Archive for the ‘BTP’ category

Winning: the only thing?

December 18th, 2011

The holiday season is a good time for reflection. For me reflections this year are colored by the ongoing fallout from the child sex abuse allegations at my university, which is reverberating at institutions throughout our country.

I have worked in all the major sectors of our economy: for-profit, not-for-profit, and government. For most of my career, I’ve been in universities. Not-for-profit institutions are exempted from paying taxes because federal and state governments deem we are doing public good. Still, I have seen so many leaders and organizations in this arena act as if Vince Lombardi or Niccolo Machiavelli were their patron saints. It comes down to “winning,” outperforming the “other guy,” such as a “competing” institution, which is often charged with performing the same public good—like charity, health care, or education.

Of course, most decisions we make on a day-to-day basis are pragmatic and mundane. Few rise to ethical or moral issues. But I have seen many executives, leaders, and governing bodies, even when faced with moral dilemmas, calculate solely based on pragmatic projections—relying exclusively on legal, financial, and public-relations advice—forgetting the mission, moral, or ethical dimensions of important matters.

Sometimes those of us with administrative or governing authority must stand up, remember why we’re here, return to core values, and do the right thing. Is that a risk? Perhaps. But there are risks worth taking.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

Whither Healthcare Reform?

December 1st, 2011

In multi-specialty groups and integrated academic health systems like mine, psychiatry struggles not to lose money. This economic anomaly stems from a system that biases economic rewards (i.e., gives more money) more for doing things (“procedures”) than for thinking and talking to patients. And it’s not just between specialties, but within: general medicine loses money; procedural subspecialties like cardiology and gastroenterology make money. And a cardiologist, gastroenterologist, or dermatologist, for example, who wants to earn more will devote more time and effort to procedures, shying away from low-reimbursement time with patients.

Care of patients with diabetes mellitus illustrates the dysfunction in America’s healthcare non-system today. Diabetes is a life-long disease. Patients age more rapidly than peers without the disease. Their organs degrade and blood vessels clog. But close monitoring, tight disease management, and behavioral factors like diet and exercise can combat many of these effects and prolong life and function. That’s good for people and saves money. But in our current system, doctors and hospitals aren’t rewarded for these low-tech, long-term, preventative interventions. It’s better for the bottom line to do the many late-stage extensive procedures these patients are likely to require: fixing retinas, bypassing coronary arteries, transplanting kidneys, amputating limbs. And most insurers seek to maximize profits not by cost-effective long-term care and prevention, but by finding ways to encourage people who become sick to leave their programs.

I can’t predict how or when we will see genuine healthcare reform in the United States. But the skyrocketing costs of health expenditures in our country, which buy only mediocre outcomes, dictate that things will need to be fixed and soon. And I have to believe that covering all our people with good health care will demand a cost-effective system, emphasizing prevention and effective long-term care. This, in turn, will require investment and uniformity in information technology, standardization of optimal practice, and—at long last—due attention to behavior. The behavior of our population—whether diet and exercise or compliance with prescribed treatments—is a huge driver of medical costs and an obvious target for attention in the New World Order. I believe that in the system to come, psychiatrists will play a role of great importance, as experts in behavior and specialists in conditions that commonly exacerbate other diseases. Stay tuned.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

To protect the most vulnerable

November 12th, 2011

Rape is a terrible crime against anyone. Sexual abuse of children is among the worst. It is often perpetrated by adults whom the child trusts and respects. And it leaves scars on the brain and psyche that may never heal.

This is a time of soul searching at Penn State. Students, staff, and faculty are hurt, angry, confused, and shaken by the swirling story of sexually abused children. I am new to Penn State, but in my almost-two years here, I have been deeply impressed by the talent, energy, loyalty, decency, and commitment of the Penn State community. And our university has an amazingly dedicated alumni and donor base throughout the country.

I know no more than what I read and hear from the news media. Like everyone, I am left to conjecture about who did what and why. I cannot pass judgment on anyone, nor would I wish to. But right now it appears that children were sexually exploited, and some people who could have taken early steps to stop the abuse did not.

What lessons can we learn from this horrible experience?

I have participated in many discussions about the competence and professional behavior of certain medical students, residents, and physicians. Typically, colleagues express concern about the welfare and career of the student or doctor, which is reasonable and compassionate. But I always focus on the “end user”: future patients, whom we can’t know today. Our primary obligation, I contend, is to them, the most vulnerable, who will enter naïve into a doctor-patient relationship. Will this student, resident, or doctor be good and safe for these people, whose lives depend on our actions? I wonder if university administrators worried so much about the well-being and future of alleged perpetrators that they couldn’t “see” the kids who were injured and others who would be at risk? Did they fear potential damage to the reputation of our august institution so much that they missed the question of right and wrong, ultimately damaging this university far more?

In the denouement of the movie “A Few Good Men,” one of two marine defendants in a court martial explains to his subordinate that they were supposed to fight for those who could not fight for themselves. As healers and as administrators, we have a similar and sacred charge. I pray people will draw lessons from Penn State’s current travails. I hope that the next person to witness or hear of a child being brutalized will do the right thing—without hesitation or thought of politics. I hope the next doctor worried about the integrity or competence of a colleague will do the same.

Alan J. Gelenberg, M.D.
Shively/Tan Professor and Chair of Psychiatry
Penn State

And now, Lee

September 9th, 2011

As I matured as a therapist, I started integrating elements of Buddhism into the psychodynamic approach in which I had been trained. (I believe Marsha Linehan did something similar in creating DBT, and I enjoyed Jack Kornfield’s book, A Path With Heart.) In particular, I have always been stirred by the simple wisdom in AA’s Serenity Prayer. As we stop banging our heads against the walls of things we cannot change, we have more energy to affect things we can change. I have tried to help patients find comfort and their own paths forward by accepting the many forces before which we stand helpless. I have shared that wisdom with my own children. And like Alice in Wonderland, sometimes I even try to follow my own advice.

Recently I posted a blog on my flight before the fury of Hurricane Irene on the Atlantic Coast. I didn’t know it when I wrote the blog, but soon after, the worst devastation from the storm hit not along the coast, but inland—particularly with flooding in Vermont. This week Tropical Storm Lee pounded my community in Central Pennsylvania with record floods.

When I first heard about global warming, I assumed the slow process of year-by-year temperature elevations would take many decades to affect real life. But climate scientists say the short-term effect is to increase weather volatility. When I moved from the desert southwest to Wisconsin in 2007, I expected a personal climate change—but not the record-breaking snowfall that began the day I arrived in Madison. Record-breaking snow followed me to Hershey, Pennsylvania, the week I moved here after Christmas in 2009. And this week my hospital was briefly isolated, I had to wade home through serious flooding, roads and buildings collapsed, our municipal sewage system has gone down, and I worry about weekend coverage for inpatients at our psychiatric hospital.

I can make small, personal efforts to conserve energy and reduce greenhouse gases. But I am helpless against nature’s fury when it appears. I can try to take reasonable steps to be prepared, and when disasters strike, I can work with colleagues and my community to help those in need. But truly we are small, and natural forces are immense. As doctors, we seldom cure, but usually we can attenuate symptoms and relieve suffering. I try to acknowledge what I can’t change and focus on what I can.

The pounding I saw from two back-to-back tropical storms taught me one other thing: the necessity of the social compact we call government. My state and community have good infrastructure, and today President Obama declared this a disaster area, allowing federal assistance. While some congressional representatives and presidential candidates rail against all government as evil and unnecessary, I realize that a well-functioning government is people helping people. It’s who we are, and it gives us more options and help in the face of powerful forces.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

Irene

August 28th, 2011

After a two-decade absence from the East Coast, I decided to pay an overdue visit to an Atlantic beach. A few months back, my wife and I booked 3 nights in a B & B in Cape May, New Jersey, and I took 2 days’ vacation from my university duties. We arrived Thursday afternoon, unpacked quickly, and set out for a couple of hours to survey the lovely beach community. Coming back to the beautiful Victorian guesthouse to change for dinner, we learned of a mandatory evacuation courtesy of Hurricane Irene, bearing down on the heavily populated region from the Carolinas up to New England. Our brief holiday had been cut short. Bummer!

We dined, got to bed early, awoke at sunrise, downed a quick breakfast, and set out for an uncertain drive home. The coastal evacuation stretched from North Carolina through northern New Jersey. We knew there would be serious traffic.

My new car feeds real-time traffic updates into the GPS guidance system. As I drove, my wife sat with an iPad on her lap, receiving live route information and weather reports. We were fed and rested. And since our home in Central Pennsylvania is well inland, we had a safe, secure destination. In short, we were as fortunate as people could be in an unpredictable situation where nature shows its awesome destructive potential. And we live in a country with basically sound social and physical infrastructure. But it was unsettling, nonetheless, and we felt anxious and small in this mass movement of people before a huge storm. When we arrived home, we were drained and exhausted.

My experience, minor in the scope of our lives, and trivial in the eye of the universe, gave me renewed empathy for people dislocated, “turned upside down,” and traumatized by big events beyond their control: natural and human-caused. PTSD, a regular subject of my newsletter, BTP, is painful and disabling—affecting perhaps 20% to 25% of those with a vulnerability when they undergo severe trauma. People with PTSD have trouble restoring their equilibrium after civilian or military catastrophes. They are hurting and need help—from clinicians, social agencies, governments, and neuroscientists.

And when natural or man-made disasters strike—like wars, earthquakes, and hurricanes—the mentally ill are especially vulnerable. The assets I had—an intact marriage, access to information via expensive services, physical and mental health—are unavailable to most people with chronic psychiatric illnesses. Most often, they lack safe, secure, reliable resources. And their ability to make quick, rational decisions under stress is typically compromised. When major threats loom, let’s keep them in mind and look out for their needs.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

Choosing A Job

August 1st, 2011

Residents frequently ask senior colleagues for guidance on choosing a job—especially their first out of training. Here are a few thoughts.

No one needs to be told the importance of location and type of practice; those speak for themselves. I always put stress on the reputation of the person and organization who will be the employer. Honesty, integrity, concern for the welfare of physicians and other employees are cardinal. Prospective employees sometimes think a written contract protects them. A contract can serve to clarify details. But ideally, after a contract is signed, it should go into a drawer and never be seen again. If one needs to pull it out and re-read it, something is going wrong, usually with trust. I would rather make 20% less from an employer I can trust than sign a “sweet deal” in writing with a less trustworthy party. If a contract dispute becomes adversarial, the employee is likely in for years of unpleasant proceedings, stress, and expense and, in the end, will be lucky to see 50 cents on the dollar—usually much less.

Everyone thinks about salary. Benefits too should be counted. Some benefits are more relevant to an individual than others—depending on family circumstances, for instance. And as important as money is, remember that it’s a vehicle to quality of life. Work type, hours, flexibility, call, the caliber and “fit” of associates also feed into job satisfaction.

Don’t forget commuting. The more time one spends on the road, the less time is available to read, enjoy recreation, and be with loved ones and friends. Some communities allow shorter commutes or public transportation that may allow work or leisure to and from work.

Do something you like, care about, feel good about. Work with people you respect and enjoy. These variables are hard to quantify but very, very important to leading a good life.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

It’s hot!

July 20th, 2011

I spent a week with family in Tucson recently, where it was 114 degrees in the shade. I’m back in Pennsylvania now. Today the heat wave that has steamed the mid-west lately rolls east, with temperatures north of 100 and high humidity. My life consists of an air conditioned home, car, and hospital. I am outside in this “soup” for short walks between these cool venues and for my early-morning jog.

Many of my patients are not so lucky. They live in less optimal environments—especially in summer—and have few options to escape heat. Add to that poor judgment: patients with schizophrenia often overdress and are unable to dissipate body heat. And many psychiatric (and general) medicines impair thermoregulation. Being elderly makes things worse too. When the heat’s on, as it is here today, remember the psychiatric patient, who may need extra consideration for health and safety.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

Resilience

July 8th, 2011

A few days ago my father-in-law celebrated his 100th birthday. Someday a lot of people may reach that milestone, but today few do. What impresses me is not that he made it (a testimony to his genes more than his less-than-healthy lifestyle), nor that he remains cognitively sharp. What impresses me is his amazing positive attitude. Almost always, he is “up.” He sees opportunities, even at his age. He finds reasons to laugh, celebrate, get excited.

Duane grieved deeply when his wife died. But he rebounded, set a new course (he was 90), and move forward. At his 100th birthday party, he entertained four generations of family members with witticisms that could be on his gravestone.

Presumably by the luck of the genetic “draw,” some of us run on the depressive end of a mood spectrum: seeing the dark and ominous side of every development, the glass half empty. Others, like my father-in-law, see what’s possible, visualize the positive, and make it happen. I just read a book by Dean Karnazes, who embodies this grab-life-by-the-horns approach and inspires others.

Good parents help their more anxious, depression-prone kids to modulate their darker thoughts and world view. They move these young people further to the optimistic, resilient end of the mood spectrum. Truly, it’s not immutable. People can learn to see the good possibilities. CBT and most therapies try to help in that vein.

I think my centenarian father-in-law inherited good genes. But he also made conscious choices over his long life, and he benefited from many of them and achieved joy and a sense of purpose.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

 

In Memorium

May 30th, 2011

Memorial Day, originally called Decoration Day, is a day of remembrance for those who have died in our nation’s service.”

It’s the Memorial Day weekend. For most of us that means leisure, barbeques, picnics, family, friends, and fun. It represents the fruits of living in a prosperous country, even as we climb slowly out of a recession (we hope). But let’s not forget the remembrance.

I served in the U.S. Army Reserve Medical Corps for six years, during which the U.S. did away with the military draft. I had misgivings then and still do. I fear our current all-volunteer military insulates the rest of us from the costs of combat—financial and human. My kids were never at risk, and I pay proportionally so much less in taxes than before Reagan was president—despite two ongoing and very long conflicts. The scars of battle tend to be borne disproportionally by those from lower socio-economic classes.

When a nation asks its young to put their bodies and lives at risk for others, noble souls always step forward. And a proportion of these altruistic and idealistic warriors come home dead or badly damaged. At a minimum we owe them and their families care and protection. It grieves me deeply to hear of families wrecked, homes re-possessed, and veterans with PTSD and traumatic brain injury (the 2 signature injuries of today’s conflicts) receiving sub-optimal care. Whatever the financial sacrifice those of us at home must bear to remediate these hurts, we owe the veterans and their families no less and so much more.

-Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

 

 

Do You Read Me?

May 27th, 2011

Doctors are blessed with a broad array of ways to stay current in our field these days: so many formats, so many platforms for reading. But not reading (or at least getting new knowledge via audio) is not an option. Not staying current would be unthinkable. Or it should be.

I am not the only medical educator concerned that many medical students and residents are not reading, or not reading enough. Some medical students read the “Cliffs notes” instead of texts in Psychiatry, Medicine, Pediatrics, etc. Many residents take shortcuts or believe they can absorb enough knowledge by practice (including unsupervised moonlighting), supervision, and “osmosis” to get by. And despite recertification requirements and CME, I run into numerous practitioners who are not keeping current with their specialties.

The challenge falls on faculties—of undergraduate and graduate medical education—and on physicians who create regulations on continuing education. I don’t want my loved ones treated by doctors who aren’t up to date.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry