Wednesday, March 26, 2014

Major Division on Psych/Medical Testing Is Brewing

The middle-aged man leaned halfway out the apartment window, steadied himself against the window sill and proceeded to use a powerful handgun to blow his brains out.  It was, in fact, an act of consideration for his wife because he didn't want to have her deal with an apartment splattered with his blood.  No one suspected he was suicidal and it came as quite a shock when his neighbors were told of his actions.  He was a hard-working man who was involved in redecorating apartments and was not only highly complimented for his work but quite successful at it.  What drove him to commit suicide?

Some initial investigation revealed that the man had been told by one of his physicians that he had cancer.  It would appear that there was insufficient discussion of exactly what this would mean in terms of his lifespan, the usefulness of treatment and also some intervention to help him with his shock and depression.  It turned out, unfortunately, that he had a form of highly treatable cancer and he would not have died in pain that was his fear.  The gun was his solution to what he perceived was to be a terrible fate that awaited him.

The man's death, in some ways, underscores a concern on the part of many in the mental health and medical communities regarding appropriate referrals for therapy and remediation after a diagnosis of something as serious as cancer.  What should have happened here? It should have called for a referral.

Recently, there was an article in an online medical blog that pointed out that there was insufficient psychotherapy being provided for women with breast cancer.  It seems that the greater number of cases are not referred for counseling and are left to deal with this on their own.  Of course, this is something that is wholly unacceptable and which only adds to the woman's depression because not only does she feel alone, but she may feel doomed.

On the other hand, it appears that there is a debate now underway regarding the utility of cognitive testing or screening for elderly persons.  The most recent article that I have seen indicated that they felt it was not useful and may, in fact, even be overused.  That word "overused" always makes me become much more aware of the situation in which this overuse takes place and the resulting charges which will be applied to Medicare or Medicaid or private insurance. 

And then, who does the testing? I’ve seen attorneys’ offices where an unqualified secretary does the testing. One point needs to be made here. The test the secretary used should never have been sold to anyone who isn’t licensed to use it and a secretary doesn’t have this needed credential.

Yes, testing can be useful, but if it is not useful, then why are we testing?  It also reminds me of the recently touted blood test that was supposed to accurately reveal whether or not you were likely to develop Alzheimer's disease.  It turns out that it was an example of over hyping a very small study and giving it too much promise.  There's still a lot of work to be done.

Then we come to the case of testing, in the home, for colon cancer and how reliable or unreliable that test may be.  Of course, patients would enjoy having the knowledge that they could do a simple test themselves in their homes in order to be evaluated for the potential for colon cancer.  The problem is that this test may either be providing false positives (indicating you have colon cancer) or not providing evidence regarding the potential of polyps which may morph into cancer.  It's not so simple as it would seem and yet it was, once again, publicized as another breakthrough in cancer prevention.

Now you are asking what is the reason that I am pointing to these problems and seemingly accentuating the negative rather than the positive?  My purpose, as it always is, is to help you see through the hype and gain enough information so that you do not get your hopes up and rush off to have some kind of test or not have it.  Remember what they said just a few months ago about women of a certain age no longer requiring mammograms?  That one has been hotly debated and physicians are concerned that women may be placed at greater risk.

The recommendation regarding cutting back on mammograms was based on a massive reevaluation of the data on women who either had treatment that they didn't require for benign lumps and masses and those who had more radical, surgical interventions.  There seem to be a question of the benefit to the women.  A reevaluation, if needed, should be made for any treatment recommendation.  Of course, everyone should try to err on the side of the conservative approach, but each case must be done on consideration of the facts surrounding the particular diagnosis.

One thing we do know is that there is a need, in many cases, for professional evaluation of someone's depression or cognitive impairment.  Certainly, when a diagnosis of a life threatening illness is made, any specialist or PCP should be considering a referral for some supportive counseling or psychotherapy.  This isn't a period when a person should be left alone to tackle the rough road ahead.

What can be done?  Everyone in the medical community, whether they deal with mental or physical health, should receive ongoing professional education on appropriate referrals and when and how you make them.  Initially, of course, this training should be started in medical school and should be continued through someone's residency and professional practice.  It isn't something you learn once and then forget.  Patients deserve better.