Category: Education

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Education Nonfiction Policy Reflection Systems

A Review of the National Council for Behavioral Health Conference.

Those of you who follow me on Twitter already know that I spent much of last week in Las Vegas. I attended the National Council for Behavioral Health Conference, “featuring the best in leadership, organizational development, and excellence in mental health and addictions practice.” Here are my reflections about the experience:

It was large. I have never attended a conference with 5000 other people. I already find Las Vegas overstimulating. Not being able to get away from thousands of people for hours on end was draining for me.

There were many sessions I wanted to attend, but could not. This, of course, was a function of the size of the conference. Humans, thus far, can only physically be in one place and mentally elsewhere. During this conference I often wished I could physically be in two places at once.

The sessions that most inspired me often had little to do with formal behavioral health. Nora Volkow, the director for the National Institute of Drug Abuse, gave a talk about the neurobiology of addictive behaviors. Did I learn anything new? No, only because I had learned this while in medical training. Did she present the information in an engaging and compelling way? Yes.

Charles Blow, an opinion writer for the New York Times, authored a memoir about his youth and past sexual abuse. During his talk he read from his book and shared his reflections about his experience. Did I learn anything new? Nothing obvious that would affect either my clinical practice or policy considerations. He won me over with his personal perspective, grace, and vulnerability.

Susan Cain spoke about introversion and leadership. Did I learn anything new? No, because I had already read her book. Was it nonetheless worthwhile to hear her speak in person? For me, yes.

The conference featured a large session called “Uncomfortable Conversations”. The intention was for Big Names in the field to discuss controversial topics. These included involuntary commitment, confidentiality laws that are specific to substance use disorder treatment that can interfere with clinical care, and the concept of cultural competency. Each pair, however, had less than ten minutes to discuss their issue. The moderator also seemed to speak more than each member of the pair. The session could have been thoughtful, though ended up feeling underdeveloped and unfocused.

Where were my psychiatrist colleagues? I understand that this is my own issue—after all, this was not a physician conference. The National Council, however, is supposed to be the leadership conference for community behavioral health. Are psychiatrists involved in leadership in community behavioral health? If not, why not? [1. As I have noted elsewhere: “Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.” Advocacy in this case is leadership.]

Only two “small” sessions I attended featured physician presentations. One involved the introduction of trauma-informed care into primary care settings. The other discussed a concrete integration of mental health, substance use, and primary care services. In both cases the physicians were family practice physicians. Which, to be clear, is fantastic. We must work across systems to provide good care for individuals and populations. I nonetheless felt both puzzled and disappointed with the lack of psychiatrist representation. [2. To be fair, Nora Volkow and several of the panelists for the “Uncomfortable Conversations” are trained as psychiatrists.]

There was a “medical track” meant for medical professionals. Few of those sessions discussed systems issues or leadership. I had planned to attend one that discussed guidelines for benzodiazepine use, though there was no room by the time I arrived. (One of my colleagues, a psychiatrist, later told me that many attendees were not doctors.)

The conference will be in Seattle next year. My colleagues and I are already discussing what we can present.

A lot of people want to do good. I often comment, “Life is terrible… and life is wonderful.” That people have done good work to help others and want to share what they learned in the process is remarkable. That people continue to strive to provide useful services to people who are suffering is humbling. That people are creating new programs to help solve problems, often rooted in inequality, a variety of disparities, and the randomness of existence, is inspiring.

When we have our heads down in our own work, we often forget that we are part of a system. Though I have critical opinions about the conference, I am grateful that I could attend. May we all seek inspiration and always learn from others.

Categories
Consult-Liaison Education Lessons Observations

More About Questions.

Last week I riffed on the importance of “what is the question“. This week I will riff on a related topic: “How will the answer affect what you do next?”

If the answer to your question won’t change what you will do, then perhaps you don’t need to ask the question.[1. This I definitely learned in medical school. It was usually phrased, “How will this affect your management?” If you’ve made the decision to prescribe an antibiotic for pneumonia, then there’s no reason to get a chest X-ray. It doesn’t matter what the answer is to the question, “What will we see on the chest X-ray?” Thus, don’t order the X-ray.]

If you know that you friend isn’t the biggest fan of cake, but you’re going to serve cake at the party anyway, there’s no point in asking your friend, “Do you like cake?” or “Do you mind if I serve cake?”

Sometimes we ask questions not because we want to learn the answer, but because we want to say something. In the above example the question “Do you mind if I serve cake?” may actually mean “I hope you won’t feel angry or disappointed that I am serving cake”.

Consider meetings or conferences where audience members have opportunities to ask the speaker questions. Sometimes the people who raise their hands to ask questions either (1) never ask an actual question, or (2) ask a question that they then answer themselves, whether the group wants to hear it or not.

To be clear, I’m not saying that we should never ask questions unless the answer will influence our next actions. Asking questions is how we learn about ourselves and the world around us.

When I first moved to New York from Seattle, many of my colleagues in New York asked me about how much it rains in Seattle.

“It actually rains more in New York than it does in Seattle,” I would reply, sometimes with unnecessary smugness.[2. I do like the Merriam-Webster definition of smug. It makes it clear that it is always annoying and never necessary to be smug.]

The question was, “Does it rain more in Seattle than it does in New York?” The answer was “no”, but it didn’t change anything anyone did. No one moved from New York to Seattle to experience less annual precipitation. It didn’t stop me from moving to New York. I still wore trench coats in both cities (though got one with more style in New York) and covered my head as needed. That there is more annual precipitation in New York is just interesting.

It is nonetheless worthwhile to consider the reasons behind questions you ask. Sometimes the answers to your questions will affect what you do next. Sometimes your questions help you learn more about other people or phenomena in the world. Sometimes your questions address only your own psychological needs, which often has bad outcomes for everyone involved in the conversation (e.g., “Do I look fat in this?” or “Are you getting your period?”).

Be careful what you ask for.

Categories
Consult-Liaison Education Informal-curriculum Lessons Medicine Reflection

What is the Question?

I can think of only two times in my life where I received formal instruction on how to ask questions.[1. Without a doubt there have been more than two occasions when someone taught me how to ask questions, but it appears that I either was not paying attention or the lesson was not memorable.]

The first instance was when my parents taught me how to order food in a restaurant. They told me to make a single choice and have my order ready before the wait staff appeared. (“Don’t waste their time.”) They told me to phrase my order in the form of a question:

RIGHT: “Can I have the grilled cheese sandwich, please?”

WRONG: “I want the grilled cheese sandwich.”

My parents also told me to look at the faces of the wait staff and to speak loud enough so they could hear me. They also told me to thank them after they took my order.

(When I became more finicky about sentence construction, I changed the beginning of my orders to “May I…?”. This is mostly due to my 6th grade English teacher who, in his booming voice, would challenge any student who said, “Can I…?” “I don’t know, CAN you? CAN you go to the bathroom? If you CANNOT, perhaps you should see a DOCTOR. MAY you go to the bathroom? Yes, you MAY.”)

In sum, I was supposed to know what I wanted and exercise good manners.

The second time I received formal instruction on how to ask questions was during my third year of medical school.[2. Of course I received formal instruction on how to ask questions throughout my training as a medical student and as a psychiatry resident. However, that was over the course of years and done with varying quality. There were also all the people who taught me how to ask questions and I didn’t understand at the time that they were teaching me how to do that. Communication is difficult. This also explains why my efforts to ask boys out on dates in my youth often resulted in said boys looking at me askance and running away.] Interns and residents often asked medical students (e.g., me) to call consults.

Here’s the thing: When you’re a medical student, you don’t know how to do things like call consults because you don’t entirely know what you’re doing. Mastery comes with practice. Mastery also results from direct feedback, which often comes from exasperated and impatient residents.

When you call a consult you’re asking another service to help you with your patient. For example, if I’m a surgeon and I have a patient who stabbed himself multiple times in the abdomen in an attempt to kill himself, I’ll do the surgery to look around inside and make sure there aren’t injuries to internal organs. However, as a surgeon, I don’t know what to do about my patient’s urges to stab himself, so I’m going to call the psychiatrist to ask her for help.

WHAT IS THE QUESTION?

A surgical intern named Tom[3. Tom had cropped blonde hair. He wore leather pants sometimes. He often went dancing when he wasn’t working. He was smart and, perhaps more importantly, he was kind.] taught me how to call a consult while we were speeding around the hospital one day.

“Before you call a consult, you have to know what you want. What is the question you want answered? The patient is your patient, so you have to provide most of the care. But if you need help, what do you need help with? Don’t just say that the patient has diabetes and high blood pressure. That’s not a question and it’s not clear what you want. Make your question very clear:

‘My patient has diabetes and high blood pressure. He took insulin regularly before he came to the hospital, but now his blood sugars are high. They haven’t been below 300 since he’s been here. Can you help us bring his blood sugars back down?’

See how that’s a clear question? If you ask a clear question, you’ll get answers that will actually help you.

And be nice. Some of the residents you talk to won’t be nice, but that’s just because they’re tired and stressed out. Don’t take it personally.”

In sum, I was supposed to know what I wanted and exercise good manners.

To be clear, it’s not like I had this one conversation with Tom and I thereafter called in stellar consults. I still went on for too long and didn’t share pertinent pieces of information. Residents interrupted me before I had spoken for five seconds and they often made no effort to mask their annoyance.

But! It set me on the path of continually clarifying for myself what I wanted and how to craft better questions. Focusing on “WHAT IS THE QUESTION” has helped me as a psychiatrist (much of the work is often helping other people clarify for themselves what they want), a teacher (if people don’t understand something and get stuck, it’s often because they don’t know what they want to know), and as a human being (when meeting someone new, the question might be as simple as, “How can I make this person feel comfortable so maybe we can become friends?”).

Sometimes asking questions is more complicated than just knowing what you want and exercising good manners (e.g., “Will you marry me?”). Doing both, though, is an excellent place to start.

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Consult-Liaison Education Funding Medicine Policy Systems

The Value of Psychiatrists.

While slogging through a crappy first draft of a document about the value of psychiatrists in mental health and substance use disorder services, I did a literature search for supporting evidence.

I found nothing.[1. Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.]

“So how exactly are we helpful?” I mused out loud. Maybe we aren’t: There are groups out there who do not believe that psychiatrists can or do help anyone.

I am an N of 1. Therefore, this post is an anecdote, not evidence. Nonetheless:

Psychiatrists provide psychiatric services. These are increasingly limited to only medication management, which is unfortunate. Psychiatrists need psychotherapy skills—or, abilities to connect with people to build trusting and respectful relationships—to do effective medication management. I can write dozens of prescriptions and change doses as much as I want, but if the person I am working with doesn’t trust me, none of my tinkering matters.

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications. This “deprescribing” also requires the use of psychotherapy skills: Some people feel great discomfort when coming off of medications. Sometimes the reasons are physiological; sometimes they’re psychological. Psychotherapeutic interventions and education are necessary in helping people cope with and overcome these discomforts.[2. For any psychiatrists out there: You could build an entire practice around “deprescribing”. This is one of the most common clinical requests I receive through my blog. I don’t have a private practice, so I turn all these people away. To be clear, deprescribing isn’t limited to private practices; I deprescribe in my clinical work in the jail.]

Psychiatrists often have the most clinical expertise. Most have had exposure to the spectrum of psychiatric services (in residency training) and thus have perspective about how systems work (or fail). Thus, psychiatrists can provide clinical consultation about specific patients and program design, implementation, and improvement. One example is the use of medication assisted treatment for substance use disorders. Certain programs or agencies may believe in abstinence only and will view medications as another misused substance. That perspective is not invalid, though giving people more options may help someone reach the goal of abstinence.

Psychiatrists can provide education to other staff to improve their clinical skills, which can elevate the quality of care clients receive across the agency. Psychiatrists can also provide leadership and influence the direction and ethos of a clinical service. For example, you can imagine how a psychiatrist might influence a service if he believes that the only way to help patients is to convince them to take psychotropic medications forever. A different psychiatrist who believes that employment or housing may be more effective than medication for some patients would provide a different influence.

Psychiatrists can triage patients who are in crisis. A roving psychiatrist on the streets or visiting people in their homes often can’t do things like draw blood, but they can assess people and circumstances to determine whether a visit to the emergency department can be avoided. Psychiatrists can also provide strong advocacy: Psychiatrists can work with law enforcement so that people who would be better served in a hospital actually go to the hospital, and not to jail. Similarly, if someone who has a significant psychiatric condition requires medical attention, psychiatrists can talk with hospital staff to advocate for this. Too many of us have stories about our patients who needed medical interventions, but others thought their symptoms were entirely due to psychiatric conditions.

Psychiatrists go through medical training and often have ongoing contact with other medical specialties. They are thus familiar with the practical realities of communication about and coordination of care for patients across systems. While overcoming the financial and policy hurdles to integrate care are important, the reason why integration matters (or, at least why I hope it matters) is to improve the experience for the patient. Administrators should consider the interaction and experience between the physician and the patient as paramount. The system should not sacrifice that relationship to make administration easier.

This is the message that all physicians, psychiatrists or otherwise, need to communicate to administrators. We don’t do ourselves any favors by assuming that people know what value we bring to patients or to the system. Sometimes it also helps to remind ourselves, too, so we can improve our work for the people we serve.

Categories
Consult-Liaison Education Medicine

Foundations.

I never did follow up here on the talk I gave to attorneys about “Psychiatry 101“. Teaching the foundations of any subject is both challenging and rewarding. It is also an excellent way to remind ourselves of the importance of the basics. Foundations anchor and guide us, particularly when we start getting lost in complex or unusual situations.

During my talk I review the definition of “mental disorder”.[1. I dislike the term “mental disorder”, primarily because of the stigma attached to it. The term focuses on what is wrong, not what is going well. We also get so caught up talking about “disorders” that we stop talking about “people”.] DSM-5 states that a mental disorder has two components:

  1. disturbance in cognition, emotion regulation, and/or behavior (the assumption is that pathology in the brain/mind manifests as this disturbance)[2. The underlying assumption that “disturbances” reflect pathology in the brain/mind is up for discussion, given that we don’t know if there is a distinction between the brain and the mind. The two seem related, but how they are related remains unclear. Furthermore, some people would argue that not all disturbances represent pathology. Context matters. People who choose not to eat during a hunger strike against the government are demonstrating a “disturbance” in behavior. Does that represent pathology?] AND
  2. the disturbance leads to distress OR impairment/disability

Both conditions must be met. However, the second criterion has two parts. This complicates the definition of a mental disorder. Distress does not equate to disability. People can experience low distress and high disability: Consider the person who has lost all his relationships and is unable to hold a job because he believes that he is the Messiah. People can also have high distress and low disability: Take someone grieving the loss of his spouse.

Symptoms help define diagnosis, and diagnosis guides treatment. Danger arises when psychiatrists treat symptoms without a clear diagnosis. An analogy: Say you are lost in a city. You call your friend to pick you up.

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“Main Street.”

“Main Street and what?”

“Um… Main Street and Popcorn Alley.”

“Okay. Stay there are I’ll be there in about 15 minutes,” your friend says to your relief. You and your friend were able to define where you were located, which allowed your friend to figure out how to get from his house to Main Street and Popcorn Alley.

But what is the conversation went like this?

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“I don’t know. The streets don’t have signs on them.”

“Okay. What do you see around you?”

“Uh… there’s a coffee shop on one corner and a sandwich shop on the other corner.”

“What else do you see?”

“Well, there’s a parking lot across the street.”

At best your friend would probably express gentle frustration with your lack of clarity: There are many coffee shops, sandwich shops, and parking lots in the city. How is he supposed to find you with such vague directions? At worst your friend would say, “Okay, I’ll find you,” and then hop into his car and drive around, looking for the triad of coffee shop, sandwich shop, and parking lot. The diagnosis (location) is unclear, so the treatment (picking you up) is also unclear (and frustrating and wasteful).

There is variability in how psychiatrists approach diagnosis of a “mental disorder”. The criterion of “disturbance in cognition, emotion regulation, and/or behavior” is often the easier of the two to determine: Most people would agree that people who cut themselves, refuse to eat, or feel so hopeless that they literally can’t get out of bed are experiencing a “disturbance”.

If the disturbance leads only to distress, but not disability, does that mean a mental disorder is present?

Here are several instances of disturbance AND distress WITHOUT disability:

  • hearing voices say unusual things to you
  • having self-doubts and feeling terrible following a breakup
  • suspecting others of sabotaging your work

If these things happen to you, does this mean you have a mental disorder? Maybe, but not necessarily.

Here are several instances of disturbance AND impairment WITHOUT distress:

  • hearing voices say that you are God and that you should touch everyone to bless them
  • having beliefs that you do not need to eat or drink to live; air alone will sustain you
  • suspecting others of sabotaging your work, so you stop going into the office, never talk to anyone, and don’t share any of your data (some distress is probably associated with this)

If these things happen to you, does this mean you have a mental disorder? The impairment component makes it more compelling that a disorder is present. (Why, yes, I know my bias is showing.)

If we do not exercise diligence in our diagnosis of a “mental disorder”, then we may suggest an intervention that is incorrect or insufficient. Even worse, the treatment may be unhelpful or harmful.

We work with our patients to discern whether a mental disorder is, in fact, present. Together we then clarify what the mental disorder is. Lastly, we survey possible interventions.

This is the value of returning to foundations.