I got the idea for this after I saw the PowerPoint presentation on catatonia presented by my colleague, Dr. James Beeghly, MD, at one of our recent Psychiatry Department Grand Rounds conferences. The link will be in a pop-up on my main blog page, so you might consider letting that through your pop-up blocker.
And don’t worry, you can find the catatonia quiz on my Twitter and Facebook sites, too. I knew you’d be so relieved.
You might be able to search out the answers from my own Dirty Dozen and other resources here. Otherwise you could seek out Dr. Google or wait until I can put together a new Dirty Dozen update which I’ll be working on.
Another thing you could seek is the European Delirium Association website I recently mislaid. Dang!
I saw an interesting item in the AMA MorningRounds recently about how much less total face-time internal medicine residents are spending with their patients . In fact, according to a recent study published in the Journal of General Internal Medicine, of their limited time, they spent only “…approximately 12%, in direct contact with patients.”
The item was based on an article in the New York Times by Dr. Pauline Chen, MD on the Well Blog, For New Doctors, 8 Minutes Per Patient – NYTimes.com. Wow, 8 minutes–that’s about how much time many practicing primary care doctors get to spend with their patients. You could say that physicians-in-training are just getting exposure to real world practice.
Because the links to the study in Dr. Chen’s story were broken, I had to hunt down the article on PubMed just to get the non-open access abstract and full-text article. What are residents doing instead of sitting with their patients? They’re sitting in front of computer screens, poring over the Electronic Medical Record (EMR) to get the essential information on the patients they’re trying to care for–in the same total amount of time they had before duty hours restrictions. Studying the patient’s medical record is not a bad thing and neither is attending didactic and other learning conferences.
But hang on, isn’t humanistic patient care why most of went into medicine in the first place? How do we square the way we carve up our time with the ideals the Arnold P. Gold Foundation espouses, The Arnold P. Gold Foundation?
According to the authors of the study, “The goal of residency training is to produce competent physicians capable of practicing independently. To reach the educational milestones needed to demonstrate independence, residents must hone their skills in patient care and communication. As the ACGME common programs highlight, ‘For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty members.’ Prior studies have found that more time spent with patients may improve patient satisfaction, patient education, and clinical outcomes, and reduce inappropriate prescribing.”
Naturally I thought of our psychiatry residents and their “milestones.” The study involved internal medicine residents, but I suspect that psychiatry trainees also have less and less time to do more and more to prove their competency.
Where have you heard that before? I had a peek at the new Accreditation Council for Graduate Medical Education (ACGME) “Milestones” program (http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf), which is definitely complicated and reminiscent of Maintenance of Certification (MOC), and actually endorses MOC as one obviously preferred way to demonstrate a commitment to life-long learning. Have a look at page 23, under Professionalism, “Prepares for obtaining, and maintaining board certification.” And on page 27 in the Practice Based Learning module in the second footnote, “Examples include PIP module as included in the ABPN MOC process, regular and structured readings of specific evidence sources.”
That sound familiar? It should because Larry Faulkner, MD, President and CEO of ABPN (Who We Are at ABPN), is one of the members of the Advisory Group contributing to the drafting of The Psychiatry Milestone Project: A Joint Initiative of The ACGME and ABPN, as of April 2013. Don’t get me wrong; Dr. Faulkner and his staff are extremely helpful assisting ABPN diplomates navigate the wilderness of MOC, the framework for which he’s pointed out came from the American Board of Medical Specialties (ABMS).
I don’t need to tell regular readers of my blog how many physicians disagree with the regulatory board approach to life-long learning, a major criticism of which is that it takes time away from patient care.
The majority of them.
I’m not pitting the Arnold P. Gold Foundation against the ABMS, either. But I wonder if the leaders of both organizations could get together, maybe over a couple of beers, and take a little time to talk things over.
1. Block, L., et al. (2013). “In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time?” Journal of General Internal Medicine: 1-6.
The 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) common program requirements compress busy inpatient schedules and increase intern supervision. At the same time, interns wrestle with the effects of electronic medical record systems, including documentation needs and availability of an ever-increasing amount of stored patient data.
In light of these changes, we conducted a time motion study to determine how internal medicine interns spend their time in the hospital.
Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012.
Twenty-nine interns at the two residency programs.
The primary outcome was percent of time spent in direct patient care (talking with and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis adjusted for clustering at the observer and intern levels.
Interns were observed for a total of 873 hours. Interns spent 12 % of their time in direct patient care, 64 % in indirect patient care, 15 % in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40 % of interns’ time. There was no significant difference in time spent in these activities between the two sites.
Interns today spend a minority of their time directly caring for patients. Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient care and sleeping, and more time talking with other providers and documenting. Reduced work hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased supervision may limit the amount of time interns spend with patients.
I guess I’ve mislaid the website for the European Delirium Association (EDA) again. Every time I click on the link to the European Delirium Association or type it in the web browser URL search box (EDA, www.europeandeliriumassociation.com/), I get an “HTTP 404 Not Found” error message:
“This error (HTTP 404 Not Found) means that Internet Explorer was able to connect to the website, but the page you wanted was not found. It’s possible that the webpage is temporarily unavailable. Alternatively, the website might have changed or removed the webpage.”
I was alerted to this most recent review of the Maintenance of Certification (MOC) process (see link above) for the American Board of Internal Medicine (ABIM). The upshot is that the process is onerous and doesn’t ensure physicians are up to date. The same could be said for the MOC for psychiatrists and the American Board of Psychiatry and Neurology (ABPN) would do well to consider the parallel.
Currently, I’ve been co-staffing our Medical-Psychiatry Unit (MPU) for over 16 years. The ABPN doesn’t know what I do to improve my ability to provide patient care nor will I ever be able to convey to the board how I engage in continuous improvement. The MOC is like a hound dog, purporting to be a high-class way of ensuring the ability of doctors to provide high-quality care, but all it really manages to do is get in the way, snooping around my door. While the recommendation to physicians is to engage regularly in reflection about our practice in order to find our flaws in our approach to clinical care, examine the research evidence supporting different and more effective processes, the MOC doesn’t provide a method to convey how to reflect or how to demonstrate that they are, in fact, reflecting.
I think it’s ironic that the way I reflect about my practice on the MPU will never be known except to those who bill for my services based on my clinical documentation in the medical record–and it’s anybody’s guess how often the hospital gets paid for that. You heard right. We may or may not get paid (I get mixed messages from billing about it), simply because the U.S. payor system doesn’t recognize complexity in medical, psychiatric, social, and health care system delivery models and policies. Most payors cover a single problem per provider per day based on the most important clinical problem– which is the medical issue, according to the insurer’s rules. The MPU is a medical unit primarily, administered by the department of internal medicine. So in the co-attending model, the psychiatrist functions as a consultant who is required to write progress notes on every patient, but in fact is more like a volunteer in the sense that bills are submitted for psychiatric services which frequently are not paid.
It’s a lot of work to create progress notes documenting what I think are the main psychiatric issues which might interfere with treating their medical problems, or what medical problems or medications might be causing the psychiatric problems or vice versa. The internist can simply co-sign the resident physician’s note, but because the MPU is administered by internal medicine, my name as the psychiatrist can’t even appear as a co-attending. The billing department employees have made it very clear they don’t want my name on any internal medicine note that will be submitted for billing. In a real sense, the general psychiatrist on the MPU is invisible.
So I write all my own notes, which are submitted by psychiatric billers but often go unpaid (ADDENDUM: recently I discovered that while some of them might be paid, psychiatry doesn’t even bill when I’m not co-attending). So much for integrated care on an administrative level. What does that have to do with the MOC? I’ve learned to use my notes as my way of reflecting on the care of my patients, and they are my patients by the way, even though I’m supposed to be invisible from a medical billing standpoint. My daily notes, painstakingly created and often consuming at least 2 hours a day, despite my use of voice recognition software, (which makes horrendous errors if my vigilance lapses) make up my journal, as it were. I document my medical literature searches, my thought process, my conversations with family, surrogate decision makers, the diagnostic judgment calls, the “truing measures” I use to help me, by “successive approximations” arrive at the most comprehensive diagnostic and integrative formulation, and the safest, most effective treatments acceptable to patients which Frankel, Bourgeois, and Erdberg describe in their book, “Comprehensive Care for Complex Patients: The Medical-Psychiatric Coordinating Physician Model” .
Who reads my journal? No one at the ABPN or the American Board of Medical Specialties (ABMS) or the Federation of State Medical Boards (FSMB), because it contains confidential, protected patient health information. In fact, I don’t think my internal medicine co-attending or even the residents read it. None of us have enough time to read each others’ notes, although we collaborate on rounds, getting the integration job done right on a clinical level. But my journal is the way I reflect on my clinical care and I’m constantly working on how to improve it. The MOC as it is currently designed promotes reflection but doesn’t facilitate it. In fact, the MOC discourages this kind of reflection. It encourages reliance on treatment algorithms, which are useful to the extent they provoke us to question them when they invariably prove to be an inexact fit in the real world in which health care providers, patients, families, and policy makers live. The MOC makes me point and click on buttons documenting the completion of Performance in Practice (PIP) modules. But the only one who really knows about my struggle to keep up with the medical literature, to meet the needs of my patients, to find the best path through health care system complexity is me.
The MOC should be about helping doctors provide the highest quality patient care possible. It fails miserably. I can do better by daily reflection in my daily progress notes in which I document the struggle, the thinking through the ways to work around our fragmented health care system’s bewildering maze of obstacles to providing health care at all, much less the best care. I’m aware that it’s really my journal because it isn’t used by anyone else. But it’s better than the MOC.
What I think this new study does is create an opportunity for a meaningful risk to benefit ratio conversation between doctor and patient. Most often it will be between primary care providers and patients because primary care physicians actually write most of the prescriptions for antidepressants. I wonder how confident they feel about this new information.
I’m not sure whether this should change my practice right now. I think further study is needed. I asked several colleagues for their views and only one replied. The data used by the researchers in the AJP study is not identical to that which was used by the FDA to generate the warning. That might be important to know. You have to understand quite a bit about how to evaluate research studies in order to make sense of what to do with this new information by Zivin and colleagues.
The conclusions reached by the FDA and Zivin et al need not be mutually exclusive. And the decision to stick with views by either one could be defended. Patients and their doctors need to know how to discuss them without getting bogged down in the biostatistics. It might be helpful to remember that there’s more to the treatment of depression than pills, for one thing. Evidence-based psychotherapies include but are not limited to Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT).
It’s also important to know when to diagnose major depression and when not to diagnose it. Diagnostic classification manuals and depression rating scales can be helpful, along with common sense and a trusting relationship with patients.
Doctors could also practice saying “I don’t know”, and “We don’t have all the answers yet,” in front of a mirror before going into the consultation room.
Here’s an unscientific poll about picking your favorite diagnosis classification manual: the DSM-5 or Dr. Allen Frances’ “Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5”. I’m biased, of course. It might work better in either Firefox or Chrome.
This is a special Dirty Dozen using material by permission from Dr. Allen Frances’ book, “Essentials of Psychiatric Diagnosis”. Dr. Frances’ first chapter contains a section called “A Dozen General Tips” about the process of psychiatric diagnosis. It contains many lessons I’ve been teaching medical students and residents for many years.
The material in this presentation is taken from the book “Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5”, written by Dr. Allen Frances, MD and published by The Guilford Press, http://www.guilford.com/p/frances2, and is reprinted with permission from The Guilford Press, who is the copyright holder, to use the selection “A Dozen General Tips” from Chapter 1, pages 14-15 and incorporated into a YouTube video.
In order to see the picture galleries of photos or PowerPoint slides, click on the one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.