Category: Physicians

The diagnostic crisis in child psychiatry

published date
November 12th, 2006 by
The diagnostic crisis in child psychiatryThanks to Mickey for his perspective on the chaos in diagnosis in child psychiatry, described in yesterday’s New York Times. (What’s Wrong with a Child? Psychiatrists Often Disagree):
At a time when increasing numbers of children are being treated for psychiatric problems, naming those problems remains more an art than a science. Doctors often disagree about what is wrong.

A child’’s problems are now routinely given two or more diagnoses at the same time, like attention deficit and bipolar disorders. And parents of disruptive children in particular — those who once might have been called delinquents, or simply “problem children” –— say they hear an alphabet soup of labels that seem to change as often as a child’s shoe size.

Psychiatrists have no blood tests or brain scans to diagnose mental disorders. They have to make judgments, based on interviews and checklists of symptoms. And unlike most adults, young children are often unable or unwilling to talk about their symptoms, leaving doctors to rely on observation and information from parents and teachers.

““Psychiatry has made great strides in helping kids manage mental illness, particularly moderate conditions, but the system of diagnosis is still 200 to 300 years behind other branches of medicine,”” said Dr. E. Jane Costello, a professor of psychiatry and behavioral sciences at Duke University. “On an individual level, for many parents and families, the experience can be a disaster; we must say that.”

The main problem is that these diagnostic labels are findings, not diseases. A good example of this problem is attention deficit disorder, which in many families seems due to a single autosomal dominant gene. Despite this genetic simplicity, people with attention deficit disorder typically have other disorders too, including oppositional defiant disorder, conduct disorders, as well as affective, anxiety, learning disorders and even poor handwriting. This is not surprising – being overwhelmed with sensory input, as occurs in attention deficit disorder, could easily produce these multiple symptoms.

All these labels are based primarily on symptom checklists. According to the American Psychiatric Association’s diagnostic manual, for instance, childhood problems qualify as oppositional defiant disorder if the child exhibits at least four of eight behavior patterns, including “often loses temper,” ““often argues with adults,”” ““is often touchy or easily annoyed by others” and ““is often spiteful or vindictive.”

Dr. Darrel Regier of the American Psychiatric Association, who is coordinating work on the next edition of the associationՉ۪s diagnostic manual for mental disorders, due out in 2011, said that researchers would focus on drawing distinctions among several childhood disorders, including bipolar disorder and attention deficit disorder.

““We wouldn’t disagree that criteria for these disorders currently overlap to some degree,” Dr. Regier wrote in an e-mail message, “and that a significant amount of research is under way to disentangle the disorders in order to support more specific treatment indications.”

The Chinese Restaurant Menu approach used in the diagnostic manual is part of the problem since it combines rigidity and ignorance. A statistical pattern matching approach would be an improvement, but major progress will require new knowledge. Once we start to make progress the pace of advances will increase: once we have gene tests for a few diseases, progress in other diseases will also accelerate since the bin of undiagnosed patients will become simpler.

From which disease will the first advances come? Attention deficit disorder should be an early success because it often has such simple inheritance. Why don’t we have an attention deficit disorder gene yet? One difficulty may be that many single genes can cause attention deficit disorder and this heterogeneity on a population level messes up positional cloning studies. Another problem is that it can be difficult to make the diagnosis of attention deficit disorder in females, leading to data too messy for positional cloning studies.

If genetic heterogeneity is the problem a more promising strategy may be to test candidate genes in small families in which all patients share the same problem gene. This can work if you understand the biology, but since the presumption that dopamine transmission problems underlie attention deficit disorder has not borne fruit it would not be surprising if a dopamine disorder is the wrong hypothesis.

It sounds like we are in a rut, but there are enough MDs with basic science experience floating around and the cost of sequencing a gene is getting so low that someone is going to hit the bulls-eye with a good hunch on a different candidate gene.

PSA at 40?

published date
November 7th, 2006 by

PSA at 40?

Prostate Specific Antigen (PSA) is a widely-used screening test for prostate cancer. Unfortunately these tests cause a lot anguish: an elevated PSA doesn’t usually mean prostate cancer (only 25-30 percent of cases with elevated PSAs are prostate cancer), but it often means a biopsy and a lot of angst.

According to the National Cancer Institute:

Using the PSA test to screen men for prostate cancer is controversial because it is not yet known if this test actually saves lives. Moreover, it is not clear if the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments. For example, the PSA test may detect small cancers that would never become life threatening. This situation, called overdiagnosis, puts men at risk for complications from unnecessary treatment such as surgery or radiation.

So I was a little surprised to read that the authors of a new study are advocating starting PSA testing even earlier: at age 40 rather than age 50. It’s counterintuitive, but the reasoning is that if a patient has a longer baseline it will be easier to tell from the PSA whether they in fact have cancer. For example, as I read in the Wall Street Journal (Beginning Prostate-Cancer Screening At Age 40 Holds Benefits, New Data Show):

[A] 40-year-old man who has a PSA of 0.8 at 40 and then a score of 2 a few years later likely is at high risk for aggressive cancer. But if he has a score of 2 and no prior PSA test, he likely would be told he’s at low risk. By the time his PSA score reaches 4 and doctors decide to intervene, it might be too late to save him.

Meanwhile a 50-year-old man with a PSA of 4 likely will be told he needs a biopsy. However, if that man at the age of 40 had a PSA of 2, the 10-year trend suggests he likely doesn’t have cancer or at least not an aggressive cancer.

“It’s the same threshold of 4,” says Dr. Carter. “But the two people got to that threshold at much different rates. I see this as a way to decrease the men who have biopsies and identify the men with lethal disease.”

The logic sounds good, but it makes me nervous. I’m turning 40 next year and I think I’ll wait till I turn 50 to start testing. (I’ll see what my doc thinks before deciding.) I don’t have any of the prostate cancer risk factors and I’m as scared of having a false positive as I am of prostate cancer itself. In 10 years, when I’m 50 maybe there will be a better test and it won’t matter that I don’t have baseline PSA data.

Lollipop, lollipop

published date
November 3rd, 2006 by

Lollipop, lollipop

A front page WSJ story describes the commercial success of Actiq, a drug indicated for severe cancer pain. In my view it’s extremely important to have potent narcotics for people in this situation. Actiq is formulated as a lollipop, which makes it possible for people who can’t swallow to get relief.

The problem: people like lollipops, and Actiq is being prescribed for everything but what it’s indicated for. I’m worried that it might get taken off the market as a result.

Please, physicians, prescribe this drug wisely so we don’t lose it.

Hooray for hospitalists

published date
October 30th, 2006 by

Hooray for hospitalists

Hospitalists, physicians who practice internal medicine solely within the inpatient setting, are profiled in today’s Boston Globe. One of the weirder things about hospitals is there usually aren’t many doctors around. Primary care physicians tend to round in the early hours of the day, and then patients are left with nursing and administrative staff the rest of the time. Hospitalists address that deficiency by actually being in the hospital most of the day.

The article profiles Dr. Faisal Hamada, who runs the hospitalist program at Brockton’s Caritas Good Samaritan Medical Center. He’s actually employed by Cogent Healthcare, an Irvine, CA –not Philadelphia as the article states– based provider of turnkey hospitalist programs. Cogent provides the hospitalists, support staff, protocols and IT systems. The company generates a return on investment for its clients by improving the quality and efficiency of the hospital. Because hospitalists are around they can make adjustments in a patient’s schedule during the course of a day, something a primary care is unlikely to do after rounds . That kind of intervention tends to improve length of stay.

Good hospitalists develop a rapport with community physicians, which is essential so that those physicians don’t feel like the hospitalists are stealing their patients. I’m not surprised that Dr. Hamada is complimentary to the community physicians, but it’s also a fact that hospitalists tend to be more competent working in the hospital than their community-based colleagues. Hospitalized patients tend to be very sick –sicker than office-based physicians are used to seeing. Hospitals also have their policies, procedures, and informal ways of getting things done. It’s easier for a hospitalist to be good at this part of the job than someone who is only in the hospital occasionally.

One of the common complaints about hospitalists, also echoed in this article, is that there is a gap in communication between the hospitalist and the primary care physician, so that patients can get in trouble in between the time they are discharged and the time they see their community doc again. But that actually shouldn’t be such a problem in Brockton. Unlike most hospitalist programs, Cogent has its own call center to follow up with discharged patients, and has specific protocols for communicating with community physicians. In addition, Brockton is one of the three Massachusetts communities that is being wired up with a health information exchange as part of the Massachusetts eHealth Collaborative. That should make it much more straightforward for hospital-based and community-based physicians to stay in touch. Patients will benefit.

Underworked docs in the UK

published date
October 11th, 2006 by

Underworked docs in the UK

An article in the Daily Telegraph, Britain will need to hire thousands more “junior” doctors due to European Union work restrictions. The docs can currently work 58 hours per week, but an EU directive will compel a drop to 56 hours in 2007 and 48 hours in 2009. What’s more, time on call must be counted in the total.

There’s such a thing as a doctor working too many hours, but this is ridiculous.