Is Your Psychiatrist Paying Attention

In my post of 2/24/2010, Counting Symptoms that Don't Count, I discussed how many psychiatrists these days are taking huge shortcuts in order to squeeze as many patients into an hour as they possibly can. I described how they are focusing just on symptom counts without trying making the slightest effort to ascertain whether or not the symptoms in question are clinically significant for a particular diagnosis, or whether they might require psychotherapy rather than drug treatment.

As I have pointed out many times in this blog, in order to make such a determination, the doctor has to take into account the timing, pervasiveness, persistance, and subjective quality of a symptom. The psychiatrist has to know what other symptoms are present at the same time and at different times. Most importantly, the doctor has to know something about the psychosocial context of a symptom.

One of my partners reported a particular glaring example of what can happen when this is not done: A patient with no previous psychiatric history became depressed right after finding her husband in bed with another woman.  Her "depression" was characterized, not surprisingly, mostly by anger and preoccupation with the discovered affair.  Nevertheless, when she came to the attention of a psychiatrist, he diagnosed her with "major depressive disorder."  Really?  I mean, really???

Another time saving "convenience" is for the doctor to write down the information that the patient is relaying during an interview on the patient's chart, using either pen and paper or a computer, as the patients speaks. This not only saves time, but solves a second problem: Some insurance companies do not want to pay for a doctor's time unless it is spent face to face with the patient. Even time spend reviewing the patient's record and writing down all the information that insurance companies demand in order to pay the doctor is supposed to be donated, I guess. So instead of writing a progress note after the patient leaves, it is written with the patient still in the room!

So, aside from wasting the patient's time while the doctor does that, what's wrong with that?

Well, I'll tell you.  When a doctor is writing or typing away on a computer, his or her attention is split between doing that and observing the patient. Often a patient's body language or facial expression can give a doctor a clue that what the patient is saying may not be completely accurate or may not be the whole story, so that the doctor then needs to ask for clarification with follow-up questions. When the doctor is staring at a chart instead of the patient, that is probably just not going to happen.

Even more important, patients will often mutter vitally important information quickly and in passing, or even under their breath. This is particularly likely to happen if the information patients are relaying is troublesome to them in one way or another, such as reporting things they are ashamed of. If the doctor is not paying close attention, he or she will literally not hear it!

In my book, How Dysfunctional Families Spur Mental Disorders, I describe in detail a videotape of a psychiatry trainee doing a diagnostic interview in front of two senior faculty members in order to practice for her upcoming oral boards. In the videotape, a real patient was used. During the interview, the patient stated in passing that she had been repeatedly molested by a close relative. In fact, the matter even ended up in court. After the interview, the examiners both said that they "suspected" that a trauma history was "likely" in the patient.

There were three doctors in the room, all of them preoccupied with the trainee's performance.  All three of them either missed or forgot that abuse was not only likely, but had actually been mentioned!

Demystification Monday Psychiatrist vs Psychologist

Do you know the difference? If so, move along. Nothing to see here.

But I am often surprised at how often folks confuse these two professions. It happens ALL the time. Just one example: the writers of the television show Bones alternately call Dr. Lance Sweets a psychiatrist and a psychologist. Unfortunately, if you look at his fictional educational credentials, it turns out he's a psychologist. Ugh. His massively boundary-crossing, you-should-lose-your-license-and-you-make-my-skin-crawl unethical behavior makes me wish he was batting for the other team (apologies to any psychiatrists out there. I shouldn't be wishing him on you, either).

Ahem. Sorry. Moving on.

The basic educational distinctions between a psychiatrist and a psychologist:

Psychiatrists are physicians.  They go to medical school. Then they do a residency that includes specialized experience in psychiatry. They get a license to practice and a federal narcotics license and blammo: practicing psychiatrist (I'm pretty sure I made that sound a lot easier than it actually is).

Psychologists ... are more complicated. But they are not medical doctors.

You can become a "psychologist" by a lot of different routes, but it's almost always by getting a doctoral-level degree (unless you're a "school psychologist", which is often a masters-level qualification). There are several kinds of doctoral degrees, though (Ph.D., Psy.D., Ed.D.). And even within the Ph.D.s, there are a lot of different kinds--clinical psychology, counseling psychology, school psychology, etc.. But no matter which degree you get, you have to qualify to take the national exam and the state exam, and only after you pass those do you get to call yourself a psychologist (legally).

Click to see the basic requirements to become a psychologist. Here's a quick rundown on me:

• I have a bachelors degree in psychology (from Hope College ... it's in Holland, Michigan)
• I have a Ph.D. in clinical psychology from the University of Delaware. It took me 6 years to get that sucker. Anyway, it was an APA-accredited program. I took certain classes, completed a lot of supervised clinical practice, and did quite a lot of research. I did my 1-year, full-time, APA-accredited clinical psychology/pediatric psychology internship at The Children's Hospital of Philadelphia.
• I completed a 2-year postdoctoral fellowship at Brown University. I did more supervised, specialized practice and research during those years, and at the end of it, I took the state (RI) and national licensure exams.

So the most basic difference between psychiatrists and psychologist is MD vs. PhD (or other doctoral degree). But you know what? If you spend 8 years training to be a psychiatrist, you're going to think differently than if you spend that same 8 years training to be a psychologist. It's a different mindset, one I don't have the space to really explain here. Instead, I'll just offer:

The basic day-to-day distinction between psychiatrists and psychologists:

Psychiatrists evaluate, diagnose, and prescribe medication. They often work with another mental health professional who provides therapy.

Psychologists ... are more complicated. For the most part, we don't prescribe meds (there are 2 states that allow psychologists to prescribe if they get an extra masters degree in psychopharmacology). We do a lot of other things, though.

There's a general description here. Here's what I do:

• I perform psychological evaluations (which include IQ testing along with other psychological tests) and diagnose.
• I provide psychotherapy to children and families.
• I consult to schools and daycares (and anyone else who's wondering things like, "Why is that 4yo throwing chairs and threatening to kill people, and how do I get him to stop?!?!)
• I supervise and mentor other clinicians.
• I do program evaluation and research.
• I collaborate with other professionals regarding design of social service delivery systems and policies.
• Oh, and I write novels.

That is all.

Now ... does that clear anything up? Are you writing a story that includes a psychologist, psychiatrist, or some other type of therapist? Do you wonder how to portray the therapy process? If anybody has questions about the psychiatrist/psychologist distinction or anything else related to portrayal of these professionals in YA fiction, please do comment. I'll either answer them directly or cover them in future posts!

Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing

My malpractice carrier, which is physician owned and operated, recommends taking one of their seminars or online courses on different aspects of medical malpractice every year, and gives those policy owners who do a 10% discount on their yearly premium. 

The course I took this year was on misdiagnosis.

The course was not really geared to psychiatrists at all, but it seemed to me that the general advice still applies to them. However,  in my experience the advice is not clearly being followed by a lot of my colleagues these days. If these recommendations are indeed valid, and I certainly agree that they are, a lot of psychiatrists are getting away with gross negligence. 

Statistics show, by the way, that doctors are actually far more likely to get sued for something they did not do wrong than they are to get sued for actual malpractice. Isn’t that bizarre?

Some of the advice in the malpractice course concerns two major criticisms of my colleagues that I have written about extensively on this blog and in my last book: relying on symptom checklists, and relying on a diagnoses made by a prior clinician. Truly frightening.

So, as a public service, here’s some information from the course that psychiatric patients might find useful if they are considering suing a psychiatrist for malpractice. From MedRisk (Medical Risk Management, Inc.).

Misdiagnoses were more likely to be considered negligent in malpractice suits. Misdiagnoses were more than three times more likely to result in serious patient injury than medication errors.

2.      Multiple case law decisions have consistently held that the patient has no duty to volunteer information the physician does not ask about, and the patient’s only duty is to answer the physician’s questions honestly. (A smoker actually has no duty to tell his cardiologist about the smoking if the cardiologist does not ask!)

3.      Review any written history questionnaires with the patient to make sure the information is accurate. Patients who are sick or in pain can’t be relied on to even read the questions carefully, let alone provide thoughtful answers. Many patients will simply respond with a “No” to all prior diseases without reading the list and some patients, as discussed below, may not even be able to read or understand the questions. For example, the patient with a known history of high blood pressure may answer “No” when asked if he has ever been diagnosed with hypertension simply because he doesn’t know that they are the same thing. So make sure that your questionnaires are worded as simply as possible. Even then, review the responses verbally with the patient and make sure that you really do have a useful medical history. 

      

      Most healthcare instructional materials provided to patients are written on a 10th grade reading level or higher. Yet the reading level of the average patient is 4.6 grade levels below the last year of school completed, which means that a typical high school graduate reads at around an 8th-grade level. Further, the average Medicaid recipient reads at less than a 6th grade level, with more than one-third reading below the 4th grade level.

4.      Hear the patient outwhile taking the history and do not interrupt. Physicians are often overworked, overbooked, and scrambling to stay on schedule. This can leave them anxious to get to the point of a patient visit. One study found that physicians on average interrupted patients only 18 seconds into the explanation of the reason for the visit. This is significant because patients typically have a list of several complaints or observations they would like to discuss, yet rarely get beyond the first or second before being interrupted. Cutting the patient off before you’ve heard him out is called “premature closure,” and the main problem with this approach is that it assumes that the presenting complaint carries the most medical significance.

This is often not the case because the patient experiencing multiple symptoms may not know which are the most important, nor which may be related to the same underlying cause. For example, the patient who reports transient blurriness in her right eye may not realize that the simultaneous tingling sensation she feels in her right arm and leg are related. Premature closure typically involves a patient with a serious but uncommon diagnosis who presents with symptoms suggestive of a less serious and more common diagnosis.  

Contributing to premature closure is a general human tendency to hear what we expect to hear, and mentally filter out as extraneous any details that we don’t expect. Fortunately, the main assumption underlying premature closure—that patients will talk endlessly if allowed—appears to be incorrect. Several studies have found that patients who are allowed to list all their concerns without interruption rarely speak for more than two minutes. Allowing the patient those two minutes not only prevents premature closure, but can actually save you time by allowing you to focus on the most important symptoms first. It also avoids those “Oh, by the way…” conversations in which the patient brings up a new problem just as you’re headed for the door.

And finally:

5.      Every doctor owes a duty of making an independent assessment of the patient, utilizing the full range of his or her clinical skills, regardless of whether you’re a primary care provider or a sub-specialty consultant. If you’re an FP [family practitioner] and receive a specialty ob-gyn report informing you that a 60-year-old woman who had a hysterectomy 15 years ago is pregnant, you’d obviously recognize that you’d received the wrong patient’s report or that some other mix-up had occurred. Yet far less blatant errors occur all the time in the exchange of patient information, and you should always be mindful of that possibility any time the specialist’s opinion doesn’t fit your clinical finding or the patient fails to respond to treatment as expected.

Clearly, the same can be said for not entirely relying on the diagnosis of some other practitioner even  in the same specialty, who may or may not have done a good diagnostic workup, but instead doing one’s own independent assessment. If a  psychiatrist prescribes something to you after initally talking to you for just fifteen or twenty minutes, find another doctor.