the times are a changin’…

Posted on Friday 21 October 2016

I work as a volunteer physician in a [formerly] charity clinic in a rural part of a rural State. The Clinic was started by some retired doctors and operated out of a few trailers with a large volunteer staff, seeing only uninsured patients. This is an unusual place at the beginning of the Appalachian Mountains. About ¼ of the county is occupied by gated retirement communities. The rest is home to the descendants of the settlers that came after the Cherokee were marched out on the Trail of Tears in 1838 and their land parceled off in a lottery. It’s a beautiful place that has the world’s largest piece of white marble [1 mile x 6 miles x unk. depth] that sustained the county back when people built with marble [it’s now the grit in your toothpaste]. It was also the home for the "moon shiners" of a former time, and their whiskey-runners and souped-up cars were the direct progenitors of the  modern NASCAR races.

The clinic I work in was staffed by retired volunteering professionals of various ilks from the gated communities and serves the indigenous population. There’s a symbiosis between these two groups that works well – strong tax base, well stocked Thrift Shop, plenty of eager workers for building and other jobs, a better hospital than we might otherwise have, our clinic, and a  cultural mixing that’s refreshing. Both groups are mostly Republicans [for different reasons].

With the coming of the Affordable Care Act and insurance for all, the clinic changed dramatically. The old docs who founded it either died or moved on [I find myself the old man now]. Instead of volunteers, we now have a few volunteers but mostly employees. There’s a new clinic building. There are inspections and standards, a new EMR [Electronic Medical Record] system. Everyone gets vital signs and fills out a PHQ-9 in the waiting room with every visit [I wonder who looks at them? not me]. And it seems like there’s some kind of administrative snafu with almost every patient, any prescriptions. Every patient has a "primary" – a primary care-person, usually a nurse practitioner. And there are lots of "rules" from the various governments and agencies involved. The patients are confused by it all [as am I]. I actually hate that it changed, and am likely to soon move on out of frustration.

The thing that has me mentioning it here is hard to know how to say – it’s a change in attitude in both the staff and patients that I didn’t anticipate – but it’s undeniable. It’s almost adversarial. Though that word seems too harsh, it’s the best one I can think of. It’s as if there has been a shift from a hermeneutic of trust to one of suspiciousness. The staff seems often worried that the patients might be trying to game the system, and the patients are likewise concerned that something might be withheld, that the "system" is working against them. It’s bigger than the fact that there’s now money involved though the fees are quite low. In my case, because I remain a volunteer and am not a registered "provider" in any system, there’s no charge to see me. Yet the attitudinal change spills over into my office. I never anticipated anything like this happening and there doesn’t seem to be anything I can do about it.

I hope I can find a way to stay on for a while because I’ve really enjoyed my time there. It has been a good end-of-career experience. It’s an antidote to some of the disillusioning things I encounter in writing this blog. It’s a mixture of all the different ways of approaching problems help-seeking patients show up with – doing what can be done in the time alloted. I often think of the title of Adolf Meyers’ collected works "Common Sense Psychiatry" – because that’s what it comes down to. Many of the patients I see have outrageous biographies, yet have put together meaningful lives against the odds. And even with the brief and infrequent visits to the clinic, I’m often awed with the work that can be accomplished. And it’s good for a psychoanalytically oriented psychotherapist to work in a situation where the very medications I talk about here as overused can be so helpful in treatment if you’re careful.

But something about becoming a Bona Fide, Certified Center with all that entails has changed the ambience in ways I couldn’t have imagined. My working hypothesis is that the staff’s feeling of being "watched" and "judged" has been passed on to the patients. Rules and standards have replaced "Common Sense" I find myself wondering if that’s inevitable…
    October 21, 2016 | 11:58 PM

    You are not only being watched and judged.

    You are being manipulated by the largest government and business conspiracy in the history of mankind.

    Stealing the profession from physicians wasn’t enough. We now all have to jump through the hoops of meaningless “quality” markers invented by business types – who don’t know what medical quality is. We all have to work for “managers” who have not added a thing to the field since they appeared on the scene 30 years ago.

    There is nothing quite like managers telling professionals what to do.

    Bernard Carroll
    October 22, 2016 | 12:14 AM

    I saw the movie Sully last week. It’s an allegory of the autonomous clinician pushing back against managers armed with algorithms and simulations.

    James OBrien, M.D.
    October 22, 2016 | 12:16 AM

    Asking someone questions completely unrelated to the chief complaint will cause suspiciousness and a breach of trust, and rightly so.

    Sadly the movie Brazil has morphed from a dark comedy to a documentary.

    In order to practice the old way we have to be Harry Tuttle.

    Because otherwise there’s too much paperwork.

    October 22, 2016 | 2:50 AM

    This was a very curious time for me to start my own practice within a group that takes insurance because I have no direct personal experience of the model of care that preceded it. My internship was in a big-city clinic with a cryptic, impenetrable EMR and for a school counseling company, and both were completely defined by paperwork.

    In my previous careers, there were always parasitic sycophants draining money from the people who actually did the work, so that part was not anything new. I wasn’t happy about it, but it was sort of an existential given like death, voice recognition software, and touch-screen interfaces.

    Many of my clients are initially hostile to the model of care at our practice, but some are very grateful Usually, they are astounded that they actually found a therapist who takes insurance, and when they find out I’m not completely humorless and I won’t encourage them to take lots of medication they hate and don’t need, we get along pretty well.

    The really low-income clients who’ve been kicked around a lot do sometimes fear that the entire practice is some kind of scam, and they will be presented with a huge bill at the end. Curiously, one of these clients had a paradoxical transferential reaction where he/she completely abandoned her fear of being charged and suddenly became very worried that I would not get paid by the insurance company– which seemed possible at one point. Our provisional termination plan was that if I didn’t get paid, I would insist on providing three pro bono sessions to terminate, I would refuse to pay rent, and the client would be charged nothing, ever, for anything . It was basically “we did all the paperwork, spent hours on the phone with all the right people, and if you don’t do right by us? F*ck y’all.” So dealing with the insurance company cemented the alliance, gave the client a sense of at least some autonomy and control, and when the insurance company actually paid, we were in a great place to do some good work.

    I liked Sully a lot, and I’m a huge fan of Brazil.

    October 22, 2016 | 11:20 PM

    I’m about to make myself unpopular with what I’m going to say The quality measures and tracking aren’t all bad in all areas at least not all of the time. I say this as someone who works in what is essentially quality management. My specific area of focus is making sure women who are patients of a primary care practice get a pap smear every 3-5 years.

    There are a number of reasons why this doesn’t always happen. I won’t bore you with all of the details. Mostly, it’s something as simple as someone coming in for a sick visit and not being reminded to schedule an appointment. We wouldn’t know this if we didn’t track it, and I believe that has value.

    Sigh. I’m no fan of the PHQ-ization of healthcare, but data and measures have their place too.

    October 23, 2016 | 2:30 AM

    This is an enormously important post. But, while I was contemplating a response I came across this:

    Don’t agree with a number of things that Rosenbaum writes, but there is a lot to reflect upon in this piece. It isn’t written in a facile tone.

    October 23, 2016 | 2:32 AM

    It says that it is part 2. I can’t seem to figure out a link to part 1. If someone who has could post that I would appreciate it.

    James OBrien, M.D.
    October 23, 2016 | 11:21 AM


    Data mining is not the purpose of the clinic. If someone wants to do a study fine, but doctors are not conscripts for government agendas nor data entry clerk. Whatever merit you think this stuff has (and you never quantified that) needs to be balanced against the corrosive distraction from the task at hand.

    An anecdote means nothing to me. I can give you plenty of anecdotes of distracted doctors making medical errors due to this distraction. I can also give you examples of fine doctors who have gotten fed up and quit. It’s also killing bedside physical exam skills since that’s not measured in the office visit, because the doctor needs to enter the gravida and para status of a male patient and make sure that their nonsmoking status shows up every three pages.

    October 23, 2016 | 3:46 PM

    The Rosenbaum article alludes to the group that has been successful in getting these issues into the Case Reports of the MGH:

    The overriding factors in my experience are bias on the side of the medical and surgical attendings and very poor insight and judgment on the part of the patient with severe mental illness. Rosenbaum seems to take an anti-coercion stance with regard to the mentally ill. It is easy to say when you are an internist or a surgeon and you just have to discharge the person AMA.

    If you are a physician and don’t want to handle these problems realistically – get out of the way and let a psychiatrist handle it. At least that gets it to the next obstacle – the state laws about guardianship/conservatorship and whether anyone responsible in the county or state cares if your patient dies.

    October 23, 2016 | 3:52 PM

    ” I’m no fan of the PHQ-ization of healthcare, but data and measures have their place too…”

    Measures have their place if they are:

    1. Valid
    2. Subject to valid statistical analysis

    There are very few that are, especially considering the hundreds (thousands?) being put out there by the feds. These measures all have to do with business metrics and “incentives” with no real attention to quality.

    The massive major quality study done by Medicare in the 1990s that proved there was no level of overutilization or quality problems that would justify the cost of the program has been ignored ever since.

    Managed care is built on a foundation of fictitious assumptions and quality measures – but these days nobody seems to mind anymore.

    October 23, 2016 | 4:18 PM

    Link to the first article in the series:

    October 23, 2016 | 4:29 PM

    Thanks for the link.

    James OBrien, M.D.
    October 23, 2016 | 4:57 PM

    Let’s see, what problem in this chart to you deal with if you want medical care to be better and cheaper?

    21st century medicine is trying to make itself better by adding more middle men. Yet technology that works does the opposite.

    Is this insanity or stupidity? I think its letting the biggest offenders get away with malpractice because they are louder and relentless (I keep thinking about the Yeats poem, the Second Coming, “the worst are full of passionate intensity”), knowing in the end they are really unnecessary. The same applies to MOC which has no proven value but the people promoting and profiting from it are intense.

    October 23, 2016 | 11:22 PM

    I’m a private practice psychotherapist, not a prescriber. I’m curious about how the psychiatrists here calculate the pros and cons of private practice versus being in larger systems. I gather much of the frustration voiced in these comments is about managed care systems, but some of it seems more generally aimed at the ACA and the federal government.

    I feel like I enjoy a ridiculous amount of autonomy for relatively little paperwork in my job. Insurance billing is a pain, yes, but more people have insurance for mental healthcare than they used to, so I find myself grateful for the ACA. There are too many people with very high deductibles (who can’t afford healthcare after paying premiums) and that stinks, but otherwise I see the whole range of folks from very poor to quite rich and most are getting what seems to be good physical and mental healthcare for not too much money. People who could only have gone to a free or community clinic now have more choices and that seems like a good thing.

    There’s only one insurer (a private company) that requires that I occasionally have patients fill out PHQs (every 10 sessions). The federal government is not foisting forms on me. I have plenty of time to do thorough histories and there’s no one in-between my relationship with my patients.

    So partly I’m trying to wrap my head around the sense that the ACA is responsible for something awful, that the federal government is demanding that we data-mine our patients, or that this is some kind of government conspiracy (to achieve what?). Do people feel the same hostility towards Medicare as they feel towards the ACA? If not, how come? How much of the frustration is about technological change (EMRs, etc)?

    In the urban area where I work there are a lot of private practice psychiatrists in addition to groups, and yet we still have a shortage of prescribers and the practices I know are almost always full. The private practice psychiatrists I know seem pretty happy with their jobs, combining med management with talk therapy in a mix they choose.

    What keeps a psychiatrist in a managed care system that they find loathsome rather than going into private practice? Is it overhead, lack of employer-provided benefits, or some other thing? I am interested to understand the negative experience voiced here mainly because it diverges so from my own, even while I agree with so much of the other analysis around drug trials and research reporting.

    I get in the case of 1boringoldman how the culture change in the clinic you’ve been volunteering in would be really disappointing. I have heard similar stories from people inside of other organizations, like law firms or other kinds of healthcare centers, how change in ownership/management can hollow out goodwill built up among colleagues and between colleagues and clients over years. No organization seems immune to that potential failure. It wasn’t clear to me why in this case the decline in goodwill in the agency is attributed to the ACA.


    James OBrien, M.D.
    October 24, 2016 | 1:03 AM

    The ACA was 2700 pages of mandates including mandated EHR. Plus more regulation after passage. Once that level of complexity is required, boatloads of middlemen compliance officers are hired to deal with it, since most people in the system don’t even understand it. Yes, the problems with middlemen started twenty five years before that (as my chart pointed out) but few doctors were retiring early because it was still bearable.

    The ACA has already gone well over budget projections, and anyone who runs a payroll can tell you its been double digit increases every year for costs with no actual quality improvement and higher deductibles. Many people I know have had their plans cancel and drop coverage multiple times. It’s failing but it was designed to fail. I guess one silver lining when it inevitably goes to single payor is that insurance company execs will be out of work, and it will be nice to see those rent seekers out of a job.

    Most psychiatrists do not accept Obamacare, Medicare or any insurance at all. We are fortunate to be able to practice off the grid. Most other specialties do not have that option. There is no doubt that burnout and suicide rates are increasing among physicians.

    James OBrien, M.D.
    October 25, 2016 | 12:44 PM

    I had no idea this was coming out the same day:

    Complexity in nature is a beautiful thing, because it wouldn’t exist if it weren’t adaptive. However, man-made complexity is a nightmare. Medicine is deevolving. I’m more worried as a patient than a doctor.

    November 4, 2016 | 7:26 PM

    I came over looking to see if 1Boring had covered the new Rosenbaum stuff. I meant 1BOM, not 1BYM…I’m sort of surprised it hasn’t been touched upon over at Mr. Whitaker’s place.

    Not sure what she’s saying about coercion, actually. Nothing, maybe. Just going for that “open, thoughtful” (minus the disingenuousness) voice that got her first lionized then pilloried last year. (It’s easy to be open and thoughtful when you don’t know what you’re talking about.)

    This go-round, it seems like she wanted to poke a stick at mental health/psychiatry debaters in hopes of ending up clothed in purifying/glorifying flames. She self-nullified with her gauche handling of Dr. Amy Reed’s tragic situation, as far as I’m concerned. The mental health trilogy hasn’t drawn the attention that Over-preventing the Clots did last year. Good.

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