Jacob L. Freedman, MD

[[{"type":"media","view_mode":"media_crop","fid":"57113","attributes":{"alt":"Â© GUALTIERO BOFFI/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_3351751132695","media_crop_h":"304","media_crop_image_style":"-1","media_crop_instance":"7206","media_crop_rotate":"0","media_crop_scale_h":"195","media_crop_scale_w":"200","media_crop_w":"312","media_crop_x":"31","media_crop_y":"23","style":"font-size: 13.008px; float: right;","title":"Â© GUALTIERO BOFFI/SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]Joe was a musician in his forties with a history of alcoholism who had recently resumed treatment in the context of his wife’s suspected infidelity and his subsequent relapse. He arrived approximately 14 minutes late for what would end up being his final psychotherapy session. He smelled of alcohol and his speech was slurred, suggesting that he was acutely intoxicated. This was in violation of our previously discussed treatment agreement.

Joe sat down in the chair and began the session by apologizing for having arrived late for his appointment. After a brief discourse regarding his frustration with the $25 co-pay, he abruptly stood up and pulled his hand out of his coat pocket to reveal a handgun. At this point, I attempted to remain calm and asked him about his intentions regarding the firearm he had surprisingly brought to the office. Caressing his weapon, Joe responded, “I’m going down to shoot my old lady; you know I caught her messin’ ’round with another man.”

Joe then sat down and started crying. I asked him to put away his firearm and secretly pushed the hidden safety switch under my desk to summon hospital police officers for a 

. Joe muttered something unintelligible that sounded like, “And that ain’t too cool.” I asked him if everyone was safe, given how upset he appeared and the fact that he was wielding a firearm. At this point he put his head between his legs and cried, “Yes I did, I shot her; you know I caught her messin’ ’round town, messin’ ’round town.” When I asked him if his wife was still alive, Joe stood up and yelled, “I gave her the gun and I shot her!”

The momentary silence that followed was shattered as police officers arrived and kicked open my office door to find Joe pacing angrily while I sat in my chair trying to remain calm. Pointing their handguns at him, Joe suddenly dropped his weapon and ran toward the window on the other side of my office. The officers urged him not to jump out of the window -something that Joe may or may not have been considering -and I distinctly recall the larger policeman yelling, “Where you goin’ to run to now??!?!”

In his intoxicated state, Joe initially muttered something about “Mexico,” then yelled, “I’m going way down South where I can be free!” The policemen, assuming Joe was going to make a break for it, lunged at him and Joe began to struggle before falling to the floor. In the scuffle that followed, Joe was escorted out of the office in handcuffs screaming, “Ain’t no hangman gonna, he ain’t gonna put a rope around me!”

In discussing the events with my clinic supervisor, it became clear that Joe’s case was handled as best as it could have been. Luckily, there weren’t any casualties beyond the murder that had presumably occurred before Joe’s final psychotherapy visit. A chart review of recent therapy sessions showed that Joe’s risk assessment -notably his substance abuse and access to firearms -had been clearly documented and discussed with local authorities as well as with Joe’s wife before the incident. This allowed our hospital lawyers to stop hyperventilating.

Moving forward, it was clear to me that no matter one’s training, only such fundamental moments can enable one to answer affirmatively when asked, 

Dr. Freedman is a psychiatrist in Boston, MA, and in Israel, where he serves as medical director of the English-Speaking program at Bayit Cham in Jerusalem. He also works as a business consultant and serves in both leadership and advisory roles with healthcare and technology companies. Dr. Freedman can be reached at drjacoblfreedman.com.

Articles

After a code gray, it was clear to me that no matter one’s training, only such fundamental moments can enable one to answer affirmatively when asked, "Are you experienced?"

Hendrix Revisited: Joe’s Final Psychotherapy Session

Technology can be a wild card-and that scares a lot of people. I have a friend who still has nightmares about killer robots after seeing 

 well over a decade ago. Some of my neighbors refuse to use snowblowers, even though picking up a shovel in a New England winter is generally against medical advice. Plenty of my colleagues have declined to upgrade to a smartphone in spite of the many advantages and time-savers they provide modern humanoids.

I don’t consider myself to be a particularly “early adapter” when it comes to technology. In fact, I’m the guy who didn’t have a microwave oven or cable television in his house until the age of 17. Technology doesn’t woo me in the same way that it grabs other people beyond the fact that I prefer going hiking to going downtown. I also prefer barbecuing the old-fashioned way with a charcoal grill instead of a fancy-schmancy gas-powered one. This is why it’s somewhat bizarre that I’m here writing an article about the benefits of using modern technology in one’s psychiatric practice.

But adopting technology for myself is one thing. It’s something completely different when technology is available for my patients and I’m not using it. So a year ago, when the third patient of the day asked me, “What 

 do you recommend for me to stay involved in treatment?” I decided to start using more technology in my practice. Not because I suddenly felt like leaving the “Golden Age” of handwritten notes and a pocket-sized calendar for scheduling appointments, but because my patients needed me to become a bit more futuristic. I had survived learning how to use electronic medical records, and I figured I could dive a bit deeper.

Big systems of care-including the Veterans Administration and others-have spent big bucks researching the effects of clinical tools like daily mood trackers and electronic medication reminders. The results have been predictable: patients are comfortable using technology, and regular reminders help them remain engaged in treatment. In my private practice, I have seen that using smartphone technology with Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic medication reminders has increased medication compliance for my patients. Why should I be surprised? Of course a message every morning at 8 am telling Jimmy to take his Abilify helps Jimmy remember to take his Abilify! Why should I be surprised that Nancy is more likely to stay sober with regular treatment reminders? She gets a message every evening at 7 pm encouraging her to stay sober, to attend her nightly AA meeting, and to keep her children in mind . . . and she loves it! (I’ve also found it wasn’t too difficult to integrate this technology into my practice after overcoming the initial anxiety associated with using any kind of new stuff.)

Adopting technology for myself is one thing. It’s something completely different when technology is available for my patients and I’m not using it.

And then I did something really out of the blue and started incorporating 

 into my daily practice. Not because I wouldn’t rather see my patients in person and not because I needed the extra money for covering a crisis center in North Dakota . . . I swear. I started using telepsychiatry because one size doesn’t really fit all. Many patients have difficulty in getting to regular office appointments as a result of various time and travel constraints. Others have odd schedules because of their professional and social obligations that require sessions outside of my regular office slots. Of course, I use a HIPAA-compliant platform and provide the same ethical and professional standards of care, but now I’m able to practice from home and to increase my availability for both established and future patients. And, as opposed to my colleagues who engage in phone and Skype sessions, my work habits are safe and secure.

 into my practice, I still have my trusty armchair and an old couch in my office. These pieces of furniture aren’t headed for an upgrade anytime soon. But while I never would have bet my student loans on using any of this new technology stuff, “The Times They Are a-Changin’,” and it’s been a pleasant improvement to my practice. So for my neighbors on the block, I’m still the same old guy who flips his burgers on a charcoal grill. But for my patients, I’m glad they know me as a psychiatrist who’s willing to utilize new technologies on their behalf.

Dr. Freedman is a board-certified psychiatrist who practices in Boston, MA, and an Assistant Professor of Psychiatry at Tufts University School of Medicine. In addition to his practice as a clinical psychiatrist, Dr. Freedman serves as Chief Medical Officer at Mentegram and as Associate Medical Director of the telepsychiatry practice, My Psychiatric Partner. He reports no conflicts of interest concerning the subject matter of this article.

Dr. Freedman can be most easily reached at 

"Adopting technology for myself is one thing. It’s something completely different when technology is available for my patients and I’m not using it."

Embracing Technology: Do It for Your Patients!

 most of my colleagues took a similar route and accepted a position at an academic hospital or an affiliated clinic. The adventurous ones left Harvard Medical School for California-and one even went to China. But no matter where we went, at some point in the midst of that first job just about everyone needed some extra money to pay down medical school debt. With the standard aversion to moonlighting in the emergency department at the local hospital, lots of us have asked the same question: 

“What else can I do to pay the bills?”

With this in mind, allow me to share 5 extracurricular activities  for an early-career psychiatrist:

 So much of our training was dedicated to learning the ins and outs of psychotherapy, but fewer and fewer psychiatrists are seeing psychotherapy patients as part of their daily endeavors. It doesn’t have to be Freudian or even Jungian. Having a pure psychotherapy patient can be a breath of fresh air from the intensity of working in a community psychiatry clinic or running a psychiatric emergency department. Private-pay patients are a good way to make some extra income, to develop your skills as a therapist, and to diversify your patient population. Even 1 or 2 patients a week can make for a very gratifying experience.

 Most early- career psychiatrists are surprised to hear that you don’t need to complete a fellowship in forensic psychiatry to do independent medical examinations. These visits are more calculated and less about therapeutic alliance, which can be off-putting. Whether it’s for the local court system, disability claims, or a malpractice case, independent evaluations use a different part of the brain. Registering through your state’s forensic system as an “expert vendor in psychiatry” also allows you to travel to other institutions-including state hospitals-to complete evaluations. It’s fascinating to see how patients are managed in different settings. Independent reviews for external review organizations are another part-time gig that personally taught me a lot about documentation and the different standards of evidence-based care.

 I can’t say I’ve done it myself, but I have a few colleagues who tried working for insurance companies and the pharmaceutical industry who burned out pretty quickly. Nevertheless, there are interesting jobs out there as clinical investigators for novel psychiatric medications and other related positions. I know a number of psychiatrists with strong basic science and research backgrounds who have enjoyed the 9-to-5 work schedule associated with these jobs.

Congratulations on having become a board-certified psychiatrist! As an expert in your field-yes, you are now officially an expert-many businesses are interested in your skills. Organizational consulting can consist of any number of abilities you have honed as a trainee working on the inpatient unit. This is not even limited to your risk-management, conflict resolution, and negotiation skills. I am very grateful to have had the privilege to work as a consultant with a number of start-ups: some health care–related and others not. I am currently the Chief Medical Officer for Mentegram, a company dedicated to increasing practice efficiency and reimbursement-through screening technology-and to improving patient care through electronic reminders and treatment protocols. It’s absolutely a pleasure to be part of a very different team than the one that I work with on the inpatient unit during my day job.

 While it usually doesn’t pay too well, medical writing is a unique experience that allows us to help patients on a grander scale. Medical writing jobs are an interesting experience, especially when they involve translating clinical protocols or diagnostic information into patient-friendly language. Furthermore, writing is a great opportunity to keep up with new and evolving health care issues while also getting your name out there when it’s time to start the next phase of your career or build your private practice. Or perhaps you’re a budding author who’s finally ready to write the sequel to One Flew Over the Cuckoo’s Nest.

Sure, there are other things you can do out there with your training, 

but space is limited here. Beyond the economic advice, early-career psychiatrists should also hear this wisdom and take it to heart: “Don’t forget to spend time with your loved ones.” This is the most important thing to consider now that the days of pre-rounding on patients and overnight call are finished. Plus, all of your training as a psychiatrist will come in handy at Little League games when parents from opposing teams inevitably lose their cool. . . .

With the standard aversion to moonlighting in the emergency department at the local hospital, lots of us have asked the same question: “What else can I do to pay the bills?”

Extracurricular Activities for Early-Career Psychiatrists

“Sometimes when you complain for long enough about the disastrous nature of something, you end up being nominated to fix it,” laughed Dr S. “Look at me,” he continued, “I thought that the psychopharmacology teaching you were getting was terrible and now I’m stuck as your professor, whether I like it or not.”

“But Dr S,” I began, “You love teaching because it gives you a chance to brainwash us.”

Dr S grinned and raised his bushy eyebrows, “I do love brainwashing you, but not as much as you’re going to love being the new Chief Medical Officer at the local Department of Mental Health.”

“Someone’s gotta fix it, I guess,” I responded.

“You certainly qualify as a ‘someone,’” Dr S said as his grin widened, “Plus you’ve got 2 full years of training under your belt, which makes you grossly overqualified.”

“Well, let’s say for the sake of simplicity that your budget of $600 million just got cut in half and now you’re left with 6000 folks to feed, clothe, house, medicate, hospitalize, and provide psychiatrists, therapists, and case managers for. That leaves you with approximately $50,000 per person per year and then subtract your hefty salary and pension.”

“As long as I take in more than the 12 bucks an hour I’m making as a resident, I’ll be happy.”

“Let’s further assume that you can’t build any more houses or group homes because 50% of your budget is getting eaten up by psychopharmacology prescriptions. Frankly, this is one of our main problems: nearly half of our guys are on the streets and sleeping on park benches, if they’re lucky. To make this even easier, let’s just say you’re only in charge of chronic psychotic patients and don’t have the complicating variables of substance abuse, personality disorders, and malingering to deal with.”

“So what do you want to do to maximize services and minimize costs? Starting today and starting right now because we don’t have any time to waste, Dr Freedman.”

 “Well, let’s start by outlawing prescriptions for any of the brand-new super-expensive drugs until we find out whether they work any better than the other ones we’ve come to know and love.  They’re costing us a fortune.”

“But what about one of these new drugs that might modulate BDNF? It might be the most pro-cognitive antipsychotic medication we’ve ever had! Do you really want to be personally responsible for preventing your chronically psychotic patients from having their BDNF tweaked? That could make all the difference and finally cure our most refractory patients!”

“I love it when you play ‘the excitable sales rep,’ Dr S. And you’re right, I guess I can’t rule out putting something that exciting into our local water supply, but I need more research saying it actually works differently from anything else we’ve already got before switching over all of our folks to it because it’s gonna bankrupt my whole department.”

“OK, fine, but what about atypical antipsychotics in general? Walmart only charges us 10 bucks a month for the first-generation meds, and we’re hemorrhaging nearly $1000 a month for each new atypical antipsychotic script. Not to mention the cost of metabolic adverse effects on our patients in terms of decreased functionality and increased mortality/morbidity as a natural result of obesity.”

“I can see that you want me to grossly oversimplify the academic literature in a 

kind of fashion, but I still don’t find it particularly ridiculous to suggest that any single drug is better than its peers, with the exception of clozapine

 for our most chronically psychotic patients. But am I really ready to treat these folks with only typical antipsychotics and clozapine at this point?”

“I guess I can’t say I’m prepared to be so black-and-white. But it makes sense to have a darn good reason not to treat our guys with clozapine and I’m not sure we have one in a lot of our cases.”

“Frankly this makes me pretty livid at times; I need to forget about it now or I’m going to need a PRN. Next subject: any thoughts on treating with long-acting injectables? Those cost us a fortune, too, when we use them.”

“True they’re expensive, but not as costly as hospitalizing someone when he misses a few oral doses accidentally or starts refusing his PO meds because he’s ‘doing better’ and ‘doesn’t need’ his antipsychotics anymore.”

“Good point, I like the idea of increasing the use of shots as long as our patients go along with it. Did you know that in Great Britain more than 30% of their psychotic patients are treated with long-acting injectable formulations?”

“I actually take the time to read the articles you recommend to us, so yeah, I’m familiar with that figure and with the fact that many of our patients would clearly benefit from the stability and guaranteed treatment adherence of long-acting injectable antipsychotics. In short, I’m definitely willing to increase the use of long-acting injectables in our population in order to minimize hospitalizations that could have otherwise been avoided with better treatment adherence.”

“OK Dr Freedman. You’ve done a good job so far as the Chief Medical Officer of DMH. Unfortunately you’re fired because we need to get you back to the inpatient unit to finish rounding.”

“That’s it? No severance pay, no state pension?”

“Maybe I’ll rehire you again next week during psychopharm seminar, OK?  Now go save the world.”

Acknowledgment-The author would like to thank Dr S-as well as Drs A, Z, P, C, and F-for the superb psychopharmacology teaching he’s received over the past few years.

The author reports no conflicts of interest concerning the subject matter of this article.


1. McEvoy JP, Lieberman JA, Stroup TS, et al; CATIE Investigators. Effectiveness of clozapine versus olanzapine, quetiapine, and risperidone in patients with chronic schizophrenia who did not respond to prior atypical antipsychotic treatment. 

2006;163(4):600-610.
http://www.ncbi.nlm.nih.gov/pubmed/16585434
 

Sometimes when you complain for long enough about the disastrous nature of something, you end up being nominated to fix it. 

My Recent Promotion

As a brand-new psychiatrist for patients with first-episode schizophrenia, I had hoped to keep my previous career as a semi-pro basketball player in my back pocket as a secret weapon. I recall watching my patients become stabilized with antipsychotics as their positive psychotic symptoms slowly disappeared. But despite the victorious absence of thought broadcasting and command auditory hallucinations with our first-line treatments, I was dismayed to see how many of these young individuals remained incapacitated to varying degrees by psychotic negativism and cognitive impairments.

In many patients with schizophrenia, antipsychotic treatment leads to only mild to moderate improvement in negative and cognitive symptom domains.

 Persistent psychotic negativism and cognitive deficits have been correlated with poorer outcomes in this patient population.

 Luckily, we had other tools in our arsenal besides our trusty D2-blockers. Our program used cognitive enhancement therapy-an evidence-based, nonpharmacological treatment of these symptom domains involving computerized cognitive training and individualized social cognitive programming.

 Our patients also participated in a MacFarlane-style psychosocial multifamily group to help them connect with each other through cooperative problem solving.

 There was also a National Alliance on Mental Illness Family-to-Family group to engage and support our patients’ primary caregivers in the treatment process.

And still many of our patients remained paralyzed by their illnesses, spending most of their days at our program staring at the wall in front of them. With the blessing of our medical director, I started taking 3 young men with first-episode schizophrenia to a local basketball court on Tuesday afternoons. The first week was loaded with missed passes, mostly because all 3 men made no eye contact. On the way back from the court, I tried to engage these previously unengageable patients by discussing Larry Bird and other basketball legends. I was shocked when one patient told me, “I’ve always admired Magic Johnson for the work he does in AIDS advocacy.” These 13 words were the most I’d ever heard him speak.

The following week held another pleasant surprise when all 3 patients arrived at my office door holding the basketball to tell me they were ready. It would be ludicrous to call my basketball group a 

-this was no new penicillin. But it was a serendipitous, Alexander Fleming–type experience, watching as my random idea to take 3 patients out to play basketball hatched into an established group therapy session in less than a month. Our walks to the court were characterized by ageappropriate trash-talking, interspersed with psychopharmacology check-ins. The group was its largest one day when a social work intern joined and we had a half-court game with 6 patients that only ended after the sun set and it was too dark to play. All of the regular participants became more interpersonally engaged, and 2 patients began to stick around together to shoot hoops after the group session had ended.

Refractory psychiatric illnesses are no different from complicated infectious diseases in that they both require multiple concurrent medications and treatment modalities. And while group basketball therapy wasn’t penicillin, it was a solid complementary intervention, perhaps more like the third antiretroviral agent in the treatment regimen of a patient with HIV infection. So while there is no evidence base for this novel treatment-group basketball therapy-the cost-benefit analysis proved extraordinary. The patients who participated had positive social interactions with their peers, strengthened the therapeutic alliance with their treating psychiatrist, and engaged in regular exercise-something with proven benefit in patients with schizophrenia.

 In fact, the only “con” of this intervention was a twisted ankle suffered by the administering physician (me).

In reflecting on this experience, I recall a time when I had the privilege of meeting with a nationally renowned psychopharmacologist who-following a long discussion on the future of antipsychotics-told me: “We need to think outside the box, not because the box is broken, but because we need more than just boxes to treat patients.” Neither he nor I predict that new antipsychotics that tweak the 5HT-7 receptor will become the knights-in-shiningarmor of schizophrenia treatment. Rather, it is clear that the complete and efficacious treatment of this complicated illness will be found in using multiple modalities, including psychopharmacology, cognitive enhancement therapies, family engagement, and perhaps one day-if someone publishes a randomized placebo-controlled study-group basketball therapy.

Schizophrenia, “just the facts” 5. Treatment and prevention. Past, present, and future.

 Green MF, Kern RS, Heaton RK. Longitudinal studies of cognition and functional outcome in schizophrenia: implications for MATRICS. 

, et al. Negative symptoms have greater impact on functioning than positive symptoms in schizophrenia: analysis of CATIE data. 

Eack SM, Hogarty GE, Greenwald DP, et al. Effects of cognitive enhancement therapy on employment outcomes in early schizophrenia: results from a 2-year randomized trial.

 McFarlane WR, Link B, Dushay R, et al. Psychoeducational multiple family groups: four-year relapse outcome with schizophrenia. 

National Alliance on Mental Illness. NAMI Family-to-Family Education Program. 

http://www.nami.org/Template.cfm?Section=Family-to-Family

Refractory psychiatric illnesses are no different from complicated infectious diseases in that they both require multiple concurrent medications and treatment modalities.

From Boxes to Baskets

Perhaps I was being narcissistic to think that Mr L, owner of the country club, would remember a lowly caddy. And yet I was still nervous that he might recognize me beneath my new disguise as a psychiatrist on the inpatient unit where he was now a patient.

Perhaps I was frightened that he might see right through my ID badge and yell at me for retrieving the wrong putter? Didn’t I remember who he was? Perhaps I was so habituated to the humiliation of handing him the incorrect club that there was no way that I could fathom having the knowledge to formulate a proper treatment plan. But the reality was that Mr L was here, suffering, and in need of compassionate and competent psychiatric care.

The dilemma was that I happened to be the only doctor in house, unable to dodge our inevitable interaction. Mr L was previously a real estate powerhouse, a veritable Goliath in his personal life, who shook the ground when he walked up the fairway whistling marching tunes he recalled from his decorated military career. Try as I might, I couldn’t imagine Mr L in need of a sophisticated psychiatric evaluation and treatment plan; I could only picture him glowering over me as I replaced his divots. But there was no alternative to the caddy-turned-physician that Mr L now required. I went to see my patient to render the effective, empathic care I had been trained to provide for all my patients. Fortunately for both of us, I was now taller and balder and had more facial hair, and I was thus unrecognizable to Mr L through his cataracts and the cloudy lens of time.

Of course I felt obligated to discuss this predicament with my supervisor, who was able to share a similar story of a time when he was the lone doctor on an inpatient unit. He had encountered a hockey coach from his youth who was clearly suffering and in need of treatment. It became clear that he had been as distressed as I was now about having to care for an individual who invoked such distinct memories and transferential feelings. Perhaps just as salient was the overpowering fear we also shared during this experience-a fear of our own vulnerabilities that had been exposed in witnessing the very human imperfections of our fellow human beings.

This awkward patient-psychiatrist interaction had led my supervisor to a conclusion: if he could ever help it, he would do his best to refer any familiar patient to a colleague-respectfully avoiding any problematic boundary issues as well as any potential threats to objectivity in the care of the patient. Yet sometimes these situations arise unavoidably, especially in smaller towns or areas in which there are fewer psychiatrists. One may simply find oneself face-to-face with the uncomfortable fact that he or she is the only psychiatrist available . . . the only one there to carry out the pledge to do no harm and to relieve suffering.

During my career-initially as a caddy and now as a psychiatry resident-I’ve had the immense privilege of listening to the stories of others. Here was a story and a lesson I was sure to keep in my golf bag: be it a hockey coach or a real estate magnate, we all have vulnerabilities to psychiatric illness. Anyone can become buried in a sand trap and have the urge to throw his clubs in defeat. It’s up to us to learn from these lessons, aim for the green, and play the ball as it lies.

During my career-initially as a caddy and now as a psychiatry resident-I’ve had the immense privilege of listening to the stories of others. Here's one of those stories.