now, I am asking what the diagnosis is. I am being told that diagnostic criteria is a joke.
 
I get that neither of you understand.

1) In very general terms, a medical malpractice tort is comprised of a duty owed, a deviation from the community standard of care, and a resulting injury.
2) Almost all of common law recognizes that diagnosis precedes intervention.
3) Most federal and state law enforcement agencies recognize that intervention must be appropriate for the diagnosis. See FDA indications for medications. See DEA enforcement actions. See state boards actions.
4) There is a professional standard of care for diagnosis in mental illness, termed the DSM5.
5) Within the DSM5, there are diagnostic criteria.
6) The DSM5 specifically indicates that normative stress reactions are not diagnosable.

My question remains: In instances where the anxiety is understandable, what diagnosis are you giving to justify the prescription of benzodiazepines?

Because right now, I am asking what the diagnosis is. I am being told that diagnostic criteria is a joke.
I would strongly disagree that the DSM5 is the standard of care for diagnosis of mental illness. At any rate, we are not talking about mental illness here. It is usually the physician ordering the investigation (which might be a surgeon, a neurologist, a PCP etc) who will prescribe the benzodiazepine for procedural anxiety. They don't care or have any interest in the DSM5. It is recognized as the standard of care to prescribe a benzo for sedation prior to an MRI for patients who are not tolerating it. Also this anxiety is not normal as most patients arent requesting/needing benzos prior to said procedure. It would be highly irregular for a patient to see a therapist prior to a procedure to help with anxiety. I have only ever once treated claustrophobia in a patient who failed to have an MRI twice (with benzos) and it was ridiculous. She had one session with me 2 hours prior to the MRI. Fortunately, it was enough to cure her of her claustrophobia to get the MRI done. You list out criteria for malpractice, but you don't seem to understand it yourself. benzodiazepines for procedural anxiety is the standard of care. The diagnosis is procedural anxiety. It's not in the DSM5, and the people typically prescribing benzos have never read the DSM5.

You can bet I want my damn valium before I have any dental procedure.
 
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I would strongly disagree that the DSM5 is the standard of care for diagnosis of mental illness. At any rate, we are not talking about mental illness here. It is usually the physician ordering the investigation (which might be a surgeon, a neurologist, a PCP etc) who will prescribe the benzodiazepine for procedural anxiety. They don't care or have any interest in the DSM5. It is recognized as the standard of care to prescribe a benzo for sedation prior to an MRI for patients who are not tolerating it. Also this anxiety is not normal as most patients arent requesting/needing benzos prior to said procedure. It would be highly irregular for a patient to see a therapist prior to a procedure to help with anxiety. I have only ever once treated claustrophobia in a patient who failed to have an MRI twice (with benzos) and it was ridiculous. She had one session with me 2 hours prior to the MRI. Fortunately, it was enough to cure her of her claustrophobia to get the MRI done. You list out criteria for malpractice, but you don't seem to understand it yourself. benzodiazepines for procedural anxiety is the standard of care. The diagnosis is procedural anxiety. It's not in the DSM5, and the people typically prescribing benzos have never read the DSM5.

You can bet I want my damn valium before I have any dental procedure.

Now we’re getting somewhere.

Federal courts have accepted my testimony about just such matters, so I’m assuming I know something about the issue including malpractice. Maybe I do, maybe I dont.

The dsm5 absolutely has a specific phobia for dental stuff. I’d see zero issues with that diagnosis and resulting benzodiazepines treatment. But there are specific diagnostic criteria for that diagnosis.

There’s a lot of crap I want. But that’s not diagnostic. Or treatable.

Preprocdural anxiety is not a recognized diagnosis in the dsm5; and to my knowledge not recognized in the icd10. So what is the diagnosis?

Absent the dsm5: what icd10 code are you using?
 
I get that neither of you understand.

1) In very general terms, a medical malpractice tort is comprised of a duty owed, a deviation from the community standard of care, and a resulting injury.
2) Almost all of common law recognizes that diagnosis precedes intervention.
3) Most federal and state law enforcement agencies recognize that intervention must be appropriate for the diagnosis. See FDA indications for medications. See DEA enforcement actions. See state boards actions.
4) There is a professional standard of care for diagnosis in mental illness, termed the DSM5.
5) Within the DSM5, there are diagnostic criteria.
6) The DSM5 specifically indicates that normative stress reactions are not diagnosable.

My question remains: In instances where the anxiety is understandable, what diagnosis are you giving to justify the prescription of benzodiazepines?

Because right now, I am asking what the diagnosis is. I am being told that diagnostic criteria is a joke.


The diagnostic criteria aren’t a joke, your bizarre attempted use of them at the expense of common sense and standard clinical practice is a joke.

I’m not sure if your just trolling to say internists/neurologists/pcp/ER docs should be prescribing MRI/CT exposure therapy instead of benzos or if your just generally unfamiliar with the practice of medicine. Varying levels of procedural sedation ranging from general anesthesia to oral sedatives is a cornerstone of humane modern medical care and is clearly the standard of care. This isn’t saying everyone needs a benzo to get a procedure done safely, but some do. It doesn’t require a DSM diagnosis to treat a symptom, but if you felt compelled to put something from DSM unspecified anxiety I’m sure would work fine.

Plenty of meds are FDA approved for procedural sedation and lots of others are used off label as part of standard of care.

Addendum- As far as ICD-10 goes for my intellectually disabled folks who need benzos for blood draws to prevent hitting the nurses, our EMR does the specific code but it is something along lines of violent or aggressive behavior.
 
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The diagnostic criteria aren’t a joke, your bizarre attempted use of them at the expense of common sense and standard clinical practice is a joke.

I’m not sure if your just trolling to say internists/neurologists/pcp/ER docs should be prescribing MRI/CT exposure therapy instead of benzos or if your just generally unfamiliar with the practice of medicine. Varying levels of procedural sedation ranging from general anesthesia to oral sedatives is a cornerstone of humane modern medical care and is clearly the standard of care. This isn’t saying everyone needs a benzo to get a procedure done safely, but some do. It doesn’t require a DSM diagnosis to treat a symptom, but if you felt compelled to put something from DSM unspecified anxiety I’m sure would work fine.

Plenty of meds are FDA approved for procedural sedation and lots of others are used off label as part of standard of care.

I’m not trolling at all. I asked what the diagnosis is and you decided to go use ad hominems.

I am specifically asking about the diagnosis and not the treatment.
 
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Now we’re getting somewhere.

Federal courts have accepted my testimony about just such matters, so I’m assuming I know something about the issue including malpractice. Maybe I do, maybe I dont.

The dsm5 absolutely has a specific phobia for dental stuff. I’d see zero issues with that diagnosis and resulting benzodiazepines treatment. But there are specific diagnostic criteria for that diagnosis.

There’s a lot of crap I want. But that’s not diagnostic. Or treatable.

Preprocdural anxiety is not a recognized diagnosis in the dsm5; and to my knowledge not recognized in the icd10. So what is the diagnosis?

Absent the dsm5: what icd10 code are you using?

Again, what the hell do you suppose people should use as a diagnosis for administering lidocaine before inserting a central line?

Typically the cited indication for this is “local anesthesia”. The indication for benzos prior to an MRI is “sedation.”

Treatment of even physiological responses that are predictable barriers to necessary care is acceptable.

If it is indeed true that unless one identifies a specific pathology prior to prescribing/administering a medication (with the assumption that the medication treats the pathology), that person is guilty of malpractice, then the entire field of anesthesiology would be shut down.
 
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Again, what the hell do you suppose people should use as a diagnosis for administering lidocaine before inserting a central line?

Typically the cited indication for this is “local anesthesia”. The indication for benzos prior to an MRI is “sedation.”

Treatment of even physiological responses that are predictable barriers to necessary care is acceptable.

If it is indeed true that unless one identifies a specific pathology prior to prescribing/administering a medication (with the assumption that the medication treats the pathology), that person is guilty of malpractice, then the entire field of anesthesiology would be shut down.

1) there are other factors in malpractice which I have partially identified.

2) If there is no diagnosis; then how do you identify which patient who is scheduled to undergo X procedure/lab/whatever is prescribed benzodiazepines? Is this simply based upon request?
 
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I’m not trolling at all. I asked what the diagnosis is and you decided to go use ad hominems.

I am specifically asking about the diagnosis and not the treatment.


In my patients cases obviously depends on specific patient but it may be specific phobia, may be assaultive/aggressive behavior or may be treating transient symptoms related to GAD/PTSD/Panic Disorder/Schizophrenia that are exacerbated by a medical procedure. As a psychiatrist I obviously am not taking care of a bunch of patients without psychiatric diagnoses.

For anesthesia/ER docs who need to use something IV for their general practice of performing procedures, fairly certain they just bill some sort of code for procedural sedation but that’s outside my field.
 
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1) there are other factors in malpractice which I have partially identified.

2) If there is no diagnosis; then how do you identify which patient who is scheduled to undergo X procedure/lab/whatever is prescribed benzodiazepines? Is this simply based upon request?

1) What other criterion were you suggesting the administration of benzos for sedation violates, then? I’m arguing that the administration of benzos is standard of care and the lack of a pathology/diagnosis is no more a problem for this than it is for the administration of local anesthesia.

2) Yes, it may be by request. Essentially, if you identify that lack of sedation poses a barrier to the necessary test being performed, then treatment of even physiological responses posing barriers becomes part of the procedure itself. As I said, I’ve had incapacitated people put under general anesthesia for imaging before. I do not presume that propofol treats any pathology/diagnosed condition. It was a necessary part of the procedure for the procedure to even be viable.

Again, this is not a new justification. It is literally the justification for almost all anesthesia. Nobody presumes the anesthesia itself is a damn treatment. The mere planning of a procedure is usually the indication for the anesthesia. For many procedures (cholecystectomy), it is understood that anesthesia is necessary in all patients for the procedure to be acceptable and viable. In other cases (lidocaine for a peripheral IV), it is only necessary for some patients for the procedure to be viable and indeed these patients are usually identified by their expressed concerns or wish for preprocedural medication.
 
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If you absolutely need a DSM diagnosis, how about: Psychological Factors Affecting Other Medical Conditions (The factors disrupt treatment of the general medical condition, including not seeking medical care, nonadherence with follow-up visits or prescribed treatment, or maladaptive modifications of treatment by the patient or family. As an example, denying the need for evaluation of radiating, exertional left sided chest pain.).
 
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Now we’re getting somewhere.

Federal courts have accepted my testimony about just such matters, so I’m assuming I know something about the issue including malpractice. Maybe I do, maybe I dont.

The dsm5 absolutely has a specific phobia for dental stuff. I’d see zero issues with that diagnosis and resulting benzodiazepines treatment. But there are specific diagnostic criteria for that diagnosis.

There’s a lot of crap I want. But that’s not diagnostic. Or treatable.

Preprocdural anxiety is not a recognized diagnosis in the dsm5; and to my knowledge not recognized in the icd10. So what is the diagnosis?

Absent the dsm5: what icd10 code are you using?

F41.9

I am not sure if you are mistaking the letter of the law for a normative statement about how things ought to work, or seriously believe that anyone is ever going to care about someone getting a handful of Valium before a scan.

Which is it?
 
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1) there are other factors in malpractice which I have partially identified.

2) If there is no diagnosis; then how do you identify which patient who is scheduled to undergo X procedure/lab/whatever is prescribed benzodiazepines? Is this simply based upon request?
I already said that it may be upon request, but also it might NOT be, it might be an option that I would bring up. There are a number of factors that I would consider in deciding which patient would benefit. If I ask about anxiety and feel that it will be a barrier for adherence and following through on the recommendation being a big one. So assessing benefit, which is related to how much harm I think not offering the option might cause. Also considering the harms, such as fall risk. When I had my eye procedure and had to move from one room to the next, both the ophthalmologist and assistant took an arm and did not let me walk unassisted. How was I getting home? I had a friend assist me and drive.

So I consider those sorts of things as well. This is pertinent as well if you are going to give someone a benzo before a plane flight.

As far as diagnosis, it seems to me that sometimes we treat symptoms without a diagnosis and it is not bad medicine. Sometimes you rule out dangerous conditions and then treat symptoms. Not everything can be put in a little box, that doesn't mean it's inappropriate for a physician to take any number of steps to make a patient more comfortable.
 
1) For those that actually offered the diagnosis, I thank you. That was pretty much all I was curious about
1) What other criterion were you suggesting the administration of benzos for sedation violates, then? I’m arguing that the administration of benzos is standard of care and the lack of a pathology/diagnosis is no more a problem for this than it is for the administration of local anesthesia.

2) Yes, it may be by request. Essentially, if you identify that lack of sedation poses a barrier to the necessary test being performed, then treatment of even physiological responses posing barriers becomes part of the procedure itself. As I said, I’ve had incapacitated people put under general anesthesia for imaging before. I do not presume that propofol treats any pathology/diagnosed condition. It was a necessary part of the procedure for the procedure to even be viable.

Again, this is not a new justification. It is literally the justification for almost all anesthesia. Nobody presumes the anesthesia itself is a damn treatment. The mere planning of a procedure is usually the indication for the anesthesia. For many procedures (cholecystectomy), it is understood that anesthesia is necessary in all patients for the procedure to be acceptable and viable. In other cases (lidocaine for a peripheral IV), it is only necessary for some patients for the procedure to be viable and indeed these patients are usually identified by their expressed concerns or wish for preprocedural medication.


1)

A. I'm mostly interested in the diagnosis. Which is why I asked about the diagnosis in my original question. And said I am interested in diagnosis...repeatedly. You said that asking for a diagnosis was evidence that I have lost my mind. And ascribed several implications to my question which I have never said.

B. I never stated that administration of benzos for sedating is a violation of professional standards of care. I stated that not using the professional diagnostic taxonomy is a violation of the standard of care in diagnosis. And that not using a diagnosis to justify a treatment is probably a violation of professional standards. I imagine your billing services gives a diagnosis.


2)

A. So you're talking about Psychological Factors Affecting Other Medical Conditions. That's a diagnosis. That would have answered my question.

B. In reviewing billing for anesthesia, it would seem that an ICD10 code for illness or injury is still required.

C.


If you absolutely need a DSM diagnosis, how about: Psychological Factors Affecting Other Medical Conditions (The factors disrupt treatment of the general medical condition, including not seeking medical care, nonadherence with follow-up visits or prescribed treatment, or maladaptive modifications of treatment by the patient or family. As an example, denying the need for evaluation of radiating, exertional left sided chest pain.).

Thanks!

F41.9

I am not sure if you are mistaking the letter of the law for a normative statement about how things ought to work, or seriously believe that anyone is ever going to care about someone getting a handful of Valium before a scan.

Which is it?

1) Thanks for the diagnosis.

2) I don't believe in either of those choices, or your proposed dichotomy.

What I wanted to know was what diagnosis is used to justify a benzo prescription when the anxiety is understandable for the situation. As far as I am aware, billing requires a diagnosis, so I assume there is one.

I already said that it may be upon request, but also it might NOT be, it might be an option that I would bring up. There are a number of factors that I would consider in deciding which patient would benefit. If I ask about anxiety and feel that it will be a barrier for adherence and following through on the recommendation being a big one. So assessing benefit, which is related to how much harm I think not offering the option might cause. Also considering the harms, such as fall risk. When I had my eye procedure and had to move from one room to the next, both the ophthalmologist and assistant took an arm and did not let me walk unassisted. How was I getting home? I had a friend assist me and drive.

So I consider those sorts of things as well. This is pertinent as well if you are going to give someone a benzo before a plane flight.

As far as diagnosis, it seems to me that sometimes we treat symptoms without a diagnosis and it is not bad medicine. Sometimes you rule out dangerous conditions and then treat symptoms. Not everything can be put in a little box, that doesn't mean it's inappropriate for a physician to take any number of steps to make a patient more comfortable.

1) I would assume a prescription for flight anxiety is justified under a specific phobia. That's probably fine. But I was asking about the diagnosis when a situation causes anxiety. I would imagine taking a needle to the eye would be almost universally recognized as something to be anxious about. Recticulum answered that question in that situation.

2) Do you really bill without a diagnosis? I was unaware that this was okay.
 
1) For those that actually offered the diagnosis, I thank you. That was pretty much all I was curious about





1) Thanks for the diagnosis.

2) I don't believe in either of those choices, or your proposed dichotomy.

What I wanted to know was what diagnosis is used to justify a benzo prescription when the anxiety is understandable for the situation. As far as I am aware, billing requires a diagnosis, so I assume there is one.

I think the strong reaction you are getting is a) a function of perceived hostility and b) not making it super clear that this is all you were looking for when you started this tangent with a gesture in the direction of "triers of fact", with all the threat/criticism that that entails. Perhaps you did not mean to be at all critical in saying that the courts would disagree with the decision in question; I submit that this is a failure of conversational pragmatics on your part if that is the case, but I don't think we need more tangents.

Now that I reflect on it there is also a very big difference here in our conceptions of what diagnosis is for. You are clearly very concerned about diagnoses qua medicolegal designations and the role they play for the insurer decision-making process in determining if money is going to be forked over. I think most of the psychiatrists here think of diagnosis more as a tool for describing the world (and possibly as designators of natural kinds for those with a more realist ontology). While both of these concepts are spoken of in English as "diagnosis", it should be clear that they are very different kinds with very different properties. Asking a question very relevant to the medicolegal uses of diagnosis to someone thinking of diagnosis in world-descriptive terms is just never going to go well.
 
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1) For those that actually offered the diagnosis, I thank you. That was pretty much all I was curious about



1)

A. I'm mostly interested in the diagnosis. Which is why I asked about the diagnosis in my original question. And said I am interested in diagnosis...repeatedly. You said that asking for a diagnosis was evidence that I have lost my mind. And ascribed several implications to my question which I have never said.

B. I never stated that administration of benzos for sedating is a violation of professional standards of care. I stated that not using the professional diagnostic taxonomy is a violation of the standard of care in diagnosis. And that not using a diagnosis to justify a treatment is probably a violation of professional standards. I imagine your billing services gives a diagnosis.


2)

A. So you're talking about Psychological Factors Affecting Other Medical Conditions. That's a diagnosis. That would have answered my question.

B. In reviewing billing for anesthesia, it would seem that an ICD10 code for illness or injury is still required.

1)
A. If you're talking about technicalities of how things are documented in the medical record: I would say an anesthesiologist may be the best person to ask about this. That being said, I think we're talking about different things. The diagnosis for things like anesthesia and procedural sedation often has no direct relationship to the anesthesia. As I've said, the implication of these sorts of procedures is that you are inducing a particular state by suppressing normal physiology, not directly treating the patient. My understanding is that anesthesiologists will bill a CPT code and may associate with an ICD-10 diagnosis but the association is atypical in that it doesn't imply direct treatment (which gets back to my description of the logical relationship of the anesthesia/sedation as a corollary of the procedure itself, i.e. the associated diagnosis would be that justifying the procedure itself). Like, for anesthesia for a cholecystectomy, I imagine the associated diagnosis is cholelithiasis, or whatever. You can argue with me about the technical necessity of associating a diagnosis, but you're being pedantic. There's no direct association in terms of treatment between anesthesia and cholelithiasis unless you consider it (logically, I don't really care about the technicalities here), part and parcel of the surgery itself. I don't actually think we should be associating procedural sedation with its own diagnosis for patients requiring it for imaging. If you're going to associate it with a diagnosis, it would be the diagnosis justifying the imaging (such as abdominal pain or similar). Again, this is all just technical because you're not specifically treating anything by sedating the person. You're just using medication to ameliorate a barrier that may not be pathological in nature. This is the same thing with local anesthesia in minor procedures. You can't really bill "pain" because the pain isn't present—it's the physiological response you're trying to avoid. It's also not really treating anything specifically. The closest thing you can associate is the diagnosis indicating the procedure itself, which only makes sense if you consider medication used to diminish predictable responses that would impact the viability of a procedure a necessary corollary of the procedure itself.

B. As I said, you're being pedantic. Technically, there is probably an associated diagnosis. My argument is that this is a consequence of the structure of our billing system not being sophisticated enough to capture the actual logical relationships involved here. In any case, you didn't seem too be talking about diagnosis as it related to potentially messing up our billing. That's a different thing and is likely much more technical. I have a hard time believing that someone would be found in court to be guilty of malpractice on the basis of not associating a diagnosis for pre-cholecystectomy anesthesia in Epic. One could easily argue that this is standard of care and a necessary part of the procedure. If someone pressed you for diagnosis you would argue why the procedure was indicated in the first place.

2) As above, I'm not even sure that you'd need to associate a unique diagnosis. The diagnosis could just be the indication for the procedure itself. If someone has abdominal pain and needs a CT but can only get it with sedation, the associated diagnosis would be the abdominal pain. It's not like anesthesiologists are diagnosing people with "psychological factors" prior to putting people under. As has been expressed previously, much of these "factors" can be rather normal responses and depending on the rationale may or may not indicate actual problematic "psychological factors." If someone denies recommended invasive testing for a disorder based on the fact that they don't personally find the stress of going through the testing to be worth the benefit, we're not diagnosing them with "psychological factors." This may just be a normal decision based on the available options presented to them (or it could represent a phobia). Some people will make a decision to have a test only if the option of sedation is provided, as it alleviates much of the associated stress. In such cases, this is more reasonably seen as a reflection of the test itself than their psychology.
 
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I think the strong reaction you are getting is a) a function of perceived hostility and b) not making it super clear that this is all you were looking for when you started this tangent with a gesture in the direction of "triers of fact", with all the threat/criticism that that entails. Perhaps you did not mean to be at all critical in saying that the courts would disagree with the decision in question; I submit that this is a failure of conversational pragmatics on your part if that is the case, but I don't think we need more tangents.

Now that I reflect on it there is also a very big difference here in our conceptions of what diagnosis is for. You are clearly very concerned about diagnoses qua medicolegal designations and the role they play for the insurer decision-making process in determining if money is going to be forked over. I think most of the psychiatrists here think of diagnosis more as a tool for describing the world (and possibly as designators of natural kinds for those with a more realist ontology). While both of these concepts are spoken of in English as "diagnosis", it should be clear that they are very different kinds with very different properties. Asking a question very relevant to the medicolegal uses of diagnosis to someone thinking of diagnosis in world-descriptive terms is just never going to go well.

1) I predominantly work in forensics, which guides my thinking.
2) My question was based upon genuine curiosity. There was no hostility intended on my part.
3) Imagine if someone posted something like, "I don't use a formal diagnostic procedure. I just prescribe controlled substances when I feel like it might be a good idea.". I would think that a reasonable person might try to guide such a poster into understanding that there are many reasons why that might not be a good idea, and why posting that stuff is probably a not great idea. I think that someone who did that in the face of hostility is probably being pretty nice.
 
1) I predominantly work in forensics, which guides my thinking.
2) My question was based upon genuine curiosity. There was no hostility intended on my part.
3) Imagine if someone posted something like, "I don't use a formal diagnostic procedure. I just prescribe controlled substances when I feel like it might be a good idea.". I would think that a reasonable person might try to guide such a poster into understanding that there are many reasons why that might not be a good idea, and why posting that stuff is probably a not great idea. I think that someone who did that in the face of hostility is probably being pretty nice.

It makes sense that this way of thinking about things would be a natural inclination for you, so I can totally believe it was genuine curiosity.

I think you may dramatically underestimate the extent to which drugs are used for non-specific effects in medicine in general, and also the extent to which formal diagnostic procedures guide medical decision-making on a day to day basis, even in specialties that routinely have objective laboratory measures and imaging. While often able to supply explicit reasons when called upon later to do so, the literature on clinical judgement in medicine at least suggests that pattern-matching and impressions of a gestalt are much more important and dominate the process. Medical testing is often informative but not dispositive; the mapping from a particular pattern of results to a 100% clear diagnosis is fairly rare. This is discussed widely in academic journals and in more applied settings intended to train medical clinicians. I have a very hard time imagining how discussing it on an Internet forum would put someone in legal jeopardy given the utterly pervasive and uncontroversial nature of this idea.

I agree with you that "I gave a benzo because it was a good idea" by itself is inadequate, but if you word that differently and offer really any meaningful attempt at justification, aren't you describing clinical judgement?

It is not uncommon for people outside of medicine to have an idea of precision and formal rigor that is very unrepresentative of clinical practice. Physicians are mostly not logicking their way through their day, but drawing upon schemas and prototypes induced over thousands of repetitions of patient encounters and performing something more like a fitting procedure. It is really only when this fails or is obviously inadequate that you start seeing explicit reasoning begin.

I personally would say that the nature of mental "disorders", whatever that means, is such that this sort of non-explicit reasoning is always going to be inescapable in psychiatry to a greater extent than other fields, but again, a different tangent.

It is interesting to me that so many people here, I think, perceived hostility in what you were saying that you say you had no awareness of intending. Whether that says more about us or about you is obviously an open question, but for my own part it is a vibe I have gotten from previous posts of yours, so I think the explanation is something more than sensitivities about this specific, particular topic per se.
 
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It makes sense that this way of thinking about things would be a natural inclination for you, so I can totally believe it was genuine curiosity.

I think you may dramatically underestimate the extent to which drugs are used for non-specific effects in medicine in general, and also the extent to which formal diagnostic procedures guide medical decision-making on a day to day basis, even in specialties that routinely have objective laboratory measures and imaging. While often able to supply explicit reasons when called upon later to do so, the literature on clinical judgement in medicine at least suggests that pattern-matching and impressions of a gestalt are much more important and dominate the process. Medical testing is often informative but not dispositive; the mapping from a particular pattern of results to a 100% clear diagnosis is fairly rare. This is discussed widely in academic journals and in more applied settings intended to train medical clinicians. I have a very hard time imagining how discussing it on an Internet forum would put someone in legal jeopardy given the utterly pervasive and uncontroversial nature of this idea.

I agree with you that "I gave a benzo because it was a good idea" by itself is inadequate, but if you word that differently and offer really any meaningful attempt at justification, aren't you describing clinical judgement?

It is not uncommon for people outside of medicine to have an idea of precision and formal rigor that is very unrepresentative of clinical practice. Physicians are mostly not logicking their way through their day, but drawing upon schemas and prototypes induced over thousands of repetitions of patient encounters and performing something more like a fitting procedure. It is really only when this fails or is obviously inadequate that you start seeing explicit reasoning begin.

I personally would say that the nature of mental "disorders", whatever that means, is such that this sort of non-explicit reasoning is always going to be inescapable in psychiatry to a greater extent than other fields, but again, a different tangent.

It is interesting to me that so many people here, I think, perceived hostility in what you were saying that you say you had no awareness of intending. Whether that says more about us or about you is obviously an open question, but for my own part it is a vibe I have gotten from previous posts of yours, so I think the explanation is something more than sensitivities about this specific, particular topic per se.
It's not just you. Check out the psychology board. Maybe even search for "tone"
 
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I re-read through the thread, you all need to stop worrying too much about PSYDR. I regret wasting time engaging. In retrospect it’s clear he is “concern trolling” to get folks riled up for fun or legitimately has no understanding of what it means to practice medicine. Given he is posting on this board in first place seems unlikely to be the second, so seems moreso just another troll like whoever it was who claimed continue dance therapy after a patient broke hip or whatever.
 
I don't know him. But I will say he does know what he is talking about, especially in regard to forensic psychology
I re-read through the thread, you all need to stop worrying too much about PSYDR. I regret wasting time engaging. In retrospect it’s clear he is “concern trolling” to get folks riled up for fun or legitimately has no understanding of what it means to practice medicine. Given he is posting on this board in first place seems unlikely to be the second, so seems moreso just another troll like whoever it was who claimed continue dance therapy after a patient broke hip or whatever.
 
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I don't know him. But I will say he does know what he is talking about, especially in regard to forensic psychology
which is completely irrelevant to what was being discussed. he spuriously invoked having been an expert witness in federal court, despite the fact no federal court would ever qualify a psychologist to testify regarding the standard of care in medicine, which he demonstrated being completely clueless of.
 
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which is completely irrelevant to what was being discussed. he spuriously invoked having been an expert witness in federal court, despite the fact no federal court would ever qualify a psychologist to testify regarding the standard of care in medicine, which he demonstrated being completely clueless of.

So when you say I don't know anything about a subject, and I respond that courts believe I do; that's spurious. Got it.

(it's awesome when I ask a question, and get ad hominems before answers).
 
So when you say I don't know anything about a subject, and I respond that courts believe I do; that's spurious. Got it.

(it's awesome when I ask a question, and get ad hominems before answers).

It's pretty clear that you don't really understand what ad hominem means. Pointing out problems with your claims relating to credibility is not ad hominem. My telling you that you're insane if you believed what I thought you did earlier in the thread was, admittedly, a rather mild example of an ad hominem attack. Then again, we're also on an internet message board right now, not in debate club.
 
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It's pretty clear that you don't really understand what ad hominem means. Pointing out problems with your claims relating to credibility is not ad hominem. My telling you that you're insane if you believed what I thought you did earlier in the thread was, admittedly, a rather mild example of an ad hominem attack. Then again, we're also on an internet message board right now, not in debate club.

"argumentum ad hominem, is a fallacious argumentative strategy whereby genuine discussion of the topic at hand is avoided by instead attacking the character, motive, or other attribute of the person making the argument, or persons associated with the argument, rather than attacking the substance of the argument itself."
 
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"argumentum ad hominem, is a fallacious argumentative strategy whereby genuine discussion of the topic at hand is avoided by instead attacking the character, motive, or other attribute of the person making the argument, or persons associated with the argument, rather than attacking the substance of the argument itself."

Can you please take the middle school debate team stuff elsewhere? It doesn’t impress anyone, most of us got over that phase decades ago and it certainly doesn’t contribute to a discussion about providing more compassionate or effective care to our patients. Despite universally questioning your sincerity, several practicing physicians answered your question by providing diagnoses and addressing billing questions related to procedural sedation. There are plenty of forums online where people enjoy argument for sport, but that is not the mission of this forum. Please let us go back to discussions more productive to caring for our patients or helping new physicians on their career journey.
 
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"argumentum ad hominem, is a fallacious argumentative strategy whereby genuine discussion of the topic at hand is avoided by instead attacking the character, motive, or other attribute of the person making the argument, or persons associated with the argument, rather than attacking the substance of the argument itself."


I thought you said you were just asking a question out of genuine curiosity with no other intent...
 
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3) Imagine if someone posted something like, "I don't use a formal diagnostic procedure. I just prescribe controlled substances when I feel like it might be a good idea.".

This is pretty much the perfect description for what I do every day. It's pretty awesome.
 
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Sarcasm aside, there are a good number of prescribers who appear to be doing this exact thing, in spite of the extant literature.

Your preaching to the choir in general here. SDN is predominately young physicians who started practicing after the “benzos are amazing” days and we spend a sizeable amount of time tapering meds started by old school PCPs and psychiatrists.
 
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"argumentum ad hominem, is a fallacious argumentative strategy whereby genuine discussion of the topic at hand is avoided by instead attacking the character, motive, or other attribute of the person making the argument, or persons associated with the argument, rather than attacking the substance of the argument itself."

I thought we were talking about ad hominem the fallacy, so I was somewhat loose with the language because I thought we were in agreement about the topic of conversation. Obviously you are interested in becoming extremely technical, so I'll clarify.

In a technical sense, discussions of your credibility are ad hominem arguments. But, as with most informal logical fallacies, the fallacy itself isn't a strict problem with the logic of the form of argument but implies a particular application. Ad hominem arguments, when the topic being discussed relevantly involves a participant's credibility, are not necessarily fallacious. Irrelevant discussions about personal attributes or character are.

Actually, if we want to be technical, your initial assertion of relevant authority is an ad verecundiam argument, which may or may not be fallacious depending on the veracity of the claim to relevant authority. Splik was challenging that parts of what you have said undermine your claim to authority. He was challenging your argument on the basis of credibility. You were the one who initially proposed that your authority was relevant to this discussion. Ensuing discussions of whether or not that is accurate are not fallacious. This whole argument is actually an investigation of whether your argument is fallacious.
 
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I thought you said you were just asking a question out of genuine curiosity with no other intent...

Totally was. In review, I asked a genuine question about the topic at hand. I was told I was a joke, had my profession denigrated, that I was crazy, and that the entire question of diagnosis was irrelevant. I ignored the ad hominems, explained why I thought it was relevant (i.e., legal systems). Some found that me responding with a reasoning as to why the issue was relevant to be spurious. Which is interesting, because it is a catch 22 where if I respond to questions of relevancy, I am mentioning an irrelevant thing. Got some more ad hominems, which didn't answer the question. Then finally got some answers. I thanked the people who answered my question. I specifically responded to your follow up, because you had other questions.

Others have continued to question my credibility, which is their right. I do not believe I have used an argument from authority, so my credibility isn't really a factor in the question or why it is relevant. And the question has been answered.


I thought we were talking about ad hominem the fallacy, so I was somewhat loose with the language because I thought we were in agreement about the topic of conversation. Obviously you are interested in becoming extremely technical, so I'll clarify.

In a technical sense, discussions of your credibility are ad hominem arguments. But, as with most informal logical fallacies, the fallacy itself isn't a strict problem with the logic of the form of argument but implies a particular application. Ad hominem arguments, when the topic being discussed relevantly involves a participant's credibility, are not necessarily fallacious. Irrelevant discussions about personal attributes or character are.

Actually, if we want to be technical, your initial assertion of relevant authority is an ad verecundiam argument, which may or may not be fallacious depending on the veracity of the claim to relevant authority. Splik was challenging that parts of what you have said undermine your claim to authority. He was challenging your argument on the basis of credibility. You were the one who initially proposed that your authority was relevant to this discussion. Ensuing discussions of whether or not that is accurate are not fallacious. This whole argument is actually an investigation of whether your argument is fallacious.

I didn't really have an argument. I had a question, which was specifically about diagnosis. I repeated this question several times. I was told it was irrelevant. I provided a reason why I believed it was relevant. At no point is my expertise in the subject really a concern or the basis of my argument as to why I believed it was relevant. I readily admitted that my expertise wasn't a factor. Who I am still would not change that there is a question about diagnosis, and that some might find that relevant. It took forever to get a simple set of diagnoses. Now the question has been answered.

You just said I didn't know about the term I was using. I kindly provided you a definition. You are free to use that definition to determine your own proposition about my knowledge. Which is irrelevant. Because I asked a question, got called a bunch of names, stuck with it, explained why it is relevant, and finally got an answer.
 
Sarcasm aside, there are a good number of prescribers who appear to be doing this exact thing, in spite of the extant literature.
It's only slightly sarcastic, since my practice is primarily hospice and palliative.

Literature is helpful, but at the end of the day you do the best you can with what you know and the tools you have, while continually looking for better options. I'm often practicing based on consensus/old wives tales/magic. RCT? Ha.
 
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Something that might be overlooked is that the phenomenon of long-term benzodiazepine prescribing and single-use (such as an MRI or airplane) can conflict with each other.

Imagine a person who has been on an as-prescribed dose of a benzodiazepine for decades, has declining physical health, and worsening anxiety.

He or she needs an MRI, has become increasingly anxious of simply leaving the house, and has been diagnosed with benzodiazepine tolerance withdrawal—withdrawal symptoms both when reducing the dose and also during periods of dose maintenance.

In such a situation, the as-needed benzodiazepine for the MRI has very little effect in the benzodiazepine-tolerant patient and can negatively impact tapering.

What an awful situation for someone who has not flown in decades or has delayed MRI scans, when others can benefit from the utility of very short-term usage of those medications.

I think benzodiazepines are wonderful medications (they work well and quickly; in low frequency use have very low side effect profile), but their utility is ruined by inappropriate prescribing in which they stop working and instead increase illness. I know there are some people who have been on them decades and are highly functional. I believe them. But I believe mental/physical deterioration is a likely outcome as well.

I don't see how single use prescription for an MRI would lead to long-term use. When a doctor prescribes you one pill, you get one pill. When a doctor prescribes you to take a pill every day and you don't know any better, you take it every day. I don't think it's a big mystery in how long-term benzodiazepine use begins. It begins with a plan for a person to take benzodiazepines long-term. If you peruse recreational drug forums, that is not a plan that people who are very comfortable experimenting with exotic drugs would make. They know about tolerance, and they know about dependence. They may be reckless and impulsive, but they're not masochists.
 
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Well, there's what should happen, and what usually happens. In this case, they happen to be very different things.

You have implied several times that getting benzos for procedural sedation “usually” (your words) leads to long term benzo prescriptions. This doesn’t seem common to me at all, most folks who have had any sort or surgery including minor stuff like wisdom teeth, colonoscopies, etc have gotten IV benzos and as far as I know this isn’t creating a ton of folks dependent on benzos.

The issue is psychiatrists and PCPs writing TID Xanax three months at a time for “anxious” folks generally with comorbid personality pathology because the docs will do anything to keep them out of the office or from blowing up their nurses phone. That’s the problematic prescribing that needs to be addressed, not giving someone 1mg Ativan prior to a procedure.
 
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You have implied several times that getting benzos for procedural sedation “usually” (your words) leads to long term benzo prescriptions. This doesn’t seem common to me at all, most folks who have had any sort or surgery including minor stuff like wisdom teeth, colonoscopies, etc have gotten IV benzos and as far as I know this isn’t creating a ton of folks dependent on benzos.

The issue is psychiatrists and PCPs writing TID Xanax three months at a time for “anxious” folks generally with comorbid personality pathology because the docs will do anything to keep them out of the office or from blowing up their nurses phone. That’s the problematic prescribing that needs to be addressed, not giving someone 1mg Ativan prior to a procedure.

I'm implying that the number of people on maintenance benzos has been rising dramatically, particularly in older individuals, despite efforts educate providers about the harm. It's clear that more and more providers are not prescribing these medications as they should. The implication is in the cavalier attitude that they are prescribed, much like opioids in the start of that epidemic. As for the procedural stuff, I don't have as much of a problem outside of pathologizing normal anxiety and increasing the overall level of people not being able to "handle" regular life occurrences without medication.
 
I'm implying that the number of people on maintenance benzos has been rising dramatically, particularly in older individuals, despite efforts educate providers about the harm. It's clear that more and more providers are not prescribing these medications as they should. The implication is in the cavalier attitude that they are prescribed, much like opioids in the start of that epidemic. As for the procedural stuff, I don't have as much of a problem outside of pathologizing normal anxiety and increasing the overall level of people not being able to "handle" regular life occurrences without medication.
Interesting to ponder whether being in an MRI machine or airplane is regular or not.

If it were a roller coaster and a person were terrified of it but had the option not to do it because it is a recreational activity, it seems like a clear-cut decision to not to give a benzo for it.

Also reminds me of the different approaches to child birth over the ages, where it went from being done in the home, to be done in hospitals often very sedated (1950s?), and then to the hospital less or not sedated (current).

Also the differences with regard to endoscopies which in some parts of the world are much less frequently done with sedation, versus the US where sedation is the standard and it's difficult to find a provider who will do it without MAC anesthesia—even with colonoscopies. The training is different.
 
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I'm implying that the number of people on maintenance benzos has been rising dramatically, particularly in older individuals, despite efforts educate providers about the harm

Actually, your explanation of your implications have changed multiple times throughout the thread.

It's clear that more and more providers are not prescribing these medications as they should. The implication is in the cavalier attitude that they are prescribed, much like opioids in the start of that epidemic. As for the procedural stuff, I don't have as much of a problem outside of pathologizing normal anxiety and increasing the overall level of people not being able to "handle" regular life occurrences without medication.

Anxiety, by definition, isn't "normal." It's pathologic. An MRI isn't a "regular life occurrence" nor is a plane ride for many.
 
Anxiety, by definition, isn't "normal." It's pathologic.

I have generally agreed with you on most things in this thread but I don’t think this particular assertion is true. Everybody has had anxious states and in many cases they are adaptive. Feeling anxious about Step 1 doesn’t mean med students have pathological anxiety. For the majority of these people, measured levels of anxiety probably improve their performance.
 
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I have generally agreed with you on most things in this thread but I don’t think this particular assertion is true. Everybody has had anxious states and in many cases they are adaptive. Feeling anxious about Step 1 doesn’t mean med students have pathological anxiety. For the majority of these people, measured levels of anxiety probably improves their performance.

The nervousness one feels with Step 1 doesn't make them avoid it. That's the part that makes it pathologic. If a person with a medical condition needs an MRI and refuses it due to anxiety, that shouldn't be considered normal.
 
The nervousness one feels with Step 1 doesn't make them avoid it. That's the part that makes it pathologic. If a person with a medical condition needs an MRI and refuses it due to anxiety, that shouldn't be considered normal.
Avoidance isn't a necessary component of anxiety. Anxiety is not by itself pathological.
 
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The nervousness one feels with Step 1 doesn't make them avoid it. That's the part that makes it pathologic. If a person with a medical condition needs an MRI and refuses it due to anxiety, that shouldn't be considered normal.
I agree that a whole bunch of maladaptive behaviors distinguish pathological anxiety from normal anxious states. I don’t agree that anxiety doesn’t have non-pathological forms.
 
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