Please read my books! Both are available as paperbacks or as ebooks. These are just the warm-up books - both were written over ten years ago - but the next wave is coming soon!
Goodreads | Homicidal Intent by Vivian Chern — Reviews, Discussion, Bookclubs, Lists
Monday, March 10, 2014
Sunday, March 9, 2014
Now for something completely different - a book review!
Jason Porter nailed it. Thank you. You just got into my bibliography of the (non-fiction) book I'm writing. I wish I did not understand this book so well but I do.
For people who don't understand, don't try to analyze. This is the story of a breakdown (in colloquial terms). It makes sense. It is moving. And it shows us how normal stuff is really not normal at all - and vice versa.
Jason is a good writer, he can use language, and he is funny while being sad. I don't generally read books like this one, since my everyday life is overflowing with these stories, only not told as poignantly, eloquently, or without self-pity. I guess that's why this book was so moving and impressed me - because most of the depressed people I see every day can't get off that pity pot.
Anyway, if you like books that are only about character - this is a great one. Me, I usually like books with plots, but I think the writing in this book is good enough to write a more complex story next time.
I do highly recommend this book for everyone, though. Maybe it will help people's eyes to open inward a little bit.
For people who don't understand, don't try to analyze. This is the story of a breakdown (in colloquial terms). It makes sense. It is moving. And it shows us how normal stuff is really not normal at all - and vice versa.
Jason is a good writer, he can use language, and he is funny while being sad. I don't generally read books like this one, since my everyday life is overflowing with these stories, only not told as poignantly, eloquently, or without self-pity. I guess that's why this book was so moving and impressed me - because most of the depressed people I see every day can't get off that pity pot.
Anyway, if you like books that are only about character - this is a great one. Me, I usually like books with plots, but I think the writing in this book is good enough to write a more complex story next time.
I do highly recommend this book for everyone, though. Maybe it will help people's eyes to open inward a little bit.
Thursday, March 6, 2014
Going Postal?
It's been a while, friends, and now I am back to tell you - I can't accept Medicaid anymore. Or Cigna. Or a whole bunch of insurances which don't pay anything. And here's why.
Since I last wrote a blog post many things in my life have changed drastically. My forensic practice is still busy-ish - but I don't get five DYFS cases a week anymore. Partly because I'm "too expensive" (it takes me at least ten hours to do an evaluation properly) and partly because I'm a maverick - I say what I think, not what someone wants to hear. So if a referral CAN parent her children, and I say she can - that DYFS office (now known as the Division of Child Protection and Permanency, or DCP&P) might not be so interested in sending me more cases.
So I started accepting insurance. Lo and behold, I now have around 900 patients. In three years. I keep discharging people when they get better - or when they are non-compliant - but still my total, as per my EHR - hovers around 950, even as I mark patients "inactive" every day. And still there is not enough money to pay for the month. I am earning about what I earned as a fellow when I also moonlighted, almost twenty years ago. And I don't mean with inflation - I mean in actual dollars.
I see my own doctors, as a patient, too. I had knee surgery, I have weird allergy symptoms, I have stuff. I'm past the mid-point of my life and things start deteriorating. A few weeks ago I went to the gastroenterologist. She saw me for less than ten minutes and my insurance paid her over $300. She scheduled me for some invasive procedures (for which I have to take a day off from work, too) that will bring in a few thousand dollars more. That's fine. She's making a living, and she takes insurance.
Why can't I make a living by taking insurance? If I see someone for ten minutes (which is not possible in psychiatry no matter how bad a doctor you are) I would get about $45. Why exactly is gastroeneterology more important than psychiatry? I know people THINK that anyone can do psychiatry. Certainly all the family doctors, pediatricians, psychologists, social workers, internists, and for all I know, dentists and chiropractors, believe they can treat psychiatric disorders as well as I can. Just prescribe some medication that they saw on a TV commercial and everyone is good to go.
Let me tell you something. None of that is true. Even many PSYCHIATRISTS don't know much about psychiatry. We are no longer permitted to treat patients with psychotherapy, so our patients go to social workers who try to talk people out of their schizophrenia, or depression, or obsessive-compulsive disorder, for years before they end up in the right place. The insurance companies would love to skip the middleman and send patients directly to a pharmacy (for the cheapest drug, of course, not the best one) without ever stopping by a psychiatrist's office. But here's the thing: we psychiatrists are the ones who see, identify, and prevent, disasters. School shootings. Murder-suicides. Train shootings. Infanticide. Even elaborate Ponzi schemes by manic individuals who believe that what they are doing is okay because they have the power to re-earn all that money. We are the ones who can identify and treat these conditions, in these individuals, before disaster happens. Like the NSA and Mossad, we work behind the scenes to make sure that people don't get crazy enough to do those awful things that we keep hearing about.
The problem, of course, is that people don't always want to get help, and that even when they do, we can't force them to take medication or go to a hospital until they expressly say the words: "I have a PLAN to kill myself or somebody else." How stupid is that? A crazy guy brought a rabbit into my office. It could have been a gun, but that's another story. When someone starts to lose contact with reality (and this guy certainly had, and I'm not going to tell you how I know, because of course having a pet rabbit does not mean you are crazy, so if you want to know how I figured it out, go study psychiatry for four years after four years of med school after four years of college), it's time to get that person into a safe place where he can be medicated based upon what a reasonable person would want. This is the main problem with the way the law sees psychiatry and psychiatric patients. And when insurance reimbursement is so low that psychiatrists are reduced to spending ten minutes a month or every three months with their patients - how are we supposed to use all that training to identify who is totally nuts and potentially dangerous?
We are the ones who prevent the world's disasters - at least the small disasters - the small-time bombings (anyone remember the unabomber?) the school shootings, the murder-suicides, the infanticides. We are the ones who treat countless numbers of mentally ill people so hopefully they don't go flying off the roofs of "downtown parking structures." Yesterday, one of my young male patients missed his appointment. Around the same time, I saw online that the body of a young white male was found on a local street, an apparent suicide victim. My heart almost stopped, even though I kept telling myself that this patient was not even depressed, would never kill himself, and probably just mixed up his days. Thankfully, it was not my patient. But was this young man someone else's patient? Or had he been unable to ever even see a psychiatrist, because his insurance wouldn't pay or he could not find a doctor who would accept it, or because someone told him to "be a man" or "suck it up"? We may never know, but we do know that statistically, if nothing else, the horrible cases we see on the news are only a small fraction of the truly mentally ill people who are helped - who are SAVED - by psychiatrists.
I think that we psychiatrists should be paid fairly - the same as gastroenterologists or dermatologists or any other specialists - so that we can treat our patients fully, and help prevent further tragedies. We should be paid fairly so that all psychiatrists can afford to accept insurance, and still keep up with their continuing medical education. Hospitals should be allowed to hospitalized mentally ill people who are not imminently dangerous. People who have emotional problems should be permitted to get better in their own time, not forced to continue to work in a place that figures prominently in their delusions, until they get so angry that they end up "going postal." Imagine that, something that has occurred so frequently that it is an expression. And we can treat that! We can work with angry, delusional, psychotic, hostile, and paranoid people and make them better! But we also have to be able to pay our mortgages and feed our families. Plus why does my orthopedic surgeon, an antipathic and possibly sociopathic individual, deserve a better car/house/vacation/retirement fund than I do? I promise you I know more medicine than he does. He is a carpenter of bones. I am an artist, a master of neurobiology, someone who understands the complexities and clinical challenges of post-synaptic receptor down-regulation.
We fought for "parity" in congress and in our state legislatures. But some insurances won't pay for treatment of post-traumatic stress disorder because it is not "biological." Excuse me, nasty insurance company with a big lobby in Washington, but every time I type a word here, biological events of incredible complexity occur. Somehow, psychiatry has become a non-specialty, an unloved stepsibling to the rest of "real" medicine. For this reason, psychiatrists are doing silly things, like genetic testing to see which version of liver enzymes their patients have, so they can pretend that they now know which medication the patient will respond to the best. In reality, these tests are expensive and useless. You can tell clinically if you need to increase someone's dosage - and that is the ONLY way you can tell. How quickly or slowly someone's liver metabolizes a medication tells you NOTHING about how that medication is going to work at the synapse (the space between the neurons in your brain). Insurance won't pay for those tests, but some patients will. Some patients believe that you get what you pay for, and so they go "out of network" to see overpriced quacks. I think that this "get-what-you-pay-for" mentality is what makes me the angriest out of all the things I've just mentioned. That my patients think they are getting worse care than people who are going to the no-insurance accepted doctors. Which is ironic, because I have plenty of patients who ended up with me after their no-insurance doctors could not help them (and I could, can, and do) and even a few patients who were referred to me by the no-insurance doctors who just could not get those few people better. (Hint: It's all about that downregulation of the post-synaptic receptors).
Here is my summary: Psychiatry is a medical specialty. A complicated specialty. To do it right requires a lot of time with each patient. And the lives we save are not just those of the patients who don't commit suicide, but the lives of untold innocent victims who survived because a psychiatrist managed to help a patient headed toward insane violence. One of these days someone will figure out how to study this concept, how to deduce how many school shootings did NOT occur because someone was psychiatrically treated appropriately. For now, you have to take my word for it. And please ask your congresspeople and insurance companies to pay us enough money to treat all patients appropriately, so I don't have to come back here and say I don't accept insurance anymore. Because that will be a sad day for a lot of good people.
Since I last wrote a blog post many things in my life have changed drastically. My forensic practice is still busy-ish - but I don't get five DYFS cases a week anymore. Partly because I'm "too expensive" (it takes me at least ten hours to do an evaluation properly) and partly because I'm a maverick - I say what I think, not what someone wants to hear. So if a referral CAN parent her children, and I say she can - that DYFS office (now known as the Division of Child Protection and Permanency, or DCP&P) might not be so interested in sending me more cases.
So I started accepting insurance. Lo and behold, I now have around 900 patients. In three years. I keep discharging people when they get better - or when they are non-compliant - but still my total, as per my EHR - hovers around 950, even as I mark patients "inactive" every day. And still there is not enough money to pay for the month. I am earning about what I earned as a fellow when I also moonlighted, almost twenty years ago. And I don't mean with inflation - I mean in actual dollars.
I see my own doctors, as a patient, too. I had knee surgery, I have weird allergy symptoms, I have stuff. I'm past the mid-point of my life and things start deteriorating. A few weeks ago I went to the gastroenterologist. She saw me for less than ten minutes and my insurance paid her over $300. She scheduled me for some invasive procedures (for which I have to take a day off from work, too) that will bring in a few thousand dollars more. That's fine. She's making a living, and she takes insurance.
Why can't I make a living by taking insurance? If I see someone for ten minutes (which is not possible in psychiatry no matter how bad a doctor you are) I would get about $45. Why exactly is gastroeneterology more important than psychiatry? I know people THINK that anyone can do psychiatry. Certainly all the family doctors, pediatricians, psychologists, social workers, internists, and for all I know, dentists and chiropractors, believe they can treat psychiatric disorders as well as I can. Just prescribe some medication that they saw on a TV commercial and everyone is good to go.
Let me tell you something. None of that is true. Even many PSYCHIATRISTS don't know much about psychiatry. We are no longer permitted to treat patients with psychotherapy, so our patients go to social workers who try to talk people out of their schizophrenia, or depression, or obsessive-compulsive disorder, for years before they end up in the right place. The insurance companies would love to skip the middleman and send patients directly to a pharmacy (for the cheapest drug, of course, not the best one) without ever stopping by a psychiatrist's office. But here's the thing: we psychiatrists are the ones who see, identify, and prevent, disasters. School shootings. Murder-suicides. Train shootings. Infanticide. Even elaborate Ponzi schemes by manic individuals who believe that what they are doing is okay because they have the power to re-earn all that money. We are the ones who can identify and treat these conditions, in these individuals, before disaster happens. Like the NSA and Mossad, we work behind the scenes to make sure that people don't get crazy enough to do those awful things that we keep hearing about.
The problem, of course, is that people don't always want to get help, and that even when they do, we can't force them to take medication or go to a hospital until they expressly say the words: "I have a PLAN to kill myself or somebody else." How stupid is that? A crazy guy brought a rabbit into my office. It could have been a gun, but that's another story. When someone starts to lose contact with reality (and this guy certainly had, and I'm not going to tell you how I know, because of course having a pet rabbit does not mean you are crazy, so if you want to know how I figured it out, go study psychiatry for four years after four years of med school after four years of college), it's time to get that person into a safe place where he can be medicated based upon what a reasonable person would want. This is the main problem with the way the law sees psychiatry and psychiatric patients. And when insurance reimbursement is so low that psychiatrists are reduced to spending ten minutes a month or every three months with their patients - how are we supposed to use all that training to identify who is totally nuts and potentially dangerous?
We are the ones who prevent the world's disasters - at least the small disasters - the small-time bombings (anyone remember the unabomber?) the school shootings, the murder-suicides, the infanticides. We are the ones who treat countless numbers of mentally ill people so hopefully they don't go flying off the roofs of "downtown parking structures." Yesterday, one of my young male patients missed his appointment. Around the same time, I saw online that the body of a young white male was found on a local street, an apparent suicide victim. My heart almost stopped, even though I kept telling myself that this patient was not even depressed, would never kill himself, and probably just mixed up his days. Thankfully, it was not my patient. But was this young man someone else's patient? Or had he been unable to ever even see a psychiatrist, because his insurance wouldn't pay or he could not find a doctor who would accept it, or because someone told him to "be a man" or "suck it up"? We may never know, but we do know that statistically, if nothing else, the horrible cases we see on the news are only a small fraction of the truly mentally ill people who are helped - who are SAVED - by psychiatrists.
I think that we psychiatrists should be paid fairly - the same as gastroenterologists or dermatologists or any other specialists - so that we can treat our patients fully, and help prevent further tragedies. We should be paid fairly so that all psychiatrists can afford to accept insurance, and still keep up with their continuing medical education. Hospitals should be allowed to hospitalized mentally ill people who are not imminently dangerous. People who have emotional problems should be permitted to get better in their own time, not forced to continue to work in a place that figures prominently in their delusions, until they get so angry that they end up "going postal." Imagine that, something that has occurred so frequently that it is an expression. And we can treat that! We can work with angry, delusional, psychotic, hostile, and paranoid people and make them better! But we also have to be able to pay our mortgages and feed our families. Plus why does my orthopedic surgeon, an antipathic and possibly sociopathic individual, deserve a better car/house/vacation/retirement fund than I do? I promise you I know more medicine than he does. He is a carpenter of bones. I am an artist, a master of neurobiology, someone who understands the complexities and clinical challenges of post-synaptic receptor down-regulation.
We fought for "parity" in congress and in our state legislatures. But some insurances won't pay for treatment of post-traumatic stress disorder because it is not "biological." Excuse me, nasty insurance company with a big lobby in Washington, but every time I type a word here, biological events of incredible complexity occur. Somehow, psychiatry has become a non-specialty, an unloved stepsibling to the rest of "real" medicine. For this reason, psychiatrists are doing silly things, like genetic testing to see which version of liver enzymes their patients have, so they can pretend that they now know which medication the patient will respond to the best. In reality, these tests are expensive and useless. You can tell clinically if you need to increase someone's dosage - and that is the ONLY way you can tell. How quickly or slowly someone's liver metabolizes a medication tells you NOTHING about how that medication is going to work at the synapse (the space between the neurons in your brain). Insurance won't pay for those tests, but some patients will. Some patients believe that you get what you pay for, and so they go "out of network" to see overpriced quacks. I think that this "get-what-you-pay-for" mentality is what makes me the angriest out of all the things I've just mentioned. That my patients think they are getting worse care than people who are going to the no-insurance accepted doctors. Which is ironic, because I have plenty of patients who ended up with me after their no-insurance doctors could not help them (and I could, can, and do) and even a few patients who were referred to me by the no-insurance doctors who just could not get those few people better. (Hint: It's all about that downregulation of the post-synaptic receptors).
Here is my summary: Psychiatry is a medical specialty. A complicated specialty. To do it right requires a lot of time with each patient. And the lives we save are not just those of the patients who don't commit suicide, but the lives of untold innocent victims who survived because a psychiatrist managed to help a patient headed toward insane violence. One of these days someone will figure out how to study this concept, how to deduce how many school shootings did NOT occur because someone was psychiatrically treated appropriately. For now, you have to take my word for it. And please ask your congresspeople and insurance companies to pay us enough money to treat all patients appropriately, so I don't have to come back here and say I don't accept insurance anymore. Because that will be a sad day for a lot of good people.
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