Friday, February 22, 2013

Rate My Doctor

I was delighted to hear that Dr. Shane, one of the finest forensic psychiatrists in Canada, was working to limit the damage done by the Rate Your Doctor organization.  As a forensic psychiatrist he is not supposed to be popular.  I totally relate to him.

I just reviewed my rate my doctor site. I was mr popularity in school. I'm a psychiatrist and an addictionist. I've reported pedophiles who have had hundreds of victims. I've notified Transport Canada that their pilot is smoking crack or marijuana.  A lot of my work is done on behalf of third parties where the person I'm seeing is being assessed for dangerous ness to society or whether they are a risk to others in the workplace.  I'm a methadone doctor and I have had my prescriptions forged and have on several occasions discharged patients from the methadone program for illegal abuse of methadone or breaches of the protocols of the methadone program that require the physician to terminate the person's care.
I have been asked by the police to treat people for bestiality.  Routinely I'm asked to sign forms for people in which they are lying and wanting me to lie on their behalf to get money falsely from insurance companies or the government.  I say no and they hate me.

When I reviewed complaints I'd received 90% were because I'd 'diagnosed' a person as having a drug addicton or alcoholism and the person was being required to see me because of domestic violence or workplace safety issues or harm to children.

I am referred patients by doctors and commonly the doctor referring the patient doesn't advise me or may not know the patients history. I have refused to see several men because they tried to conceal from me their history of rape and violence against women.  I have found out this information from collateral sources. I have refused to see them because I have a female assistant who I will not put at risk.  I might have seen them if they had been honest with me.  I refused to see a Nazi once. He was very threatening. My windows were shot out. I've changed my phone numbers on several occasions and I've lost a staff member because of the venomous rage poured out at her by a patient blacklisted by most psychiatrists for their damage to property in the office.

My own life has been threatened on many occasions simply because my correct and truthful assessment has resulted in a person losing their income because of dangerous drug addiction, because they were hearing voices telling them to kill their boss and I am required by law to report this to the person they are threatening, that they were under control of spirits that wanted them to violate children and I am required by law to report this to child protection service. When called by the RCMP regarding whether threatening and dangerous persons should be issued a firearms license I have had that person turn up at my office threatening me. One person sent to by police after an arson attempt tried to pour gas on me and set me on fire. The police accepted the person needed to be restrained.

A patient brought a gun to an interview demanding I give them valium.

I was a supervisor in the dangerously insane ward of the asylum. I did see patients in jail. I was a supervisor in the psychiatric emergency.  I have been a supervisor in a detox unit.  i have many times had to say no to people who felt entitled to services which they were not and they were not willing or could not  pay for those services.  I have had patients come to my office demanding an MRI saying they need one and their stupid gp won't give them one and if I don't do it they're make me wish I had.  They want the MRI for free because they're involved in some litigation and hope that the MRI will help them get more money. However they don't meet the 'criteria' for MRI .

I have always worked in the areas of greatest need. When I was a country family physician and northern flyin doctor I was much loved and appreciated.  When I was a psychoanalytic psychotherapist I was highly regarded.  When I began working in areas where I was required by law to serve the state and the client or have to consider the rights of children as opposed to parents and doing occupational psychiatry where the issues of safety sensitive factors employment arise,  suddenly I've got this filth on rate your doctor.

When I diagnose alcoholism the pilot is required to enter a treatment program. Their disease is so severe that they want to 'kill the messenger'.  They are putting their co workers and others not to mention millions of dollars of company property at risk and they are very angry at everyone whose job it is to think of more than just them but consider the life of others.

There are 'feel good' psychiatrists. They are junior psychiatrists and they rarely have the responsibility for major decisions outside of the individual.    They can remain 'popular'.  They are not Forensic Psychaitrists.  They are not Occupational Psychiatrists. They are not Addiction Psychiatrists.  They are not Emergency Psychiatrists or Psychiatrists that work in the Asylum.  They never say 'no' and their patients love them. I sometimes have the unhappy task of treating the patients of these doctors who have left their patients grossly addicted to a variety of medications that the patients are very angry to be having to stop when the 'good' doctor gave them this and they can't understand why he won't see them or why he can't prescribe to them anymore.  Many of these 'good doctors' have lost their 'prescribing' priviledges. Not Ironically a couple of these psychiatrsts are called as the very best psychiatrists and I could just throttle them for the mess they made of their poor patients which we in addiction psychiatry are left to clean up.

I have one patient who is still angry with me because I stopped her from killing herself.  She insists that if I didn't resuscitate her God would have saved her baby from dying.  There's no reason outside her psychotic thinking to believe her death would have revived a dead baby but she wanted to try and I interfered with that.  I know one schizophrenic patient that believes anyone who is treating him "nice' is just preparing to kill him.  I have to be extremely 'neutral' with him. No medication has altered his underlying paranoia but he's not been chronically suicidal in my care.

I do use 'story telling' as a therapeutic tool.  I do cognitive behavioural and supportive therapy.  I do not let people venomously 'vent' about their ex-husbands or ex wives in my office.  This is not 'good therapy'. It's highly lucrative but it only reinforces the injury and re traumatises the patient.

I'm not being paid to passively listen to patients.  I'm first and foremost a medical psychaitric diagnostician. I have to be sure a patient doesn't have symptosn of anxiety or depression because of an undiagnosed cancer, brain tumor, thyroid disorder, or metabolic problem.  In a therapeutic assessment I'm informing patients as I go along often answering questions and correcting misinformation they increasing come baggaged with by reading fear mongering web sites which are selling a diagnosis or treatment.

I have far more effective 'tools' for helping people than passive listening.  I have done years of training in active 'listening' therapies but there are few who are specifically suited for these types of therapy. Less that 10 % of patient's referred to psychiatrists are appropriate for anything like the televison psychiatry models of therapy. Further the research says those types of therapy work best where patients are paying for that kind of care. Hence psychoanalysis is no longer covered by health care funding insurance programs.  I am specifically trained in 'change' therapy. As an addiction specialist I'm trained in motivational therapy which implies that the person will 'change'.  The state pays for psychiatrists to help people change for the better, not to make them feel good sick.  The health care system isn't in place to perpetuate disease. (At least it's not supposed to be)

My obese patients want to 'talk' about their problems but are very angry when I say after a couple of sessions or so , "If you're not willing to do some thing about your problem then there's nothing further I can do".  Based on a motivational assessment they aren't even in the 'contemplation' phase and are best advised to come back in 6 months to review what they're willing to do about their problem. All the 'life style' disease problems don't get better by having patients go on and on about 'why' they drink, gamble, over eat, shop, hoard, live on pornography sites.  These people want to collude with you and talk about thier problems as a means to maintain their problems without actually doing anything about their problems.  As a result of research findings we're not supposed to see these people and perpetuate their illness by enabling. They are angry because they get tremendous 'secondary gain' by seeing top specialists and showing that another doctor 'failed' to help them because their addiction is a really sick disease.  It's considered a waste of tax payer money for specialists to persist in therapy where the patient only talks about change but doesn't make any actual change.

A large part of my therapy for some patients is 'educational' as is the case with all 'cognitive behavioural therapy'. Many of my patients however are referred because of behavioural problems.

Only 20 % of my present practice are relatively highly functional individuals with 'neurotic' concerns. When I had a psychotherapy practice this was about 80% of my patients.  My present practice for the last 15 years has focused more on trauma and addiction:  head injury, ptsd, personality disorder, and major medical illness.  Most psychiatrists exclude personaliy disorder and addiction and head injury from their practice.

Because I've worked in areas of greatest need I've always had very sick patients as well as less sick patients but more I've had a higher per centage of really sick patients.  Many of my patients have major medical and neurological illness. They are not likely to return to work but it is hoped that they can have a better health care outcome. Often there are a dozen other specialists involved in the care of these complex patients.  No psychiatrist in the "business" of medicine would touch these patients because they are extremely costly, timely and sick.  They're generally very unhappy with life and their medical care in general, frankly because they have had horrible events happen to them . As a psychiatrist I can't offer them a new life, or millions of compensation and often all I'm doing is trying to provide sometimes only 'palliative' care.  Smart and popular psychiatrists send these patients back to gps, avoid them like the plague, and won't see them more than once for a consult.  Dozens of my patients have been rejected dozens and dozens of times by 'cherry picking' psychiatrists.  Sometimes like me, other psychiatrists are just  overburdened  and may not be able to take on another highly disturbed patient.

I have to move my patients around so that my waiting room isn't a nightmare of trauma for the patients. I don't want my active crack using patient to come before or after the lady I'm seeing for grief after losing her baby.  I try to avoid having my rape patients  sit next to the sex offenders I see. I have a lot of difficulty managing my booking schedule and it's a real hard time for new staff who sometimes wil book three severe borderline personality disorders in a row and wonder why I look like vampires have sucked my blood at the end of the day.  I can't see two grieving patients back to back and I don't like seeing more than one manic in any day. I can see schizophrenics one after another.  There's a reason for that.  Most active addicts can not be seen for more than 15 minutes though for special reasons you may have to see them for an hour. That's usually far too stressful for them. The same goes with adolescents and people with early dementia.  I can only do one family, group or couple in a day usually because the intensity of the complexity is so draining.  Emergencies are always screwing up my schedule. Scheduling my office is like booking an operating theatre. It's a speciality in itself.  Despite notices patients often arrive with reams of paper work and cavalierly 'expect' doctors to just get this done by a deadline arbitrarily set by someone who usually doesn't know anything about medicine.  My schedule is booked 6 months in a advance. Now where is there going to be 'time' for this 'urgent' report thatn's never properly funded to be done.  Patients get moved to accommodate emergencies.  So every patient often thinks their particular 'need' (never want) is an 'emergency' and want you to just cancel or move all the other patients to accomodate them.  Sometimes we don't leave the office till 8 or 9 pm and often on weekends I'm working.

Because I do truama I'm commonly having to do medical legal reports and suddenly because judges (who scheduling problems make mine look trivial )  free up courts, I'm scrambling to have a report done and to see a patient so that this can all be available for a court date that moved sometimes months ahead. I'm a treating clinician and as such I have to be willing to provide these reports if  I am to be of help to my patients. I have much more control over independent medical examinations because I can simply not book these. They pay much more than regular psychiatry and most of my colleagues are doing these so they can continue to do the 'publicly funded' psychiatry.  More and more psychiatrists are simply not doing 'public funded' psychiatry but rather working in administration, on salary or doing private work for companies and insurance.  Private psychiatry has high overhead, no benefits, no pension, no cars, no lunches, no fixed hours, no overtime.  My colleagues in 'salaried' positions are rich and luxurious in their slower paced much more highly rewarded positions often far from the maddening crowds.

There's no money where the most angry patients live and the risks are increasing every day as the cost of the complaint process sky rockets because of all the "time loss" for private clinicians. When a patient complained I wouldn't see them that day, I lost a full day of work, having to cancel patients and re book them so that I could accomodate this 'bully' who wanted to jump the queue and thought by threatening my secretary they could.  When I reported staff office theft I had to cancel an afternoon of patients to meet with the police and go over all the damage this irate and violent person had caused.

Everyone likes to provide one time 'consults'. The doctors who do this are popular with patients and commonly disliked vehemently by family physicians who want someone whose going to share the burden.  Familiarity breeds contempt.  It's really easy to see a person, get in and get out and hope to never see the person again. A number  of psychiatrists specialize in this approach.  This is essential in other areas of medicine but the work of psychiatry is in the ongoing and chronic care and the 'acute management' of sick patients.  The government expects the health care teams to take care of these patients and they do but more often than not the patients don't want this often 'factory' type care. They want to see a psychiatrist and not a counsellor with only 2 years of training and rarely the appropriate supervision.  The psychiatrists in the teams rarely spend any real time actually meeting and  talking to patients.  They adjust medications maybe every 6 months.  When I worked in mental health teams only a small portion of my time on salary was devoted to direct patient care. The majority of times I was going to committtee meetings, meeting with other staff, reviewing reports, making phone calls, doing lunch.

I talk to patients. I listen to patients.  I am known by patients. I'm an open book.  Most of the patients who chose to see me and want to see me want to 'change' and want more than a band aid. Many of my patients come in at a particularly low spot in their lives and leave restored. I joke about my practice saying "I overhaul ferraris or sometimes just tune up ferrari's:. The people I choose to work with are usually survivors or fighters.  So often I feel priviledged to be a part of their journeys.

The majority of my colleagues who are practicing frontline clinical psychiatry are facing all the same systemic problems as I am. I see the addiction doctors and the occupational pscyhiatrists and forensic pscyhiatrists are often faced with similiar complaints as I have.  I admire their work and feel sorry that so many of the people who I see doing a really tough job are the ones getting it in the neck becasue they're there. I don't respect those who are hiding somewhere far from the patients,  smiling. I may envy them at times but I don't respect them.  I also know I have some of the most amazing colleagues and some of those in other areas of subspecialization in psychiatry are my true heros. A couple of my favourite women psychiatrists are working all day long just like me but with injured children and a fundamental lack of resources in the community.

5 million Canadians can't find a family physician, 1 in 5 and of the people who need a psychiatrist maybe 1 in 10 at most actually get to see one once and one in a hundred actually get to see someone who will see them regularly.  20 years ago I could refer a patient to a colleague and they'd see that patient for consultation that week. Today I wait 2 years to get a patient into a pain clinic, 6 months for an MRI, a year to see a subspecialist neurologist, and thats just some of the wait list problems constipating the system and making all the patients who are often getting sicker and sicker while they wait incredibly angry.  I don't blame them but it's not my fault personally that someone other than front line workers are getting the big bucks of health care.  Whenever I hear of millions or billions of dollars going to health care I think of fat cats in committee meetings discussing how many 'meetings' they're going to have to discuss how they're going to spend the money.  I don't see the resources translating into services that make my or my patients lives easier.  

Many of my patients come to me because I respect their spiritual traditions so ironically for an overtly Christian psychiatrist I have a fair slice of patients from every other religion in the world as well as agnostics and atheists.  I love that the atheists tell me that they like that they know where I stand.  Freud was very Jewish.  Jung was spiritualist.  My Moslem patients say they  want someone who has a faith and wont' disparage theres.  My buddhist and hindu patients like that I support their mediation. Dozens of patients over the years have told me that they were discriminated against for their faith and that psychiatrists belittled their religion in countless ways they probably weren't even aware they were doing.

Patients are referred to me. Over the years I've accepted more patients from certain family physicians whose work I've admired.   I am not accountable for the tremendous shortage of psychiatrists.  I am not required to see all patients referred to me and turn away a dozen referrals a week because I'm overbooked or because the patient doesn't 'fit' my practice.  My assistant tries to communicate with the receptionists in the gps office. Many referrals come from walk in clinics where receptionist turn over and many doctors results in my assistants responses not getting passed on.  I am not required to communicate in this way.  I am only responsible for patients once I've actually seen them. I am not required to see a person more than once for assessment.

If I choose to provide care I do so based on what is indicated for the particular condition. Many patients want them to see me daily, 2-3 times a week, weekly.  I used to see patients 2 x a week and weekly.  In response to the shortage and because there are no psychiatric resources I've reduced the frequency I see my patients to what isn't ideal but remains marginally okay. I't's much easier to see a few patient frequently or a lot of patients for assessments. It's very hard to see a lot of patients at 2 week,  one,  three, and six month intervals in terms of scheduling. I have patients coming back to see me who I first saw 25 years ago.  What they had then was 'cured' but what they have now has come on with age and is a different kettle of fish. I try to see people I've seen before a s priority.  I've seen thousands of patients over the years so there's more and more difficulty getting people in when they return or when the need to be seen.

Walk in clinics are a very mixed bag.  20 years ago I used to have referrals from a half dozen physicians who I communicated regularly with and who knew me and my work and didn't send patients to me that they hadn't already thoroughly screened. This is not the cases with walk in clinics.  Commonly today I see patients who were seen by several psychiatrists that year or just got out of hospital and the referring family doctor doesnt' know this and hasn't communicated it.  I am deeply saddened by how little walkin clinic doctors know their patients and then I know many patients are 'doctor shopping' and 'specialist shopping' and their's no system tracking patients to see whose doing this.  One patient I knew was seeing three psychiatrists and I only learned when I wasn't paid for their visits to me, something I only found out a month later, having accomodated their 'emergency'.

I have been working without any of the resources I was promised in my training for nearly a decade.  I am routinely handling emergencies in the office because there are no resources in the community.  I am treating people who once were locked up for life without any of the resources they were promised when their hospital was closed.  I had  several head injured patients I was seeing every three months then had to see monthly and discuss weekly because the government closed their clubhouses and these poor tragic individuals were left in their rooms all day.  Naturally their psychosis got work and their angry outbursts increased.

No one notifies me months in advance that they're going to suicide.  When I had a psychotherapy practice like most private psychologists I was always on time and always on top of my schedule.  If a patient had problems I could send them to the hospital and they got good psychiatric care.  A few months back I witnessed my patient jump in front of a bus while my assistant tackled them to save their life and not have bus driver and passengers traumatized. I stopped my practice and spent an hour with patient the ambulance and finally got the patient to the hospital where they were discharged an hour later. So without any 'back up' the family physician and moved our schedules and patients around to see this incredibly sad and highly suicidal man several times a week until he was over his crisis.  Office practice was never meant to serve this purpose but there are no hospital beds and none on the horizon.

The hospital emergency used to have a ward where psychiatric patients could stay a week, then if they needed longer they had a ward where they could stay a month and then if they needed longer they could go to a hospital where they could stay for 6 months or years.  No body had figured out that all of this has gone and the money has been spent on 'planning' , 'administration' , 'talking' and 'politics' and 'ideas' and 'consultants' and 'business consultants'' and a whole lot of other things but the fact is there's no money and countless patients in dire need.

Some days my office is busier than a psychiatric emergency. Other days I think I'm back at the asylum.  I start my day at 7 am. I'm required to review my emails. I've got a hundred a day. Most of it is spam and the government won't pass the appropriate legislation to stop these 'business bullies'.  I am in direct patient contact often 10 to 12 hours a day. Some days I see 10 or 12 patients while others I see 50 or more.  I get dozens of phone calls a day and dozens of f axes and dozens of lab work and other records I have to review.  I rarely get lunch and drink coffee always on the run.  I feel guilty but still take bathroom breaks.  Sometimes I feel like not coming out of the cubicle. I routinely cancel lunches and miss all manner of engagements and have cancelled vacations many times to accomodate work demands. I have many colleagues who do far more than I do in this regard and there are all kinds of 'platitutes' out there about not working so hard but never do those spouting platitudes help with the heavy lifting or late night shifts.

When  a person misses an appointment and doesn't notify us in 24 hours those dozens of people on the emergency wait list can't be called. Those others who are waiting six months to see a psychiatrist in the lower main land can't be seen earlier.

A lot of people sent to psychiatrists are incredibly angry long before the time they get to see us. This wasn't the case 25 years ago.  Rarely was I referred an 'angry' person. Most of my patients were 'sad' or anxious. Now all the sad people seem to be creamed away by counsellors and psychologists whereas the angry and the angry/depressed/anxious are sent to us. My obstetrician colleague says the same. He's not had an easy delivery in years.  Like us his fee schedule hasn't changed and the amount of time he has for a patient hasn't been adjusted to deal with the aging population and greater risk.

The government has been cutting my income since I started practice. I made the most money I ever made in my life working as a general practitioner in my first job.  It's been down hill financially ever since. The government says they're going to cut doctors incomes again.

So I try not to read rate your doctor.  I wouldn't recommend for anyone to be a specialist clinician in Vancouver today.  I am really thankful for men of Dr. Shane's caliber who take the time to address the problem.

I see that there is a Rate My Judge site in the US but not in Canada. I really wonder if it's a good thing to have a criminal popularity poll against judges.  I know I'm terrified when I see pedophiles and violent people and psychopaths and sociopaths. I'm afraid to do the right thing because I don't want to face the abuse that comes from those people who want to fly planes stoned, work drunk, beat up their wives, have sex with their children.  99% of my patients are fine human beings. I know it's their 'sickness' but that doesn't necessarily limit the damage they can do.  Rate your doctor like rate your judge strikes me as likely to appeal most to people who are looking for a place to put their anger and carry out vendettas.

I noticed though that many people did rate my work positively and thanked me for my care.  I am humbled by that and very thankful indeed. It's the highest praise when patients take the time to share the positive. I realize I personally must make a greater effort to be thankful to all those I often take for granted because I 'expect' them to do their job. I know I too tend to 'blame' the customs officer for the delay when the fact is he's there and a half dozen others didn't make their shift and they not him account for the back up.

I  am more likely to be annoyed by the person who isn't doing their job according to my expectations too without realizing that my expectations of what they are supposed to be doing is not what their boss or the governnment or administration is telling that person to do.  It was said that a paediatrician has 90 minutes of examinations and things to do with a child before they actually see the child and hear the child's complaint for the booked 15 minute appointment.  Everyday I have a new and more absurd and utterly ridiculous demand put on me by some one who may never have seen a patient or have a clue about what a psychiatrist does.  This is increasingly common with insurance companies and employers.

Patients get angry about confidentiality but they have signed away that confidentiality to their employer or to their insurer and if their insurer is with their employer I'm required by law to share my records 'regardless'.  I'm now required by law to keep detailed records and produce those records for the courts as well.  It is against the law for me to not 'lie' for patients yet I've been approached hundreds of times by patients demanding and expecting me to do just that.

Just as I teach my patients getting over major trauma or cancer or life threatening events  to focus on the positives I have to do that myself.

Thank you all who have thanked me.  I really appreciate it.  And I'm sorry to those who I've somehow offended because I lacked the skill to serve you better despite the fact that I probably was not what you wanted. Somehow it's a shame the system results in such mismatches or it's just sad that people can't have what they want all the time.


Leslie Belanger said...

Doctor, I am really impressed with how you have graciously and carefully treat your patients. I wish there were more psychiatrists out there with your treatment approach. I had severe trauma as a child and have been working very hard at changing my life...I know my situation has been very difficult to handle, but I have been quite motivated to get better. My wondeful doctor passed away in 2008 from cancer and I haven't been able to find a doctor to continue with the process...can you imagine...I did get one consult, who spent 10 min with me and said she couldn't help me...I waited 1 and 1/2 years for that appointment. I am hanging in though...change is hard, but it is good, and I get the sense that you really believe that. You should be thanked more for the hard work you do and dedication you have. Gives me hope that I will find someone with your skills, here in Ottawa, or in the future. You honor your chosen profession. Thanks.

Leslie Belanger said...

Doctor, I am really impressed with how you have graciously and carefully treat your patients. I wish there were more psychiatrists out there with your treatment approach. I had severe trauma as a child and have been working very hard at changing my life...I know my situation has been very difficult to handle, but I have been quite motivated to get better. My wondeful doctor passed away in 2008 from cancer and I haven't been able to find a doctor to continue with the process...can you imagine...I did get one consult, who spent 10 min with me and said she couldn't help me...I waited 1 and 1/2 years for that appointment. I am hanging in though...change is hard, but it is good, and I get the sense that you really believe that. You should be thanked more for the hard work you do and dedication you have. Gives me hope that I will find someone with your skills, here in Ottawa, or in the future. You honor your chosen profession. Thanks.

Mary Stark said...

I came across your text quite by accident, having Googled "rate my doctor, Canada". Your thoughtful remarks have made me realize the inherent pitfalls of the rating process. Thank you for your insights into the challenges of your specialty and the practice of medicine in general in Canada in these times. I hope that describing these difficulties gave you some relief. Btw, it sounds like you need to look after yourself a whole lot more. Do it for everyone's sake, as you obviously have a lot to offer your patients if you stay healthy!

haykind said...

I appreciate your kind comments I've since learned that addiction medicine doctors and addiction psychiatrists specifically carry an unholy burden of complaints which will certainly discourage doctors working where they are most needed. Other countries, provinces, and states have responded to this reality and moved to protect addiction psychiatrists from these vexatious responses to correct diagnosis and recommendations. My first complaints were from workers in the logging industry. The executive and union leaders thanked me for single handedly increasing the accident free days in the workplace and saving countless lives by correctly diagnosis those workers who were addicted, putting themselves and everyone else at risk. Thankfully many patients over the years have returned to thank me for being 'truthful' and helping them get the help they needed.

Dallas Cooper said...

You're the best! I'm toadally pleased that you've taken the time to post your comments on this topic as you have.


Dallas Cooper
Vicroria, BC