Archive for the ‘Psychiatry in the Media’ category

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

April 21, 2015

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

April 8, 2015

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.

Jackpot Fever

March 30, 2012

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.

Keeping It Off

December 30, 2011

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!

Doctors Should Stop Wearing White Coats

September 8, 2011

I stopped wearing my white coat regularly about four years ago. I get questions from people at work about it all the time. Most commonly I get asked why it is that I don’t wear one. I admit, it might be easier for me if I did–and occasionally I will put it on, usually for an important meeting, or when I want to have a more authoritative role with a particular patient. A white coat makes a physician more recognizable as a doctor, and has big pockets, so a doctor can carry his or her important papers, reference books, and of course their cell phone.

That being said, I absolutely hate wearing my white coat. I have two of them, and find them to be a terrible nuisance. They get ring around the collar after one wearing, the smallest size could house a small football player, and can cause someone to be 10 degrees warmer, especially in a hospital where the air conditioning is unreliable, and the heat too high.

Also, and definitely most importantly, white coats are disgusting, and I mean that in a clinical way. White coats have been banned in the U.K. since 2007. While it is not clear whether the bacteria on white coats actually causes more infections in patients, to me it doesn’t matter. It gives me one more reason to not wear my white coat. Wearing one doesn’t make me a better doctor.

New FDA Warnings For Two Psychiatric Medications

September 1, 2011

In the past week, the FDA has come out with warnings for two psychiatric medications, citalopram (a common antidepressant) and asenapine (a newer antipsychotic). The warning for citalopram (otherwise known by the brand name Celexa) can be found here, and states that higher doses of the medication may be associated with some heart abnormalities. The warning for asenapine (known by its brand name Saphris) can be found here, and warns of possible allergic reaction. Now, as I’ve mentioned in previous posts, I work in a veteran’s hospital, where medications are limited by what is provided in the pharmacy there. So I’ve never prescribed asenapine, because it’s new and still very expensive; therefore I can’t speak to how well it works, or what its side effects are. I do, however, prescribe citalopram quite frequently, however, and have gotten to high doses. The FDA will tell you that there is no evidence (no published trials) that it works better at higher doses, but plenty of psychiatrists can tell you from clinical experience that it potentially can work better for some patients at higher doses. The FDA is now saying, though, that it should not be prescribed at higher doses. This is a new way of wording its warnings–it is not saying, be careful, check an EKG, monitor carefully. The FDA is saying to not prescribe altogether.

When the FDA says something like this, and you work in a federal hospital, you have to listen. However, the FDA does not tell us what the clinical consequences of these heart abnormalities are. As far as I know, no one has had sudden cardiac death from this medication (which is ultimately what could happen from these type of heart abnormalities). They also do not comment on other antidepressants in the same class. Why citalopram and not escitalopram (brand name Lexapro)? The suspicious part of me wonders if it is because escitalopram is still on patent, and more expensive and profitable for the company that makes both medications. Also, I wonder who sponsored the data, which has yet to be published.

So what does this mean for patients? Well, unfortunately for patients who were doing well on higher doses of citalopram, they may have to try going back to lower doses, or try an alternative medication. Ultimately every medication will have potential risks to it, but sometimes when you weigh the risks against the benefits, the benefits win. For people who have been through the devastating effects of depression, it may be worth it.

I also don’t think this trend will stop with these two medications. There are many new psychiatric medications coming out, and only time will tell how safe they are to use.

NFL Player Announces Mental Illness

August 3, 2011

This article in CNN about Brandon Marshall, a football player for the Miami Dolphins, just grabbed my attention. Not because it was a football article–I know very little about the sport but enjoy the Superbowl commercials every year–but because it was about a little known diagnosis called “Borderline Personality Disorder.” Well, I should be more clear–I think it is very well known in the field of psychiatry, but perhaps less well known in the public eye. Most psychiatrists who see a diagnosis of BPD listed in a patient’s chart, have a sense of dread. Why? Well, as the CNN article states, these patients are very impulsive, have extreme mood swings, and tend to act out. As opposed to most people who can acknowledge their feelings and engage in healthy behavior to cope with them, these people tend to act out in extreme behaviors to manage their feelings. This is very difficult for a doctor to handle sometimes–dramatic phone calls in the middle of the night, self-harm behaviors such as cutting, and suddenly hating the doctor they had idealized the week before.

What I find so interesting about this article, and so classic of the diagnosis, is the aspect of attention-seeking behavior. Obviously an NFL football player is in the spotlight for his talent. However, for Brandon Marshall, he is also well known for his legal troubles. This Wikipedia article notes a history of arrests for domestic violence, disorderly conduct, and a DUI. Interestingly he was also hospitalized when his wife stabbed him in April of this year–unstable and chaotic relationships are another aspect of borderline personality disorder.

Although Marshall is announcing his diagnosis because he wants to bring recognition to this illness, he has only been diagnosed in the past few months. Treatment for this disorder is a specific type of long-term psychotherapy. Given that he has not likely to have gone through this treatment yet, it makes one wonder if he is making this statement as another grab for attention. If that is the case, it would certainly confirm the accuracy of his announcement.