NY Times roundup

Here are three recent New York Times articles that caught my eye. On March 13th, Tara Parker-Pope’s health blog “Well” reprinted “The 12 Most Annoying Habits of Therapists.” Actually, the list comes from PsychCentral, a blog written by psychologist John M. Grohol, and in my opinion reads better there. I won’t list all 12 habits — you can look for yourself — but they include starting sessions late, eating in session, falling asleep, and so forth. The voluminous comments on both blogs relate the sad state of so much therapy out there, including professional lapses far worse than the listed 12. I plan to use the blog post itself, and some of the commentary, as a teaching handout when I lead a psychotherapy seminar later this year. Even beginning therapists should not make these mistakes.

Speaking of psychiatry training, on March 16th, psychiatrist Richard A. Friedman M.D. wrote about a growing lack of confidence in psychiatry residents, citing their inability to make clinical decisions in routine cases, e.g., when to hospitalize or medicate patients. He blames faculty over-concern:

The fault, I believe, lies with medical educators like me. In the pursuit of patient safety, we have deliberately prevented residents from acting independently on their own judgment in situations where a patient poses a theoretical risk.

I share his concern to this point. I encounter resident insecurity much more often than overconfidence. I also agree that one reason for this may be a medical culture that increasingly recognizes a single right (or safe) way to proceed; independent judgment is discouraged.

But Friedman then goes on to blame “a series of reforms that began in the 1980s with limits on residents’ work hours.” The current limits set by ACGME include an 80-hour workweek with a maximum shift of 30 hours. Friedman apparently feels such a schedule lacks “ample opportunity to stand on your own — and risk making a mistake.”

I beg to differ. Sleep deprivation is not a teaching tool. There is no evidence it trains anyone to make decisions with more accuracy or confidence, although it is often justified this way post-hoc. Conflating confidence-building with hazing oversimplifies a complex issue. We don’t need to toughen up residents, we need to help them make confident decisions. Two different things.

Besides, psychiatry residents generally worked fewer hours than residents of other specialties even before the ACGME limits. In other words, the recent limits have had less effect in psychiatry than in specialties such as surgery or ob-gyn. Could it be that psychiatry pays a bit more attention to how people think, feel, and learn, and therefore we were ahead of the curve?

And speaking of being ahead of the curve, today the Times reported that the American Psychiatric Association is ending industry-financed medical seminars at its annual meeting. President Nada L. Stotland, M.D. said the APA was not aware of any other organization that had made a similar decision on seminar sponsorship. Perhaps we psychiatrists will start a trend in medicine. (Neither the article nor the APA website says whether this change will occur in time for the annual meeting held here in San Francisco this May. I imagine not.)

I confess that I attended one of these seminars when the huge APA meeting was in San Francisco some years ago. Normally I avoid all industry largesse, but I was curious and justified it as research. Ironically, although it was lavishly catered and slickly presented, it was perhaps the least biased industry-sponsored talk I’ve ever heard. The smaller local ones are much worse in my experience, presumably because the level of scrutiny is so much higher at the annual meeting. There is press coverage, for example.

In any event, this is the right direction for psychiatry and medicine in general. But speaking of press coverage, I am curious about one detail. The Times, as well as Reuters, reported the APA policy change today, yet blogger Daniel Carlat M.D. scooped them by almost a week. Do official news agencies wait for press releases, while bloggers do the real investigative reporting?

2 comments to NY Times roundup

  • have you ever snooze off during sessions??

  • Completely fall asleep? No. I do yawn now and then, and occasionally have had to fight pretty hard to stay awake. As with many other happenings in therapy, the important question is why. If I didn’t sleep enough the night before, my sleepiness has nothing to do with my patient, and I’m doing him or her a disservice by not being alert. Conversely, some patients induce sleep even in well-rested listeners who don’t normally snooze in sessions. In this case my sleepiness is actually important to notice (and maybe even comment on); it’s a form of countertransference that can shed light on the patient’s dynamics.

    I would only call sleepiness a “bad habit” if it happens repeatedly. Everyone has an off-day.

    Thanks for writing.

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