J. Wesley Boyd

The Health and Health Care of US Prisoners: Results of a Nationwide Survey

OBJECTIVES We analyzed the prevalence of chronic illnesses, including mental illness, and access to health care among US inmates. METHODS We used the 2002 Survey of Inmates in Local Jails and the 2004 Survey of Inmates in State and Federal Correctional Facilities to analyze disease prevalence and clinical measures of access to health care for inmates. RESULTS Among inmates in federal prisons, state prisons, and local jails, 38.5% (SE = 2.2%), 42.8% (SE = 1.1%), and 38.7% (SE = 0.7%), respectively, suffered a chronic medical condition. Among inmates with a mental condition ever treated with a psychiatric medication, only 25.5% (SE = 7.5%) of federal, 29.6% (SE = 2.8%) of state, and 38.5% (SE = 1.5%) of local jail inmates were taking a psychiatric medication at the time of arrest, whereas 69.1% (SE = 4.8%), 68.6% (SE = 1.9%), and 45.5% (SE = 1.6%) were on a psychiatric medication after admission. CONCLUSIONS Many inmates with a serious chronic physical illness fail to receive care while incarcerated. Among inmates with mental illness, most were off their treatments at the time of arrest. Improvements are needed both in correctional health care and in community mental health services that might prevent crime and incarceration.

The crisis in mental health care: A preliminary study of access to psychiatric care in Boston

1. Seupaul RA, Jones JH. Does succinylcholine maximize intubating conditions better than rocuronium for rapid sequence intubation? Ann Emerg Med. 2011;57:301-302. 2. Heier T, Caldwell JE. Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesth Analg. 2000;90: 175-179. 3. Patanwala AE, Stahle SA, Sakles JC, et al. Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Acad Emerg Med. 2011; 18:1-4. 4. Mallon WK, Keim SM, Shoenberger JM, et al. Rocuronium vs succinylcholine in the emergency department: a critical appraisal. J Emerg Med. 2009;37:183-188. 5. Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology. 1997;87:979-982.

Availability of Outpatient Care From Psychiatrists: A Simulated-Patient Study in Three U.S. Cities

OBJECTIVES The study examined availability of psychiatrists for outpatient appointments in three U.S. cities. METHODS Posing as patients, investigators called 360 psychiatrists listed in a major insurers database in Boston, Houston, and Chicago (N=120 per city) and attempted to make appointments. Callers claimed to have Blue Cross Blue Shield or Medicare or said they would pay out of pocket (N=120 per payer type, divided evenly across cities). RESULTS In round 1 of calling, investigators were able to reach 119 of the 360 psychiatrists (33%). Of 216 unanswered calls, 36% were returned. After two calling rounds, appointments were made with 93 psychiatrists (26%). Significant differences were noted between cities but not between payer type. CONCLUSIONS Obtaining outpatient appointments with psychiatrists in three cities was difficult, irrespective of payer. RESULTS suggest that expanding insurance coverage alone may do little to improve access to psychiatrists-or worse, expansion might further overwhelm the capacity of available services.

Psychiatry in the Harvard Medical School—Cambridge Integrated Clerkship: An Innovative, Year-Long Program

ObjectiveThe authors present what is to their knowledge the first description of a model for longitudinal third-year medical student psychiatry education.MethodA longitudinal, integrated psychiatric curriculum was developed, implemented, and sustained within the Harvard Medical School-Cambridge Integrated Clerkship. Curriculum elements include longitudinal mentoring by attending physicians in an outpatient psychiatry clinic, exposure to the major psychotherapies, psychopharmacology training, acute psychiatry “immersion” experiences, and a variety of clinical and didactic teaching sessions.ResultsThe longitudinal psychiatry curriculum has been sustained for 8 years to-date, providing effective learning as demonstrated by OSCE scores, NBME shelf exam scores, written work, and observed clinical work. The percentage of students in this clerkship choosing psychiatry as a residency specialty is significantly greater than those in traditional clerkships at Harvard Medical School and greater than the U.S. average.ConclusionLongitudinal integrated clerkship experiences are effective and sustainable; they offer particular strengths and opportunities for psychiatry education, and may influence student choice of specialty.

Co-Occurrence of Substance-Related and Other Mental Health Disorders Among Adolescent Cannabis Users.

Objective:Cannabis is the most commonly used illicit substance in the United States and is increasingly being legalized throughout the United States. Many believe that cannabis is relatively harmless, and some believe that cannabis is not addictive. We wondered what the rates of cannabis abuse and dependence might be among adolescents referred for substance use evaluations and also about the incidence of co-occurring psychiatric illnesses and substance use disorders among those individuals. Methods:Herein, we analyze intake data from 483 adolescents referred for evaluation at an adolescent substance abuse clinic, with information gleaned from the adolescents and their parents or caregivers. Results:Forty-seven percent of our sample met the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria for cannabis dependence and another 32% for cannabis abuse. Among adolescents with cannabis use disorders, the co-occurrence of alcohol and opioid abuse or dependence was high. These individuals also suffered from significant psychiatric comorbidities otherwise. Conclusions:Our results show that cannabis use carries the risk of dependence and also carries with it significant risk of comorbidities, both with respect to other substance use disorders and other psychiatric illness. Given the growing body of research linking cannabis use with addiction and other psychiatric illness, public health efforts ought to center on the potential dangers of cannabis use.

Narrative aspects of a doctor-patient encounter.

In this essay I want to examine the ways that doctors communicate with their patients, in particular the stories that doctors tell their patients. I contend that the kinds of stories that physicians tell patients have a direct bearing on the nature of their relationship as a whole. Specifically, I shall argue that physicians who tell their patients the most complete stories possible about their illnesses, acknowledging uncertainties wherever they exist (to the extent that this is possible), show the greatest amount of respect for their patients as persons. This quest for completeness must be supplemented by an attempt on the part of the physician to explore the patients understanding and beliefs so as to formulate not only a more complete narrative, but also to formulate one that better serves the needs of the patient.

Availability of Outpatient Mental Health Care by Pediatricians and Child Psychiatrists in Five U.S. Cities

The authors sought to assess the availability of outpatient mental health care through pediatrician and child psychiatrist offices in the United States and to characterize differences in appointment availability by location, provider type, and insurance across five cities. To do so, the authors posed as parents of a 12-year-old child with depression, gave a predetermined insurance type, and asked to make the first available appointment with the specified provider. They called the offices of 601 individual pediatricians and 312 child psychiatrists located in five U.S. cities and listed as in-network by Blue Cross Blue Shield, one of the largest private insurers in the United States. Appointments were obtained with 40% of the pediatricians and 17% of the child psychiatrists. The mean wait time for psychiatry appointments was 30 days longer than for pediatric appointments. Providers were less likely to have available appointments for children on Medicaid, which is public insurance for low-income people. The most common reason for being unable to make an appointment was that the listed phone number was incorrect. Pediatricians were twice as likely to see new patients and to see them sooner than child psychiatrists. Increasing the number of both types of providers may be necessary to increase access to mental health care for children.

Caution is Warranted when Engaging with a State Physician Health Program: Comment on “A Retrospective Cross-Sectional Review of Resident Care-Seeking at a Physician Health Program”

To the Editor: I am a former associate director in one state physician health program (PHP) and have worked with physicians with mental health and substance use disorders for over 20 years, and I feel compelled to respond to Parry and colleagues’ [1] recent paper in this journal about resident participation in state PHPs. My concerns focus on some statements they made in their paper about the Colorado PHP as well as more general concerns about PHP standard operating procedures. To begin, the authors cite research that shows “successful outcomes” for physicians in PHPs but fail to note that almost all of this research was conducted by individuals who run PHPs or work closely with them. As such, reported success rates are often inflated because of study designs that often exclude those who dropped out or committed suicide while being monitored, or those who were lost to follow-up otherwise. Additionally, I have seen many instances in which individuals who did not have substance use disorders were compelled to enter PHP monitoring agreements. If these individuals remain abstinent for the duration of their monitoring agreements they should not be counted as “successful” given that they had no impairment in the first place. Second, the authors state that individuals who are applying for licensure in Colorado are required to report their personal health history either to the Board of Medicine or the PHP. The authors correctly note that the latter option offers clients more privacy, but can such a report made to the Colorado PHP truly be considered “voluntary,” which the authors do? After all, being compelled to choose between two options and choosing the one that is perceived to be less bad should not be considered a voluntary choice. Such self-disclosure should be considered a utilitarian move to mitigate harm to one’s career until proven otherwise. Lastly and most importantly, the authors “recommend that residents be made aware that PHPs offer thorough assessments either in-house or externally.” This might be true in Colorado—it is also true in Massachusetts—but most state PHPs do not do any extensive evaluations in-house but instead require participants to obtain an evaluation at facilities that often charge

Substance Use and Addictive Behaviors Among Physicians

5000–6000 for a 4-day evaluation, which is generally not covered by insurance. Failure to comply with the request to go for this evaluation, in many instances, will result in the PHP informing the licensing board about noncompliance which might bring with it significant sanctions. I have seen instances where physicians have lost their ability to practice medicine after voluntarily engaging with PHPs and then failing to comply PHP recommendations. To compound the potential for trouble, the evaluation centers that PHPs generally use often have significant conflicts of interest in several ways. First, these centers also often offer treatment (which can be 90 days in duration and cost tens of thousands of dollars, generally not covered by insurance), so if an evaluation produces a recommendation to stay for treatment, how can one be sure that a recommendation for treatment was not motivated by financial incentives? Additionally, almost of these centers have bidirectional financial ties to state PHPs, given that these centers support regional and national meetings of PHPs (see, for example, page 30 of [2]) and also often depend on PHPs for referrals to keep them viable. Hence, any recommendations that these evaluation centers make ought to be viewed with caution. Interestingly, I have almost never heard of individuals being referred to academic medical centers for evaluations, even in states with medical schools that have excellent forensic psychiatry programs. To compound matters, most states have no meaningful avenues for physicians to appeal PHP recommendations, meaning that physicians often have little choice but to comply with any and all PHP recommendations or else risk being reported * J. Wesley Boyd jwboyd@cha.harvard.edu

How broad are state physician health program descriptions of physician impairment

Health care personnel experience rates of substance-use disorders (abuse and dependence) that are comparable to the general public. Unlike the general population, however, physicians are more likely than nonphysicians to misuse prescription drugs and to do so for reasons of self-treatment. There are a number of nonspecific signs and symptoms that might suggest a problem, and being familiar with these is important for all physicians. If there is a problem, intervening as early as possible is important, both for the health of the physician and for his or her patients. The best approach for intervening with physicians is one that is highly structured. Residential programs of 2–3 months in duration are often recommended, but there is scant evidence that these extended stays produce better outcomes than shorter stays. If a physician has undergone extended inpatient treatment, aftercare plans generally include monitoring by a state physician health program. These programs can provide advocacy for physicians who have maintained abstinence and complied with all aspects of their monitoring agreements. Success rates for physicians who undergo substance-use disorders treatment and/or monitoring are generally very high, probably because the costs of failure and the rewards of success are both very high for doctors. Many physicians who have been caught in the grips of a substance-use disorder recover fully and return to the successful practice of medicine, and might even be better physicians given their newfound focus on their own health and well-being.