Bill, I'm well aware of efforts to improve delivery of patients to care that are outcome oriented. You're also aware that there is a lot of work being done to make sure these measures don't penalize doctors working with difficult populations or in resource strapped communities. You may or may not be aware that many of these measures include an "out," for patient refusal or are compliance free--such as measures for tobacco cessation (advice provided) or beta blockers at discharge after MI (prescription given OR contraindication noted).
"All of this is to tell you - once again - that I disagree with your attempts to make it seem like behavior modification is impossible. Impossible for some? Absolutely. Can't make a difference? BS. Some MDs most definitely do better than others, and some third party health plans do better than others."
Great. Hearing about your from a distance experience with quasi related work is nice. I also know about your two referrals for mental health evaluations (and how one worked). But I've been actually trained to do capacity evaluations, and I've been involved with them in clinical medicine now for eleven years, six as an attending physician. I spend much of my time surrounded by psychiatry--my partner and half of our friends--and these issues are discussed constantly. I have been involved in as many psych-hold situations (as a practitioner) just TODAY as you have (as a lay person) in your life. I know I was an 18 year old kid when you met me, but seriously--what amazes me here is your willingness to tell me how these things work rather than ask me.
I did indeed have flashbacks to your Va. Tech comments when you started writing here. Then, it sounded pretty much like you faulted individuals who didn't hold or treat the guy, but... gosh how many times can I say it?... we're not. allowed. to just hold. anyone we want. You have to be pretty freaking disturbed to be on a hold. We HAVE to let untold numbers of totally psychotics roam the streets (and truth be told, most of them do fine, and/or are a threat to no one other than themselves, be it from suicide or substance abuse).
I am perfectly aware that mental health treatment (or anti-retroviral compliance, or heart failure management, whatever) can be done effectively, or ineffectively. Where we differ is that you seem to think the higher performing groups are going to effectively, substantially, reduce these events, or as if it's clear that this one could have been stopped; you write as if someone clearly dropped the ball. Yes, there are great models for active mental health teams that go into the community, monitor intensively, provide lots of therapy and followup, and do better than others. These teams are funded by someone, and they're given certain amounts of authority too. Where there is no team set up, well, it's not as good. Where funding has been slashed, well, it's not as good. Dur.
Go ahead and say you're not letting "health care professionals" off the hook, but what you should be saying is that you wouldn't let mental health systems (legislatures to judges to police to health systems to families etc) off the hook (entirely). Talking about the individual professionals makes about as much sense as saying it's some ER doctor's fault a cardiac arrest patient died at Denny's. She can't control the presence of an AED. She can't control bystander education on CPR. She can't control 911 services. A mental health professional can't just go into the community looking for cases to treat; they deal with what they're brought. Was this guy brought to "health care professionals" attention? Hmm? So what are they supposed to do? And he may be a total whackadoo, but that doesn't make him holdable or force-treatable. We have to impress a judge for that stuff (other than temporary emergency). I have heard he was nuts and the college students thought he was a potential risk, but I haven't heard anything convincing he's said that would make him holdable (but please fill me in). Maybe the college shoulda had the police pick him up. Maybe a student shoulda called the police on him. His parents (I don't know all the details but they apparently tried to help in reasonable ways). Someone shoulda forced an eval to at least keep him from buying a gun so easily. Shoulda Shoulda.
What you're hoping (no data--I mean, 5 minutes ago you were saying we shouldn't expose people to the true cost of healthcare because there wasn't proof and the benefit would be marginal--WTF) is that an awesome system might have gotten the guy on treatment or locked him up. That's all possible. Especially in some imagined setting where the psychotics can be forcibly medicated (not in the USA, no they can't). This might have reduced the risk, in retrospect. So now what?
Going forward, you can't just treat the one person who will shoot up a crowd every 5 years-no one knows who they are. You need a comprehensive healthcare system that gets to all these people (the mentally ill) so that only the noninsane proceed with mass killings (which they will). So who's funding this comprehensive mental health safety net? Again, 5 minutes ago, you wanted a healthcare system that's "pay or pray," and whether this dude had insurance or not, many to most of these schizophrenics do NOT, and states with crushing deficits are cutting services not increasing them. Here in San Diego, they basically ceased funding for psychiatry to see all mentally ill poor people unless they were basically in crisis, pushing all psych care of stable schizophrenia and bipolar and depression to community clinics when 1) these people don't have PCPs and 2) the PCPS are not equipped to deal with these patients, they aren't psychiatrists. Beds at County Mental Health are hard to come by. So how do you address that minor problem?
In an effort to make your head explode, I went looking for something from Salon on the matter. I found an interesting article from a reasonable sounding psychiatrist who among other things diagnoses the guy with probable schizophrenia, excuses the media of responsibility, points out that hindsight is 20/20, advises us that the laws in AZ make it relatively easy to force evaluations of potentially mentally ill people, compared with other states, and explains that yes, dur, coverage matters:
"During media coverage of stories like this, we often hear that we should take mental health seriously in this country. What would that mean, exactly?"
"It would mean you would actually have the resources to do something we haven't done yet, which is get people treatment. We have been very good at emptying the hospitals. What we haven't done is to offer treatment once people are out of the hospitals. In Arizona, for instance, they closed down most of the hospital beds. They are next to last in the United States in the availability of hospital beds for the population, and they have closed down some of the outpatient clinics. If you want to get serious about mental illness, then you need to provide the resources so people can be treated."
Remember, this is AZ, where they recently defunded programs that will be required to save currently identified individuals due to debt. Those people are going to die prematurely as a result. Are we going to imagine that they'll fund a comprehensive plan to treat thousands of these people in the hopes of preventing a future attack? We'll see.
http://www.salon.com/life/feature/2011/ ... index.html