Friday, October 28, 2016

Virtual Journal Club--Week of October 24, 2016

The following article, "My Name is not 'Interpreter'" was brought to my attention by Dr. Onaiza Ansar, of HealthPartners West Clinic. The topic is "microaggressions", or as I think of them, the commonplace thoughtless stumblings of people trying to adapt to a more diverse world. Whether we mean them as aggression or not, if our words and actions are perceived as offensive, we are placing barriers and roadblocks in the way of therapeutic alliances we are trying to build, or provoking needless tension on our workplace teams.  I find it humbling to consider the ways I may fail to act with sensitivity and empathy toward others. I hope a read through this article, and Dr.Ansar's own story below, may provoke us toward more thoughtful behavior.

From Dr. Ansar: It is a very nice article. It reminded me of my first job as attending when one of the rheumatology attending ,who I asked to see one of my patient for consultation on inpatient unit,  assumed that I was a resident even after I introduced myself and then went on to quiz me. Being  psychiatrist I was not sure if I should take an offence in that or enjoy her ‘blind spot’ related to her racial bias or age bias or both.  I decided to enjoy and continued to let her quiz me, smiling inside me when the charge nurse could not take it any longer and stepped forward and stated to her, “Dr____ , I don’t if you met with Dr Ansar. She is our staff psychiatrist and attending who requested consult from your service. It is great that you both can talk to each other directly about patient’s care plans.”  I cannot forget the look on her face. I also learned in that job that somehow when I talk to consultants coming to see my patient on inpatient psych unit over the phone it was a great conversation but in person it was like the above encounter so I preferred to call instead of my usual attempt to meet with them if I can.

Second thing I want to mention is when I was in above situation I was wondering if this is my highly sensitized feeling or this is really happening until the charge nurse stepped forward and she and I were discussing it later one that she clearly noticed what was going on…. In short it was not ‘just in my head.”

Monday, October 17, 2016

Virtual Journal Club--Week of October 17, 2016

A little lighter reading this week--the short article about use of text and email with patients was in the current issue of Psychiatric News, and I'm posting it along with a couple of links to previous articles in the series re: digital ethics, and as a bonus, since it's that time of year, one on the ethics of political statements. (The last has a number of links to other articles regarding the "Goldwater Rule", as well)

Ethics of Email
Skyping with Patients
Professionalism on Facebook

The Psychiatrist's Role in Public Elections

Tuesday, October 4, 2016

Fall Resident Retreat Day

Beautiful day of serving together with Feed My Starving Children, enjoying a fine meal of Indian cooking, and recreating at the Minnesota Zoo.





Lift with your LEGS, Taylor!


Nothing more stylish than Residents in Hair Nets

77 Kids will get a hot meal daily for a year thanks to our efforts.














Virtual Journal Club--Week of October 10, 2016

What to do when Plan A doesn't seem to help? A lot of attendings have their own "favorite" strategies--but how good is the evidence? This week, a couple of gleanings from STAR*D (Sequenced Treatment Approaches to Relieve Depression--clever, eh?) to add onto your understanding of Treatment Planning and Management this month.

Google drive links:
Bupropion augmentation
Medication augmentation





Virtual Journal Club--Week of October 3, 2016

Sorry to have not kept up, but let's get back at it, shall we?

Having mentioned the Milestones on Treatment Planning, and Clinical Practice Guidelines, I thought I'd post a couple of interesting meta-analyses re: anti-depressant and anti-manic medications:
Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Cipriani, et al., Lancet 373: 746-58. 2009
Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. Cipriani, et al., Lancet 378:1306-15. 2011.

These aren't easy reading, but are worth digging into, as ultimately Clinical Practice Guidelines end up being based on them. Perhaps the first thing to notice is how the meta-analysis is done: seeking a body of literature that asks the questions regarding comparisons of different treatments, then choosing randomized controlled trials to be grouped together to gain the best possible picture of how anti-depressants stack up against one another. There are a lot of numbers here--does the "bottom line" surprise you? I felt that the results were actually quite similar to the "daily clinical experience"-based approaches that we tend to use in day-to-day practice. Note also the authors' explicit comments regarding possible sources of bias--specifically the financial incentives of study authors in the cases where data is provided from industry-sponsored studies.

Google Drive links--
Comparative efficacy and acceptability of 12 new-generation antidepressants
Comparative efficacy and acceptability of antimanic drugs in acute mania



October Milestones of the Month--PC3 and ICS2


October's Milestones follow on the heels of September's--basically, we're moving from development of Formulation and Diagnosis of Psychiatric Illnesses, and the Medical Knowledge thereof, into application of these to Treatment Planning and Management.  Again, note the developmental framework--identifying options, to handling the basics consistently well, to progressively working out treatment strategies for more complicated presentations. Note in PC3: 2.2A the reference to current clinical practice guidelines. It's a good idea to have these handy, know them, and refer to them. You can find a full collection on Psychiatry Online, which is available via the Regions Medical Library.   

Next, all your knowledge and treatment planning is for naught if you don't document it! ICS2 emphasizes the role of documentation, presentation, and team communication in the treatment of our patients. The foundational concept is being accurate and timely at all times, but this milestone is also a reminder of the need to take special care to protect patients' confidentiality and maintain appropriate boundaries in the digital world. Note words such as discretion and judgment,as well as efficient, concise, and pertinent.
Note also 2.3B--keeping the patient (or your colleagues) at the center of communication, instead of focusing on the computer, as related here by the indomitable ZDogg, MD:  "EHR State of Mind".