Podcast Number 53: In Which We Teach Dinah How to Edit and Post the Podcasts
Roy and ClinkShrink are the tinkering Geeks, and finally, they are teaching Dinah to edit and post the podcasts. Roy has declared he'd rather poke his eyes out with a fork, but ClinkShrink has endless patience (and patients). Four minutes into the editing and Dinah said, "Wait, we've been talking for four minutes and we haven't said anything!" Clink responded, "Exactly." And so we ramble about the following:
We invite listeners to give an iTunes review and Roy longs for a Wikipedia entry for Shrink Rap.
and who can figure out if Dinah liked it or not? And where's the photo of the wife?
A brief mention of Koro, a delusion about shrinking genitals
Whether or not people like obnoxious TV doctors, and again we're back to talking about House (and Frazier, and Tony Soprano and Mad Men, and Apple TV.....)
M: The first movie ever made about a serial killer in 1931: ClinkShrink gives it two thumbs up.
URAC: An insurance accrediting company that Roy likes.
We're hoping to get on a more regular podcasting schedule! Thank you for listening.
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.
I just finished reading Dr. Gary Small's book, The Naked Lady Who Stood on Her Head. I talked about it during our podcast, and maybe, someday, that podcast will be posted.*
In the final chapter of the book, Dr. Small talks about his mentor, friend, and father-figure who has been mentioned throughout the book. The mentor approaches him on the golf course, where they meet to talk, and says he needs psychotherapy and Gary is the man to do it. The author is surprised, hesitant, and a bit uncomfortable with the demand (it comes as more than a request). His wife likens it to the need for a plumber or a dentist, and Dr. Small takes on the task. The mentor calls all the shots: where the meetings will be, what pastry they will eat, the form of his payment. The author initially misses the diagnosis and uses this as an example of how one can be blinded.
So is it okay for a friend to treat a friend?
I was in an institution where the resounding feeling is that psychiatric disorders are medical diseases like any other: the patient should go where the care is best. Obviously, our institution gave the best care, and so there was no taboo about faculty being treated (or even hospitalized) within the department. This is not to say that everyone treated their friends, but people might not move their care as far away as one might imagine (and sometimes people treated their friends).
At the same time, the standard professional boundaries suggest that friends should not treat friends, and that such arrangements are not kosher, especially after the fact if the treatment is called in to question.
Dr. Small talks about a delay in diagnosis. He doesn't talk about the fact that the patient here is dictating the care in a way we generally don't view as being helpfu to patients-- even VIP patients-- or that the desire to please authority figures can be very powerful. ------ * Regarding the My Three Shrinks podcast: We've decided that I, the non-geek, should try to produce the podcasts for the near future. Roy said he'd rather stick a fork in his eye than teach me to do this. Clink is trying, but even the process of transferring the recordings to my computer has been rough, not to mention that our podcast programs don't sync. Soon... we hope.
It's one of those questions to which there is no real answer. Being a doctor takes a long time, it requires reliability, diligence, and a willingness to learn things you may not want to learn (organic chem anyone????) and do things you may not want to do. It requires endurance and passion. You need to be tolerant of many things: arrogant supervisors, irritable colleagues, sick people who may not be charming and who may, in their distress, be down-right nasty. You have to tolerate a militaristic order and be willing to work with a system that may be very difficult, wrong, and demand your obedience in ways that may be uncomfortable. Oh, I am so happy to no longer be a medical student or a resident in training.
So can you do it with bipolar disorder? Can you do it with diabetes? Can you do it with attention deficit problems? Can you do it if you're disorganized or ugly?
The question assumes there is one bipolar disorder, that for everyone it has the same course and the same prognosis. Some people have an episode a few times in a life, and between episodes, their mood is stable, their emotions gentle. Others cycle from one mood to another, feeling the whole bipolar thing most minutes of most days. Some patients with bipolar disorder are in and out of the hospital, behave in impulsive and criminal ways when ill, and can't hold any job. Some do fine with medications and therapy, while others have refractory conditions that defy the most creative of cocktails and the best of therapists, even with their total compliance. And some people become doctors and then get bipolar disorder.
Look, he came back! Guest blogger Mitchell Newmark, M.D. put on his armor and came to blog with us again.
The Relative Unimportance of Diagnosis in Psychiatry
As we will soon be witness to the emergence of DSM-V, the new rule book for psychiatric diagnosis, I am reminded of all the pitfalls of diagnosis in psychiatry.In other fields of medicine, diagnosis is based primarily on etiology, with objective findings, rather than on symptoms alone, as it is in psychiatry.When you go to your internist with stomach pain, there’s an endoscopy to look for ulcers, a sonogram to look for gall stones, a blood test to look for hepatitis.But in psychiatry, there is no CT scan to check for Bipolar Disorder, no blood test to assess if the patient has Schizophrenia, no spinal tap to check for Major Depression.
For the psychiatric community at large, diagnosis is important for many reasons.It helps doctors sort out patients so that clinical trials can be conducted on similar groups of patients.It enhances communication among healthys when behavioral, affective and cognitive symptoms can be categorized.But for the individual patient, it is less useful.Some patients fit nicely into DSM categories, and others don’t.There are many patients who have unique combinations of symptoms across several diagnostic criteria.This leads to assigning multiple diagnoses, and confusing the treatment picture.Since diagnosis is based on symptomatology, treatment should also be based, more often than not, on symptoms, regardless of the “official diagnosis.”Latching on to a diagnosis may often limit the treatment options because medicines or psychotherapies designed to treat one disorder are considered inappropriate for treating another disorder.Flexibility is essential for coming up with the best treatment plan for an individual, especially those patients who do not fall neatly into a diagnostic box.
I am always happy to discuss diagnosis with patients, but even this can cause difficulties.For example, when I see a patient in their late teens or early twenties with protracted psychotic symptoms, not due to drug abuse or medical issues, and without the mood changes seen in depression or mania, I am asked “Is this schizophrenia?”According to the DSM, the answer is yes, but many patients recover from these episodes completely.The psychiatric answer is “this seemed like schizophrenia, but it must have been something else.”Meanwhile, the patient has had to cope with being labeled with a devastating diagnosis.I would prefer to answer, “these are the symptoms you have, so let’s treat them with the appropriate medicines.We may discover over time that you have schizophrenia, or an illness like schizophrenia, an illness that does not have a clear cut diagnosis, or this episode may resolve completely and indefinitely.”And that’s the truth.
Someday I may be able to send a patient for a PET scan and get a report back stating “Impression: Bipolar Disorder, Type !!.”By then the DSM will be a thing of the past.
ONE GUYS STORY A BLOG AND VIDEO INSPIRATION AND HELP THE HEAVY CHALLENGE TO LOSE WEIGHT
It's easy to lose weight I've done it a hundred times
For something that seems so transparently clear, the path to sucessfull weight loss is remarkably opaque. The calories in calories out paradigm makes sense but I suspect (as millions of others, no make that hundreds of millions have found out) that there is something more to the story... Kind of like classical physics and The Theory of Relativity. Maybe some Einstein of nutrition will fill in the gaps with a Weight Loss and Diet Theory of Relativity but anyway back to the point....I was watching the Cnbc program, One Nation Overweight, which chronicles the stories of several people who have managed to succeed in their effort to weigh less and enjoy life more.
One person who I found particularly interesting and inspirational was Jim Trudeau. He has weighed as much, according to the program, as 600 pounds and managed to lose two hundred pounds and is on track to lose more. It follows him as he walks, runs, swims and sweats his way around the peaks and valleys of a weight loss resort called the Biggest Loser Resort. And yes, its named after the TV show. I think it may have been called Fitness Ridge before that. Trudeau has been out there several times, spent thousands of dollars and lost hundreds of pounds. (But don't misunderstand, he may get some of the tools and his mojo at the resort but he's following a plan at home 24/7)
Trudea is an articulate lawyer turned businessman who this being the Internet has a blog.. He gives insights into what and how he is doing on the blog...As far as his 15 minutes of fame on tv (actually more like five)...
"Let's start with the actual TV show. Now CNBC/NBC/GE/Comcast had a whole lot of time and money vested in my segment. Crews came to St George 3 times and Madison once. My guess is they spent around 150 man hours just on the actual filming, toss in travel expenses, editing, and production and they spent a heck of a lot of money for what turned out to be five minutes or so of air time. I know they interviewed other guests and the owner of the ridge and none of that made the show :( I don't feel like the piece examined the ridge and what it offered very well. Some stuff they filmed that you didn't see. At the ridge: Pool class, lifting weights, medicine ball sit-ups, swimming laps, eating meals, playing volleyball, other triathletes from the ridge, and graduation. In Madison: making breakfast, Jacky's interview, grocery shopping, state st., and Sunshine Daydream. As far as the rest of the program, I thought they really glossed over the fact that the guy who had the surgery to prolong his life died. I realize that CNBC is a financial station so I understand the bend they took with their theme but it seems like it is awfully tough to quantify a lot of the numbers, costs and per centages that were bandied about. At least the last 5 minutes seemed slightly uplifting :)".
Over time, I've noticed some trends among our blog commenters. Some readers comment on the content of our posts, others link us to Viagra spam, and finally, some readers talk directly to us. We hear about their own experiences of the topic we've blogged about, or simply about their day. This is good, though I could do with a little less Viagra or AirJordan spam in my life.
Sometimes readers inject enough of themselves into their comments that it becomes clear they have opinions about us, the Shrink Rappers, feet, ducks and all. Sometimes it seems like readers are poised to like us, and other times it feels like readers are lying in wait, looking to attack. I was particularly struck by the comments people made on my post about The Texting Shrink. Rachel says I have a kind-heart and another commenter (?--I think it was Retriever) noted that I do this to increase my availability to patients. Dr. Steve put it bluntly: I am idiot! I hope I do have a kind heart, but I text with patients because I've found this to be to my convenience--- it's a quicker way to deal handle brief messages, and none of it's about being more available. My life is better if I get a "stuck in traffic" text and know I have time to run to the restroom or eat a snack. And if a patient needs me to phone a pharmacy or return a call, it's so much quicker to click on the texted number than it is to re-listen to my messages and try to decipher that phone number 6 times by replaying voicemail -- and oh, I don't have a pen and can I memorize it quickly enough?.
Am I an idiot? I believe I've thought it through, but I may be.
The Texting Shrink was only one example. In our years of blogging, many posts have inspired strong reactions, and I've come to be very careful about my choice of words, especially when discussing medications. Sometimes it feels like no matter how gently I word things, someone is poised to simply say, psychiatry is bad, no one should see a shrink, no one should take psychotropic medications, all shrinks care about is money.
Some people think their healthys don't care about them -- and for all I know, they may be right -- others believe their doctors think and care about them a lot, in a way that may not be realistic. Obviously, doctors think and care about their patients (oh, I hope), but docs are people with their own lives and problems.
I'm hoping for a happy medium somewhere. Like Dr. Steve says, I may be an idiot.
