Whether Nero actually played the violin while Rome burned or not, the story is a great metaphor for misguided priorities, or indifference, or narcissism, or incompetence, or being clueless, or maybe even not sweating the things you can’t do anything about. Whatever it means, I prefer using it to describe other people rather than myself. And obviously my last post on screening was written without surveying the landscape – like the Medicare Manual:
| Medicare covers yearly screenings for depression. |
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| These screenings are designed to be completed by a doctor or other primary care provider to ensure you are correctly diagnosed, treated and followed-up with. For Medicare to cover the annual depression screening, the screening must take place in a primary care setting. This means it will not be covered if you are screened in an emergency room, skilled nursing facility or as a hospital inpatient. |
| The annual depression screening includes a questionnaire that you complete yourself or with the help of your doctor. This questionnaire is designed to indicate if you are at risk or have symptoms of depression. |
| If the results of the questionnaire indicate that you may be at risk or have symptoms of depression, your doctor will do a more thorough evaluation to assess if you suffer from depression. If your doctor decides you do suffer from depression, they will provide treatment and follow-up or refer you to a mental health professional for further care. |
| Annual depression screenings can be performed separately by your primary care doctor but will typically take place when you have a scheduled office visit. The Welcome to Medicare Visit and first Annual Wellness visit require that your doctor review your potential for depression or other mental health conditions. However, these visits do not require your doctor to screen you for depression. A review is when your doctor discusses your risk factors for depression such as a family history of depression. However, you will not be given a screening questionnaire during a review. |
| If you have Original Medicare, you will not have to pay a deductible or coinsurances for the annual depression screening as long as you see doctors who accept assignment. If you have a Medicare Advantage plan, you will not have to pay a deductible, copay or coinsurances as long as you see network doctors. |
| If you need further evaluation to diagnose your condition or if you need mental health treatment, there will be cost sharing. You will need to pay deductibles, coinsurances or copays for this care. The amount you pay depends on the type of care you get. |
| For more information about your costs when you receive outpatient mental health care, please click here. |
Maybe the Nero metaphor is appropriate for things that are too big to even think about. But at least I know what got me here. Psycritic commented on my last post, and included a YouTube link to a young ER doc, Leana Wen, passionately talking about the importance to both physicians and patients of the history in making a diagnosis – 80% she said. She had two examples – her mother whose cancer was interpreted as a viral illness and a patient of hers who had every test in the world chasing a chest pain that was probably musculoskeletal. I mentioned my recent extensive [and negative] cardiac work-up initiated because of my family history [I guess] and the fact that I’m sort of old [a brief physical exam following an impressive array of tests using some unfamiliar Cadillac machinery]. I’ll have to admit a fascination with machinery and particularly the modern echocardiogram. It was something to behold. Who knew that the little murmur I heard myself was a small inconsequential calcification on a mitral valve leaflet?
But it was the hurried doctor visits that occupied the space between "hello" and the ordering of tests that stuck with me. I recognized most of the doctors and vice versa – former students from my teaching days. I expect because of that, they were on their best behavior, but it was unfamiliar behavior. The past history and family history were on forms filled out in the waiting room along with HIPPA things. There was no room without a computer flashing things about me gathered from hither, thither, and yon. The present history was terse, hurried, and as Dr. Wen discusses, punctuated by frequent interruptions. If there was a physical exam, I missed it. I could have a liver the size of a beach-ball, but it would remain just my little secret. I’m a good sport and I had a good time having my various tests. The technicians loved being asked about their machines and proudly showed me all kinds of wonderful things, vastly improved since my own internist days.
Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”
As a child, I resolved not to be like the old people I was around, constantly talking about the good old days being better. They were knocking "my days" which I was sure were the best of days. Even as a child, I suspected that what they really missed was how they felt when they were young. But now I’m old and I’m in a quandry. It really does seem to me that everyone medical is playing to a different set of audiences than in my day: insurance regulators, government regulators, HIPPA directors, medicolegal advisers, machine operators, and who-knows-whomever-else. I’m not sure that what is wrong with this guy and what does he need are on the top of the list where they belong.
So is it reasonable to ask a doctor to take a moment with each patient to ask, "Is this person depressed?" Is the reason that "we’re not properly inhabiting the offices where we meet our patients" as I suggested that it’s so crowded in there with all those regulators that we just don’t have the time?
As I’ve said before, I’ve experienced exactly the same b.s. with cash-only psychiatrists in 50-minute sessions.
On the other hand, I’ve had excellent attention and diagnosis from a doctor in the chaos of an emergency room. The lack of attention from a physician is a problem of attitude, not of regulation.
Alto,
I would agree that it is not entirely a systems problem/problem of regulation. Would strongly disagree that it is entirely a problem of physician attitudes.
A little off the point, but doesn’t “yearly depression screenings” just reek of a treatment in search of disease? What percentage of these screenings result in temporarily unhappy but otherwise normal individuals being convinced they have a chemical imbalance and put on psychotropics? Seems to me these are yet another pharma marketing tool.
I forget the author, but it’s a great quote, “before you let someone convince you that you’re depressed, first make sure you’re not surrounded by a$$holes”.
The author was Steven Winterburn (often misattributed to Steven Gibson), and here’s the exact quote, “Before you diagnose yourself with depression or low self-esteem, first make sure that you are not, in fact, just surrounded by a$$holes.”
Unfortunately for pharma, there is not much money to be made from that advice.
Totally agree Jeff C. And I would refuse to participate in one for obvious reasons since all human emotions get pathologized as a psychiatric illness.