Eating My Words and Changing My Mind: New Thoughts on Board Recertification

Well, last month I talked about how I was glad I took the boards.  And I still am.  However, since then, a Newsweek article came out trying to make sense of the American Board of Internal Medicine’s financial history, and it’s not good.

While this does not necessarily reflect on the two association I took my boards with (the American Board of Psychiatry and Neurology and the American Board of Addiction Medicine), the report has definitely made me think twice about the recertification process and the complexities of holding these organizations accountable to the physicians and the public that they serve.

There is a new grassroots organization, called the National Board of Physicians and Surgeons, and it has cropped up as an alternative method of maintaining certification for various specialties in medicine. They are going about this by addressing two major complaints that physicians have about the current board recertification process, which are money and the relevance of the exam itself.

Personally I think that the development of competition in the free market can only be a good thing; and I am very much anticipating the development of this alternative source of recertification. I am also very glad to see physicians taking a stand for themselves, as often times when new changes and new regulations occur, we complain but do not take any action. I am trying to do my part by openly admitting that I made a mistake in writing my last post–while I still believe the initial certification is important and worthwhile, I believe I spoke too broadly in stating that recertification in and of itself is also worthwhile, without examining the current process more closely. I hope others take a stand too, because only together can we effect future change.

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I’m Glad I Took the Boards: Thoughts From a Board-Certified Psychiatrist

Recently there has been a great deal of controversy surrounding ABIM, the American Board of Internal Medicine, and its board certification requirements.  Currently the board require physicians to take an exam and recertify every 10 years in a process termed MOC, or Maintenance of Certification.  The process is time-consuming and costly, and many physicians claim it does not improve their day-to-day practice.  Doctors have become more vocal in their grievances with the organization, and its possible misuse of funds.

Despite all these criticisms, many physicians continue to comply with the process; not just internists, but in may other specialties, including psychiatry.  At a conference I recently attended, there was a booth set up by ABPN, the American Board of Psychiatry and Neurology.  The representative was there to answer questions for psychiatrists about board certification.  I learned that their requirements have changed, and that in 2020, when I would be up for recertification, I had new requirements to fulfill.  The requirements included performing activities comprised of continuing medical education, self-assessment, improvement in medical practice, and patient safety activities.  When I asked about the cost, the representative brightly told me that some of the modules “likely” have a cost associated with them.  She did not mention the cost of the actual exam.

Mind you, I am board certified in another specialty, Addiction Medicine.  Since I took the exam in 2012, in order to maintain my board-certification, I have to pay the board $400 every year.  This is in addition to the educational requirements I have to complete.

I mention all this not as a complaint, but rather because I’d like to offer another point of view.  Though some physicians could care less about diploma and the board certification it represents, it means a great deal to me.  The day I found out I passed the boards (and I was one of the last classes that had to undergo an oral exam), I was ecstatic. I felt that my hard work had paid off and that this piece of paper was tangible evidence of my journey.  It meant more to me than my residency graduation.

Not only did the exam feel like a milestone, but I felt that the work and effort I put into studying for it was actually useful. The field of psychiatry is constantly changing and I know that when it comes time to recertify, unless there is a viable alternative, I most likely will.  However, I feel that the money that goes into my educational requirements, the board review course I will take (not required but something I find useful), and the cost of the exam itself, will be money well spent.  I will study the topics covered by the exam and I will appreciate the knowledge that I will acquire.

And yes, I will hang up my new diploma.

Pilots, Old People and Prediction

Unless you’ve been under a rock lately, you have probably heard about the pilot who appears to have purposefully crashed a flight full of 150 people.  There was another article recently too about a 100-year-old man who killed his wife and then himself.  Both of these incidents had some warning signs, that in hindsight, are felt to have been able to predict what ultimately happened.

I’m here to tell you that the belief that we can predict violence is absolutely false.  We (psychiatrists, police, people in general) have absolutely no ability to predict human behavior.  I have talked about this before, in my own work.  It makes people feel better to think that we can predict the awful tragedies that happen each and every day.  No.  All we can do is identify risk, and ideally, mitigate that risk as much as possible.  Unfortunately the way that most laws are written, we cannot do a whole lot unless there is evidence of imminent harm or danger.  This is what happened with the man that killed his wife–the police were called out to the home several times, but each time left because there was no evidence of acute risk.  Unfortunately there was not really any sign that this man would commit murder-suicide.  In retrospect, this man appears to have had signs of dementia, and some signs of aggression, but nothing (at least not reported) that would have led to what he did.

With our pilot, there appears to have been some premeditation.  Scary.  I had a conversation, or rather a debate last week with another psychiatrist and two psychologists about what the diagnosis for this man was.  We all had different ideas before some of this information came out.  We will probably never fully know what happened.  Regardless of what the underlying causes were, the whole thing is a tragedy.  Hopefully we learn and start to try to mitigate risk in a useful way, whether for the pilots who hold so many lives in their hands, or the older folks who seem to need some help.  I just hope we don’t fool ourselves into thinking that any of this could ever have been predicted.

I’m Back!

Wow, I was looking at this blog the other day and read a few of the posts…I was thinking back to why I stopped and I think it was when I got a life! I started dating and then married my-now-husband. I was promoted at work. My husband and I purchased and moved into a real house. I forgot about this blog.

But I think you can have a life and a blog! I enjoyed writing here and I still have a list of topic ideas I would like to revive. So consider me (and the blog) officially revived!

One major thing I have gone through…that is extremely personal, yet so huge that I need to mention it right from the get-go: I was pregnant for most of last year, and everything was going great…we got the nursery ready for our incoming baby girl…but 3 weeks before my due date, I went in for my normal weekly check up, and my doctor couldn’t find a heart beat. I was devastated and still am, but now I am finally at a point where I can talk about it (and write about it) without breaking down in tears. I will tell my story, in a different post, but wanted to at least mention it here. When something like that happens, it changes you, your outlook on life, and for me, I always like to make those changes for the better.

So here I am–for anyone reading this, know that minus this very sad thing that has happened, I generally try to keep things light and I am excited to get back to sharing my thoughts on well, everything.

Psychiatrists Aren’t Psychics

I know the two words sound very similar, but they are most certainly not the same. I recently received a request to see a patient to determine if he could get through a procedure without having a panic attack.

If I could predict the future, I would have won the lottery last week! Sadly, I didn’t.

I suppose I understand that other physicians would like to have psychiatric issues under control so that they can get their work done. That’s why I do what I do. However, psychiatric issues, just like medical issues, can be quite unpredictable. No one gets frustrated when a person has an unexpected bout of asthma, but if someone has a panic attack, the reaction to that is that the person isn’t in control of their behavior. The thing is, although some psychiatric issues certainly stem from voluntary behavioral actions, some presentations are involuntary. Like a panic attack, which is a result of the sympathetic nervous system gone haywire.

Anyway I try not to be rude to those asking for help, but needed to vent a little today. Thanks for reading and hopefully you learned something too!

Jackpot Fever

I feel like recently I’ve been bombarded with the news of the $540M jackpot that has risen to record levels. It’s on billboards, the news, my morning radio talk show, and all over the internet. Initially, maybe a week or so ago, I was thinking, who cares, there’s always an ongoing jackpot…but then it started growing larger and larger. My morning talk show hosts were asking callers what they would do if they won the jackpot.

And suddenly, I found myself fantasizing about what I would do if I won. Would I tell anyone at first or have the sense to consult with a financial expert first? Would I quit my job? Would I give large chunks of it to family members? Would I go on a shopping spree? Would I upgrade everything (including car, condo, and most importantly shoes)?

I also, of course, began to wonder what it is that is making everyone so excited about this jackpot, which individuals presumably have extremely teeny-tiny odds of winning? The psychiatrist in me began to think about gambling as an addiction or impulse control disorder, which is easier. It is easy to write off gambling addicts who can’t leave the casino after hours and hours of sitting at the slot machines. But what about the average person, who is getting caught up in lotto fever?

I think there are probably a couple of things that drive people to buy lottery tickets despite the ridiculous odds. This article defines the current odds at 1 in 175,000,000! There’s probably better odds of getting into a plane crash, being attacked by a terrorist, and getting eaten by a shark. So despite the odds, what is turning rational people into thinking they actually have a chance?

Well, the first is probably the fantasy–just like me the other day, buying a ticket allows one to escape reality for a short period. And who doesn’t want to escape reality once in a while? My days are not extremely thrilling as a general rule. I think the other is entertainment. When I watched the Superbowl in February, I was bored to tears until my friend and I made a $10 bet (which I won, thank you very much). All of a sudden I was invested in the winner of a game I normally could care less about. The time passed more quickly, and I was perhaps able to enjoy the social gathering in a different way than usual. Same principle can be applied to the lottery; buying a ticket it makes life a little more entertaining and now there’s something to look forward to when it’s time for the drawing. A little excitement has been created, a small risk has been taken, and there is a sense of anticipation about the possibilities.

Finally, I would say the last factor that comes into play is one that I’ve brought up before–that of cognitive dissonance. Even though logically we know that the odds of winning are very low, we convince ourselves that “it’s only $1, so why not?” For some, however, that daily $1 adds up to a lifetime of disappointment and loss. For others, like me, there’s a momentary flash in my mind of those Jimmy Choo’s I’ve been eyeing. And that’s enough–I plan to purchase a ticket tonight. Wish me luck.

Doctors Don’t Know Anything

My apologies for slacking on writing posts recently…little preoccupied with my own life, but we’ll get to that in another post perhaps. Today, though I wanted to discuss doctor’s lack of knowledge about so much! Recently I saw my neurologist and had a follow-up MRI for the MS symptoms I experienced last year. A year ago, I had an MRI that showed multiple lesions, and a few weeks ago, I was told by my doctor that most of the lesions were gone and there was nothing new! Great news, right? Here is the conversation that my doctor and I had:

Doc: So your MRI looks a lot better…a lot of the lesions are gone…
Me: You sound surprised. Is this what you were expecting in the course of treatment?
Doc: Well, sometimes this happens…
Me: Do you think it’s the medication I’ve been taking?
Doc: Perhaps…
Me: Do you normally see this in MS after starting treatment?
Doc: In some cases…
Me: Can you tell me anything definitive?
Doc: Possibly…

Ok, the last two lines were made up, but you get the idea. My doctor really could not tell me whether I am getting better because of the medication I am taking, the lifestyle changes I’m making, the cinnamon I’m eating, or just the course of the illness. I do understand that MS is an unpredictable illness and often times it is difficult to predict whether symptoms are related to specific findings, as well as response to treatment. In fact although I complain (from a patient standpoint) I also have the perspective of a physician. As a psychiatrist, there are many unknowns about mental health, including its etiology, let alone its treatment. We rely on research studies for evidence-based treatment options, but sometimes there just isn’t any data. We then have to rely on our own or others’ clinical experience to guide us. I often start patients on antidepressants, and the patient improves. Did the patient improved from a placebo effect, the medication, the support and counseling, or even exercise? Hard to say in some cases.

Despite my questions, I am of course happy to be doing better. I feel confident enough that the medication I am taking is helping to some degree, so I will continue to take it. But it’s just a guess.

Keeping It Off

I found this NYT article yesterday about the difficulty of successful weight loss, and finally finished reading it today. I have been interested in this topic recently–the science behind weight loss. Partially I’m interested in this because there is increasing evidence that obesity has underlying biological factors that contribute to its epidemic; i.e. obesity is more like a disease, not a choice. The article is fairly long, but some of the more interesting points I found were the following:

1. There are hormonal changes after weight loss (lower peptide YY and leptin, higher ghrelin) that make it hard to keep the weight off (i.e. someone who used to weigh 150 pounds and now weighs 120 pounds, is different than someone who naturally weighs 120 pounds)

2. Some people have specific genes that make them more predisposed to eat higher calorie foods, and make it harder to lose and keep weight off

3. People who successfully keep weight off are the minority of those who try to lose weight, but they all have specific consistent habits, including tracking their food and exercise, weighing themselves daily, exercising daily, eating breakfast everyday, watching less TV, and not “cheating” on holidays and weekends

4. After weight loss, you are more susceptible to cravings than before (and this is shown on brain MRIs in research, and is some of the evidence behind obesity having similarities to addictions)

5. Knowing some of these things can help to improve ways of losing weight

Now after read this article I feel a bit more informed. It is easy to tell those who are obese to eat less and exercise more. While these tenets are still the core of achieving weight loss, we are starting to learn that not everyone has the ability or the genetics to do this things as effectively or efficiently. That being said, it’s not a reason to give. It may just be that we need to start approaching weight loss for people in a different light, for example slowing it down rather than speeding it up. Another reason to avoid those infomercials late at night!

Good luck and as always feel free to leave comments or feedback!

Obesity Counseling to be Paid for by Medicare

Recently I have become interested in the obesity epidemic plaguing our country. I’ve actually been interested in obesity and co-morbid psychiatric illness since residency, but recently my interest has been revived. I read that Medicare is going to be reimbursing health care practitioners for obesity counseling and screening. My initial thought was that this is a positive step in the right direction. But the cynic in me began to wonder–what does obesity counseling exactly consist of? Who will be administering this counseling? Will it be nurses, doctors, nutritionists, or psychologists? What data is available that tells us this will actually work?

Currently, the art of “counseling” is already in danger of becoming an extinct entity, as a result of changing insurance reimbursements, which tend to be better for psychiatrists who prescribe medications rather than psychotherapy. This has influenced the state of psychiatry training programs, which have begun to deemphasize training for therapy, favoring instead a focus on psychopharmacology and biology. This has its pros and cons, as with anything, but has turned psychiatrists partially into pharmacists. I find it unfortunate.

But back to obesity counseling. Usually now, when obese patients see their doctors, they hear a lot of the same information over and over again–that obesity leads to hypertension, diabetes, strokes, heart attacks, shorter life expectancy, and so on. To deal with obesity, patients are told to eat healthier and to start exercising. Well, no kidding! All of this information is now readily available anywhere online and is not news to people. So what makes doctors think that repeating this information will all of a sudden get a patient to lose weight? It doesn’t. Which leads to no change, which in the long run, makes doctors become pessimistic, believing none of their patients will change. So they start treating the diabetes and high blood pressure, ignoring the underlying obesity, and it turns into one big never-ending cycle.

I hope this is not what “obesity counseling” will consist of. I hope that what doctors and other health care practitioners start learning is that motivational interviewing and motivational therapy is the way to get patients to start changing. We have to allow patients to tell us why they want to change, not us tell them why they need to. People only change when they are ready to. We need to start learning how to get patients to get closer to that point. It’s easier said than done.

Group Everything Is Better

Hi everyone! Sorry I’ve been MIA for the past few weeks. I have been busy with work, and also busy with taking care of myself. I started back up in the gym, and yesterday ran a 5K with a friend of mine. Training for even 3.1 miles is hard when you haven’t run in a few months! Luckily I had been working out so it wasn’t too bad.

Tonight I wanted to bring up the topic of relying on groups for motivation to do what you want, partially because that’s what I have been doing recently. There is a reason that AA (Alcoholics Anonymous) and Weight Watchers work for people. There is evidence that group programs such as these are some of the most effective ways to stay sober and lose weight (respectively of course!). Working in groups is useful for a number of reasons, including being held accountable by others, feeling responsibility for others’ progress, and seeing other people’s progress as an inspiration for yourself. It is helpful for people to get advice from those who have been in their shoes, in order to overcome the obstacles that come with any journey of self-change.

Lately I have been trying to work with others (such as running with friends) in order to accomplish some of my own goals. Having someone else doing the same thing as me keeps me motivated to keep up my progress, which is not easy when I am by myself.

I would encourage that anyone out there who wants to improve themselves in any way–whether it is recovery from mental illness, beating an addiction such as smoking, or wanting to get in better shape–to consider trying it out with other people. You might be surprised at how much more you can accomplish!

Happy mental health! Next post will be much more timely than this one!