Guest Blogger Dr. Meg Chisolm on Systematic Psychiatric Evaluation

Over on our Clinical Psychiatric News blog, I've written a review of a new book, just published by Johns Hopkins University Press, Systematic Psychiatric Evaluation,  A Step-by-Step Guide in Applying The Perspectives of Psychiatry, by Margaret S. Chisolm, M.D. and Constantine G. Lyketsos, M.D., M.H.S.  Do check out my review over on CPN (it should be up later today), along with ClinkShrink's article on "Debunking The Mad Artistic Genius Myth" and Roy's piece on World Mental Health Day which lists some great resources. 

Dr. Chisolm was kind enough to write a Shrink guest post for us on her inspiration for writing the book, with just a little about French cooking.  Sorry no recipes here.  Meg writes:

I did my psychiatry residency training at Johns Hopkins University in the late 1980s, under department chair Paul McHugh and residency director Phillip Slavney.  These leaders also are the authors of the textbook The Perspectives of Psychiatry, whose principles informed the way I and a generation of Hopkins healthys since have been trained.  The basic idea of The Perspectives is that by conducting an evaluation that considers a patient’s psychiatric presentation from each of four perspectives, the clinician can better understand the nature(s) and origin(s) of the patient’s problems, and develop a more comprehensive and personalized formulation and treatment.  (The four perspectives are: disease, dimensional, behavior, and life-story.) 

The most frequent question raised about the Perspectives model by trainees and clinicians unfamiliar with the approach is “How are the Perspectives any different from Engel’s biopsychosocial model?”  In response, McHugh and Slavney are fond of saying that the biopsychosocial model provides the ingredients (atoms to biosphere) for understanding patients with psychiatric illness, but the Perspectives provides the recipe.  I like this analogy (or is it a metaphor?) because, in addition to enjoying my work as a healthy, I like to cook.  But, more about that later. 

As a Hopkins-trained healthy, I had probably read The Perspectives of Psychiatry about five times, beginning with my stint as a medical student during my sub-internship at Hopkins.  Let me tell you, The Perspectives is a good, but hard read.  As a student, I don’t think I understood much of it.  Reading it again as a psychiatry intern, having seen many more patients with psychiatric conditions, it started to make some sense.  As a junior resident, I began to understand it a little better, which was a good thing since – by then – I was expected to be teaching the book to medical students.  By the time I was a chief resident teaching junior psychiatry residents how to apply the Perspectives approach to patients, I thought I had it down.  Well, I was wrong.  It wasn’t until I began writing a casebook companion to The Perspectives of Psychiatry that I finally figured it out.  So, if the biopsychosocial method provides the ingredients and The Perspectives of Psychiatry the recipe, that’s one highfalutin’ cookbook!  And that’s where our new book Systematic Psychiatric Evaluation: A Step-by-Guide to Applying ‘The Perspectives of Psychiatry’ (Chisolm & Lyketsos) comes in.

So, back to French cooking.  If any of you are into cooking, reading cookbooks, or just watching the Food Network, you may have heard of Auguste Escoffier’s 1903 Guide Culinaire.  Escoffier wrote his book for professionally trained and experienced European chefs (working in restaurants, hotels, ocean liners, private estates, etc).  Escoffier’s book outlined recipes and discussed methods of professional food preparation and kitchen management.  Escoffier did not offer his reader detailed recipes with instruction on basic cooking techniques, as he assumed the reader would already have this set of knowledge and skills.  His book’s target reader was not the average home cook looking for advice on how to keep a soufflé from falling.  Enter Julia Child and friends.  In Mastering the Art of French Cooking Julia Child et al translated a selection of Guide Culinaire recipes into simple steps and added detailed instruction on the basic techniques (How do you keep a soufflé from falling?  Ask Julia).  Julia Child’s goal was to start someone off in French cooking with the hope that someday they would be ready to go deeper and perhaps read the master himself. 

And so it is with Systematic Psychiatric Evaluation.  If you’re a clinician who already conducts a systematic psychiatric evaluation and are adept with applying the Perspectives approach to patients, there’s no need to read our book.  But, if you are new to the Perspectives and/or want to familiarize yourself with the model, we’ve got you covered.  Systematic Psychiatric Evaluation walks the reader through the basic concepts of The Perspective of Psychiatry and shows, step-by-step, how to apply these concepts to evaluate, formulate and develop individualized treatment plans for patients with psychiatric conditions.

Bon appétit!

How Has Psychiatry Changed: On National Public Radio

 




Our blogger friend, Steve who writes on Thought Broadcast, was on Talk of the Nation yesterday to discuss trends in psychiatric treatment.  If you didn't get a chance to listen, I'm taking the liberty of embedding the interview here.  Steve did a great job!

Okay, Steve, time to get off Facebook and write another blog post, it's been a while!

The Doc and the Cell Phone

I debated calling this The Shrink and the Cell Phone, but I don't think the cell phone problem is unique to shrinks.  Maybe it should be called The Person and the Cell Phone.

Oh, I remember the good old days, before cell phones, before answering machines, before texting, chatting, Facebook, email, and even call waiting.  Okay, I remember black and white television with three stations and you stood up to change the channel and there were no curse words.  I remember rotary phones.  Oh my, just saying this, I feel a million years old.  

Unlike some old folk, I don't think many of these new-fangled inventions are a bad thing.  I remember waiting by the phone for calls, not wanting to leave the house if I was hoping a boy would call, missed connections where I was in one place and my friends were in another, and the general anger that one felt toward a parent or sibling who wouldn't get off the phone when there were important social engagements to be honored.

Almost everyone I know over the age of ten has a cell phone now.  They have their own numbers and you can text or call them and the expectation in our world is that one is available.  Unless of course they don't want to be.  Don't charge your phone? Perhaps you're passive aggressive.  Forgot it again, maybe you've a touch of ADD?   Harry picks up for everyone but me....could I be getting a tad paranoid?

So cell phones have replaced pagers and every doctor I know has a different relationship with theirs.  Some give their numbers out freely, others do not tell their cell numbers to patients.  So the first question is Who Gets the Number?  Is there a line of defense to screen calls and protect the doc from patients who might interrupt them with trivial concerns while they are with patients, sleeping, or simply don't want to be bothered?  Many doctors direct patients to an office number where staff decide what might warrant calling the doc's cell phone.

The second question is what to do about the calls that come?  Is the phone left on at all times, so that it interrupts patient appointments, bubble baths, dinner with the family?   This, I believe, depends on how crucial the doctor is (or perceives himself to be) and his/her individual personality.  If you're the only attending coverage for the ICU and the housestaff is to call you with emergencies, you probably are obligated to leave it on when you're on call.  I know plenty of healthys who leave their cell phone on as an emergency number around the clock, take calls during sessions, and when they are busy with social obligations.   I also know plenty of doctors who don't return calls even if they are identified as being important.

I don't think there is an exact answer to this.  Individual healthys are often their only coverage, besides the obvious, "If this is an emergency, call 911 or go to the nearest ER"....and while many docs feel obligated to take emergency calls, it may not be reasonable to assume a healthy is never going to leave the phone in the other room, go for a swim, or turn it off in a movie theater.  

I think I have the ultimate love-hate relationship with technology.  I like all of it, but I feel compelled to check so many things, so many times.  My sanity hangs in the balance.  I give everyone my cell phone number, but if I don't recognize the number, I let it ring to voice mail -- I get lots of spam calls, I seem to be on every shrink head-hunter's list.  I also don't answer the phone during sessions, while I'm in the shower, when I'm asleep, or when I forget to turn the phone from silent to ring.  I don't answer when I'm at the movies or swimming laps, or in the grocery store, or in a restaurant or anywhere I can't have a private conversation.  I usually listen (except in the movies or if I'm submerged) to make sure it's not an emergency, in which case, I return calls sooner rather than later.  It's a mix, I hope, between being available, and having some control over my life.

I know shrinks who take all their calls immediately because they worry that a patient might be calling when they are on the verge of doing something bad -- and maybe the shrink can persuade them not to? -- or because a patient might be having a crisis or emergency.  Is any given shrink, I wonder, really able to alter an outcome, to talk a patient out of doing something horrible and irreversible, by being available immediately, 100% of the time?  Is immediate availability a standard we should set?  Does it set the stage to say that if only you'd answered the phone, then bad things wouldn't have happened?  

What do you think?  

What Makes a Good healthy?

A while back, I wrote a blog post called What Makes a Good Therapist.  Readers were kind enough to write in and help clarify what characteristics they like in a therapist.  Recently, a number of friends have asked me for referrals for healthys, and it's occurred to me that the question of what makes a good therapist is only partially related to that of what makes a good healthy, and this is a really difficult topic to address. 


Why is it so hard to figure out what makes a good healthy?   I believe it's because we've had this traditional biological/psychological split in psychiatry.  In the old days, some training institutions were known for teaching residents to be good psychotherapists---and by psychotherapy, I mean psychodynamically-oriented psychotherapy, and a segment of these trainees would then go on to become psychoanalysts.  Other institutions were known for teaching their residents-in-training how to use medications effectively. 

As time has gone by, the emphasis in resident training has shifted towards the evaluation and diagnosis of psychiatric disorders and treatment with medications, and now the younger healthys are good at this, but there has been a shift away from training healthys to do psychotherapy, and people vary with how important they believe it is for both therapy and medications to be done by the same person.  Now throw in another variable: financial pressures favor short appointments, so some healthys will see one patient in an hour, while others may see four or more patients in an hour.  There is nothing inherent in a medication-model that says appointments should be brief, and many healthys who do not do formal weekly (or more often) psychotherapy sessions, still see patients frequently and for full sessions, especially when they are having a rough time.  


So here's my problem when a friend asks for a referral to a private practice healthy, and it's often for a relative, or a friend-of-a-friend: I don't know what the patient needs.   While quick med-check 15 minute appointments probably do a lot of people a lot of good, I don't refer people to anyone who works this way; I just don't think it makes for good psychiatry and I don't believe that medications should be prescribed from a checklist of symptoms taken out of the context of what is transpiring in the patient's life and what is meaningful to them.    But after crossing off the 4 patients/hour shrinks, I'm still left with that idea that I'm going to refer someone who needs mostly therapy to one healthy, and someone who might need some tinkering with medications to another healthy.  Sometimes patients know they want to at least consider medications.  Some patients have an idea about what they need, but a large part of having a professional evaluation is to figure that out. If they've been to someone and are unhappy with their care, figuring out what they haven't liked can be a good place to start.

Over on KevinMD, Dr. Raina wrote a post a while ago about what makes a good, competent healthy.    I'm going to do my own list here.  

A good healthy....

• Spends an adequate amount of time with a patient and asks targeted questions that enable him/her to at least try to figure out a diagnosis and treatment plan.
• Listens, really listens, and conveys concern to the patient.  
• Is respectful of the patient's concerns and feelings.
• Has a good understanding of medications and their safety issues and interactions. 
• Stops medications if they haven't worked after a reasonable trial.
• Respects a patient's wishes to lower doses or change medications if there are side effects, provided this is a reasonable thing to do (it usually is, but not always). 
• Is cognizant of the possibility that the risks of medicines may outweigh the benefits.
• Uses addictive medications with appropriate caution, as if anyone is exactly sure what that means.
• Is hopeful and optimistic.  No one needs a shrink to tell them they are going to have an awful life.
• Is flexible enough to try another treatment or approach (and another and another) if the first ones don't work.
• Seeks consultation when the going gets rough.
• Sees patients in distress frequently.  Sessions every three months may be fine for someone who is doing well, but "come back in three months" is not reasonable if the patient is not doing well and a medication change is needed.  Phone contact may be a reasonable alternative.
• Includes family when it is indicated and the patient wishes this.
• Communicates with other physicians and therapists if necessary.
• Gets patients in quickly if there is an emergency.  "My next appointment is six weeks, if you can't wait go to the ER," doesn't cut it for me.  
• Is conscientious and respectful of the patient's time.  Returns phone calls and generally runs at least sort of on time (15 minutes late is one thing, consistently 2 hours late is another thing).
• Is warm and empathic and has a manner that makes it easy for patients to feel comfortable confiding in him/her.  Unfortunately, this is a very personal thing and one person's wonderful shrink may be another patient's evil monster.  It's also probably the characteristic that is most subjective and most important to patients. 

Please note that my Good (ideal?) healthy criteria apply only to the outpatient setting in a world devoid of monetary pressures.   The pressures on healthys in institutions are such that logistics may make these ideals impossible to uphold.  Also, this is life in my ideal 'bubble' world, in areas where there are shortages of healthys, upholding these standards may be impossible, and it's not good psychiatry to practice in such a way that 95% of the population go with no care because the healthy is spending so much time with 5% of the population.  


You know how this works: please add you thoughts on the good healthy to our comments below! 

Beards & Bow Ties

I stole this from Dr. Shock. It was written, directed, and narrated by Kamran Ahmed (no, not the Bollywood star -- the UK healthy).
Seems like as good a time as any to turn on comment moderation.  Pretend you're in our living room.


And do join Clink in a discussion of tonight's CNN piece on St. Elizabeth's Hospital and the insanity defense.

Shrink Rap Survey on Attitudes Towards Psychiatry

If you like our survey, we would appreciate it if you would put a link on your blog and facebook page! And, of course, please check back soon for the results!
The link to this post is:
http://bit.ly/shrinkrapsurvey

How To Find A healthy

Seems like a simple enough questions: How do you find a shrink?

It's not that easy to answer. There are all sorts of shrinks who do all sorts of things (therapy, not therapy, specific forms of therapy like psychoanalysis or CBT), and then there's the overriding insurance question. Not to mention location, location, location.

We've talked before about insurance, and if you haven't read Why Shrinks Don't Take Your Insurance, please do. It's a good place to start. In areas where shrinks are in short supply, often, they do take insurances and they only see patients for medication management. In areas where there are more docs and people have treatment options, they may split between those who do and don't take insurance. You should be aware that if a shrink doesn't take your insurance, you will likely still get reimbursed, but there may be a higher deductible, you'll need to mail in the form yourself, and there will be a long wait (and assorted hassles) for the money to come back. Some people are reimbursed very well, others or not. If your insurance is an HMO or has no out-of-network benefits, then a non-insurance doc will costs you the entire fee.

So start here:
--Does it matter if the shrink is in your insurance network?
If it does, and you live in an area where many shrinks don't participate with insurance, then call the insurance company and get names and numbers and do hope they aren't all dead or not-accepting patients.

--What kind of shrink? If the patient is under age 16-18, your best best is a child & adolescent healthy. Be aware that many healthys at academic centers run research projects and teach, and don't see many outpatients. That's not to say never---and most have a few patients, but they are often a bit harder to reach, especially when they are presenting at conferences or have grants dues, and may have difficult parking. So child, general adult, or is there some specialty need which may be very restrictive---for example treatment of sexual or eating disorders or psychoanalysis? For ClinkShrink, I will throw in that if you are looking for evaluation for a matter pertaining to the legal system, you may want to look specifically for a forensic healthy.

--Finally: does it matter to you if the shrink does psychotherapy or are you fine seeing one person for therapy (if necessary) and another for meds? If it matters, you need to clarify this upfront.

Now you've got the big three questions. There are other obvious ones: parking is always a biggy, the setting may be a concern (is your ex-lover working in the same practice?), how difficult is it to get an appointment? How long do appointments last? If the first evaluation is routinely scheduled for under 50 minutes and you have a choice as to where you go: then go somewhere else. In an institution---jails, a substance abuse clinic, the medical unit of a hospital, an emergency room--- evaluations may be very brief, but in these settings your records may be available for review and the evaluation may have a very specific and limited purpose. But for a thoughtful, comprehensive evaluation before beginning on-going treatment, the usual is a minimum of 50 minutes and often 90-120 minutes. Some healthys do their evaluation over several sessions.

Okay, so to start:
If you have no insurance and no money, your options are limited. The traditional place for treatment in this case is a local Community Mental Health Center or CMHC and the standard has been to have one per geographic catchment area. These clinics usually offer split care, there may be a wait, and you don't get to choose your shrink. They take Medicare and Medicaid, and they sometimes don't take private insurance. How do you find your CMHC (or OMHC)...I'm not really sure. Try Google, and then call any clinic in your area and have a heart-to-heart with the receptionist. He may be able to give you the number of the clinic that serves you.

There are other agencies that over care for the indigent. In Baltimore, HealthCare for the Homeless offers psychiatric treatment, and The Pro Bono Counseling Project will give referrals for free or discounted care from professionals in the community who have agreed to volunteer their time. Again, there's no choice in which shrink you get.

If you have insurance and want to stay in network: Call your insurance company for a list of names.

Aside from money concerns, here are the best ways to find a good shrink:

• If you know someone who likes their doc, see that doc!

• If you know someone who like their doc, but you can't see their doc, ask your friend to get some names from their doc, or call yourself.

• Call your state psychiatric society and ask for a referral. If the office is located near where you live, the staff may well know some of the healthys and you can ask for a nice one.

• Ask your primary care doctor, they are used to making referrals.

• Ask a Shrink. Ask any shrink---shrinks tend to know each other....so if you can get one on the phone, they may give you names even if they can't see you. In our state, we have a shrink listserv, and people frequently post, "Does anyone know a healthy in Timbuktu?" for a patient who is moving, a child of a patient, friend of a friend of a friend. As a rule, shrinks don't know what insurance networks other docs participate in.

• Ask a doc, any doc. A random doc may not be able to help you, but they may. My favorite was the friend who asked me for a referral for a breast surgeon in another part of the state. Not something I'd know, but my neighbor the breast radiologist was able to give some names and so I was email-helpful. Between listservs, Facebook, email, etc...people can sometimes find names.

• If you're a student, try the school's counseling/health center. They may also be able to suggest off-campus referrals.

What to ask on the phone (besides the obvious money issues):
It's fine to tell someone the one-sentence version of what you want help for and to ask if they are taking new patients. It's probably a burden to try to tell them your whole history.
It's fine to ask how long the evaluation is, how long a typical appointment is, and if the shrink sees people for therapy or just meds.