From Bedside to Bench

During all my years of practicing medicine, I have been close to research in the institutions where I worked. I have admired and assisted clinical researchers, but I had never felt inclined to join their ranks. When I became the Clinical Director of the Youth Program two years ago, however, that changed. With this new role came the task to promote research and to become more personally involved in the research being conducted in my program and institution.

It is remarkable how much research is conducted in a university teaching hospital, with little funding and most research being conducted off the corner of people’s desks. Most of these researchers are earning their living from their clinical work, with next to no additional funding. Often the only additional funding they receive covers costs related to materials for research and a few hours from a research assistant. It is not unusual for physician researchers to be self-supporting, receiving no direct compensation for this work. This is my experience in psychiatry, but I suspect that it is not much different in other medical specialties.

Much of the research conducted in the clinical programs in which I work is to benefit our programs and our patients, first and foremost. We ask each patient to complete surveys and simple diagnostic measures before and after all programs, in some cases after each session, so that we can be sure that there is value to the programs and therapies we have developed and that we use. In many programs that we are developing, we ask for feedback after each session. For example, if we are starting each session with a mindfulness exercise that no one finds helpful, then we change exercises. All this data provides us with valuable information about the profile of the patients we are treating. It also indicates the type and severity of the conditions being treated in a tertiary care treatment facility.

As I began to consider all the data we have available that patients have given permission for us to use and analyze, I began to consider that, even when I worked as a psychiatrist in private practice, I had a great deal of patient data at my disposal. Occasionally, when a situation I had managed was very unusual, I would discuss with a patient and their family the possibility of sending a short communication about the case to a journal. I had no one to advise me on the process. I had to negotiate and consider the ethics of the situation on my own with the patient and their family. Often the patient and the family had considered their situation to be unique. They were eager to participate in this minimal research process as a specific case discussion to benefit other patients and families who might find themselves in a similar situation.

The minimal level of funding available in universities and the complete lack of funding available to physicians in private practice to pursue limited clinical research underlines the shortsightedness of our single payor. Imagine if research were promoted by Provincial Ministries of Health in Canada, to the extent that expertise and funding were readily available to Primary Care and other specialists in the community, what we might learn to improve best practices in Canada. Imagine if the funding in Alternate Funding Plans was sufficient that every physician in our teaching hospitals could be involved in research without financial penalty, what we might learn about secondary and tertiary care.

An example of the kind of research that is possible when the payor supports it is the study conducted by the United States Center for Disease Control, supported by Kaiser Permanente, is the Adverse Childhood Experiences Study. I learned about this study when I was researching (unfunded, of course) other data we might like to collect in programs. It is “one of the largest investigations of childhood abuse and neglect and later-life health and well-being”.

This is the kind of work we could be doing across Canada. I could not find any evidence of this research, although I would be relieved to know that I was wrong.

 

Journalism and the Scientific Method

Three years ago, I reviewed Seth Mnookin’s book The Panic Virus. In that review, I noted the importance of science reporting in assisting the public’s understanding of scientific research and science in general. Keeping this in mind, I want to highlight an article from the Ottawa Citizen by Elizabeth Payne, a Postmedia health reporter. The article addresses the question, “Could infections cause Alzheimer’s?”

In her article, Payne considers the controversy about the link between microbes and Alzheimer’s disease. She reports that those scientists who favour the microbe hypothesis have made a widespread plea that the public “embrace” their hypothesis.

Payne’s reporting is factual and clear. It leaves the reader with the opportunity to consider whether the microbe hypothesis research supporters or the plague hypothesis supporters are more credible. It calls upon us implicitly to consider both theories, but to remain open to the results of the ongoing research on Alzheimer’s disease. To be open to possibility, to be able to assess alternatives as revealed by rigorous study, is the essence of science. Through her reporting, which points out the conundrum of a controversy in scientific research, Ms. Payne makes it clear why the public should not, in fact, “embrace” a hypothesis until the research and much more consideration yield a clear result.

I am a clinician, not a researcher, but I work in a university teaching hospital affiliated with a research institute and so I have participated in clinical studies. When focused on one’s own research study, it is easy for a researcher to become attached to trends that one believes are emerging from one’s research. I have done enough research to realize how dangerous this is. I have learned that one must be faithful to the scientific method that has fostered the real breakthroughs.

The scientific method is systematic and allows for the modification of the hypothesis. Learning the scientific method is one of the first lessons in science class in elementary school. I remember having to devise experiments in Grade 3, not for a science fair project or research but to demonstrate that I understood the scientific method. That same lesson was repeated at the beginning of many grade school science classes for years to come. The scientific method is fundamental but, like all fundamentals, it is more easily expressed than understood. Ms. Payne’s excellent article reported some news from medical science and reminded us of how difficult it is to learn the scientific method.

(Note: The excellent graphic depicting the Scientific Method included here comes from the Science Buddies Website. Science Buddies is an award-winning, not-for-profit organization dedicated to building scientific literacy.)

DSM V and Thomas Szasz

Like many North American Psychiatrists, I have spent a good part of the past six months thinking about DSM V, The new Diagnostic and Statistical Manual of the American Psychiatric Association. Like DSM III and DSM IV before it, the new manual’s publication is giving rise to significant controversy that is likely going to set back the goal of decreasing the stigma surrounding psychiatric illnesses, their treatment, and mental health practitioners. Criticism against the manual is coming from such highly respected organizations as the British Psychological Society.

In reading through some of the negative opinion, I was taken back over thirty years to a time when Thomas Szasz’s The Myth of Mental Illness was causing a sensation among a number of mental health practitioners.  The Myth of Mental Illness was published in 1961 and Szasz was among those who were highly critical of the American Psychiatric Association’s manual:

“It is important to understand clearly that modern psychiatry – and the identification of new psychiatric diseases – began not by identifying such diseases by means of the established methods of pathology, but by creating a new criterion of what constitutes disease…Thus, whereas in modern medicine new diseases were discovered, in modern psychiatry they were invented.” (Italics are Szasz’s)

This is very similar to some of the concerns expressed regarding DSM V, and, behind the debate, one senses the same emotional response that many had to Szasz’s seminal work. At the time, those who included psychiatry as one of the medical sciences could be disturbed by reading Szasz’s work since he expressed so authoritatively exactly the opposite view.

With this in mind, consider this statement from the Open Letter to the DSM-5:

“We thus believe that a move towards biological theory directly contradicts evidence that psychopathology, unlike medical pathology, cannot be reduced to pathognomonic physiological signs or even multiple biomarkers.”

Reference: http://www.ipetitions.com/petition/dsm5/

When I have skimmed DSM V, and read the introduction, I was struck by the expressed strong desire of the authors to address psychiatric diagnosis scientifically. It seemed to me that the intent was that mental illnesses would be illnesses with as much validity as all other medical illnesses, leaving behind the credibility gap of the past, when mental illness, by virtue of being “less worthy” than physical illness, led to stigmatization.

It is a long time since I have thought about Thomas Szasz. To me, he was one of the forces that upheld stigma by emotionally focusing on those circumstances where there were uncertainties in an attempt to persuade that authoritarianism was more important in psychiatry than science. The visceral, emotional reactions to DSM V also seem tinged with belief more than science, if indeed science is an objective pursuit.  Read the Open Letter and then go to The Thomas S. Szasz, M.D. Cybercenter for Liberty and Responsibility ( http://www.szasz.com/) and see how they compare to you.

The Patient’s Medical Home and Me

Last week, after I posted my blog on my concerns regarding “Primary Care Pediatrics”, Shereen Miller responded thoughtfully, asking, “Who is the quarterback of each person’s health care?…Should someone be in charge, connecting all the dots…”

This question is immediately answered for me by the Patient’s Medical Home, as described by the College of Family Physicians of Canada in their position paper A Vision for Canada: Family Practice: The Patient’s Medical Home. (http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf)

This paper defines the Patient’s Medical Home as “a family practice defined by its patients as the place they feel most comfortable – most at home – to present and discuss their personal and family health and medical concerns. It is the central hub for the timely provision and coordination of a comprehensive menu of health and medical services patients need. ” Does this not sound exactly like the service Shereen is seeking, as a patient?

As a specialist physician providing mental health care, I also like the idea of a family physician trained to coordinate my patient’s personal health care so that my team can attend to mental health concerns. All too often, it is necessary for the multidisciplinary mental health team to attempt to piece together a patient’s health status ourselves, without the longitudinal view of a personal  family physician who has monitored someone’s health over many years.

While the introduction of primary care models in the past decade in Ontario has given more patients access to a hub for their primary care, there is not yet a system in place for specialists like me to easily plug into the central team. To some extent, this is because many specialists are in hospitals, physically and virtually disconnected from patients’ family physicians. I can see the value of better connections between specialists like me, who are experts with difficult to manage chronic illnesses, and family physicians and their teams. Right now in Ontario, many family physicians’ teams have the services of allied health professionals, e.g. social workers, pharmacists, nurses, directly on the team but this collaboration does not yet completely extend to specialist physicians such as psychiatrists, internists or pediatricians. Some of the large university family health teams do have these “shared care” services but, as far as I know, none of the community-based family physician groups have access to specialists as I have described above.

In my view, such a system offers tremendous advantages to patients. First of all, because of the ready access, collaboration regarding which patients’ conditions need a consultation versus therapy could be undertaken quickly, eliminating some of the time usually spent waiting. Another consideration mentioned by Shereen was the notion that the doctor is not always required in a patient’s assessment and diagnosis. Certainly psychiatrists are very used to working with allied health professionals – I have worked on multidisciplinary teams since my residency and, like all of my psychiatric colleagues, team-based care for patients with psychiatric conditions has the best outcomes. This system eliminates another layer of inefficiency, allowing patients better, quicker access to specialty care.

I have been sold on the idea of the Patient’s Medical Home since I first read about it and heard it described. To extend this care to include specialists requires some changes to our current funding models, but different funding and not more funding is required.

Having said this, I am sure there are disadvantages to the model I have begun to describe.   I would like to hear about them to see if they can be overcome. I am also taking the advice from my readers by examining some of the models in place in other countries to see how they would refine this concept of specialty care being a “room” in a Patient’s Medical Home.

It is important for all of us to consider how the developments in primary care can more fully exploited for every patient’s benefit. How would this work for you?