American Association For Emergency Psychiatry Newsletter Fall Issue 2013
Letter from the President Psychiatry 24x7 Gas, food, and entertainment are all available 24 hours a day, 7 days a week, at least for me and many of my fellow Americans. Gas-Station-FoodMini-Marts provide one stop shopping for all of the above. 24-hour pharmacies provide drugs and basic medical supplies. Some locales boast 24 hour plumbing and car repair. Why isn't psychiatric and medical care available 24x7? Emergency Departments already provide psychiatric and medical care 24x7, but it is expensive and often unpleasant. At least, that is what I hear from patients, colleagues, family, and friends. These same people do not complain about midnight gasoline or donuts. Shellâ„˘, Dunkin Donutsâ„˘, et al offer the same product 24x7 without a dramatic degradation in service after dark. Why can't physicians and therapists provide equally pleasant service 'round-theclock?
Seth Powsner, MD President 2012-2014
The American Association for Emergency Psychiatry or AAEP is a multi-disciplinary organization that serves as the voice of emergency mental health. The membership includes directors of psychiatric emergency services, psychiatrists, nurses, social workers, psychologists, physician assistants, educators and other professionals involved in emergency psychiatry.
You can probably suggest a number of difficulties that face any organization attempting 24x7 service of any sort. Many of these would be valid. But, bear with me and reconsider the possibility of providing 24x7 care, if only as a thought experiment.
The AAEP sponsors educational programs and provides a network of experts to address clinical, educational, administrative, research and legal problems (continued)
AAEP Board Roster President Seth Powsner, MD Seth.firstname.lastname@example.org President-Elect Kimberly D. Nordstrom, MD Immediate Past President Scott Zeller, MD SZellerMD@gmail.com
Letter from the President (continued) -1- Payment. Will anyone pay? Of course they will. Someone already pays. Decades ago, when I was in private practice in Chicago, it was common for therapists to start as early as five in the morning so that two or three patients could be treated before the business day began. Likewise, two or three might be seen at lunchtime. And, even more would be seen starting after five in the evening. Third party payers do not reduce reimbursement based on time of day. Patients paying on their own might even pay extra for hours that fit their workweek.
Board of Directors: Leslie Zun, MD, MBA email@example.com
-2- Space. Downtown office space might cost less after dark. Physicians could share office space with attorneys.
Jagoda Pasic, MD, PhD firstname.lastname@example.org Daryl Knox, MD Daryl.email@example.com Jack Rozel, MD firstname.lastname@example.org Social Work Liaison Janet Richmond, MSW email@example.com Director, Emergency Psychiatry Research Michael P. Wilson, MD, PhD Director, Emergency Psychiatry Standards and Guidelines Garland H. Holloman, Jr., MD
AAEP Executive Office Staff: Executive Director Jacquelyn T. Coleman, CAE AAEP@EmergencyPsychiatry.org Executive Assistant
-3- Demand. Surely no one doubts there is demand for psychiatric care after hours. Ask any colleague running a psychiatric emergency service or a psychiatric consultation service that handles requests from an emergency department. -4- Staff. Ahhâ€Ś there's the rub. Who chose a career in psychiatry or social work or counseling to be up at night? Certainly there were no such types among my training class. Then again, none of my fellow trainees could spell latte: they would have to wait for Starbucks to be invented before they knew what latte was. But times, and clinicians' sense of time has changed. Hit the pause button on your staffing doubts for now and accept the possibility that there may be some staff that would prefer nights, or at least a more flexible schedule than my teachers ever contemplated. -4a- Salary. What does one psychiatrist cost? About $200K a year for outpatient work, based on figures from the BLS, U.S. Bureau of Labor Statistics. How many hours could a service expect for such a salary? Here are some rough calculations:
Marie L. Westlake AAEP@EmergencyPsychiatry.org
(Continued on page 3)
Letter from the President (continued) $960K to hire 4.8 psychiatrists @ $200K/year 4.8 psychiatrists <- 8760 hours/year / 1828 hours/year/psychiatrist 8760 hours a year <- 24 hours/day x 365 days/year (168 hours a week <- 24 hours/day x 7 days/week) 1828 hours / psychiatrist / year <- 40 hours/week x ( ( 365 days/year - 10 federal holidays) / 7 days/week ) - 4 weeks vacation - 1 week sick time ) -4b- Overall cost. Allowing for various other expenses we can estimate $1.2M to 1.7M to have a psychiatrist available 24x7 or $137 to $194 / hour based on adding $160K for 24x7 secretarial support <- $33K salary * 4.8 secretaries Filling only half the hours requires charging big city fees of $200-400/hour (less for 45 minute sessions). Reviewing these calculations, a 24x7 psychiatric practice looks quite possible for a large metropolitan area, or for a well paid work force (eg, an Internet / software company). Psychiatry 24x7 might be beyond the reach of some organizations; however, there may be yet more situations that could be profitable. Some health systems might offset psychiatric visit costs if they reduced Emergency Department visit costs. An ACO, Accountable Care Organization, might "profit" from such a shift of Emergency Department costs. We can imagine shiny, bright, Apple Storeâ„˘ style clinics, for Psychiatry and other traditional medical care. These clinics would avoid the most burdensome aspects of EMTALA regulations by being situated far away from Emergency Departments and major medical centers. These clinics would be convenient to the covered population. Their purpose would be to reduce health care costs through convenience. "If you build it they will come" says the voice in Field of Dreams. That's a recurrent nightmare for many health system managers. Capacity seems to lead to cost. A walk through Manhattan suggests it is true for coffee shops. Ashton et al, 2003, can be read to suggest the situation is worse in health care: greater consumption may actually lead to poorer outcomes. Yet hardly anyone discusses a widely visible counter example: free water fountains in most office buildings do not to lead to hyponatremia.
Letter from the President (continued) What would all this mean for Psychiatry? Would freely available psychiatric care, psychotherapy, and psychopharmacology be more like coffee shops or more like water fountains? Would co-pays make a difference? Ie, if patient have to pay something would it significantly affect demand? If clinical co-pays at night were less than Emergency Department co-pays, would that matter? What does 24x7 mean for the populace? Once upon a time, when I was young, dinner was at 6pm, period, full stop. At least that was the case in suburbia 'cause everyone took the train home. Unless you lived in Manhattan or on a farm, it was a huge imposition to ask anyone to stick around a few more hours to finish up a project-- they'd miss the train home. The Interstate Highway system, the auto industry, and now the Internet, have all but eliminated the train. Some commuter rails have responded by offering 24x7 service, or close to it. Dinner tables are still adapting. Thanks to the electric light, it is possible for people to work 24x7. Thanks to the Internet, people can work asynchronously. What is not so clear is whether people can or want to live asynchronously. Which brings us back to #4 above, staff, and to potential patients. Are there a significant number of people who want psychiatric treatment at midnight? Maybe. What if there are alternatives? How many of our emergency cases became emergencies because routine care was not available outside of work hours, or simple not available for weeks? Ie, how much midnight care is simply cost shifting? On the other hand, how much midnight care is midnight crisis? Some of the questions of health care priorities may be answered by the free market. We could have all health care available all the time, but with a price differential: no co-pay for recommended preventative care, small co-pays for broken bones, small co-pays for prescheduled diabetic check-ups, larger copays for walk-in visits, even larger co-pays for prime time walk-in visits on week day evenings or weekend mornings. Psychiatry 24x7? It may just be a matter of price point. When we set aside our preconceived notions and "do the numbers" as Kai Ryssdal inveighs, the numbers are compatible with some markets, and perhaps soon, even more. Suppliers of telepsychiatry services could argue the price can be reduced even further and allowing more flexible "tele-sessions" between patient and treater. Telepsychotherapy has offered that option for some time.
Letter from the President (continued) Psychiatry 24x7, maybe it's already here but the email announcement was caught in my spam filter. --------Ashton C.M., Souchek J., Petersen N.J., et al. Hospital Use and Survival among Veterans Affairs Beneficiaries. N Engl J Med 2003; 349:1637-1646; October 23, 2003 full text available http://www.nejm.org/doi/pdf/10.1056/ NEJMsa003299 Bureau of Labor Statistics -- Psychiatrists http://www.bls.gov/oes/current/oes291066.htm accessed 2013.09.04 20:35 UTC Bureau of Labor Statistics -- Medical Secretaries http://www.bls.gov/oes/current/oes436013.htm accessed 2013.09.04 21:35 UTC Federal Holidays http://www.archives.gov/news/federal-holidays.html accessed 2013.09.04 20:40 UTC Field of Dreams http://en.wikipedia.org/wiki/Field_of_Dreams accessed 2013.09.05 02:15 UTC Ryssday, Kai http://www.marketplace.org/people/kai-ryssdal accessed 2013.09.08 17:00 UTC Telepsychotherapy http://www.nytimes.com/2011/09/25/fashion/therapists-areseeing-patients-online.html accessed 2013.09.08 17:25 UTC
Letter from the President (continued) Telepsychiatry http://www.e-psychiatry.com/services.php accessed 2013.09.08 17:25 UTC http://www.in-sight.net/ accessed 2013.09.08 17:25 UTC http://jsahealthmd.com/ Accessed 2013.09.08 17:25 UTC http://www.telepsychiatry.com/index.cfm accessed 2013.09.08 17:25 UTC
Interested in writing for the Newsletter? All members of AAEP are invited to submit articles for publication the Newsletter. We welcome articles relevant to the field of Emergency Psychiatry from all perspectives: from psychiatrists working in a PES to social workers, nurses, students, or physicians in the field. Newsletters are sent to the Membership electronically on a quarterly basis. For deadlines and additional information on how you can contribute to the Newsletter, please contact Marie Westlake at 888-945-5430 or email AAEP@EmergencyPsychiatry.org.
Emotional Temperature and Pulse: The Role of Affect and Mood in Risk Assessment By: Jon S. Berlin, M.D. Some years ago, a distinguished emergency psychiatrist said that, when it comes to the process by which he decides if a person is acutely suicidal or not, he just knows. He was participating in a panel discussion on suicide assessment, and the subject at hand was what to do in that frustrating gray area when the actual information one has available is inconclusive. Other excellent panelists were articulating how they decided subtle cases by gathering and synthesizing various kinds of clinical data, including risk factors and protective factors. He didn’t disagree with any of them. Yet here was a cerebral scientist and biologically oriented practitioner who seemed to be suggesting that he could divine* the strength of a person’s death wish. Given his devotion to the systematic investigation of objective reality, this was very thought provoking. In demurring to elaborate, he may have been implying that the process couldn’t be put into words, which I wasn’t sure about. But with respect to what he was apparently saying about the role of clinical sagacity and intuition in making a quick or deep clinical judgment: after interviewing thousands of emergency patients and training dozens of psychiatry residents, I began to appreciate what he meant. In some ways, it was not so different from what a cardiologist friend once told me about a man he had seen on call with mild abdominal pain. He couldn’t completely explain why, but he felt that the cause of it was an incipient aortic dissection. The presentation was quite non-specific, yet somehow he just knew. No one else who evaluated the gentleman that night thought the case was acute, but my friend insisted on waking up a vascular surgeon, and he turned out to be right. Only in retrospect could he begin to articulate the intangibles or describe a telltale constellation of signs and symptoms. Generally speaking, one of the most important and difficult psychiatric skills to learn and explain is the ability to take another person's emotional temperature or pulse. It is a kind of vital sign, a quick first step. From there we try to take a deeper reading, to tune into the individual’s chief area of psychological distress, and to ascertain his degree of crisis or acuity. Underlying emotion and mood is the key. In the professional development of psychiatry residents, difficulty with listening on these levels is as much a cause of concern as a problem with intellect or ethics. We
Emotional Temperature and Pulse: The Role of Affect and Mood in Risk Assessment by Jon S. Berlin, M.D. (continued)
do not expect them to become virtuosos, but by the fourth year we do want them to become at least competent or proficient. In a broader context of discussing the nature of experience, the philosopher Dewey said of an interview that it “may be mechanical, consisting of set questions, the replies to which perfunctorily settle the matter.” Preferably, however, this meeting between two people is an experience, with an element of suspense, and as such he says it’s the emotion in it that is “the moving and cementing force.” (1) There is a significant cognitive component to the clinical interview. There are questions to be asked and answered, and defenses to be understood and relaxed. A person’s perspective on his or her own life is important. But the affective component is unquestionably greater. In assessing suicide risk, cognitive data divorced from affective data is of little or no use. If a woman in the emergency department says she is going to lie down on the railroad tracks, but looks and acts happy, her mood influences us more than her words. If she has an anguished and desperate expression on her face, we would make a referral to 24-hour care. However, if she were able to resolve her current life crisis, if other significant mitigating and protective factors came into play, and if later on in the ED while waiting for a bed she were overheard singing softly to herself with sweetness and soul, “I'm going to lay my head on some lonesome railroad line / Let the 219 train ease my troubled mind,” the equanimity in her voice would underscore the evolving and eased clinical assessment taking shape in our mind. We might end up letting her go home. The refrain of this song, which includes the words “I won’t be blue always”, is also reassuring, but what convinces us is the delivery, not the content. We could also hear something in her tone of voice that makes us think that suicide is not an immediate concern, but might be in her future one day without appropriate therapy. Patients seen in emergency settings are often very guarded, and the strength of a person’s suicidal urge is always a black box to a certain extent. This is a key difference from the diagnosis of an abdominal aortic aneurysm: we have almost no way of knowing for certain if our assessment is correct.
Emotional Temperature and Pulse: The Role of Affect and Mood in Risk Assessment by Jon S. Berlin, M.D. (continued) Black boxes can give rise to punitive frustration. ED clinicians may throw up their hands and release no one. They tend to forget that emotional guarding is a necessary defense mechanism. I have often wondered if the bad policy of forced disrobing stems partly from an unconsciously symbolic and misguided attempt to speed things up and force people to expose themselves psychologically. Of course, this backfires. Black boxes stimulate innovation. Blood tests for suicide potential or functional imaging may one day have clinical application, and they are so much easier to measure. What is actually happening when we plumb the depths of a person? We have no way of knowing, regardless if the observer is trained or untrained. He is a black box too, and we are just beginning to elucidate the neurobiology of emotion. (2) Add the concept of attunement, and the simultaneous engagement of two minds is doubly unquantifiable. ED and PES practitioners usually do recognize when the readings they are getting have the ring of truth. The problem is that they are very difficult to validate empirically, and they are subject to error. Yet it is quite valid to make them part of the data on which a clinical assessment is based. A psychiatric examination is incomplete until we attempt to gather data about internal states from the individual himself or herself. Appearance, posture, demeanor, gait, type and quality of eye contact, facial expressions, smell, affect and mood components, and style of interaction and engagement are still the entryway of the mental status and of the clinical project. Listening on an emotional and intuitive level is the first step in connecting with a person and developing a therapeutic alliance. It encourages a person to open up and reveal more. It is therefore a key step in formulating an impression about risk and implementing collaborative treatment. After 35 years, I still find the process of attunement somewhat mysterious, but not indescribable. A recent and well-referenced definition of empathy is very instructive. It begins: "a complex affective and cognitive process of feeling, imagining, thinking, and somatically sensing one’s way into the experience of another person.” (3) We might tend to think of empathy more narrowly, but the passage continues, “The capacity for empathy lies at the heart of our ability to understand other people,” which not only speaks to empathy but also the heart of the clinical examination.
Emotional Temperature and Pulse: The Role of Affect and Mood in Risk Assessment by Jon S. Berlin, M.D. (continued) The psychoanalytic literature might have the best language for reading people and drawing them out, but good personnel of all theoretical persuasions have the capacity to develop this skill over time. The role of empathy and emotion needs to be characterized neurobiologically. But experience teaches us that there is a way to check in quickly with someone's psyche, like taking a pulse, then perhaps a more internal reading, and it does mean something of value when an expert says he or she just knows. *Divine: “To make out by sagacity, intuition, or fortunate conjecture...” Compact OED, 2nd edition, 1994. References Dewey, J. “Having an experience,” Chapter 3 in Art as Experience, 1934. Lee H, Heller AS, van Reekum CM, Nelson B, Davidson RJ. “Amygdala-prefrontal coupling underlies individual difference in emotion regulation.” Neuroimage. 2012 Sep;62(3):1575-81. Auchincloss EL, Samberg E. Psychoanalytic Terms and Concepts, Yale Univ Press, 2012.
Calling All Authors! The American Association for Emergency Psychiatry would like to invite all members and colleagues in the field of Emergency Psychiatry to submit a manuscript or book review for publication in the AAEP Journal, Emergency Psychiatry. This Journal is intended to be a forum for the exchange of multidisciplinary ideas. Manuscripts are welcomed that deal with the interfaces of emergency psychiatry. This includes psychiatric evaluation of individuals in the emergency room setting, education and training in the field and research into causes, and treatment of behavioral problems. Manuscripts are evaluated for style, clarity, consistency, and suitability. Submit manuscripts or queries electronically to: Marie Westlake, Executive Assistant, at: AAEP@EmergencyPsychiatry.org. Include the address, telephone number, and email address for the corresponding author on all manuscripts.
Please join us! AAEP Business Meeting and Reception Friday, October 11, 2013 6:15 p.m. Marriott Philadelphia Downtown Thirteen Lounge AAEP members will vote on an important Bylaws amendment, so please try to attend. The reception will immediately follow the Business Meeting. Refreshments will be served and cash bar will be available. For questions, contact the AAEP Executive Office by email AAEP@EmergencyPsychiatry or phone 888-945-5430.
Highlights from the AAEP Business Meeting and Reception in San Francisco!
Dr. Seth Powsner presents the 2013 AAEP Residents Award to Scott Alan Simpson MD MPH of the University of Washingtonâ€™s Department of Psychiatry and Behavioral Sciences
A special presentation of the AAEP's Emergency Psychiatry Achievement Award to Garland "Bo" Holloman Jr., MD, was made by Dr. Powsner. Dr. Scott Zeller accepted the award in Dr. Holloman's absence.
AAEP 2104 Residents Award 2014 The American Association of Emergency Psychiatry (AAEP) is pleased to announce their annual award for residents demonstrating excellence in emergency psychiatry. Psychiatry residents at all levels of training are eligible for the award. Criteria for the award are expertise and excellence in emergency psychiatry as demonstrated by outstanding clinical skills, administrative responsibilities, and educational activities. Each residency program may nominate one resident for the award. Eligibility:
Applicants must be in good standing in an approved US/Canadian psychiatry residency training program. Each program may nominate one resident.
$250, plus paid expenses (two nights hotel and airfare) to attend the AAEP spring meeting (during the APA meeting in New York, New York, May 3-7, 2014)
Demonstrated interest and excellence in emergency and/or acute care psychiatry. Excellence may be in the area(s) of clinical work, research, administration, or teaching.
Application Process: Program Directors should send entire packet to include 5 copies each of: Resident’s CV Resident’s essay on interest in emergency psychiatry Letter of support from Department Chair/Program Director or designee Letter of support from Psychiatry Emergency Director or designee Due Date:
All materials are due by March 1, 2014
AAEP Resident Award Selection Committee One Regency Drive, P.O. Box 30 Bloomfield, CT 06002 Phone: 888-945-5430 Fax: 860-286-0787 Email: AAEP@EmergencyPsychiatry.org
American Association for Emergency Psychiatry (AAEP) Members presenting at the American Psychiatric Association 65th Institute on Psychiatric Services Meeting Transforming Psychiatric Practice, Reforming Health Care Delivery Philadelphia, PA ď ł October 10 - October 13, 2013
Thursday, October 10, 2013 8:00 a.m.-9:30 a.m. Resolving a City-Wide Crisis of Police Diversion and Psychiatric Patient Boarding in the Emergency Department: Presenter: Jon S. Berlin, M.D. 8:00 a.m.-9:30 a.m. Person Centered Risk Management and Malpractice Issues in Emergency Psychiatry Chair: John S. Rozel, M.D. Presenter: Kim D. Nordstrom, J.D., M.D. 3:30 p.m.-5:00 p.m. The Meeting of Minds: Joining Recovery in Mental Health and Addictions. Chair: Hunter L. McQuistion, M.D. 3:30 p.m.-5:00 p.m. Deadly Emergencies in Psychiatry: Keys to Recognize and Treat NMS, Serotonin Syndrome, Excited Delirium and Other Diseases that Kill Chair: Kim D. Nordstrom, J.D., M.D. Presenters: Michael Wilson, M.D., and Kim D. Nordstrom, J.D., M.D. Friday, October 11, 2013 8:00 a.m.-9:30 a.m. Psychiatry in the Storm: Issues of Public Psychiatry During Hospital Evacuations Presenter: Amit Rajparia, M.D.
10:00 a.m.-11:30 a.m. Growing a Generation of Recovery Oriented Psychiatrists by Teaching and Modeling Motivational Interviewing as our Fundamental Communication Style. Chair: Michael A. Flaum, M.D. 10:00 a.m.-11:30 a.m. From Reflection to Reflex: Making Ethical Decisions in Real Time in the Psychiatric Emergency Service. Chair: John S. Rozel, M.D. Presenter: Alin J. Severance, M.D. 10:00 a.m.-11:30 a.m. The Limits of Current Health Reform for Psychiatry Presenter: Ole J. Thienhaus, M.B.A., M.D. 1:00 p.m.-5:00 p.m. Cultural Appropriate Assessment Revealed: The DSM-5-TR Outline for Cultural Foundation Interviews Demonstrated with Videotaped Vignettes Director: Francis G. Lu, M.D. 3:30 p.m.-5:00 p.m. Act (In) Fidelity Presenters: David C. Lindy, M.D. Saturday, October 12, 2013 8:00 a.m.-9:30 a.m. â€œConsidering Clozapineâ€?: A Consumer-Oriented Initiative Addressing EvidenceBased Medication Choice in a Public Mental Health System Presenter: Cassis Henry, M.A., M.D. 8:00 a.m.-12 noon Clinical Approaches to Working with People who are Homeless and Have Mental Illnesses: Challenges and Rewards Director: Hunter L. McQuistion, M.D. 8:30 a.m.-11:30 a.m. Essentials of Psychiatric Emergency Care for Children and Adolescents Chair: John S. Rozel, M.D. Epidemiology and Trends in Child and Adolescent Emergency Psychiatry Presenter: Jagoda Pasic, M.D., Ph.D. Trauma Informed Care in Children and Adolescents Presenter: John S. Rozel, M.D.
Medical Evaluation of Children and Adolescents with Psychiatric Symptoms Presenter: Leslie Zun, M.B.A., M.D. Clinical Decision Making and Disposition with Children and Adolescents Presenter: Seth M. Powsner, M.D. 10:00 a.m.-11:30 a.m. The Federal Affordable Care Act in Action: Implementation of Health Homes in New York City Chair: David C. Lindy, M.D. 1:30 p.m.-3:00 p.m. Disaster Response for People Affected by Superstorm Sandy in New York City Chair: David C. Lindy, M.D. 3:30 p.m.-5:00 p.m. The â€œFuture of Psychiatryâ€? Project: Background, Rationale, and Progress to Date Chairs: Michael A. Flaum, M.D., and Hunter L. McQuistion, M.D. Sunday, October 13, 2013 8:00 a.m.-9:30 a.m. Emergency Psychiatry in Health Care Reform: Reducing Costs, Improving Care Chair: Scott Zeller, M.D. Presenters: Leslie Zun, M.B.A., M.D., and Avrim B. Fishkind, M.D.
New textbook "Emergency Psychiatry" (Cambridge, 2013) just released ... In Chapter 2, "Management of Agitation and Violence," opens up with an overview which includes the following: "Most recently, the American Association for Emergency Psychiatry (AAEP) published guidelines on managing agitation through its Project BETA: Best Practices in the Evaluation and Treatment of Agitation. The publication of these high quality guidelines is an important step in improving the consistency and safety in the management of agitated patients. The algorithms from Project BETA are included in this chapter."
AAEP Members-Only Listserv Check out the AAEP members-only listserv discussion group that is available via invitation to members in good standing only. This is a great opportunity to discuss pressing issues, diagnostic dilemmas and treatment approaches in Emergency Psychiatry, and to obtain consultation from your fellow experts on difficult cases. If you have misplaced or did not receive your invitation email, please contact Marie Westlake at: AAEP@EmergencyPsychiatry.org.
AAEP Member Announcements What’s going on with your Emergency Psychiatry facility, with you and/ or your staff? We’d like to know and share it with other AAEP members in our newsletter. Has your program moved to a new building? Did you or one of your colleagues publish an article related to Emergency Psychiatry? Have you, your staff, or your program recently been honored? Is there a new educational or training process you are using that you believe could help your peers? We welcome you to share any news relevant to Emergency Psychiatry with your fellow members.
American Association for Emergency Psychiatry One Regency Drive P.O. Box 30 Bloomfield, CT 06002 Phone: 888-945-5430 Fax: 860-286-0787 Email: AAEP@EmergencyPsychiatry.org