Showing posts with label prescribing. Show all posts
Showing posts with label prescribing. Show all posts

Wednesday, December 07, 2011

Guest Blogger Dr. Jeff Soulen on the Pros of E-Prescribing

Over on our Clinical Psychiatry News website I'm writing about my struggles with electronic prescribing.  The post, "To E-Prescribe or Not? That is the Question" will be posted on December 7, 2011.  In order to write it, I bothered just about every shrink I know, or it least it felt that way.  One of the psychiatrists who was kind enough to respond with a great deal of useful information was Dr. Jeff Soulen, a psychiatrist in private practice, who has had a positive experience.  This is Dr. Soulen's first experience as a blogger. 

I've been using Allscripts for about 3 years now, and I must say I like it a lot. It's free (no need to sign up for the paid Deluxe version) with a browser-based interface, so I can access it anywhere -- helpful when I'm away from my charts.  I pretty much do 100% of my scripts electronically except controlled substances, for which it's still illegal to e-prescribe. What I like about it:

  • I see a list of every script my patient has filled, including those from other docs, though this information is sometimes spotty. It's led to some important discussions about controlled substances I didn't know the patient was taking, drugs that have interactions with the ones I'm prescribing, etc. Kind of wondrous to enter a patient's name, zip and birth date and 5 minutes later the whole list is on your computer screen.
  • Patients love it.  Once they are in the system-- which takes a couple minutes the first time-- it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them - no need to bring a paper script and wait.
  • For repeat scripts, it's faster than hand-writing - select from the list of scripts you've sent previously for that patient and send.
  • No more transcription errors from a paper or phoned script.
  • It's been a huge time-saver in that I no longer get calls requesting refills of scripts where I wrote refills, but the pharmacy in their rush put 'no refills' in their computer. This used to happen a lot.
  • All the mail-order pharmacies seem to be tied-in at this point, so sending mail-order scripts electronically is as easy as sending to a local pharmacy. Way faster than filling out fax forms by hand, then faxing them. And patients seem to receive mail-order meds about 4 daysafter I send an electronic script - significantly faster than faxed or phoned scripts.

It is true that an occasional script fails to make it through the system to the destination pharmacy. So far that's been well less than 1% of the scripts I have sent, and re-sending a script a few times a
year takes much less time than calling patients/pharmacies several times a month to tell them that yes, the original script did have refills on it.

If you want to prescribe from a smartphone, you have to purchase the Deluxe version.  I don't know how much that costs.

Bottom line, for my solo private practice it's been terrific -- faster and more accurate for me, gives me information on drugs my patients are taking and have failed to mention, and patients love it. I e-prescribe for all those reasons, not because of Medicare penalties.


If you surfed over to the CPN article, you'll know that my experience with e-prescribing has not been as happy as Dr. Soulen's.  Of course you're invited to tell us about your experiences...

Wednesday, October 27, 2010

Antidepressants on Kevin.MD

Dheeraj Raina is a psychiatrist who has a blog post on KevinMD called "How an Antidepressant Can Hurt Your Patient."

The post is directed at primary care docs and talks about the danger and downside of prescribing anti-depressants. Too much use as 'feel good' drugs without careful consideration of the diagnosis, appropriate treatment with adjunctive psychotherapy, and the risk of manic induction and suicide.

It's probably not likely that every patient with anxiety and depression will end up seeing a psychiatrist. Obviously, we at Shrink Rap don't think antidepressants should be doled out mindlessly--- if primary care docs are going to prescribe them, they should--

Know how to diagnose depression.
Know how to use the medications. This is not as easy as it might sound: Antidepressants take time to work and the dosing requires titration. Sometimes they need to be changed, increased, augmented. If the first try at a standard dose works, you can call it a day---but this is why the meds have the rap for being only as good as placebo. They don't work if you don't know how to use them and one size doesn't fit all.
There are risks, side effects, adverse reactions, and contraindications.
With psychotherapy, time, and support, there are people who won't need treatment with medications and those options get bypassed when a script gets written in a quick visit.

PS. I agree with Dr. Raina that this can't be done in a 15 minute office visit.

Thursday, April 08, 2010

Shopping Spree

CNN recently had a story entitled How physicians try to prevent 'doctor shopping', about states' efforts to control and prevent prescription drug abuse. While it's a good story, it's unfortunate that we only tend to talk about this issue after the overdose death of a celebrity. Here at Shrink Rap we've talked before about our concerns and challenges related to this issue in a series of blog posts and one podcast which we've collectively referred to as "the Benzo Wars".

The Shrink Rappers have seen both sides of the prescription drug abuse issue and so we have different opinions about it. Neither opinion is all right or all wrong, we just differ on the degree of the problem and to some degree how it should be handled. Our opinions are shaped by the patients we treat: Dinah has a private practice and (I'm guessing here) probably doesn't have many patients with active addictions or legal problems related to this. I work in prison, and nearly 80% of my patients are locked up for crimes related to substance abuse.

First, the things we agree about (and that the CNN story also addresses): we agree that doctors can't be detectives and that we aren't lie detectors. We have no special ability to figure out who is or isn't lying to us about their pain and anxiety or exaggerating problems to obtain medication. We agree that most doctors have certain 'red flags' that raise a concern about abuse. We agree (although Dinah thinks I don't believe this) that patients with real pain and panic disorder deserve care that is delivered in an empathic, sensitive fashion and that questioning or doubting these patients can cause serious problems with the doctor-patient relationship.

That was the easy part.

What the CNN article doesn't address is this: what do you do when you find out that your patient is, in fact, receiving multiple controlled substances from more than one doctor? The CNN article implies that whenever this happens it means the patient must be "doctor-shopping" and that there's a problem.

This situation is going to be more of a challenge for Dinah than it is for me, because in correctional facilities controlled substances are rarely prescribed. When they are ordered, they are dispensed in a tightly supervised manner and generally for a limited time. If an inmate is caught with pills in his cell---whether or not they were prescribed for him---you know the medication is not being used as prescribed. Easy enough.

But what about free society? What if the patient tells you, "I have chronic pain and I get medication from Dr. So-and-So." Truthfulness is a good indicator that the patient probably isn't out to snooker you. True drug addicts rarely give you an avenue to check up on them easily. Nevertheless, physiologic dependence can happen even in the absence of abuse. If the patient is coming to see you for anxiety, I probably still wouldn't choose a benzodiazepine as a first-choice medication because I wouldn't want to cause yet one more dependency issue. There are non-habit-forming alternatives and SSRI's have been shown to have anxiolytic effects.

But what if the patient comes to you already on a benzodiazepine? This is where the benzo war started on the podcast, and where Dinah and I may differ. In this case I think you have to consider what the goal of treatment is going to be and physicians are going to differ with regard to their comfort levels in this situation. Presumably the patient has been referred to you because the previous prescriber either was unable or unwilling to continue the prescription. Unless the prescriber was dead or retiring, to me this could indicate a clinician's concern about the patient's pattern of use and I'd be reluctant to merely continue the status quo. A reasonable treatment goal would be to build coping skills to the extent that either the patient would no longer need medication, or could function with a non-controlled alternative. As strange as it may sound coming from a psychiatrist who mainly does medication-management, I do believe that psychotherapy can help with this.

What if you find out that the patient actually is selling, trading or giving away your controlled substances?

Most free society docs don't find out about this until the patient gets arrested. But say the patient is released on bail---do you accept them back in treatment? Do you continue to prescribe for them? Or what if the other doctor is prescribing unusual combinations of meds, or meds in doses that would raise the eyebrows of even the most liberal psychiatrist? Do you assume the doctor is over-prescribing or do you assume the patient must really 'need' the medication?

It's a complicated situation, made more complicated by the fact that even non-controlled psychiatric medications have street value. And don't even get me started on legalized marijuana.

I'm not trying to start Benzo War Part II, but it's an issue that doctors struggle with. I await your thoughts.

Thursday, June 05, 2008

Online Access to Prescription Medication History

I saw a headline this morning that the California attorney general is moving to provide instant access to a patient's prescription history for doctors and pharmacists (regulatory boards and law enforcement organizations currently have ready access to this info).  

State Atty. Gen. Jerry Brown unveiled a plan Wednesday to provide doctors and pharmacists with almost instant Internet
 access to patient prescription drug histories to help prevent so-called doctor shopping and other abuses of pharmaceuticals.

Brown told a Los Angeles news conference that the state's prescription monitoring is a "horse-and-buggy" system that needs significant improvements because it now can take healthcare professionals weeks to obtain information on drug use by patients. That delay can allow some patients to get large quantities of drugs from multiple doctors for personal use or sale.

"If California puts this on real-time access, it will give doctors and pharmacies the technology they need to fight prescription drug abuse, which is burdening our healthcare system," Brown said.

The database, known as the Controlled Substance Utilization Review and Evaluation System, contains 86 million entries for prescription drugs dispensed in California.
I have mixed feelings about this issue.  Maryland passed a similar bill this past session to study such a program.  There is a very serious problem with abuse and diversion of controlled medications, such as Percocet, OxyContin, Lortab, and Xanax.  It is indeed very easy to get scripts from duped physicians and nurse practitioners and PAs, get it filled, and then sell it on the street for a 1000-5000% profit.  We need methods to control this.

The flip side is the risk of privacy violation.  Patients could have their privacy breached.  So, how much are we as a society willing to give up to combat this problem?

My suggestion:  Build in banking-level protections, provide patients access to their own histories, provide patients the ability to permit or deny access on an individual basis (so that they have control over access), and permit patients to see who has accessed their records.  Also, provide protections to prescribers and pharmacists which allow them to not prescribe or fill a medication if the patient refuses access to their history.

This provides a greater amount of control over access to personal info, while still providing the ability of prescribers and pharmacists to exercise careful judgment about the medications they write or fill.

I'm not totally sold on this solution, but it does seem to be a better compromise than the big brother approach.  I'd like to hear your thoughts on this difficult problem.  Please add your comment below.

Thursday, February 28, 2008

For The Sake Of Argument

[Subtitle: Clink Takes The Bait]

But first, Good News for those following the HBO In Treatment Sub-Blog: Post on Sophie below this: Click Here.

If I were a trout I'd be three feet out of the water by now. Dinah's post "When A Shrink Picks A Benzodiazepine" is like a bright colorful feathered fly with a tantalizing spin. I tried resisting, but I just had to leap for it.

In my clinic today two patients had benzodiazepine issues. Patient One had been taking his mother's Xanax. Patient Two had his parole violated for a dirty urine. He said he had been getting his psychiatric care through a local program, but that they had only prescribed Xanax "to help me with my marijuana problem". I asked him what they were giving him for his bipolar disorder, and he said, "Oh nothing. Between the marijuana and the Xanax I was alright." Right.

I'd like to think the outpatient doctors for both Patient One and Patient Two were both as careful as Dinah. Hopefully they both took good substance abuse histories and knew their patients well. I'm sure they were well-intentioned. Right. The problem with the approach Dinah suggests is that people with active addictions aren't going to tell you about them. They're going to conceal their substance abuse histories and lie about the pharmacies they go to. Taking a history isn't going to help too much.

So for the sake of argument (and we do like to argue here at Shrink Rap!) let's say Patient One's mother has, as Dinah suggests, a fear of flying that necessitates occasional benzodiazepine use. So nervous flying mom also has a pot-smoking son who also drinks a bit (but is smart enough to hide the empties), a son who also snorts his Ritalin. Patient One's doctor takes a history and learns nervous flying mom has never abused alcohol or been dependent on drugs. He doesn't find out about snorting, pot-smoking son because nervous flying mom is clueless. He writes a prescription for a benzodiazepine and now pot-smoking son mentally blesses him whenever he opens his mom's medicine cabinet. And I have a new parole-violating patient. And mom's doctor never has a clue this is going on.

So when I hear about free society docs who never have a problem with patients on benzodiazepines, I can't help but wonder if the problems are truly that rare or if they just never find out about them. The patients disappear when the med gets tapered (or they get arrested) and the doc never hears the end of the story.

And I wonder why, when working in a public clinic, it is "very rare" that Dinah will start benzodiazepines in that setting. I suspect it's because with those patient the substance abuse issues are a little harder to conceal, especially when they come to her freshly released from jail. Thus, addicts from low socioeconomic classes are pretty much stuck buying their stuff off the street.

So I agree with Dinah that prescribing involves a risk-benefit assessment. I just don't get the part where the risk of temporary nervousness while flying outweighs the risk of diversion, misuse, abuse and dependence. I'm still working on that part.

(Dinah and I could keep this up until people beg for more In Treatment posts. I'll try to contain myself.)

Friday, February 22, 2008

Sober Thoughts

[I'd like to thank Clinking By Proxy for helping me post while my Comcast was down. I owe you chocolate. And yes, Dinah, I'll babysit Max. He's adorable.]

I used to think that I wouldn't write about substance abuse because I wasn't an "official" substance abuse expert, at least not on paper. I didn't do an addictions fellowship and addiction per se was not usually the primary focus of treatment in my outpatient clinic. Then came my Dose Dependent post and the Benzo Wars podcast and all the subsequent comments, positive and negative, about the issue. I discovered I had a lot to say, mainly as a result of several years of direct practical experience.

Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with.

Those are the folks with the severe addictions, the ones that result in arrest and incarceration or homelessness and poverty. There are lots of other addicts out there whom I never see, the middle-class non-criminal addicts whose addiction touches the lives of their families and loved ones but never quite sinks to the level of the streets. These addictions are no less serious. I think I get vocal about these folks (and about things like prescription controlled substances) because I can see where things are headed. I know how bad they can get and the human wreckage that will be left along the way. I can tell you story after story about people who have never done a thing wrong in their lives until that on-the-job accident and the first opiate prescription, or that first hit of cocaine (or the first benzo prescription) and the next thing you know the wife is gone, the job is gone, the house is gone, and they're in prison. It does happen, more often than you think.

Doctors can't always tell who is or isn't an addict among these nice, educated, relatively well-heeled genteel non-criminal folks. Addiction is a hidden disease, a disease of denial, a thing that's carried in secret and buried away even from the addict. Addicts can hide their problems even from people living in the same household. Shame is a powerful motivation for secrecy. Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to. Giving a warning about addiction potential or cautions about continuous use is one way of approaching this problem, thus leaving the responsibility for the addiction back with the patient ("I warned you this could happen, I have it documented in the informed consent section of my progress note.") but this would be little comfort to me when I see these folks in prison.

When I read comments from people who say they're reluctant to take more of their prescribed controlled substance, I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary. You're the one carrying both the symptoms and the addiction risk. As one of our anonymous commenters said:

"We didn't wake up one day addicted. It was one or more of your colleagues with an MD after their name who started all of this for the vast majority of us so as someone else said, why don't you take it up with them at your conferences or in professional writings or wherever it is that you all gather to talk down about us and the problem your crew created?"
That's exactly why we're blogging and podcasting about this. Thank you.

Saturday, February 16, 2008

The N = 1 Trial

[Clink Note: First I put up this post, then Dinah posted over it, then she reposted it at the top of the blog with bookend comments. I've taken out her bookend comments and put them immediately after this post, so please do scroll down to read them or click here. Oy. My Comcast access has been really spotty or non-existant this week so I have to act fast while it's up.]

In the January edition of American Psychiatry News Dr. Glenn Treisman writes a critique of the "fail-first" policies of managed care organizations entitled Promoting The Concept Of The Individual Trial (free registration required to read the article). He begins with a brief case presentation of a patient who was successfully treated as an inpatient with a drug that was nonformulary according to his new insurance company. The patient was discharged and his outpatient doctor, who didn't have access to his previous treatment records, switched him to a different formulary medication which he had previously failed. The patient relapsed and required rehospitalization.

He begins with a critique of the idea of therapeutic equivalence. Therapeutic equivalence refers to the idea that different medications can be shown to be equally effective in treating a given medical condition. Dr. Treisman rightly points out that this evidence is based on treatment response of large groups of patients and may not be predictive for a given individual. For example, SSRI's as a whole may be equally effective in treating depression but a specific patient may find Zoloft more effective than Paxil. There may also be specific individual issues such as co-existing medical conditions that may influence a clinician's choice of medication. (See also Dinah and Roy's posts on How To Choose An Antidepressant, Part 1 and Part 2).

He goes on to attack what he refers to as a perversion of the term "evidence-based medicine". This term originally meant that doctors should base their treatment decisions upon current research, using the best information that is available at the time. He alleges that insurance companies use evidence-based practices as an excuse to deny care and save money:

"At times, evidence-based medicine has come to be used as an excuse to change the equation of medical treatment entirely. The new equation is to start with the premise that treatment should not be used unless it has been 'proven' to work."
The misuse of therapeutic equivalence and evidence-based medicine, according to Treisman, has caused patients to become disillusioned and suspicious of traditional medical care and turn to alternative and homeopathic treatments. And for doctors he feels the nonformulary approval process "wastes the time of busy physicians" and injures patients.

So that's my recap of the article. My reaction to the article is that I agree wholeheartedly with Dr. Treisman that it's good to remember the limitations of large clinical trials when you're treating the individual patient. It's also good to remember that therapeutic equivalence is a regulatory concept not necessarily a clinical truth.

Here's where I disagree:

The nonformulary process and the emphasis upon adherence to treatment guidelines is not solely the fault of the "evil" greedy insurance companies. I think we as physicians need to accept our role in driving these policies.

Health care cost containment is everyone's responsibility. It's easy for doctors to feel bothered by paperwork, to feel threatened by challenges to clinical autonomy, or to be offended by suggestions that one's practice is not up to modern clinical standards. But the fact of the matter is that in psychiatry there are a lot of free-wheeling physicians out there. Indiscriminate use of expensive medications for vague clinical indications (Seroquel for anxiety, anyone?) drives up the cost of health care for everyone. And practice guidelines were not developed by insurance companies. They were created by professional organizations to enhance the overall standard of care and quality of care given by their physician members. The professionals themselves recognized that there were issues with wide variation in patient care, or suboptimal care, long before insurance companies got ahold of these guidelines.

It's a facile sleight-of-hand trick to point to the evil greedy insurance companies for the policies that now nag us. I'd remind folks that we have only ourselves to blame.

Friday, January 25, 2008

The 4H Club

When I took a medical history from one of my patients he told me, "I belong to the 4H club: hepatitis, HIV, herpes and hemorrhoids."

In medicine you see the term "comorbidity" used quite a bit. It basically just means that a patient has more than one medical problem happening all at once. It isn't specific to any particular combination of illnesses. In forensic psychiatry it usually means mental illness combined with substance abuse, combined with personality disorders. In the correctional world you can add a few extra layers of pathology by throwing in the medical diseases: hepatitis, HIV, head trauma, diabetes and other stuff, like the 4H list given to me today by one of my patients. (On the positive side, he had no history of closed head trauma.)

Practically speaking, what this means for treatment is that everything is going to be a little more complicated. You have to think about how the personality disorder will color the patient's reaction to your care, how the head trauma will affect his ability to understand what you say to him, and what the co-existing medical conditions will do to your choice of psychopharmacology. That can be a challenge. (OK, so the hemorrhoids in today's patient didn't really complicate the pharmacology. At least not until they invent rectal psychotropics.)

Working in a correctional environment actually helps when you're dealing with some of these multiply co-morbid cases. The structured environment gives some predictability and stability to their lives. It takes away some degree of stress in that they don't have to think about where their next meal is coming from. The clear rules and expectations set boundaries for containing the maladaptive behaviors. And while drugs and alcohol certainly do exist in jails and prisons, there's a lower likelihood that the patient will be using inside the walls than in free society. Finally, the patient has access to medical care that he might not otherwise have in the streets so the co-existing medical conditions are less likely to hinder treatment. My job would be much harder if I were treating these folks in free society.

Then again, in free society I'd have a desk and a telephone. And modern ventilation. And office supplies. And an office. Clerical support. A fax machine. Ample parking space. Unlocked restrooms. A vermin-free place to eat. And...

Oh, never mind.

Tuesday, January 22, 2008

Here's When You Need A Psychiatrist

Have we written this one yet? I seem to think that Roy, our Consultation-Liason Boy, may have done this.

This is just my opinion, it's written with the non-shrink doc in mind, and it assumes access to psychiatric care:

So when should a patient be referred to a psychiatrist for care?

  • When their distress due to psychiatric illness is such that they can't contain it and are driving the primary care doc nuts.
  • Any patient with the new onset of a psychotic illness should initially be stabilized by a psychiatrist (this is just my opinion) if they are willing to go. Psychotic illness: any illness accompanied by hallucinations and/or delusions. Psychosis is frequently seen in Schizophrenia and Bipolar Disorder, but can also be seen with depression, delirium, and a host of other non-psychiatric illnesses. If the patient's hallucinations are caused by a brain tumor and they resolve with removal of the brain tumor, then the psychiatrist may not be necessary. Maybe Roy can write us a "causes of psychosis" post.
  • For depression: my conservative rule would be to refer after the patient fails one antidepressant medication given at a therapeutic dose for long enough. What's a therapeutic dose: I go as high as a) the patient will tolerate or b) to the highest recommended dose (which ever comes first). If a patient can't tolerate more than 50mg of zoloft, well, this isn't a full trial. Switch to another med and try to get the patient up to a full dose. Wait AT LEAST four weeks (the mantra is 3 to 6 weeks) on a good dose. It's not uncommon to get a patient who has been on small doses of many anti-depressants, none for very long. And primary care docs aren't the best at augmentation strategies.
  • Any patient with Bipolar Disorder needs a psychiatrist to stabilize them, and a psychiatrist available for management of episodes. If someone has been stable on Lithium for the past 8 years, they don't need a psychiatrist to prescribe it.
  • When prescribing that first antidepressant, ask every patient with depression if they've had a manic episode: "Have ever had a time when your mood was too good, when you had excessive energy and needed less sleep, when you talked faster than usual, your thoughts raced, you were more impulsive than usual with regard to spending or sex?" Anyone who doesn't look at you like you're nuts for asking this needs to be questioned in more detail about manic episodes. If the patient has a history of even one manic episode, you're dealing with Bipolar Depression and prescribing antidepressants could be very risky-- not a bad time to refer.
  • Don't prescribe Xanax for a chronic anxiety disorder. It's hard to treat patients who get dependent on xanax and it's hard to refer them if they end up on high doses.
  • Any patient with a recent serious suicide attempt or recent psychiatric hospitalizations should be stabilized by a psychiatrist.
  • Any patient with any psychiatric disorder that is compromising their ability to function, who does not improve after two to three months of treatment, should be referred for psychiatric care-- so OCD or Panic Disorder that is not getting better quickly.
  • If a psychiatric disorder puts anyone's life at risk, it's probably more than a primary care doc wants to or should deal with.
  • Any patient who is being treated by a primary care doc for a psychiatric illness should be asked if they want to see a psychotherapist (a shrink or a psychologist or a social worker or a nurse therapist). The patient may say that the pills have cured their depression and they don't need to talk. In the absence of information, this should be respected. But the gentle offer of a psychotherapy referral should be made early.
Sorry, a little haphazard, maybe Roy can come in and add an addendum....

Tuesday, January 15, 2008

Violent Mood Swings

"My mood is swinging."

When I see this as a chief complaint in a progress note I know what I'm going to read next: a diagnosis of bipolar disorder, not otherwise specified, and an order for the mood stabilizer du jour. What I will not (usually) see is a description of what mood states the patient is "swinging" between, the duration of those mood states or a list of associated symptoms. This isn't specific to correctional work in that I've also seen documentation like this in discharge summaries I've received from hospitals.

I'm familiar with the various "flavors" or subtypes of bipolar disorder that have been hypothesized, but the guys I treat don't fall into a clearcut diagnostic category (unless you count personality disorders) and sometimes there are cases that really push the boundaries between an Axis I and an Axis II problem. I see this a lot when I'm dealing with inmates with a history of institutional violence.

People who do research on violence struggle over how to define or characterize violent acts. You'll see references to predatory violence versus instrumental violence versus opportunistic violence versus impulsive aggression. The nuances elude me, other than to say that the one consistent thing seems to be the degree of planning (or lack thereof) involved in the act.

Before deciding to throw meds at the problem, I'll usually do an assessment to clarify whether or not violence really is an issue. You'd be surprised the number of guys who self-identify temper as an issue, but when you take their histories they've actually held it together quite well. Someone who only has one ticket (infraction) for fighting in a year of incarceration really can't be considered to have too much of a problem with violence. In cases like that I'll ask more questions to figure out exactly why the patient thinks it's a problem; more often than not, they're troubled by the fact that they merely have violent thoughts. In that case the inmate has unrealistic expectations of what a medication can do for their problem.

Other questions I ask are:

* who are you fighting with, inmates or officers or both?
The choice or level of discrimination reflects the degree of control over the violence.

* have you gotten into fights that you haven't had tickets for?
If the answer is yes, this usually means that the patient and his/her opponent plans the fight to avoid detection by custody, another situation where medication is unlikely to be of benefit.

* do you fight when you're sober and clean?
By far the most common precipitant for violence is substance abuse, either in the facility or in free society.

* do you have a bad temper even when you're not depressed?
Clinical depression can decrease frustration tolerance for prisoners. This is often the factor that causes them to seek treatment when they wouldn't even think of seeing a shrink on the outside. Treating the underlying depression fixes the temper problem.

* tell me about some of the situations you've gotten mad in recently
Often there's a good reason for it. Medication is unlikely to help you keep from getting mad when you've got people cursing at you or threatening you. Normal anger exists for a reason and medication will not keep someone from ever getting angry over things that would anger anyone.

So once I've done all this I'll decide whether or not the violence issue is one that might benefit from medication. I'll make it clear in my note that violence is the target symptom and I won't try to stretch a diagnosis to justify a treatment plan.

I think all classes of pharmacologic agents have been used to treat violence at one time or another, but most recently mood stabilizers have shown the most utility for aggression associated with personality disorders. Lithium has been used for this since the original studies in the 1970's, when it was found to cut the violent infraction rate in prisoners by about half. (Interestingly, some of this subjects also discontinued the medication on their own because they didn't "feel" it working, even when it was.) Valproic acid, carbamazepine and now the atypical antipsychotics have all been used for this. SSRI's can have an interesting pro-apathy (if that's a word) effect in some people, giving them the ability to "shrug off" experiences that they normally would have gotten upset about. Regardless, the goal is to lengthen the patient's fuse and give them time to think before they act.

As one patient of mine put it: "The medication doesn't lengthen my fuse. It gives me a fuse."

Monday, December 03, 2007

What Good Are Psychologists?

So this morning I'm scheduled to see eleven people and an officer catches me at the door, before I even have my coat off, to tell me that one of my patients is down and waiting to see me. I get to the clinic and see two of our institutional psychologists sitting in an office, chatting. I don't think too much of this---it's the usual morning start, they've made the morning coffee---until I happen to see the morning clinic schedule for the psychologists.

Four fulltime psychologists are scheduled to see a total of six patients today.

The thought flitted through my head: "What good are these people?"

The unvarnished truth is that a single correctional psychiatrist will see as many patients in a given year as three fulltime psychologists. This is pretty consistent from what I've learned from talking to correctional psychiatrists in other states. And this makes sense---the vast majority of referrals are medication issues and they can't do anything about that so the referrals get routed directly to me. I also get the diagnostic dilemmas, the unexplained mental status changes that you need medical training to sort out. (Heaven help me if I see another inmate in alcohol withdrawal diagnosed with schizophrenia.) Psychiatrists see more people because they are trained to do things that psychologists can't do, and psychiatric issues come up much more frequently than psychological issues.

That being said, the psychologists I work with are wonderful. They have great senses of humor, they help me keep up my morale and they don't hesitate to step up to the plate to help with what they can help with. They handle the emergency referrals that come up during my clinic. When the secretary is off or out sick (I don't have a clerk of my own, I have to borrow help from the psychology department secretary), the psychologists help traige referrals, set up my clinic schedule and pull charts.

They have their own specific professional duties, of course. They give input into classification decisions (where an inmate is assigned to do his time, what security level he needs) as well as input into program eligibility. When requested they'll do parole assessments and respond to staff needs in case of crisis (suicide response debriefing, mass disturbance debriefing, etc). They provide crisis intervention counselling, substance abuse groups, sex offender therapy and set up behavior plans for inmates who require them.

So this is what psychologists are good for in prison, in case you were curious.

Monday, October 22, 2007

And Now a Word or Two about Mood Stabilizers

I came to talk about mood stabilizers and figured I'd start by summarizing our sidebar poll "What is Your Favorite Mood Stabilizer?" Only every time I come on, the poll has gotten more votes, so I guess I'm waiting for the mood stabilizer poll to stabilize.

Here's where we're at so far:

What's Your Favorite Mood Stabilizer?

32 (22%)
Depakote (Valproate)
27 (19%)
Zyprexa (Olanzapine)/ other atypical anti-psychotics
29 (20%)
Carbamazepine (Tegretol)
1 (0%)
Gabapentin (Neurontin)
9 (6%)
Lamotrigine (Lamictal)
44 (30%)

143 votes, Lamictal has been consistently in the lead since the beginning. Both surprising and not surprising.

I talked about How A Shrink Chooses an Antidepressant. I have less to say about how a Shrink Chooses a Mood Stabilizer. In fact, I'm not really sure. I'll tell you how This shrink chooses a mood stabilizer. It's not that much different, so click on the that post for more details.

  • History of Past Response.
  • Family History of Response
  • Patient Preference. This is a big one with mood stabilizers. The gold standard is Lithium and some patients just won't hear of it. They think taking lithium means they're really far gone, that it's heavy duty stuff, that it means they're crazy.
  • Medical issues: lots of them with mood stabilizers.... lithium can effect the thyroid and kidneys, it interacts with lots of other meds, depakote can effect the liver, so can tegretol, lots to think about, lots to monitor.
  • How strongly I'm convinced that the patient has had a full blown manic episode. Plenty of people say "I'm Bipolar" but the history doesn't reveal a story for episodic, syndromic co-occurance of the hallmark symptoms of mania: elevation in mood or irritability, increased energy/ decreased need for sleep, quickening of thoughts or speech, impulsivity with regard to spending, sexuality, religion, hallucinations, grandiose delusions, inflated sense of worth or well-being. None of these symptoms alone are enough to diagnose mania, ya gotta have a few and they have to occur at the same time as the other symptoms. Lots of people shop impulsively to cheer themselves up, lots of people have periods where they feel more energetic and productive, lots of people get happy when they win the lottery. It's sometimes hard to get a history for a syndromic diversion from a baseline (or pre-morbid) personality.
  • If I think someone definitely has bipolar disorder, and there isn't a reason not to use it, I start with Lithium. It's a good mood stabilizer. It's cheap. I'm familiar with how to use it. It's also a good anti-depressant augmenter. Despite all the hype about the awful side effects (weight gain, nausea, tremor, cognitive slowing, renal and thyroid impairment), I've seen lots of people have good responses and not have any side effects, so I start with that assumption and I use low doses. If the patient gets better, I don't push the level, even if it's really low. If the patient has intolerable side effects, I try another preparation of lithium (eskalith, lithobid), and if that doesn't work, I stop it and try another med. Why do I like lithium? I think because I've heard enough people put up resistance, then try it and come in saying "I feel normal for the first time." The down side is that you have to do bloodwork every 3-4 months even if the patient is well and has no symptoms.
  • If I'm not so sure about the manic component as a real, syndromic entity, and the primary complaint is depression, I start with Lamictal. The upside-- it's well tolerated, people like it, there's no routine labwork and there's no stigma. The down side-- slow going to build up from a dose of 25mg to the therapeutic range of around 400mg. Another down side-- that fatal rash risk. And the final down side-- I've heard a couple of anecdotes of patients who have ended up in the ICU with rashes, liver zorkout, life-threatening problems. Not a lot, but it only takes one such story to make you hold your breath when you write a prescription and I have a friend who says "I'll never be able to prescribe Lamictal again." It's not science. I actually tell patients this story-from-hell when I prescribe it, and they'll still take it over lithium. Mostly, it's a good medication, it's well tolerated, and it helps.
  • If a patient doesn't want Lithium, I prescribe depakote. It's associates with it's own issues, including weight gain, needs lab monitoring, and if the patient doesn't have insurance, it's expensive and hard to get samples of.
  • I haven't prescribed tegretol in ages and I wondered if the reason it's so unpopular on our sidebar is because it isn't used so much.
  • I prescribe anti-psychotic medications to people who are agitated, acutely suffering, not sleeping, in need of something quicker than lithium/depakote/ or lamictal. These medications work, they're well-tolerated, patients like them. And I worry about the metabolic effects and wish there was some free ride.
  • Sometimes I use one of the older anti-psychotic-- navane may be my favorite
  • If there is no history of substance abuse (---hmmm, that's rare in people with bipolar disorder), I may prescribe some ativan or klonopin for the short term.
  • I haven't used Trileptal, I don't know why. I have a patient or two on Neurontin, I stopped prescribing it when studies showed it didn't help with mood stabilization. Perhaps I was wrong. And I haven't seen very many people tolerate Topamax, though I have seen it work wonders for migraines.
  • Lithium is my favorite.
Okay-- I know there are lots of people out there who've had bad experiences with lithium. I'm not advocating that anyone re-try a medication they didn't tolerate. I'm just suggesting that everyone responds differently and before the medication is prescribed, your doc doesn't have any way of knowing if you will have problems or be one of those people who has a wonderful response and no side effects.

And to one of our anonymous commenters who wrote in:
Anonymous said...

I hope you have a really great reason for purposely for gathering useless data.

Yes, anonymous, I had a really great reason: I was curious, wondered if I'd learn something (and I did) and I thought I'd use the information for a blog post. Rest assured, I have indeed gathered completely useless and out of context data. It still makes me happy when my useless information is quoted by the Wall Street Journal.

Monday, October 08, 2007

My Three Shrinks Podcast 36: Just Do It

[35] . . . [36] . . . [37] . . . [All]

Folks, we have heard your requests for us to upgrade our sound quality. That is coming up, probably in Podcast #38. Yes, the Google Ads have paid only about 5% of the cost of the upgrade, but we may keep them on the site until they've hit $100, as I believe that is the minimum for a pay-out ($19.05 for September).

October 8, 2007: #36 Just Do It

Topics include:
  • Crisis in the Treatment of Incompetence to Proceed to Trial. In the recent Online AAPL Journal, an article by Wortzel about problems with assessing defendants who are not competent to stand trial and restoring them to competence. [hmm, wonder whose topic this one is] At any given time, these people occupy about 10% of our nation's state psychiatric hospital beds. A complicated discussion ensues about who pays for forensic mental health care and how the system results in decreasing access to care for uninsured non-forensic patients.

  • We respond to a question to the NYT Ethicist column, by Randy Cohen, which you can read here (as well as his answer). [Note: we last saw Randy when he stopped by to respond to a discussion about a previous column of his about suicidal people making wills.] The question involves whether it is okay for a physician, who is a psychiatrist, to prescribe a stimulant (Adderall) to his college kid for the purpose of improving test-taking performance. (We discussed the practice of treating family members in a prior post, My Patient, Myself.) A secondary question involves that kid sharing the medication with a friend. We also discuss the issue of using performance-enhancing amphetamines for non-illnesses, in addition to the potential for a performance-reducing effect due to side effects (which is also taken on my Gawker's Unethicist). (We also ask for help from any DEA agent listeners.)

  • Clink celebrates her 25th Running Anniversary. She's been just doing it for a quarter century.

  • Price Transparency for Psychotropic Drugs. Dinah discusses her post about the list of prices for antidepressants. Roy unsuccessfully looks for the prices of these drugs on the Maryland Medicaid website.

Coming up in Podcast #37... SSRI Poop-out (aka tachyphylaxis) and other good stuff. Oh, and here's a pic from my Vegas conference trip. Yummy!

Find show notes with links at: The address to send us your Q&A's is there, as well.

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from
Thank you for listening.

Wednesday, September 26, 2007

The Co$t of Being Depressed

Okay, I've truly lost it. I've just spent the last half hour on the phone calling a couple of pharmacies to find out the cost of antidepressants, all for Shrink Rap. You see, as a doctor, I've never learned what this stuff costs. I know vaguely that the older stuff is cheap, and the latest greatest is expensive, sometimes really expensive. I actually started my research yesterday. I thought I'd compare the prices at a local independent boutique pharmacist in a ritzy neighborhood where home delivery is offered, to a chain, to Walmart or Sams Club with the assumption that Walmart would be the cheapest--though really, I'm not sure of this. My quest was limited, however. By the time I really sat down to do this, it was so late I was limited to 24-hour pharmacies, so no Walmart in the comparison.

With my gratitude to the pharmacists who humored me, here's what I found.

The local independent pharmacy informed me that "our system doesn't allow us to look it up without a prescription." Huh? I asked again several times, they couldn't tell me what a medication cost. Okay....

CVS-- a large chain store-- I got a pleasant sales person on the phone.
Similarly at Walgreens. Pharmacists are generally nice people, I've found.
So all prices are for
30 pills, I aimed at the usual antidepressant doses. A little bit of confusion around Elavil (amitryptiline), one of the older tricyclic antidepressants which I just about never use, but it's cheap. I asked about a 100mg dose and CVS told me it came as 75 mg while Walgreens said they had it as 100mg. I only asked for a few prices at Walgreens, mostly to see if there was variation (there was). Zoloft, Lexapro, and Trazodone are scored pills, so if you take half the listed dose, this will last you two months. Many people, however, are on 200 mg of zoloft, and since the largest pill is the 100mg tablet, double the price for high doses. These are the cash prices, in US dollars, and I called pharmacies in Maryland. I tried to set this up as a table spreadsheet, but blogger ate that format.

Paxil, 20 mg...................... 125.99
generic Paxil 20 mg............ 48.95
generic Prozac, 20 mg ........19.19 .............29.99 (Walgreens)
Zoloft, 100 mg ....................140.99
generic Zoloft, 100mg ......... 45.19
Celexa, 40mg .......................122.99
generic Celexa, 40mg............ 33.69
Cymbalta, 60mg .................. 149.99........... 142.99 (Walgreens)
Nortryptiltine, generic, 75mg.. 31.69
Lexapro, 20 mg ..................... 106.99......... 105.99( Walgreens)
Elavil, 75mg ............................53.59
generic Elavil, 75mg................ 10.99,,,,,,,,,,, 12.39 (walgreens)
Trazodone, 150mg ,,,,,,,,,,,,,,,,,,, 23.19
Wellbutrin XL, 300mg............ 215.99
generic Wellbutrin XL, 300mg... 149.99....... 139.99 (Walgreens)

[from Roy]
Don't forget about Walmart's $4 list. You can buy 30 pills of any of these for $4, whether you have insurance or not. In the hospital, we frequently choose meds for uninsured pts based on this list (eg, Prozac 20 mg = $4/mo. Elavil, Paxil, Trazodone and Doxepin are other choices for antidepressants.)

Thursday, August 30, 2007

My Patient, Myself

I saw this abstract and wanted to post it. Entitled Psychiatrist Attitudes toward Self-Treatment of Their Own Depression, it's a survey conducted of Michigan psychiatrists regarding their opinions toward self-prescribing. A survey of more than 500 Michigan psychiatrists showed that more than 40% would medicate themselves for mild to moderate depression and that 15% had actually done so in the past. Seven percent of psychiatrists said they would treat themselves for severe depression or depression involving suicidal ideation.

The AMA code of medical ethics states: "Physicians generally should not treat themselves or members of their immediate families...It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems."

So why or when would a doctor consider treating himself? I don't know Michigan well, but I'd guess they probably have the same shortage of psychiatrists that other Midwestern states have. If you're a depressed psychiatrist you may be the only game in town. Maybe he'd be concerned about privacy and information-sharing among colleagues.

Or maybe the AMA would consider mild clinical depression to be a "short-term, minor problem" for which the self-treatment exception would apply. There are probably hundreds of physicians who at one time or another have written antibiotic prescriptions for themselves or for family members. I wonder if this also applies to prescribing for family pets? Should a psychiatrist prescribe Prozac for his obsessional cat? Thorazine for the nervous dog? A recent survey of neurologists showed that more than 90% agree that it would be appropriate to self-prescribe for acute minor illnesses. Another survey of young Norwegian physicians found that 90% had self-prescribed in the past year.

Don't ask me what Michigan surgeons would do...

Wednesday, June 27, 2007

I Still Prescribe Seroquel But I Don't Get Paid To Do It.

Chapter 10 remains up at Double Billing. Thanks to those who've commented!

And don't forget to check out the ClinkShrink fiction venture at Double Celling!


How this money may be influencing psychiatrists and other doctors has
become one of the most contentious issues in health care. For instance, the more
psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for
whom the drugs are especially risky and mostly unapproved.

Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.

Wow! Or maybe Oy! That's a lot of money, they don't say How Many Vermont psychiatrists see that kind of moola. One, two, ninety percent of those maple-syrup, Birkenstock-wearing Shrinks, or all of them?

So, for the record, last year I earned $0.00 from pharmaceutical companies. Funny, it was the same amount that I earned the year before and the year before that and the year before that. What am I doing wrong? Where's my 45 grand?

Full disclosure: I work in two different settings that serve indigent, often uninsured, patients. Some of the people I see in private practice have no health insurance. Atypical antipsychotics cost a lot of money. If you don't have health insurance, they remain pretty much inaccessible to many many people. So I'm nice to the drug reps, I chat for a few minutes, I sign for samples, sometimes I even call and request samples, I use their pens, and if you show up needing an antipsychotic agent, you get the one that's in the closet. I used to run a clinic, and part of that work entailed educational programs for the staff and boosting morale: go straight for the stomach. Sometimes I asked the pharmaceutical reps to provide lunch and they'd bring a tray of sandwiches. This went over well with the staff.

Do the pens and sandwiches influence what I prescribe? I can't say no for sure, but it feels like they all come, so what's to say which I use more? Really, boils down to my anecdotal evidence more than anything else: if the first time I try a med, the patient returns saying it helped, I'm more likely to use it. If I have to slowly titrate up and it takes a lot of time and a lot of appointments, I'm less likely to use it. Sorry, Effexor. If the first patient who tries it comes back ranting it was horrible, I get a bit colored. I talk to my shrinky-friends: are they having the same experience? If not, I'll reassess and try again. Even if I don't use the drug myself, I still smile at the reps, sign on the dotted line, and throw the samples in the closet for whoever else wants it.

So why aren't they paying me? Really, that post I wrote on Why I Still Prescribe Seroquel, shouldn't that be worth a few bucks? Look, I'm cheap, never mind the 45 grand, I'd have done it for a mere $20,000.

Finally, I need to say a few words about media sensationalism. Villainizing psychotropics seems to be the thing to do, and hell, get those docs who prescribe them while you're at it. I really wish that atypical antipsychotic medications didn't cause weight gain, diabetes, and metabolic problems. And now that I know this, I tell people. Many people don't develop these side effects-- I've become more diligent about checking labs and warning people of the risks. Though I really wish I could say that it's rare for people to develop diabetes either on or off these meds-- the truth is it's a really common illness and a lot of my patients have it before they see me, a lot get it during the course of treatment, and some get it during the course of treatment with atypical antipsychotic medications. If there was something else I could prescribe, I would and often I do. From my perspective of the doc-in-the-office, there sometimes is just no option but to use these medications, they're what we've got. This isn't to defend the drug companies, I believe their goal is simple: to make money. Kind of like your health insurer runs ads with soft music telling how they care, but really they just want to make money. What surprises me is that anyone expects anything else from them. No answers, sorry.

My last word about media sensationalism: It's hard to get Medicaid, you have to be sick. An episode of depression treated with Prozac doesn't do it. To get Medicaid, at least in Maryland, you have to be chronically ill (and even that isn't always enough), so a bad psychiatric illness, chronically, probably one that you need a chronic, expensive, antipsychotic medication to get. No wonder antipsychotics are a high percent of the Medicaid budget.

Okay, send the check, I'll be waiting

Tuesday, June 19, 2007

From The NYTimes: When is a Pain Doctor a Drug Pusher

Oh, no, I did it again, I posted over Roy! I swear, I didn't know. Scroll down for his post.

We like to talk about subjects where the lines get blurry. Who should get care? When is it an illness? Xanax? Seroquel? Which side of the fence and how far over might one lean?

So here's an interesting cover story in the Sunday New York Times Magazine: When is A Pain Doctor A Drug Pusher?

It's the story of a pain doctor who has been sentenced to 30 years in prison for his sloppy and questionable prescribing practices. The article's author, Tina Rosenberg, comes at it with the tone that it's outrageous that he was sent to jail, deemed a criminal, for his lax practice. Bad doctoring, she contends, is cause for civil malpractice litigation, not criminal prosecution. The docs who prescribe in exchange for sex or drugs, they are the criminals. The doctor in the story did none of those things. She makes the point that the standards for prescribing narcotics, especially to a chronic and drug-tolerant population of pain patients (who may be peppered with occasional abusers) are purposely not stated, and leave the doctor open to both scrutiny and criminal charges.

There are red flags that indicate possible abuse or diversion: patients
who drive long distances to see the doctor, or ask for specific drugs by name,
or claim to need more and more of them. But people with real pain also
occasionally do these things. The doctor’s dilemma is how to stop the diverters
without condemning other patients to suffer unnecessarily, since a drug diverter
and a legitimate patient can look very much alike. The dishonest prescriber and
the honest one can also look alike. Society has a parallel dilemma: how to stop
drug-dealing doctors without discouraging real ones and worsening America’s
undertreatment of pain.

* * *
But such guidelines are futile while there is one pain specialist for,
at the very least, every several thousand chronic-pain sufferers nationwide. And
even though pain is an exciting new specialty, doctors are not flocking to it.
The Federation of State Medical Boards calls “fear among physicians that they
will be investigated, or even arrested, for prescribing controlled substances
for pain” one of the two most important barriers to pain treatment, alongside
lack of understanding. Various surveys of physicians have shown that this fear
is widespread. “The bottom line is, doctors say they don’t need this,” said
Heit. “They’re in a health care system that wants them to see a patient every 10
to 15 minutes. They don’t have time to take a complete history about whether the
patient has been addicted. The fear is very real and palpable that if they
prescribe Schedule II opioids they will come under the scrutiny of the D.E.A.,
and they don’t need this aggravation.”

By the time I finished this article, I was glad I'm not a pain doc. I was even more glad I'm not a pain patient.

Wednesday, June 28, 2006

Roy: Healthcare Truth & Transparency Act

I've been a lax blogger (working too hard). SHP inspired these thoughts.

This from the APA today:

RE: New APA-backed U.S. House Bill Attacks Consumer Confusion about Physicians and Non-Physicians

We are pleased to let you know that today Representative John Sullivan (R-OK) and Representative Gene Green (D-TX) introduced bipartisan legislation to help safeguard patients from misleading claims by healthcare providers about qualifications and training. Representatives Sullivan and Green were joined by Representatives Michael Burgess (R-TX), Joe Schwarz (R-MI), Charles Bass (R-NH), Michael Bilirakis (R-FL), and Pete Sessions (R-TX) as original cosponsors.

The bill, the Healthcare Truth and Transparency Act, will promote patient safety and informed choice by better distinguishing between physicians and non-physician groups who create confusion by their apparent efforts to cloak themselves in the medical or physician label. As an example of the potential for consumer confusion, your DGR provided our congressional leaders with examples of the growth in the use of "medical psychologist" -- a misleading and frankly meaningless term that is the creation of those in organized psychology who seek prescriptive authority by state legislative fiat, not by virtue of medical education or training. The Sullivan bill says that:

‘It shall be unlawful for any person who is a licensed health care service provider but who is not a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine to make any deceptive or misleading statement, or engage in any deceptive or misleading act, that deceives or misleads the public or a prospective or current patient that such person is a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine or has the same or equivalent education, skills, or training. Such deceptive or misleading statements or acts shall include advertising in any medium, making false statements regarding the education, skills, training, or licensure of such person, or in any other way describing such person’s profession, skills, training, experience, education, or licensure in a fashion that causes the public, a potential patient, or current patient to believe that such person is a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine.’

As part of our ongoing efforts to deal withnon-physician scope issues, the APA has also joined a coalition of medical specialties and the AMA in foundingthe Coalition for Health Care Accountability, Responsibility and Transparency (CHART), which is committed to promoting and supporting the Sullivan bill.

Both the Sullivan bill itself, and APA's membership in and support for the CHART organization, together with APA's founding role in the AMA scope of practice center, are concrete examples of our continuing efforts to proactively respond to the psychology prescribing struggle. We hope theapproach taken by the Sullivan bill willoffer our District Branches and State Associationsa template for relatedefforts in the states. At a minimum, enactment of the Sullivan bill will provide a means at the federal level of addressing efforts by non-physician groups to use tactics that may mislead and confuse the public. As part of our ongoing campaign to assist our District Branches and State Associations, APA is also working on other legislative "templates" that we hope will be of use in playing offense as well as defense in the states.

Trick-cycling's post about nurse practitioners and physicians, along with today's well-timed announcement, made me think of posting this. I do find still that many folks don't know their ologist from their iatrist. Now there's the urse actitioner. The legislation would require these non-MD providers to correct patients, when asked the question, "What's up, Doc?"