Category: Policy

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Observations Policy Reflection Systems

Pondering the Purpose of Policies.

What’s your policy on wearing pants?

We all have a personal policy about pants. My policy is that I shall wear pants on all days unless (a) I am attending a special event where a dress or skirt is indicated or (b) it is a hot day and I must wear something professional, so a dress or skirt is the cooler option.

Hang in there with me. This isn’t actually about pants.

I’ve been chewing on the purpose of policies. Much of my work life is dedicated to the creation and amending of policies for a system.

It makes me feel disappointed to see that policies often cater to the lowest common denominator. They seem to solely focus on preventing undesired behaviors and outcomes. It’s almost as if policies are written for those people or organizations, whether they exist or not, with the worst intentions.

Policies aren’t inspiring. They don’t talk about what could be or what we should strive for. This might be why we find policies tedious to read.

A colleague pointed out that, yes, policies are for the lowest common denominator because people often have the worst intentions.

“Think about the Ten Commandments,” she said. “Like ‘Thou shalt not kill’ and ‘Thou shalt not steal’ and ‘Thou shalt not commit adultery’. Those are really basic things, but we need them. Those are policies to help us get along.”

Indeed, those religious prohibitions are not inspiring. What if we rephrased them? What if we said “Thou shalt honor life” instead of “Thou shalt not kill”? Doesn’t the idea of honoring life inspire more creativity and joy than a fearful instruction to not kill?

I think my colleague would reply that people need explicit directions. A exhortation to honor life does not guarantee that people will stop killing.

In his book Practical Wisdom, Barry Schwartz laments how policies can affect our abilities to do the right thing the right way. If we rely on policies, we ignore the nuances of the situation and stop thinking. When we stop thinking, we lose our wisdom. We end up looking to policies to prevent the worst thing from happening. The prevention of the worst thing, however, does not equal the creation of something better.

Call me naive—you won’t be the first—but I believe that, for most people, they meet the expectations you have of them. If you have high expectations, people will often meet them. (To be clear, there is a balance: Most expectations must be realistic. If they aren’t, people become demoralized.) It’s meaningful to people when they realize that someone believes in them when they may not believe in themselves. High expectations are frequently a form of respect.

(Perhaps I am straying. A significant difference between individual expectations and policies is the relationship. Relationships between people rely on invisible things like trust, hope, and respect. Relationships between organizations rely on visible things like contracts, memoranda, and policies. We often don’t feel like we have total control over what we do as individuals. How can an organization, comprised of potentially hundreds of people, control its behaviors to meet the expectations of another organization without those invisible connections?)

Someone on Twitter recently commented that policies should reflect the morals of the organization. I like that. If policies focus on documentation requirements and payment arrangements, but say nothing about the quality of services, what does that say about the organization? Does a mission statement have any meaning if the policies and procedures do not align with the stated mission? If the policies only comment on how to prevent the worst thing from happening, why would anyone expect extraordinary quality from the organization?

Perhaps I need to reframe, for myself, the purpose of policies. Policies help prevent bad things from happening. That’s good. Prevention is underappreciated: It’s difficult to measure things that didn’t happen. The difficulty in showing that less bad things happened, however, doesn’t mean that the activity of prevention is worthless.

It’s not an “either/or” issue. Policies prevent bad things from happening, which is valuable. But, as I noted above, preventing bad things and creating better things are two different activities. We don’t want to focus our energy on just preventing bad things from occurring. We must also create new things, or we otherwise will not progress.

The primary reason for my personal pants policy is comfort, though there are professional implications, too. Much of my work in the past involved talking to people in atypical places: Sometimes I’d have to step over puddles of mud to talk to the man living in the park; sometimes I’d have to slip between towers of yellowed magazines to reach the elderly woman seated on her bed. These days, wearing pants makes it less likely that male inmates will make unwelcome comments about my legs. Pants prevent bad things from happening to me.

My other clothing policy is to wear bright colors or patterns to work. People—colleagues, patients, strangers—often comment on the shirts I wear, frequently while smiling. That helps build rapport and connections, even if they are initially based on something as superficial as polka dots on a shirt. These relationships, though, often help create better things and situations for us all.

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Consult-Liaison Education Medicine Policy Systems

Online Screening for Depression?

Inquisitve reader Amy asked me if I had any opinions about online screening for depression. The British Medical Journal recently published a debate on this issue.

What an excellent question, Amy! I read the opposing arguments and these are my thoughts:

First, I see two different issues. The first is whether the 9-question Patient Health Questionnaire (PHQ-9) is an appropriate tool to use to screen for depression. The second is whether the public should trust Google to administer the PHQ-9.

Before I do delve into that, though, let’s take a step back and consider the purpose of screening tools. Screening tools help physicians figure out how much more we should learn about a person. For example, asking for a person’s biological sex is a screening tool. The moment I learn that the person before me is female, I will ask her questions about menstruation and pregnancy history. I’ll skip those questions if the person is male. Similarly, if a person tells me that he smokes cigarettes, then I will ask more questions about how much and how often he smokes, what he gets out of smoking cigarettes, and if he thinks smoking causes him any problems. This helps me assess potential risks to his psychological and physical health. It also helps me assess if he has any interest in changing his smoking behaviors. Screening tools help us sort and gather information to generate diagnoses and interventions.

The literature states that the PHQ-9 was developed both to diagnose and measure the severity major depression. The PHQ-9 was modeled after the criteria for major depression in DSM-IV. Thus, the problems with the PHQ-9 for diagnosis are the same as the problems with the DSM for diagnosis: Context is completely missing. The authors of DSM argue that the situation and underlying causes of major depression don’t matter; they state that the presence of certain symptoms determine whether the diagnosis applies.

Long-time readers know my refrain: Context does matter. Major depression is “comorbid” with many other psychiatric conditions, meaning that someone experiencing the symptoms of major depression often experience symptoms of other psychiatric conditions. For example, bipolar disorder, by definition, includes episodes of major depression. People with diagnoses of post-traumatic stress disorder (PTSD) and schizophrenia often experience major depression. Some people who take drugs, whether prescribed or obtained from illict sources, experience symptoms of major depression. Sometimes the symptoms of major depression are actually due to a medical condition, such as certain cancers, infectious diseases, or thyroid conditions.

There are several papers that make the case that the PHQ-9 is a useful tool in the screening for and diagnosis of major depression. Given that major depression is comorbid with other conditions, a positive PHQ-9 result is useful to help get people into care. A professional can then help clarify symptoms, determine possible diagnoses, and suggest treatment and other interventions. Recall that the purpose of diagnosis is to guide treatment.

Here is where we get into the second issue as to whether the public should trust Google to administer the PHQ-9. Most task forces agree that there is no point in performing screening tests if you can’t do anything with the results. If you can’t refer someone with a positive PHQ-9 result to a professional who can clarify diagnosis and provide treatment, then why bother? You’re potentially causing more problems and distress for the person seeking help. Thus, the question is whether Google will direct people with positive PHQ-9 results to helpful resources.

There is a shortage of psychiatrists and other mental health professionals in the US. One wonders if an online depression screening tool will lead people to believe that they are “majorly” depressed, when they are not. They will then seek services that are hard to find. If these individuals are able to get into primary care services, those medical professionals may not be able to determine if someone has depression because of bipolar disorder, or depression due to the recent death of a loved one. Wrong diagnosis often results in wrong treatment or overtreatment. Recall that we should first do no harm.

However, it is clear that people seek information about depression and other psychological experiences on the internet. The questions on the PHQ-9 can educate the public about the differences between major depression and having a sucky day. The more information and education we can provide to the public, the more empowered the public can feel about not only what isn’t going well, but also what they can do to improve their health and wellness. I do not view my work as a psychiatrist as a guild secret. The more understanding and communication we have in our communities, the more we can address our psychological health on individual and societal levels.

The other reaction I had to that BMJ debate was related to a comment that Dr. Duckworth made under “attitudinal barriers”. He noted that a “key reason may be that people with mental health conditions perceive that they do not need treatment. Studies show that they report attitudinal barriers to seeking care much more often than structural or financial barriers.”

I don’t see how the PHQ-9 is related to “attitudinal barriers”. Screening tests don’t reduce stigma. Sure, people may avoid treatment for depression because they don’t know that they are depressed. However, I suspect that more people avoid treatment for depression because of the stigma associated with psychiatric conditions and treatment. If we want to reduce and remove “attitudinal barriers” related to depression, we must help share stories that remind everyone that people with depression are, first, people. The PHQ-9 is not a means to that end.

I don’t know the workings of Google well enough to comment more about whether we should trust Google to administer the PHQ-9. Others with more knowledge about online security, marketing, and data mining can say more about whether Google will use PHQ-9 results for good or evil… or both. There are likely other unintended consequences that I don’t know or understand.

Thanks for the question, Amy!

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Medicine Nonfiction Observations Policy Systems

Disappointment.

My cohort graduated from our psychiatry residency almost ten years ago. The level of frustration and disappointment we’ve all experienced within the past two years is striking.

Some have taken leadership roles, only to relinquish them because of fatigue from fruitless discussions with administrators. Others have tried to alert senior managers about dangerous and irresponsible clinical practices. Their efforts were unsuccessful because concerns about finances trumped concerns about clinical services. With a bad taste in their mouths they resigned from their positions. Still others have tried to convince senior administrators about why certain clinical services are necessary. Though these clinical services save money across systems, they do not generate revenue for any specific organization.

“Just keep quiet and keep doing what you’re doing,” they hear from a few senior managers who are sympathetic to their efforts. “Maybe you can stay under the radar that way.”

One had the job duties of three positions. This physician asked for help after recognizing that this workload wasn’t sustainable. The administrators repeatedly said no. And, yet, when this physician finally resigned, the administrators split the single position into three.

“It’s like no one cares about about human suffering. It’s always about money.”

Some have become medical directors, only to learn that senior leadership expect a rubber stamp of agreement from them as figureheads to help change the behaviors of medical staff. Many of their clinical recommendations go unheeded because mandates from policy advisors and economists have primacy. For-profit corporations value profit over patients and seek the counsel only of their shareholders.

They have noticed that administrators often value the “medical doctor” credential for their reports over the clinical expertise of the person with the credential. They recognize that they are often not invited to certain meetings because some administrators do not want to hear what they have to say. They thought that they could offer specialized knowledge to proactively improve systems, but they learned that systems only react to audits.

We all sit around the table, the occasional fork clinking against plates holding desserts. No one talks because no one knows what to say. If we’re all experiencing this across different clinical settings and organizations, what encouragement could we offer?

What do we say to our patients?

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Consult-Liaison Education Medicine Observations Policy Reflection

Why I Agree with the Goldwater Rule.

The New York Times and NPR recently published articles related to the Goldwater Rule. In short, a magazine sent a survey to over 12,000 psychiatrists in the US with the single question of whether they thought Presidential nominee Mr. Barry Goldwater was fit to serve as President. Few psychiatrists responded. Of those that did, more than half—still over 1,000—said that he was not. Mr. Goldwater ended up losing the Presidential race, but he sued the magazine over this… and he won. Thus, the American Psychiatric Association has advised that psychiatrists should not diagnose public figures with psychiatric conditions. Some psychiatrists have felt otherwise for the current Presidential election.

There is a hypothetical concept in psychiatry called the “identified patient“. It is most often applied in family systems. For example, consider a family that consists of a mother, a father, a son, and a daughter. The parents bring the daughter to a psychiatrist and say that she has worrisome symptoms. Maybe they say that she is always angry, doesn’t get along with anyone in the family, and does everything to stay out of the house. The parents and the son argue that there must be something wrong with her.

As the psychiatrist works with the family, the psychiatrist learns that the parents have the most conflict. The daughter may have developed ways to cope with this stress in ways that the parents don’t like. Because the parents have the most authority in this system and do not recognize how their conflicts are affecting everyone else, they assume that the daughter is the problem. To oversimplify it, the daughter becomes the scapegoat. The daughter is the identified patient.

Presidential nominees don’t become nominees through sheer will. There is a system in place—putting aside for now whether we think the system is effective or useful—where the American public has some influence in who becomes the ultimate nominee. Candidates are eliminated through this process.

Does the Presidential nominee actually have psychopathology? Could a nominee rather reflect the public that supports him or her? Could it be more accurate to describe the nominee for a specific party as the “identified patient”?

Erving Goffman presents an argument in his book The Presentation of Self in Everyday Life that has similarities with the monologue in Shakespeare’s As You Like It:

All the world’s a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts

Goffman and Shakespeare are both commenting on the presence and importance of performance in our daily lives. Goffman argues in his text that context matters[1. I agree that context matters. See here, here, and here.]. We all do things within our power to alter ourselves and the contexts to present ourselves in certain ways.

Some mental health professionals have argued that we can diagnose public figures with psychiatric conditions because of “unfiltered” sources like social media. While it may be true that some people are more “real” (or perhaps just more “disinhibited”) on social media than others, that does not mean that people are revealing their “true selves”. Do you think that people are always eating colorful vegetables in pleasing arrangements? or that people are always saying hateful things, even while waiting to buy groceries, attending a church service, or folding laundry? or that their cats are always cute and adorable, that hairballs and rank breath have never exited their mouths?

Lastly, the primary purpose of diagnosis is to guide treatment. There is no point in considering diagnoses for someone if you’re not going to do anything to help that person.

People have commented that psychiatric diagnoses often become perjorative labels. Unfortunately, there are those who work in psychiatry who will use psychiatric diagnoses as shorthand to describe behavior they don’t like. Instead of saying, “I feel angry when I see her; I don’t like her,” they will instead say, “She’s such a borderline.” That’s unfair and often cruel. If you’re not going to do anything to help improve her symptoms of borderline personality disorder, then why describe her that way? (We’ll also put aside that such a sentence construction reduces her to a diagnosis, rather than giving her the dignity of being a person.) If we are serious about addressing stigma or sanism, then we should only use diagnosis when we intend to help someone with that diagnosis.

I agree with the Goldwater Rule, though not because of the exhortations of the American Psychiatric Association.[2. I’m not a member of the APA. The reasons why I am not a member are beyond the scope of this post.] Diagnosis should have a specific purpose. We often do not have enough information about public figures across different contexts to give confident diagnoses. Presidential nominees are often appealing to various audiences, which can both affect and shape their behaviors. Most importantly, giving a diagnosis to a public figure without any intention of helping that person doesn’t help anyone, especially those who would ultimately benefit from psychiatric services.

Categories
Education Medicine Policy Systems

Inspiration from the Surgeon General.

Somehow people knew he was about to enter the room. The thirty or so people in the room were seated, though people began to stand up.

“Are we supposed to stand up for the Surgeon General?” I asked the person sitting next to me.

She shrugged. If we remained seated, everyone would have noticed. So we stood up.

“I’ve been in this position for a year and a half,” Dr. Murthy said, “and I’m still not used to people standing up for me. Please sit down.”[1. I learned later that the Surgeon General has the rank of a Vice Admiral, as the role oversees uniformed health officers. That’s why people stand up for the Surgeon General.]

We were all in that room for about an hour, but Dr. Murthy said little. After some opening remarks about the Turn the Tide initiative related to the opioid epidemic, he asked the audience to tell him what was going well and what could use improvement.

I had never met him before, but I was immediately struck with his listening skills. It was as if he was taking a history from a multi-person patient. He made and held eye contact. He didn’t fidget. He spoke in a quiet yet firm voice. Though he didn’t come across as warm, it was clear that he was interested in and paying attention to whoever was talking to him. His thoughtful follow-up questions indicated that he was listening to what people were saying to him.

He seemed like a good doctor.

As I had never met a federal official before, I later learned that Dr. Murthy was also unusual in that he took notes. (Fun fact: He’s left handed.)

“These are usually publicity events without a lot of substance,” a more seasoned co-worker commented.

By the time the meeting was over, he had covered a sheet from a yellow notepad with copious notes. He expressed what seemed like genuine thanks to us for our time and perspectives.

It was through luck only that I was there. A colleague told me a few days prior that the Surgeon General was scheduled to speak to a local task force related to the opioid epidemic.

“The Surgeon General?” I blurted. “I’d love to hear what he has to say.”

“Then you should come.”

“What?”

Afterwards, as the Surgeon General’s staff were trying to hustle him out the door, the same colleague who invited me to this event gave me A Look. Only I could see the thought bubble above his head: “Go ask him for a photo!”

Though I appreciated Dr. Murthy’s humility, thoughtfulness, and professionalism, I was also grateful and amused with his willingness to stop for a photo.

Earlier that day I was seeing patients.

“Do you know how much longer you’re going to be jail?” I asked.

“Ten or eleven days.” He looked at my left hand. “You’re married?”

“Yes.”

“I should start going to NA meetings again. I’m never gonna meet a woman in here and I get so depressed about not having a family. I want a wife and kids, like my brother. I don’t know why he got so lucky and I got screwed. The TV doesn’t talk to him, he’s got a wife and three kids, God blesses him, but I will wait because the meek shall inherit the earth—”

“What do you think will help you not pick up when you get out?”

He shrugged. “I still don’t have a place to live. Dope helps me feel better.”

We looked at each other and said nothing.

The reality is that the Surgeon General (or any other public official) is just one person. Though he has a grand title, he alone cannot make improve health care. He is part of a system. We can only hope that he and his office will be able to shift the system—even if only just a bit—so that it works better to serve the US population.

What the Surgeon General can do and, at least for me, has done, is inspire physicians to get involved and do better. He could have swept into the meeting and spoke at length about his accomplishments and his status within the federal government. He instead presented himself as a humble ambassador and servant. He demonstrated interest in what our locality has witnessed and experienced. He recognized that, even though he was an academic physician, he is now too far removed from clinical care to speak first as an expert. He solicited and accepted feedback, some of which was discouraging. He was professional. He wasn’t defensive. He acknowledged that it may seem like our feedback would disappear into a void in Washington, DC, though everything else he was actually doing during the meeting gave us hope otherwise. It’s quiet leadership.

There are a lot of problems with health care. Physicians and patients both know this. Physicians are trained to take care of people, not to create and manage financial systems that should only support the relationships between physicians and people. However, if physicians are not involved in the conversations about these systems, then we are not advocating for the patients we serve and the profession that gives us the privilege of doing so. Yes, I know we’re too busy taking care of patients to participate in these conversations that can seem bloated and irrelevant. However, if we don’t get involved to define the problems and solutions, how could we ever expect these systems to improve?