Lockup Doc

Those with mental health and substance abuse problems have long faced discrimination from third-party payers. Payment for such conditions has typically been handled differently from “physical” health problems.

A news release today from the U.S. Department of Health and Human Services today explains that the Obama Administration has issued new rules that will require parity in the treatment of mental health and substance use disorders. Read more…

Imagine that as a child you thought you had been born in the body of the wrong gender. If you were biologically male, in your mind you really thought of yourself as female. Likewise, if you were born in a girl’s body, you thought that you were actually a boy.

Yes, you were probably more interested in children’s role-playing games more often associated with the opposite gender as well, but the issue went much deeper than that. It was your core identity that was at stake. You knew that you were the other sex, at least in all ways except for the reproductive organs of your body.

You felt this way during childhood, but nobody seemed to understand or accept this about you.  But you were dressed in the clothing of your biological gender and expected to participate in the activities stereotypically associated with it as well. Imagine that as your body matured in adolescence, you hated your Read more…

Physicians learn a lot about many different topics, both in medical training and in practice. However, there are some life lessons that we never learn as well as when we become patients ourselves.

When I was 13 or 14 years old, I regularly interacted with 2 different physicians with disparate interpersonal styles. Little did I know then that these seemingly meaningless encounters would indelibly shape my own beliefs about how people should treat each other. Ironically, many years later the experiences would help guide me as a physician in my interactions with my own patients.

For a couple of years I was the regular patient of a dermatology clinic. Two dermatologists ran the practice together, and in order for me to get an appointment that worked with my family’s schedule, occasionally I would need to alternate seeing each of them. I’ll refer to one of them as “Dr. A” and the other as “Dr. F.”

I was somewhat shy as an adolescent, and sitting in an exam room wearing only a gown and underwear always made me a little anxious.

However, any unease I may have experienced evaporated when Read more…

As a psychiatrist who has now been practicing for over a decade, I think back to the days of residency and fellowship and realize how much my approach to prescribing benzodiazepines has changed.

One of the key faculty members in my psychiatry residency program was considered an expert in treating anxiety disorders. He was very liberal with his prescription of benzodiazepines, the anti-anxiety class of medications including diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax) and others.

Having no other frame of reference, I naively adopted his unsparing prescription-writing habit of these not-so-benign medications. I unquestioningly steered down this path for the first couple years of my post-training practice.

Then I had the good fortune of working with a very competent group of experienced psychiatrists who were in full-time clinical practice. Regularly collaborating on cases with them helped to initiate my transformation to more conservative, and in my opinion, more appropriate,  prescribing habits.

My prescription style inevitably evolved further when Read more…

The American Journal of Psychiatry published an article this month entitled, “Association of Poor Childhood Fear Conditioning and Adult Crime.” I found it very interesting. Most previous studies looking at young children and whether they later became criminals have examined psychosocial factors of childhood, not neurodevelopmental ones as this one did.

Researchers assessed the fear response of 1,795 children at age 3. A shrill sound was administered, and the sweating response (indicating a fear reaction) was measured. Twenty years later, using court records, the researchers tracked down 137 of the study participants who had committed serious crimes. The young criminals had shown an absence of fear at age 3 whereas 274 non-criminal study participants had shown normal fear reactions.

Although a definite cause-and-effect relationship of the lack of fear in childhood and the later development of criminality cannot be made, this study does provide additional evidence that abnormal brain development puts children at risk of later criminal behavior.

So, other than this academic point, why does this matter? Read more…

Many non-correctional health care providers will also treat inmates from time to time. This may occur in the office or hospital. How can one best approach the challenges of working with the incarcerated in order to deliver the best possible care while simultaneously managing risk?

1. Treat the patient with respect. Not submissive respect, but mutual respect — the way we all want to be treated. I believe that this principle alone goes a long way towards helping one to establish a therapeutic alliance and to minimize interpersonal conflict and hostility. Inmates are people, too. Those who do not agree with this statement should steer clear of treating them.

2. Listen attentively. It may be tempting to get this shackled person (who you may secretly be embarrassed to have in your office) out as expediently as possible. Squelch that temptation, and listen actively as you would to any patient. All patients want their concerns taken seriously. Inmates are no exception. I believe you minimize problems for yourself in the long run (and provide better care) if you ensure that  patients’ concerns are heard, especially if they seem to have more challenging personality styles.

3. Be honest. If there is a particular reason why you think something the patient is requesting is inappropriate, then politely tell them so. If you believe they have a particular diagnosis, psychiatric or not, then Read more…

Dr. Rapheal Fraser, a psychiatrist from Australia, rocks out in this awesome “Shred This Too” clip of less than 2 minutes. He also has a website, Music, Medicine, and the Mind. I love seeing the non-medical passions of colleagues. Thanks for dispelling the boring or uptight psychiatrist stereotypes! Awesome!

The Archives of  General Psychiatry published an article this month entitled, “Metabolic Testing Rates in 3 State Medicaid Programs After FDA Warnings and ADA/APA Recommendations for Second-Generation Antipsychotic Drugs.”

The retrospective analysis examines how frequently the recommended metabolic testing for second generation antipsychotic drugs (SGA’s) was performed in Medicaid patients in 3 different states. The conclusion was that the monitoring was not being done nearly as frequently as recommended. Less than one-third of patients treated with these medications, which can cause metabolic syndrome,  undergo serum glucose or lipid monitoring.

Obviously this is not good news. In recent years, we’ve learned that the risks associated with SGA’s is higher than originally thought. My intent in this post, though, is not to focus on this study itself as much as to examine an ethical dilemma related to it that I have never heard discussed.

What I’ve been wondering: Is it ever appropriate to prescribe SGA’s to severely mentally ill patients who have no financial means to obtain the necessary blood monitoring tests? I’ll explain. Read more…

At Dr. Rich’s The Covert Rationing Blog.

The Holidays may be over, but there’s no rest for Santa or his cute little Congressional elves. So, after a respite that must have seemed all too brief, Santa has herded his diminutive (but ever-cheerful!) drudges right back into their Secret Workshop, to finish building for us kids the Healthcare We Can All Believe In.

DrRich, for one, can hardly wait to unwrap it…

It’s very cleverly done – one of the best Grand Rounds I’ve seen! Be sure to check it out.