Dollars for Docs

I apologize to my loyal readers for not posting in a long while.  Fortunately, I was awakened from my torpor by an eye-opening new database that lists some of the money paid to specific doctors by pharmaceutical companies.  The Pulitzer Prize winning investigative journalists at ProPublica tapped the public disclosures of seven companies that have begun posting names and compensation on the internet, some as the result of legal settlements.  ProPublica's "Dollars for Docs" provides both an overview of the issue, as well as a handy database search function.  It is easy to look up specific doctors, or (as I did)  to scan through a whole city or town to see who received money from these seven companies in the past two years. Some caveats are important.  First, the seven companies represent just over a third of all pharmaceutical sales in the U.S.  The health care reform law, signed in March, mandates that all drug companies report such data to the federal government beginning in 2013. That information will be posted on a government website.  So, this is a preview of the data to come.  Research funding is not included here, only speaking, consulting, and related activities.  It is also important to keep in mind that listed payments are not automatically unethical or illegitimate.  For example, honest consulting relationships between doctors and drug companies reasonably include travel expenses and a consulting fee.

Nonetheless, most of the listed activity is pretty suspect.  I first learned about "Dollars for Docs" from Dan Carlat's blog.  As Carlat points out: "The vast majority of payments are for doctors who give 'educational' talks to other doctors, presumably focusing on one of the drugs made by the funding company."  And as he notes, the sheer enormity of the database is probably its most striking aspect — published surveys show that well over 100,000 doctors receive cash from drug companies.  Most of the amounts in the database are small, up to a few thousand dollars, not much compared to the income of most doctors.  But some are considerably higher.  My eye-opening experience was to scan the list of San Francisco doctors, where I found a few colleagues I know who added tens of thousands to their income in 2009 and 2010 speaking for drug companies.  It makes me think differently about those doctors — which is the point, right?

Supporters of the status quo argue that there are many other potential conflicts of interest, and that not all recipients of industry money are necessarily biased.  Both of these points are true, but irrelevant.  Money is universally recognized as motivating; that's why people are paid to work.  A universally recognized motivation, voluntarily chosen and standing here in plausible conflict with unbiased patient care, should be unacceptable from the perspective of medical ethics.  Medical ethics does not stop with financial conflicts of interest.  Physicians are prohibited from sexual relations with patients for similar reasons: A sexual motivation is very likely (although not absolutely guaranteed) to conflict with clinical care.  Other systematic sources of bias will be addressed when they can be identified and controlled.  The fact that we can't minimize all sources of bias is not a compelling reason to ignore obvious financial ones.

When comprehensive numbers are available online in 2013, we will finally have meaningful disclosure about this potential conflict of interest.  What we as a profession, or as the public, do with these disclosures is another matter.  As I've noted before, the public seems more concerned than the medical profession itself about industry-fueled bias.  To that end, patients may begin to use such public databases as a means to choose doctors.  The website of the newly formed Association for Medical Ethics features a searchable database similar to "Dollars for Docs" but with a more explicit message: that accepting industry support is unethical in clinical practice.  If this idea catches on — and I suspect it will, at least in some areas — speaking and consulting fees will not be the only financial motivation at play here.

Psychiatric holds and refusal of medical treatment

I apologize for the stagnant blog of late.  I've been working on an idea or two that hasn't jelled yet.  Meanwhile, I ran across a familiar yet troubling occurrence the other day: The use of a psychiatric hold on an inpatient with no psychiatric disorder but who was refusing life-saving medical treatment. My comments are limited to California, as each state has its own laws about psychiatric holds, a.k.a. involuntary civil commitment.  The Lanterman-Petris-Short (LPS) Act, signed into law by Governor Ronald Reagan in 1969, made California the first state to employ a "dangerousness" standard to justify psychiatric holds.  Prior to this, mental patients were generally committed on the basis of "need for treatment."

Dangerousness is defined in the LPS law as danger to self (usually interpreted as intentional self-harm or suicide risk, not mere recklessness), danger to others, or grave disability (inability to provide for one's own food, clothing, or shelter).  For LPS provisions to apply at all, the alleged dangerousness must be the result of a mental disorder or chronic alcoholism.  The LPS Act is part of the state Welfare and Institutions Code, sections 5000 and following.  The initial 72-hour hold in California is called a "5150" as it is authorized in section 5150 of the WIC.  Here is a brief history of California mental health law.

Virtually all other states adopted psychiatric commitment laws similarly based on dangerousness after the US Supreme Court ruled in O’Connor v. Donaldson, 422 U.S. 563 (1975) that, "There is...no constitutional basis for confining such persons involuntarily if they are dangerous to no one."

Let's turn now to a non-psychiatric setting, the general medical-surgical hospital.  Some hospitalized patients cannot make informed medical choices, or they may express unpopular, "crazy" opinions.  At one extreme are patients who arrive unconscious and cannot express a choice at all.  In the typical emergency situation, doctors and nurses reasonably assume such a patient wants to receive lifesaving treatment, and proceed accordingly.   Other patients may be delirious, in great pain, or suffering from a brain injury or stroke.  They may express preferences that make no sense to the medical professionals, choices that seem "crazy."  (Questions about decision-making capacity almost never arise when the patient agrees with the doctor, only when there is disagreement.)

These situations have nothing to do with psychiatric illness.  It is well recognized that some patients lack the capacity to make medical decisions while in the throes of severe illness or injury.   As with the unconscious patient, lifesaving treatment proceeds with assumed consent.  No one lets a confused delirious patient stagger out of the hospital just because he lurches blindly in that direction.

More challenging ethical dilemmas arise when a refusing patient is simply uneducated or from another culture.  When I was a medical intern, I saw an elderly Filipino man with intestinal bleeding.  He had never been seriously sick before, and did not understand Western medicine.  He refused blood transfusion on the theory that "the more you put in, the more will leak out."  The senior medical resident requested a psychiatry consult to declare the man incompetent to make such decisions.  (This was a mistake, as I'll explain shortly.)   He then received transfusions against his will.  Soon thereafter the patient refused surgery needed to stop the bleeding.  The surgeon proclaimed he would never operate on an unwilling patient — but in an odd twist, when the patient lapsed into unconsciousness, he was "no longer objecting" and the surgery proceeded.  The patient died in the post-surgical ICU, never having regained consciousness.

This sad case highlights a few important points I'll just touch on here.  First, assessment of medical decision-making capacity is not a special skill of psychiatrists.  All physicians are supposed to do this routinely (albeit usually implicitly).  Internists need to know whether their patients can give informed consent for medical treatments, and surgeons should likewise assess the capacity of their patients to consent to surgery.  "Competence" is an overarching legal status decided by a court, not by medical or psychiatric assessment alone.  Perhaps the most obvious point: Once a patient's consent or refusal is considered valid, its ethical force doesn't diminish when the patient falls asleep or lapses into unconsciousness.

Now, how does the "5150" apply in the non-psychiatric hospital setting?  Hardly at all.  Patients with severe mental illness are sometimes hospitalized for unrelated conditions, and occasionally meet dangerousness criteria for a 5150 hold while receiving medical treatment.  But the more common situation is the misuse of the "5150" to prevent an apparently lucid patient from refusing lifesaving medical or surgical treatment and leaving the hospital.  This is startlingly common — it startles me, anyway — and happened just the other day at my hospital.

It should be obvious why the 5150 cannot be used this way.  First, it only applies to a situation in which a mental disorder or chronic alcoholism leads to dangerous behavior.  Second, refusal of lifesaving medical treatment is not "danger to self" as the law is normally understood.  Third, even a legitimate 5150 hold only compels three days of psychiatric evaluation and protective custody; it says nothing about forcing medical or surgical (or even psychiatric) treatment on anyone.

The solution is for physicians to assess the medical decision-making capacity of their own patients.  Where available, a hospital ethics consult can clarify the relevant issues, but this is usually optional.  Patients who possess medical decision-making capacity have the right to refuse treatment and to leave the hospital if they wish, even if they die as a result.  Those who lack such capacity can be treated, like the comatose or delirious patient, with assumed consent.  However, a superior court determination of incompetence to make medical decisions is required to force non-emergency medical or surgical treatment.  LPS law is silent on these matters.

Carlat on mindless psychiatrists

My fellow psychiatrist and blogger Dr. Daniel Carlat has an article in this weekend's New York Times Magazine.  "Mind Over Meds" is a memoir of Dr. Carlat's growing realization that psychiatry can't be done well in 15-20 minute medication visits, that talking to patients as people is important too. I'm generally a fan of Dr. Carlat.  His blog is one of the few listed on my blogroll (the short list of links over there on the right of this page).  He writes well, and I share his skeptical attitude toward overzealous promotion of psychiatric drugs to our profession and the public.  "Mind Over Meds" is a good article: Carlat reviews the swing from the "brainless" psychiatry of early 20th-century psychoanalysts, to the "mindless" psychiatry of today, where symptoms are treated with medications and the patient may be lost in the process.

This is all on target, and I appreciate how Dr. Carlat is willing repeatedly to make it personal and write about revisions in his own thinking — as he did in this prior NY Times Magazine article, also well worth reading.  The gist is that psychiatry has painted itself into a corner by limiting itself largely to psychopharmacology, i.e., medications, and ceding psychotherapy — understanding the patient as a person — to other mental health professionals.

Unfortunately, "Mind Over Meds" goes off the rails in two ways.  The less important is a passage that I have to believe is just badly worded, as it seems to denigrate psychologists and other non-psychiatric therapists:

Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.

A couple of early commenters have already chided Dr. Carlat for this "mental health hierarchy" language.  Discussing whether mental health professionals constitute a hierarchy is beyond my scope here, but I believe Dr. Carlat is well aware that the expertise of many psychologists (for example) to do psychotherapy surpasses his own.  In fact, he has recently taken a contrarian position in favor of granting psychologists prescribing privileges.  I doubt he meant this talk of hierarchy as a putdown, but he should have been more clear.

The bigger gaffe is that the article ultimately calls for psychiatrists to do "some sort of psychotherapy... when our patients need more from us than just medication."  Dr. Carlat seems to be satisfied with a little support here, a few extra minutes of listening there.  However, that isn't psychotherapy except in the most meaningless, hand-waving sense.  That is just listening to one's patients, something every doctor should do, from dermatologists to orthopedic surgeons.  I hate to say it, but it's no wonder health plans won't pay for that.  It used to be part of the job, not something extra.

Psychiatrists have a lot more going on than mere doctor-patient rapport — or at least we used to.  Even psychiatrists who choose not to conduct psychodynamic therapy still learned, or should have learned, about psychodynamics, an intellectual and historical cornerstone of our field.  A psychiatrist's work needs to be psychodynamically informed even if he or she only prescribes medication.  As the most obvious example, a dynamic understanding may shed light on a patient's medication non-compliance and help to address it.  Even better, a dynamic understanding of the patient may obviate the need for medications at all.  (To those who argue that psychodynamics has been supplanted by cognitive-behavioral therapies, I note that Dr. Aaron Beck, the founder of cognitive therapy, was a psychoanalyst first.  Even cognitive therapy works better if it is conducted by a psychodynamically informed therapist.)

Dr. Carlat should have gone farther.  Psychiatry needs to retake the position that we strive to understand and heal the mind from the molecule on up  (a position taken by Freud, among many others).  It is true that this encompasses a dauntingly wide spectrum, from psychopharmacology to psychological treatment, and beyond that to social and cultural influences.  As physicians we are the only mental health discipline with the training to appreciate the whole span; other professions, like clinical psychology, may have more in-depth knowledge and treatment skills regarding a particular part of this spectrum.  Of course, any given psychiatrist may choose not to practice at all of these levels — probably cannot, given the sweeping range.  But it is the essence of psychiatry to know about the full spectrum, and either offer whatever treatment is needed at any level, or refer the patient to a professional who can provide it.

It is necessary but not sufficient to see a patient behind the symptoms, to listen.  It is also incumbent on psychiatrists to conduct real psychotherapy, dynamic or otherwise, when sitting with a patient for 50 minutes and charging for it.  Ceding "real" therapy to others has diminished our field and has turned most psychiatrists into technicians.  "Mind Over Meds" is the right title for a much deeper topic.

CME in California

Last weekend I attended the annual one-day conference for providers of continuing medical education (CME) in California. Presented in Sacramento this year by the Institute for Medical Quality (IMQ), a division of the California Medical Association, there were talks on documentation requirements and updated accreditation criteria. There was praise and support for the majority of those attending, the office staff who organize much of the CME offered in the state.

I was there as chair of my hospital's CME Committee, a position I've held since January. While my primary concern is commercial bias in CME, the conference highlighted two other areas of potential controversy I thought I'd share here as well.

Regarding industry bias, there is good news and bad news. The good is that overt bias is explicitly and increasingly monitored. There are regulations at both state and national levels to maintain a wall of separation between industry funding sources and the content of CME presentations. Physician audiences evaluate each CME offering and are asked whether any bias was present. Thanks to media attention and official pronouncements, the issue is now on everyone's mind. At last it seems reasonable to hope that bald-faced marketing pitches in the guise of balanced CME are on their way out, at least in academic settings.

The bad news is that CME is not provided only in academic settings. "Medical education communication companies" (MECCs) are private entities that host about 40% of all CME accredited by ACCME, using funds mostly from drug companies. As described in the PharmaLive blog, "Most MECCs were simply spun off from advertising and marketing agencies doing business with pharmaceutical companies." Psychiatrist-blogger Daniel Carlat calls this arrangement "money laundering"; the fairness of this characterization hinges on whether the MECC itself allows its funding to influence its message. While I imagine MECCs run the gamut from earnest educators to crass money launderers, I confess to some cynicism after having experienced first-hand a public relations firm showcasing a Wyeth drug pitch in the guise of a public education event.

More subtle biases continue to slip under the radar as well. New products are welcome topics for CME, while older products, perhaps equally effective, are not. Prescription medications heavily advertised to the public — all new, relatively expensive, and not available generically — require CME introductions, so that doctors have an intelligent response when patients obey the advertising pitch and "ask their doctor" about them. Since physicians themselves seek education about new products, truly unbiased CME at this level seems an ideal not easily reached in real life.

Another topic discussed at the IMQ conference was a 2006 California law that requires all CME in the state to include "cultural and linguistic competency" (CLC) as part of the presentation. This CLC requirement aims to incorporate information regarding "health disparities" in all ongoing medical education. The basic idea is that language, economic, and cultural barriers have health consequences, and that it ought to be part of every California doctor's training to know about them, and how they apply in every clinical situation. I'm sure the legislation was well-intended, and I agree CLC warrants special focus in medical education.

The problem is force-fitting CLC into every CME presentation. Many CME speakers have an area of research or clinical expertise, which is why they were chosen to speak in the first place. Most are not experts on CLC issues, but in deference to state law they need to cover (or pay lip-service to) this anyway. Instead of making speakers talk about something they lack expertise in, a better alternative would be to require a certain number of CME hours specifically devoted to CLC for annual re-licensing. Then CLC could be presented by CLC experts, and be given the attention and focus it deserves.

Perhaps the most interesting thing I experienced at the IMQ conference was the way "improving patient care" constituted the unquestionable goal of CME. Certainly it is a hard rationale to argue with. After all, medical practice as a whole is aimed toward patient care. It also lends itself to empirical validation: Did physician practices change, and ideally did patient outcomes improve, as a result of a given educational experience? I do agree that the goal of the great majority of CME should be to improve patient care.

However, physicians are not mere technicians. I have attended CME talks on psychiatric practices in other countries. I would be hard pressed to say how this changes my care of patients here, but it still seems valuable for me to know. I have attended CME on standards of care in medical areas other than psychiatry, areas I will never practice myself. I can easily imagine valuable CME that reviews public perceptions of controversial area of medicine both psychiatric and non-psychiatric, cosmetic surgery for instance, that would have no effect on patient care per se. Each of these examples rounds out the education of physician-learners in important but intangible ways. Unless the profession and the public are content with medical "training" as opposed to education, the focus of CME should in my opinion span a somewhat wider domain.

Ironically, the IMQ conference itself awarded me 5.5 hours of CME credit for attending, and yet nothing presented will "improve patient care" in any direct sense. It was still valuable, and I am glad I attended.

NY Times roundup

Here are three recent New York Times articles that caught my eye. On March 13th, Tara Parker-Pope's health blog "Well" reprinted "The 12 Most Annoying Habits of Therapists." Actually, the list comes from PsychCentral, a blog written by psychologist John M. Grohol, and in my opinion reads better there. I won't list all 12 habits — you can look for yourself — but they include starting sessions late, eating in session, falling asleep, and so forth. The voluminous comments on both blogs relate the sad state of so much therapy out there, including professional lapses far worse than the listed 12. I plan to use the blog post itself, and some of the commentary, as a teaching handout when I lead a psychotherapy seminar later this year. Even beginning therapists should not make these mistakes. Speaking of psychiatry training, on March 16th, psychiatrist Richard A. Friedman M.D. wrote about a growing lack of confidence in psychiatry residents, citing their inability to make clinical decisions in routine cases, e.g., when to hospitalize or medicate patients. He blames faculty over-concern:

The fault, I believe, lies with medical educators like me. In the pursuit of patient safety, we have deliberately prevented residents from acting independently on their own judgment in situations where a patient poses a theoretical risk.

I share his concern to this point. I encounter resident insecurity much more often than overconfidence. I also agree that one reason for this may be a medical culture that increasingly recognizes a single right (or safe) way to proceed; independent judgment is discouraged.

But Friedman then goes on to blame "a series of reforms that began in the 1980s with limits on residents’ work hours." The current limits set by ACGME include an 80-hour workweek with a maximum shift of 30 hours. Friedman apparently feels such a schedule lacks "ample opportunity to stand on your own — and risk making a mistake."

I beg to differ. Sleep deprivation is not a teaching tool. There is no evidence it trains anyone to make decisions with more accuracy or confidence, although it is often justified this way post-hoc. Conflating confidence-building with hazing oversimplifies a complex issue. We don't need to toughen up residents, we need to help them make confident decisions. Two different things.

Besides, psychiatry residents generally worked fewer hours than residents of other specialties even before the ACGME limits. In other words, the recent limits have had less effect in psychiatry than in specialties such as surgery or ob-gyn. Could it be that psychiatry pays a bit more attention to how people think, feel, and learn, and therefore we were ahead of the curve?

And speaking of being ahead of the curve, today the Times reported that the American Psychiatric Association is ending industry-financed medical seminars at its annual meeting. President Nada L. Stotland, M.D. said the APA was not aware of any other organization that had made a similar decision on seminar sponsorship. Perhaps we psychiatrists will start a trend in medicine. (Neither the article nor the APA website says whether this change will occur in time for the annual meeting held here in San Francisco this May. I imagine not.)

I confess that I attended one of these seminars when the huge APA meeting was in San Francisco some years ago. Normally I avoid all industry largesse, but I was curious and justified it as research. Ironically, although it was lavishly catered and slickly presented, it was perhaps the least biased industry-sponsored talk I've ever heard. The smaller local ones are much worse in my experience, presumably because the level of scrutiny is so much higher at the annual meeting. There is press coverage, for example.

In any event, this is the right direction for psychiatry and medicine in general. But speaking of press coverage, I am curious about one detail. The Times, as well as Reuters, reported the APA policy change today, yet blogger Daniel Carlat M.D. scooped them by almost a week. Do official news agencies wait for press releases, while bloggers do the real investigative reporting?