Enjoying clinical uncertainty

Lucia Sommers of the Department of Family and Community Medicine at UC San Francisco commented on my last post, noting that clinical uncertainty among primary care physicians (PCPs) is usually regarded as tolerable at best.  She was delighted that I called such uncertainty intellectually attractive, and something to embrace in psychiatry.  Sommers and her coauthor John Launer recently published a book that argues for managing clinical uncertainty in primary care using "collaborative engagement with case-based uncertainty in the setting of small groups of clinicians."  This contrasts with medicine's tradition of practitioners working independently.  In her comment, Sommers asked me to describe how psychiatrists manage clinical uncertainty, and specifically whether "supervision" — cases "presented for discussion to at least another psychiatrist if not a small group," similar to what she advocates for primary care physicians — is a good strategy in my experience.  This post is my response. At its most fundamental level, human psychology exists to manage uncertainty.  Confronted with an incomprehensible, threatening world, the infant soon differentiates "good" from "bad."  Initially a crude split without nuance or shades of gray, this primitive psychological distinction,  second only to distinguishing "self" from "other," represents a huge step forward.  It sets the stage for approach versus avoidance — the first "management" the infant undertakes.  Further psychological development allows subtler gradations to improve upon this harsh dichotomy.  Developmental psychology describes how secure attachment with caretakers, and an increasingly stable sense of self, contribute to tolerance of uncertainty.  With normal development, and under most circumstances, we no longer cling desperately to sharp black-or-white categories.  We make finer distinctions, and can also tolerate degrees of uncertainty.

Adult development takes this process further.  Mastery of an academic or occupational field solidifies a stable professional identity, which contributes to comfort with uncertainty.  Many years ago I learned a type of computer programming from my friend, an accomplished software engineer.  I felt anxious when confronted with programming challenges:  Would I fail to discover the solution?  Waste long hours trying?  Feel stupid in the end?  In contrast, my friend felt no such anxiety.  He explained that even when he was uncertain how to solve a problem, he knew he soon would, or at least would soon recognize it was impossible.  He was able to wrap his arms around the whole field in a way I could not.  Uncertainty for him no longer carried implications of permanence, nor of personal failure, i.e.,  narcissistic injury.  It wasn't threatening.  In this frame of mind, a programming challenge is merely a puzzle, an engaging intellectual pursuit which can even be fun.

Although the stakes are higher, the same applies in medicine.  An intern faced with clinical uncertainty shares my erstwhile self-doubt as a beginning computer programmer.  Is my uncertainty humiliating?  A sign of failure?  Will I ever figure it out?  With more experience comes confidence that uncertainty isn't psychologically threatening.  It's an intellectually engaging puzzle, often with a gratifying emotional reward at the end.  In specialties such as primary care and psychiatry, uncertainty becomes the norm.  We get used to it, expect it; we realize it doesn't tarnish us individually.

An additional factor that may sound esoteric but is crucial to thriving in uncertainty is the flow state.  Variously described as being "in the zone" in sports, "centered" in Eastern meditative and martial arts practices, and "in the groove" in musical performance, this is a mental state of heightened awareness, engagement, and creativity accompanied by a relative lack of self-consciousness and conscious intent.  Whether in extreme sports, music improvisation, video gaming, or academic brainstorming, moment-by-moment uncertainty is less disruptive and feels more welcome in the flow state.  Although uncommon in typical medical practice, the flow state can arise during intimate discussion with a patient, during research activities, and when intensely absorbed in medical work-up or treatment planning — the very times when clinical uncertainty is actively addressed.

Peers are a good source of emotional support whatever one's level of expertise.  Seeing that a problem is inherently difficult is reassuring; its apparent difficulty does not reflect on oneself.  Social interaction bolsters self-esteem, and often humor is shared to defuse fear and anxiety.  Similar challenges shared by others promote camaraderie and a sense of being "all in the same boat."  And tales of challenges successfully overcome can instill optimism, and sometimes offer practical solutions for the problem at hand.

My own experience with psychiatric supervision is hierarchical, not peer-to-peer.  Supervisors model a great deal non-verbally and often unintentionally: our attitudes toward patients and their issues, the focus of clinical attention, our approach to formulating cases, levels of formality and informality, and so on.  The supervisor's engagement with clinical uncertainty is one such factor, sometimes discussed explicitly, more often modeled non-verbally.  Ideally, this role-modeling inspires and encourages supervisees to nurture clinical curiosity, and to avoid frantic efforts to resolve uncertainty with premature conclusions.

Having not read the Sommers/Launer book, I cannot comment on their rationale for "collaborative engagement with case-based uncertainty in the setting of small groups of clinicians."  Psychologically, such collaboration is apt to confer the benefits of peer support mentioned above.  In addition, it is often more fun and energizing to work as a team, although teamwork can be frustrating at times too.  As a practical matter, putting multiple brains to the task may resolve clinical uncertainties more quickly and/or accurately compared to a practitioner working alone.  Alternative tactics for resolving clinical uncertainty include consulting with recognized experts and conducting literature searches.

In my experience, psychiatrists manage clinical uncertainty by accepting that uncertainty is inherent in the field.  It is therefore not a source of shame or a sign of personal inadequacy.  Released from these emotional burdens, we are free to be curious, to keep an open mind, and to enjoy uncertainty as a puzzle to be solved, an engaging intellectual challenge.  Relatively unstructured dialog in psychotherapy may particularly induce flow states in both participants, with enhanced capacity to accept and work with uncertainty during the hour.  And finally, while many office-based psychiatrists practice individually, social support from peers, supervisors, and treatment teams can enhance comfort with clinical uncertainty.  I have every reason to believe the same holds true in primary care.

Undermedicated

A patient I see for psychotherapy, without medications except for an occasional lorazepam (tranquilizer of the benzodiazepine class), told me his prior psychiatrist declared him grossly undermedicated in one of their early sessions, and had quickly prescribed two or three daily drugs for depression and anxiety.  He shared this story with a smile, as we've never discussed adding medication to his productive weekly sessions that focus on anxiety and interpersonal conflicts.  Indeed, the lorazepam is left over from his prior doctor.  I doubt I would have ordered it myself, although I don't particularly object that he still uses it now and then. Of course, there's a completely innocuous way to explain this difference between his prior psychiatrist and me.  My patient could have looked much worse back then, in dire need of pharmaceutical relief.  However, he didn't relate it to me that way, and I have no reason to doubt him.  There's also the possibility that I'm missing serious pathology in my patient — that I too would urge him to take medication if only I recognized what I'm now overlooking.  But... I don't think so.  I'm left to conclude that his prior psychiatrist and I evaluated essentially the same presentation rather differently.

In particular, I'm struck by the term "undermedicated" (more often spelled without the hyphen, according to my Google search).  This judgment most often comes up in speaking about populations, as in the debate over whether antidepressants are over-prescribed or under-prescribed in society at large, or whether children are diagnosed with ADHD and prescribed stimulants too often, or not often enough.  Under- and overmedication are also commonly mentioned when describing medication management of pain, a thyroid condition, mania, or chronic psychosis in an individual.  Here the terms express disagreement with a particular dosage, where the benefits of treatment and adverse side-effects or risks are deemed out of balance one way or the other.

"Undermedicated" also implies that adding medication is the preferred or only sensible treatment approach.  While this may always be true in hypothyroidism, it clearly isn't with regard to physical or emotional pain.  The term rhetorically denies non-medication alternatives.  I would also add that, to my ear, "overmedicated" and especially "undermedicated" sound dehumanizing, as though referring to a machine that is out of adjustment, or a chemical solution being titrated on a lab bench.  Since the natural state of human beings is not to be medicated at all, it sounds a bit odd to hear someone — as opposed to one's disease — assessed this way.  Perhaps I am especially sensitized to this after reading a controversial article by Moncrieff and Cohen that highlights the "altered state" induced by psychotropics and their lack of known, specific mechanisms of action.  There is often a supposition that medication dosage correlates with symptom relief.  This is not always true of subjective states, underscoring that the complexity of human experience often belies simple "over/under" judgments.

My patient's mood and anxiety vary with his interpersonal situation.  It wouldn't occur to me to turn his "thermostat" up or down in general, even if drugs reliably could do this.  Yet I know colleagues who'd argue that one, two, or even three daily medications could help him overcome his everyday challenges of dealing with people.  These approaches point to different fundamental viewpoints in psychiatry.  Does the patient have a disease, an as-yet-undiscovered chemical (or electrical, viral, inflammatory, etc) imbalance in the brain that is best remedied by a medical intervention, accurately dosed neither "over" nor "under"?  In acute mania or florid psychosis, as in hypothyroidism, it seems to me the answer may be yes, although this is unproven and time will tell.  Perhaps, too, in severe melancholic depression.  But in social anxiety?  Self-consciousness?  Feeling discouraged about one's career?  The field's perspective on these has shifted in recent decades, such that now a hidden biological cause is assumed by default, or at least held out as a rationale for treatment.  It is only by making this dubious assumption that one can speak of undermedicating such complaints, or the people who have them.

Who is mentally ill?

My fellow psychiatrist and blogger Dinah Miller raised this simple yet profound question on Shrink Rap the other day.  Who is rightfully labeled mentally ill?  Is it anyone with a psychiatric diagnosis, past or present?  Anyone with currently active psychiatric symptoms?  Anyone receiving psychiatric treatment?  Dr. Miller observes that "the mentally ill" is an oft-cited demographic.  It carries much social weight — negative in the form of discriminatory practices related to employment, driving, and gun ownership, and positive in the form of entitlements, disability status, and the like. With so much riding on this label, knowing exactly how and to whom it applies seems crucial. "But there is no agreed upon definition of who is mentally ill, and the Diagnostic and Statistical Manual (DSM) lists hundreds of disorders, limiting its utility as the determinant of who is mentally ill and therefore eligible for discrimination, stigmatization, or special benefits....  I'm a psychiatrist, and I confess, I have no idea who these 'mentally ill' are."

She includes a brief survey that she hopes everyone — mental health professionals, patients, and neither/both — will fill out.  At this point, if you'd like to complete her survey before I bias you with my own thoughts, go ahead and do that, then come back here.

Ok, here is my view of "the mentally ill."  It's a term I've never felt comfortable with, and thus rarely use, owing to what I view as imprecision.  Certain groups define mental illness to suit their purposes.  For example, the National Alliance on Mental Illness (NAMI) declares that "mental illness is a medical condition," and then provides a list of selected mental disorders they believe qualify as "mental illness."  This in turn leads to the rather incredible claim that "one in four adults... experiences mental illness in a given year. "  However, NAMI's definition does not reflect common usage, nor does it comport with the way "illness" is used in the rest of medicine.  More commonly, mental illness is a conceptually slippery, undefined euphemism that makes it easier to talk about restricting the rights of a subpopulation, or conferring benefits on them, without being too specific about whose rights are affected and why.

Definitions can be descriptive or prescriptive.  The former is how a word or phrase is actually used, the latter how it is properly used.  In actual use, "mentally ill" seems most often to mean manifesting a severe, observable psychiatric condition that renders the person unable to live normally.  Florid psychosis, mania, and severe obsessive-compulsive symptoms are clear examples.  However, contrary to NAMI, even fairly severe depression is equivocal, and neurotic anxiety, mild depression, and most personality disorders are clear non-examples. Typical discourse around rights and entitlements conflates current mental illness with high likelihood of having mental illness in the near future.  So a person can be temporarily free of impairment and yet still be subject to the restrictions and entitlements of someone in the throes of impairment.

As mentioned, this is not how "illness" is used in the rest of medicine.  (I'm about to get prescriptive here.)  Medical anthropologists long ago differentiated disease (or diagnosis) from illness.  The former may be asymptomatic and completely unknown to the patient.  Examples include the "silent killer" hypertension and an asymptomatic brain tumor.  In contrast, illness is a subjective state of feeling medically unwell, plus the psychological, social, and cultural consequences of this state.  Those suffering a cold, "the flu," or nausea feel ill, even if the exact underlying disease is not well characterized.  Illness leads to a socially defined "sick role": the ill person is relieved of his or her usual duties, accepts help from caregivers, is more needy and less autonomous than usual, etc.  If "mental illness" were used the way "illness" is used in the rest of medicine, ego-syntonic conditions, e.g., most mania, would be termed disorders but not illnesses.  Conversely, mild to moderate depression and anxiety would be unequivocal mental or emotional illnesses, even lacking a specific diagnosis.

Since "mentally ill" obscures as much as it clarifies, perhaps no one should be labeled this way.  Indeed, only in psychiatry can a person be declared ill by someone else.  In the rest of medicine, it's self-descriptive.   In my view, "the mentally ill" harbors too many unstated implications and vaguely shared assumptions regarding whom we are talking about.  Legal restrictions and entitlements should be based on more concrete standards — and actually, they are.  "Mental illness" is more of a rhetorical flourish, a bit of hand-waving when it's difficult or inconvenient to pin down specifics.

Third-party payment for psychotherapy: (1) "Do you take Medicare?"

From late 1996 to early 2007 I was medical director of a low-fee mental health clinic where psychiatry residents and psychology interns receive training.  Since the clinic accepted Medicare for payment, I did as well.  I signed on as a Medicare "preferred provider" and have remained on the panel ever since, even though I left the clinic for full-time private practice nearly seven years ago. I never joined private insurance panels for several reasons.  As an inveterate do-it-yourselfer, I've always handled my own billing and bookkeeping.  This is considerably harder when multiple health plans are billed, co-payments collected, and so on.  I like the straightforward way I provide a service, and the person receiving the service pays me directly.  Somehow it feels more honest than contracting with health plans to funnel referrals my way.  Private health plans also pay less than usual-and-customary fees and require doctors to share patients' private details with corporate reviewers to document "medical necessity."  Moreover, since dynamic psychotherapy has always been a big part of my practice — increasingly so over time — I'm sensitive to arguments that third-party payment complicates transference and countertransference, obscures acting-out around payment, and detrimentally takes payment out of the treatment frame.  Last but not least, as I'll discuss mainly in my next post, insurers base reimbursement on a medical model that fits poorly with dynamic work.

The upshot is that I have a cash-only (or "self pay") practice, with the exception of my Medicare patients.  Until this year, Medicare "allowed" 65% or so of my full fee.  (Medicare sets an allowed fee for a given service, and then pays 50-80% of that.  I can collect the rest, up to the allowed amount, from a secondary insurer or from the patient.  This works more or less automatically for secondary insurers, and rather awkwardly when I try to collect from patients.)  In 2013 the CPT codes for psychiatric office visits were revamped.  This made billing more complicated, and introduced odd, often illogical variations in Medicare and private insurance reimbursement — sometimes paying more than before, sometimes less.

As one of the few private-practice, office-based psychiatrists in San Francisco still on the Medicare panel, I've become a magnet for these patients.  A local medical center with which I have no affiliation used to refer several callers to me every week, until I sent a letter asking them to please not kill me with their kindness.  Medicare callers request to see me for medications only, even after I explain this is not the nature of my practice.  It's more tricky when patients claim to want therapy to get a foot in the door, and then once in my office and now my medico-legal responsibility, confess that they only wanted medication refills all along.  Some callers ask to be added to a non-existent waiting list, or to call me every month or two to see if I change my mind about accepting them as patients.  Clearly, the demand is there, the economic incentive is not.

Medicare and other third-party payers have a valid need to assure their money isn't wasted.  Sometimes my claims are rejected, as when I received a notice this week that one patient's diagnosis (Depression Not Otherwise Specified, 311) "is inconsistent with the procedures" I billed (three weekly sessions of moderate-complexity medication management, 99213, combined with 50-minute therapy sessions, 90836).  It's tempting to protest this, as there's absolutely nothing inconsistent about treating atypical depression with medication and psychotherapy.  I could take the time to marshal my arguments, compose a letter, and reveal personal details about my patient to present my case.  But it's far easier to resubmit the claim with a slightly upcoded diagnosis, e.g., Major Depression, recurrent, mild severity, 296.31, and get paid.  This uncomfortably clashes with my usual tendency to downcode slightly to protect my patient's confidentiality.  (Since pressures to upcode and downcode routinely distort the documentation of diagnoses in clinical practice, I'm skeptical of all research that uses these diagnoses to derive conclusions about psychiatric practices, disorder incidence, and the like.  Garbage in, garbage out.)

Upcoding and downcoding in such cases is not criminal mischief, but an attempt to fit traditional, mainstream psychiatry into a procrustean bed of medical-model diagnosis and procedure coding.  Public and private insurers alike sacrifice ecological validity for documentation that appears, but really isn't, "evidence based."  To take one example, as of this year we must code medication "evaluation and management" separately from the provision of psychotherapy, even if in practice these are done simultaneously and inseparably.  A 50-minute psychotherapy session (90836) that includes brief attention to medication (99212) is reimbursed at a much lower rate than the same 50-minute session with more time devoted to meds (99213 or 99214).  This makes little sense when in many cases the psychotherapy is far more clinically significant than the medications being discussed.  (You'll note that I think of the psychotherapy code first, but actually it is an add-on to the primary medication "E & M" code.)  If medications are not mentioned or evaluated at all, there is yet another code to use for psychotherapy (90834), with an "allowed fee" of $89 for 50 minutes, well below what any psychiatrist or psychologist actually charges.  If this isn't bewildering enough, some of my colleagues are now doing 52-minute sessions, an insignificant increase in duration that qualifies for a different code with much higher reimbursement.

Since cash-only practice excludes all but the affluent, I view my taking Medicare as a modest concession to avoid elitism.  I also support a single-payer health care system, also known as "Medicare for all," so participating in Medicare feels like practicing what I preach.  At the same time, it's easy to see why most of my office-based colleagues opt out of Medicare: lower pay for more paperwork, rules that don't make sense, and various factors that make dynamic psychotherapy harder to conduct and be paid for.  So far I still answer yes, albeit hesitantly, when asked whether I take Medicare.  In my next post I'll expand these ideas into private insurance for outpatient psychiatry, including whether dynamic psychotherapy resembles a medical intervention enough to fit a "medical necessity" model.

Going to the APA meeting?

The annual meeting of the American Psychiatric Association (APA) is in San Francisco this May.  I've attended twice before as I recall, both times when it was here.  I enjoyed it, and even felt it was worth the $1000 we non-members pay to get in, although in my opinion it's not worth doubling that for airfare and lodging to attend in another city.  The presentations were generally of high quality, and so plentiful that I always found something worthwhile to attend.  Up to 50 CME (continuing medical education) hours are available over five days, enough to maintain a California medical license for two years.  This year, in addition to the other presentations, the new DSM-5 will be unveiled and discussed, so we can anticipate hearing a lot that is new and essential for clinical practice.  Bill Clinton will give the keynote speech. Yet it's a hard decision for me to attend this meeting.  The APA and its annual meeting reflect aspects of psychiatry that concern me.  In 2006 the drug industry accounted for about 30 percent of APA's $62.5 million in financing, half through drug advertisements in its journals and meeting exhibits, and the other half sponsoring fellowships, conferences, and industry symposia at the annual meeting.  Every year the annual meeting features a huge exhibit hall of lavish booths courtesy of the pharmaceutical industry.  In past years I watched my fellow psychiatrists line up for branded coffee mugs and similar swag; although voluntary restrictions by the Pharmaceutical Research and Manufacturers of America (PhRMA) in recent years have curtailed this, the APA itself welcomes such giveaways according to this year's information sheet for exhibitors.  This year there are industry sponsored "Product Theater" presentations most days around lunchtime (six sessions total, up to 250 attendees per session), and "Therapeutic Update" meetings at dinnertime (three two-hour sessions) — pure marketing vehicles that are not approved for CME, that lack any pretense of scientific balance or neutrality, and that come with a nice free meal to tickle the limbic systems of the recipients.  In fact, there's a surprisingly wide range of promotional and marketing opportunities at the meeting (pdf here) that the APA sells to industry.  We participants may sign up for the scientific presentations and collegiality, but the APA invites us for the millions of dollars we bring in.

Of course, individual attendees aren't forced to take a seat at a "Therapeutic Update" and may never set foot in the exhibit hall.  So what's the problem?  Can't attendees enjoy an educational experience free of commercial influence?  Unfortunately, with APA selling everything from sponsored wi-fi, to plasma-screen billboard space, to branded do-not-disturb signs at the hotel, the industry flavor will be hard to miss.  Registrants are warned that our names, titles, mailing addresses, and email addresses will be "shared" (i.e., sold) to meeting exhibitors.  Perhaps there's an unpublicized opt-out I'm not aware of.

Whatever one thinks of this blizzard of advertising to a highly selected, captive audience of over 10,000 psychiatrists, it hardly needs to be said that the practice of psychotherapy will have no deep-pocketed sponsorship; healthy nutrition, exercise, lifestyle balance, and introspection will enjoy no "Product Theater" or "Therapeutic Update."  If this year's meeting resembles those I attended in the past, many presenters will mention the importance of psychosocial factors in mental health, and, if one seeks them out, there will be talks by some of the luminaries in trauma research and psychological treatments.  But this will be in the context of blaring signs promoting the newest antidepressant, mood stabilizer, and anti-psychotic — which nowadays may all be the same product — and a zeitgeist of DSM diagnoses leading to pharmaceutical remedies.

Speaking of DSM, the unveiling of DSM-5 ought to be interesting.  DSM diagnosis is an integral part of most mental health (not just psychiatric) practice, as treatment authorization and reimbursement by health plans often hinge on the DSM disorder for which the patient "meets criteria."  Both the process of creating the new DSM-5 and its conclusions have come under repeated attack from a range of reputable critics, including the chair of the DSM-IV Task Force Dr. Allen Frances, Division 32 of the American Psychological Association (the "other" APA), the British Psychological Society, the American Counseling Association, and others.  One common criticism is that diagnostic categories are being loosened (or widened), such that more patents will meet criteria for a mental disorder, and in turn more psychiatric medications will be prescribed.  Dr. Frances charges that the APA treats publication of DSM-5 as a "cash cow," citing the hefty cost ($199 hardcover, $149 paperback) of this instant and inevitable best-seller.  My own feelings about the DSM are mixed, and I'm curious to see how the newest edition turned out, particularly the section on personality disorders.

Despite my concern about undue commercial influence, misplaced priorities, and its controversial diagnostic manual, I plan to go to the APA meeting this year.  There's too much of value to me in all those presentations.  But when I pass the anti-psychiatry protesters at the entrance, I know I will wish for some way to declare myself neither anti-psychiatry nor, despite appearances, in full agreement with the spectacle within.