The Martha Mitchell Effect

Matt Freeman DNP, MPH

 

“It’s all happening. It’s happening now.”

I could smell a hint of whiskey or bourbon on my patient’s breath. His knee bounced up and down with anxiety; his eyes scanned the room. His speech  was forced hard to follow.

“She’s in the waiting room now. She could be calling them. I don’t know. She has been checking my phone. She eavesdrops. She knows people.

The patient had a long and complex story about how his criminal history prevented him from owning a business. Therefore, everything was held in his wife’s name, and she had been threatening to turn him in: to the police, the FBI, and ICE (Immigration and Customs Enforcement.)

His speech grew louder, he fumbled for words, occasionally losing himself mid-sentence. He stood up, paced, eventually sitting back down.

I assured that my patient was not in any immediate danger to himself or others, but I struggled to figure out how I could help him. I was happy to listen, but it seemed like he needed a divorce lawyer, maybe an immigration lawyer, perhaps treatment for substance abuse.

Naturally, I wondered about hyperbole. Was this man wanted by the FBI? Did he have a crippling criminal past? Was this a delusion?

 

One phrase stuck in my mind: “The Mouth from The South.”

In one of his interviews with David Frost, Richard Nixon remarked, “If it hadn’t been for Martha Mitchell, there’d have been no Watergate.”

Martha Beall Mitchell (1918-1976), was former schoolteacher from Pine Bluff, Arkansas. Her second husband was John Mitchell, former Attorney General under Nixon and subsequent head of the Committee to Re-Elect the President. The Mitchells ironically lived in the Watergate Building.

Julie_Nixon_Eisenhower_with_Martha_Mitchell_-_NARA_-_194649Martha Mitchell with Julie Nixon

 

Amid marital spats, prescription drug abuse, and alcoholism, Mrs. Mitchell called Washington journalists, often late at night. She spoke with Helen Thomas, Carl Bernstein, and Bob Woodward. Although the exact conversations were not recorded, Mitchell reportedly revealed her husband’s complicity in “dirty tricks” operations of the Nixon administration, particularly her husband’s Committee to Re-Elect the President (CREEP).

The phone calls famously came from her pink “princess phone.” Her Arkansas twang earned her the nickname, “The Mouth from The South.”

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Martha Mitchell became a celebrity, posing for television interviews and magazine covers such as People and New York.  She called for Nixon to resign, clarifying that the public was well aware of Nixon’s misdeeds. Her histrionic demeanor could have been inherent, a reaction to her husband’s efforts to silence her, or a function of alcoholism.

Mrs. Mitchell stated, “I’ve been persecuted more than anyone since Jesus Christ.” She made it clear that she wanted to be known as “Martha Mitchell, not Mrs. John Mitchell.” Her draw for attention was famously exemplified by her clothes. “What I wear,” Mitchell said, “nobody else would buy.”

Her motivations were not political. Although she clearly detested Nixon and CREEP, her “phone capers” erupted after learning that John Mitchell was reportedly dating one Mary Gore Dean. A snub to her ego and image pushed her to pick up the “princess phone.”

John Mitchell
John Mitchell subsequently served 19 months in prison

 

Motivations aside, Mitchell was billed by some as a hero. She spoke openly and publicly about a corrupt political administration. Coming across as a deranged and attention-seeking, Mitchell incited even greater interest in journalists, eventually leading to the downfall of the Nixon Presidency.

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The Martha Mitchell Effect

The Martha Mitchell effect in psychology and psychiatry refers to a failure of a clinician to verify potentially plausible claims of a seemingly delusional patient.

When I took abnormal psychology in 1994, I remember my professor, a clinical psychologist, citing an example. A patient of his claimed that he was being followed by the FBI. In attempt at reality testing, the psychologist and the patient sat together as the psychologist called the FBI. He inquired if his patient was under investigation. Indeed he was under surveillance.. The patient had written a threatening letter to Lyndon Johnson. The patient may have been paranoid, even struggling with a thought disorder, but he was still being followed by the FBI.

 

The patient who came to see me with stories of his wife, ICE, the FBI, was under the care of a psychologist. I relayed to her his concerns, and therefore left it up to her to pursue any investigation into the veracity of his claims.

Was his anxiety and paranoia due to an actual pursuit by the government, or was he delusional? I will never know.

 

The message is critical for any clinician: We all hear outrageous or bizarre claims of persecution, spying, and other threats. Even a patient under the influence of alcohol or drugs, even a psychotic patient, even a patient with a personality disorder can still be telling dangerous truths.

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References

John N. Mitchell Dies at 75; Major Figure in Watergate. The New York Times. 10 November 1988. http://www.nytimes.com/1988/11/10/obituaries/john-n-mitchell-dies-at-75-major-figure-in-watergate.html?pagewanted=all

Maher B. Anomalous experiences and delusional thinking: the logic of explanations. In Oltmanns and Maher B (Eds.) Deulsional Beliefs. Chichester: Wiley. 1988.

Martha Mitchell speaks out about Nixon, Watergate. 15 June 2012. BBC News. http://www.bbc.com/news/world-us-canada-18436516

McLendon W. Martha: The Life of Martha Mitchell. New York: Random House. 1979.

 

This blog entry was originally a lecture I gate at Pacific Lutheran University.

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© 2016

 

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Warning Fatigue: Chatter and the Stress of Flying

Matt Freeman DNP, MPH

A trip through the terminal at Galeão/Antonio Carlos Jobim Airport in Rio de Janeiro is mundane, if not a bit grim… unless  you start listening. The steaming, sultry, deep voice of former newscaster Iris Lettieri is used to make announcements. Since 1977, Lettieri’s passionate voice has been used in Rio, and has since expanded to other airports in Brazil.

Every time I have flown in Brazil, I have been caught off guard by the sense of mystery and romance in her recorded voice.

If you have never been to Brazil, or have forgotten Lettieri’s voice, this NPR interview will introduce or reacquaint you. You will not be disappointed.

http://www.npr.org/templates/story/story.php?storyId=8976813

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Iris Lettieri is the exception.

Amid the many stresses of air travel, the overuse of announcements is grating, counterproductive, and exacerbates an already anxiety-producing experience.

Psychologists in the United Kingdom analyzed how repetitive announcements result in “warning fatigue.” Professor Judy Edworthy and Plymouth University described how listeners will “habituate” to a stimulus, and it will eventually be ignored.

There is a reasonably simple principle of neuroscience behind this: action potentials from a constant stimulus will decrease over time. As a physiology professor taught me as an undergraduate: this is why you do not smell your own perfume or cologne after a while.

 

Looped, Pre-Recorded Announcements

Edworthy’s argument is perhaps most evident in pre-recorded announcements. Journalists from The Telegraph identified twenty-seven public safety announcements during a 30-minute period at a London railway station. These included messages about using the handrails, using an elevator instead of an escalator if one has suitcases, and so on.

A spokeswoman for the railway company said that the messages were “for the safety of our passengers because we have had accidents.”

Lisa Lavia, a representative of the Noise Abatement Society, felt differently. “…the public really hate these announcements but feel powerless to do anything about them. But as the science is now showing, these nightmare messages are no longer just a nuisance–they don’t even work.”

 

Relevance

Perhaps the most baffling of looped, pre-recorded announcements advises passengers in US airports of restrictions on liquids and gels in hand luggage. This announcement is played repeatedly in the “sterile” area of the airport, after passengers have passed through a security checkpoint.

The irrelevance tacitly advises listeners, “These announcements do not apply to you. You have nothing to gain by listening.”

Anything significant, such as “the airport is now on fire,” would run the risk of being lost amid the frequent and meaningless other announcements.”

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Mass Confusion

During my first job after college, I attended a workshop on dealing with crowds and lines. One of the core lessons was: never, ever shout instructions at a large group. The typical responses are:

“What was that?”

“What did he say?

In a check-in hall at an airport, yelling “Anybody going to Chicago?” will likely create mass confusion. “Did he say Chicago? Was that our flight?” Then someone will yell from the back, “Chicago! That’s us!” The commotion escalates.

It is far easier to walk along side the crowd and ask, “Are you headed to Chicago?” Or, perhaps more productively, “Where are you headed today?” Although the illusion is that it might take longer, it is actually far more expeditious. One can identify the Chicago-bound passengers and direct them to the right place—calmly, personably. In the process, you might find that you have people in the wrong queue for the wrong airline and correct that problem too.

 

The Transportation Security Administration (TSA) has developed a reputation for so-called “barkers,” who shout instructions at groups of people waiting in line. The stressful experience of airport security is exacerbated by a barrage of repeated and blurred shouts.

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I recall one security checkpoint that was strictly for passengers transferring off of international flights. “Folks, you are about to enter a security checkpoint!” shouted the “barker.” It would be hard to imagine that anyone would be confused by the scene before them: x-ray machines, metal detectors, body scanners. After all, everyone in the queue had just gone through the same experience several hours prior. The remaining instructions were garbled, and certainly unhelpful to those who did not speak English.

I witnessed one TSA agent go against the trend. She smiled, stayed calm, and politely gestured to those who did not speak English to remove their coats and shoes. Unsurprisingly, she had the line moving far more quickly and without agitation. Furthermore, other passengers witnessed her polite demonstration, so the message propagated down the line. Without words and with a gentle smile, she silently had everyone on their way.

 

Shame and Admonishment

“We have a lot of material to cover today.” I remember far too many teachers and professors who would start off their classes with this warning. It was never helpful. After all, the professor wrote the syllabus, so it was his or her idea as to how much material would be covered in the designated instructional time. The initial pressure of “we have a lot to cover today,” just added stress without discernable benefit. What could students have done differently?

The same applies to “this is a very full flight.” This announcement precedes just about every commercial flight I have taken in or to the United States in the past few years. It is an introduction to the flight by admonishing and shaming passengers who have done nothing wrong; they just happen to be flying that day.

“We are expecting a very full flight” adds the same stress as, “We have a lot to cover today.” There is nothing I can do differently if the flight is full or empty: my hand luggage is the same size; my own height and weight have not changed. All I can expect is that I will feel perhaps more cramped than usual.

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Asking for the Impossible

Boarding is invariably the most stressful time for passengers and crew. There is the struggle to fit everyone’s hand luggage in a small space, find seats, relocate families who have been separated, and still get the plane out on time.

Instead of a self-regulating environment, passengers are bombarded with instructions to “step into [their] row” thereby leaving the aisle open for other passengers. Amid the chaos of fitting 150 people into a small space, the announcement just creates noise. If passengers self-regulate: moving and accommodating for one another, they need not pause to listen to an unnecessary announcement.

There is also the impossibility of “stepping into your row.” In a crowded single-aisle aircraft, one has to be patient as everyone else shuffles themselves and their belongings. Stepping into one’s row is not always an option. The announcement thus creates more disruption, and it asks passengers to accomplish the impossible.

 

Significance versus Fine Print

Gate agents and flight attendants read from announcements from smartphones, booklets, or from computer printouts. The longwinded nature of these announcements makes the fundamental error of mixing marketing, regulatory, and logistical information with the same cadence, length, and mixed in a single string of data. There is little sense of priority, and much of the information is superfluous.

 

Category Example Priority Can this be excluded?
Regulatory “Children under the age of 15 may not sit in an exit row.” Important
It is a federal law, but does it need to be announced?
Maybe. The gate agents and flight attendants could check this without an announcement.
Logistical “The flight time will be 3 hours, 25 minutes.” Intermediate relevance:
useful information for most passengers
Maybe
Logistical “We accept credit and debit cards with the Visa, MasterCard, and American Express logo.” Low relevance.
A passenger attempting to purchase something in cash might be informed of this only if such a situation arose. Why announce it?
Yes
Marketing “We are a founding member of the Star Alliance.” Minimal relevance
since passengers already purchased their tickets and boarded the flight.
Yes

 

Parsimony

Federal law (FAR Part § 121.317) requires that illumination of the “fasten seatbelt” sign have an accompanying oral instruction. This is not necessarily a bad idea, particularly for passengers who have vision impairments, or who might not speak English.

In reasonable situations, a crew member just says, “Seatbelts, please.” On a flight to Germany, the American captain just said, “Seatbelts, please. Bitte anschellen.” Four words. An unequivocal message is delivered in both languages, and there is compliance with US law.

Sadly, the four word announcements are rare. I often fly to and from Tel Aviv. The airline I often fly has a blaring, pre-recorded announcement. A woman’s voice at 10 out of 10 volume arouses one from sleep on an overnight flight saying, “Ladies and gentleman, the Captain has turned on the ‘fasten seatbelt’ sign. Please return to your seat and fasten your seatbelt.” This is followed by a Hebrew-speaking crewmember repeating the same message. Twenty words in English followed by 16 in Hebrew. The length of the announcement detracts from the core message: “seatbelt.”

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Redundant Information

In airplanes with video equipment, most airlines present safety information through a video presentation. These films are reviewed by the FAA, and the language has to be specific to meet regulatory requirements. As ridiculous as it seems, the law is clear that passengers must be shown how to buckle and unbuckle a seatbelt. (The idea is that airplane seatbelts operate differently than those in cars.)

Problems arise when crew restate information already in the film. This is particularly true of announcements regarding mobile phones and smoking. One could argue that this information needs to be reinforced to ensure adherence. “Nobody watches the film, so we have to announce it.” Another option is never presented: during the mandatory walk-throughs or “compliance checks,” the crew could just ask passengers individually to correct any reclined seats or obstructive luggage.

Instead of worrying about inattention to the video or announcements, why not just correct the safety problems as they occur?

 

Goal Setting

“Did you not hear the announcement?” is no longer a reasonable argument. There are so many announcements that one can easily become sidetracked. Furthermore, flying is tiring, rules vary, and some airlines and security checkpoints are stricter than others.

The TSA staff or airline crew would be wise to ask, “What is our goal?” Is the goal to have one’s announcements heeded, or is the goal to ensure that passengers are safe?

 

Moving Forward

The first question is, “How much of this information needs to be conveyed?” Aside from federally-mandated announcements, air carriers would be wise to explore passenger comprehension. During the roughly 60 minutes it takes from beginning boarding to reaching the runway, how many announcements are made? Of those announcements, what is the overall comprehension level?

Some of these issues are hard to measure. One cannot conduct a “placebo controlled” study to determine if repeated overhead announcements about leaving luggage unattended actually lead to greater attention to security. The decision to cease the announcements has to be based on principles of neuropsychology: repeated announcements will be ignored over time.

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Dialing it Down. How Can We Limit the Cacophony?

Since the “announcement culture” is ingrained in American air travel, it may take scientific analyses to argue for fewer announcements.
1. Measure Passenger Stress

Passenger stress can be assessed through psychological inventory or biological measures. Researchers could evaluate the magnitude of passenger stress as a function of the number of announcements (safety, logistical, and marketing.)

 

2. Measure Passenger Adherence

Some announcements are federally-mandated, but one could experiment with optional announcements.

  1. Conduct a trial in which one TSA checkpoint has an agent announces repeatedly that laptops must be removed from hand luggage; make no announcement in another checkpoint. See how many passengers remove their laptops between the two lines.
  2. Ask airline crews to measure the number of passengers who attempt to pay in cash as a function of a pre-flight announcement. Does the announcement actually affect adherence?

 

3. Measure Passenger Satisfaction

Airlines routinely collect extensive survey data. It would be easy to determine if passengers have greater satisfaction with their airport experience based on stressful announcements like, “This is a very full flight.” An air carrier could compare satisfaction surveys from flights where such language is prohibited to the status quo.
There are solutions to a calmer, quieter trip both on the ground and in the air. Although it would be pleasant to have the rich voice of Iris Lettieri all over the world, there is an obvious need to “dial down” the barrage of announcements.

 

 

References

Copping J. & Ljunggren H. Annoyed by public address messages? Now experts say they don’t even work. The Telegraph. 2 October 2011.

 

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©2016

The 59.8 Minute Phone Call: Prior Authorization for Psychiatric Admissions

Matt Freeman DNP, MPH

In clinical practice with adolescents and young adults, decisions about psychiatric admissions surface about once or twice a month. These are never taken lightly.

Safety invariably predominates. Although an organized and imminent suicidal plan is the most common reason for admission, sometimes the patient has experienced a manic episode that warrants stabilization. Others may be experiencing psychotic symptoms that but them at risk for harm to themselves or others.

Despite the often grim reality of psychiatric units, the goal is to protect life. Most of the admissions in my career have been brief: perhaps a 72- to 96-hour opportunity to prevent a suicide or accidental death, to ensure adequate medication, and to be as certain as possible that appropriate care is available after discharge.

The decision to admit is complex. In my experiences, it was usually a collaborative decision by a psychiatrist, psychologist, primary care provider, the patient, and the patient’s family.

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The Goal of Voluntary Admission

Involuntary or “civil” commitment is sometimes avoidable. If a patient resists admission, one can take legal steps to argue that an admission supersedes the patient’s wishes. But this “buys” only 72 hours, and can create an adversarial relationship between the patient and those caring for him or her.

Interestingly this is sometimes referred to as a “5150” on television and movies. In fact, this is a reference to California law, the Lanterman-Petris-Short Act, which is section 5150 of the California Welfare and Institutions Code. Each state has its own name or number for involuntary confinement, but those who write screenplays and television scripts are sometimes unaware that this term is specific to California.

The process for a 5150 and its analogues can be laborious. For meaningful ethical and constitutional reasons, there are specific criteria and processes for obtaining a 5150. To my recollection, I have only ever done it two or three times in 13 years of practice.

A voluntary admission carries its own burdens. The patient and his or her family may have agreed, but one then has to find an available psychiatric bed. This can mean calling hospitals—sometimes in distant locales—to find an available bed at a hospital that accepts the patient’s insurance.

As is the case with just about everything in health care, these discussions and phone calls always seem to occur late at night, after an arduous day of assessing a patient who warrants admission.

 

Now it takes even longer.

Insurance carriers have started mandating prior authorization for psychiatric admissions. In a study published in the American Journal of Emergency Medicine, the average time spent on the phone with the insurance company was 59.8 minutes.

That is 59.8 minutes with a sobbing, suicidal patient in the room next door. That is 59.8 minutes of frightened, tired parents, terrified that their son or daughter could end his or her own life or become a danger to others. That is 59.8 minutes when that patient could be en route to a hospital where his or her safety and access to care could be guaranteed.

Fifty-nine point eight minutes is the mean. The authors of the study reported one case in which the prior authorization process took four and a half hours.

It is even more absurd: of the 53 cases in the study, prior authorization was granted 100 percent of the time.

Healthcare providers take careful notes, elaborate documentation, and collaborate extensively about psychiatric admissions. But insurers have somehow convinced themselves that we are less than diligent.

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What does prior authorization require?

“Please enter your Tax ID number.”

            “4”

“I’m sorry, I didn’t get that. Please enter your tax ID number.”

            “4”

“I’m sorry I still didn’t get that. Please enter your Tax ID number.”

            “4”

After the interactive voice response menu finally recognizes my voice or phone keypad entry, I wait on hold.

“Hello!” a pleasant voice, usually with a thick accent, will answer. “What is your Tax ID number?” After repeating it twice, I provide my name. For whatever reason, names and titles do not translate easily and I am usually referred to as “Dr. Matt.”

“And how are you doing today Dr. Matt?”

I could easily reply, “volatile, rabid, and angry,” and the representative—reading from a script—will say, “That’s great to hear!”

After providing the patient’s ID number, birth date, and address, I am usually told that I have called the wrong number, even though I specifically dialed the special number for “behavioral health.”

After hold music, “What is your Tax ID number?”

And it continues.

Sometimes the system just hangs up when I am transferred. Sometimes it starts back at the same number.

If I ask for a supervisor, the agents usually say that they do not have a supervisor, or that no supervisor is available. Although I try to be as polite as possible, I once asked, “You have no boss? Nobody who oversees your work? Nobody who coaches you?” The agent said, “No.” Another replied, “I have a supervisor, but she won’t be able to help you.”

The patient in distress is quivering in a room next door.

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It gets more complicated.

Insurance plans are often specific to a particular state. A patient might reside in Oregon, but his or her insurance plan is designed for residents of Delaware. The patient’s parents or guardians might work for a Delaware-based company.

When it is an out-of-state insurer, the phone response is:

“I’m sorry, I didn’t recognize that Tax ID number”

Of course you did not recognize it; I am not in Delaware. After dialing as many random keys as possible, I might be fortunate enough to get a live person.

            “Oh, we have to enter you in our system.”

This requires my name and professional details, license, address, FAX numbers, and—you guessed it—my Tax ID number. In some cases, I will get the absurd response that I should receive a fax in two to three business days.

In several cases, I was told that since I was not in that particular state’s network, they would be unable to assist me due to HIPAA. After hanging up and calling again several times, I finally reached someone who did not claim such a ridiculous excuse. The sharing of confidential information would have been by me, and the Health Insurance Portability and Accountability Act of 1996 explicitly permits information sharing with an insurer. “HIPAA” just sounded like a good answer to that phone agent.

After that step is completed, I am given another number to call.

Tick tock. Tears continue to shed. Nervous parents clutch paper coffee cups. Sometimes agitation ensues, and the patient might start to back out of the idea of a voluntary admission.

Most insurers offer the opportunity to obtain prior authorization by means of a web site. But this is usually an exercise in futility. One has to register for the web site if it is an out of state insurer, inviting a response “within seven business days.” In other cases, the site will process everything, and then offer a fax response “within one business day.” Other sites fail to recognize the patient’s ID number.

 

Resolution

In some cases, the phone representative at the Overseas Call Center (OCC) will grant the prior authorization. In others, a “peer to peer” consultation is required.

Amusingly, the phone representative transfers me to another call center that handles appointment scheduling. An appointment for me to consult with a physician or nurse about the patient, presumably during the subsequent few business days.

Tick tock.

Sure, I am happy to clear my schedule for non-reimbursed time to chat with someone who will invariably approve my request. That is a sound use of resources.

The “peer to peer” healthcare providers usually sound as if their eyes are rolling when I do talk to them. They approve the authorization, sometimes with their apologies for the bureaucracy.

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What are the principal problems?

  • Delay in treatment in potentially life-threatening circumstances
    Spending four and a half hours on the phone is an astonishing waste of a clinician’s time.
  • Lost revenue for everyone
    A clinician makes no money on the phone fighting through broken phone trees. And the insurance carrier is paying for its representatives and “peer” reviewers for something that they will always approve.
  • Poor public relations
    Insurance companies are not known for their favorable image with the public. When parents of a suicidal young person learn that treatment is forestalled because their child’s primary care provider is on the phone for an hour, it does not look good for the insurer.

 

Is Prior Authorization Always a Bad Idea?

Insurers sometimes have decent reasons for requesting prior authorization. For example, it is not unusual to find clinicians who are overzealous about ordering expensive tests or medications when effective, more affordable options exist. Some are overly eager to order MRI examinations for back pain when patients do not meet the medical criteria for such an exam. Others might prescribe a new, shiny drug in lieu of something safe, effective, and generic.

Some of the web-based prior authorization tools like “covermymeds.com” work for multiple insurers, and are not too burdensome.

In Israel, for example, the sal or “basket” of readily available drugs for primary care providers is more limited than in the United States. Azithromycin, known with immense popularity as Zithromax or a “Z-Pack” is not in the sal. American prescribers are notorious for prescribing azithromycin for people who do not need it: particularly those with viral infections who will only gain side effects and bacterial resistance form azithromycin. If one wishes to prescribe it, the Israeli system requires prior authorization by an infectious disease specialist. It is a reasonable means of protecting antibiotic stewardship.

In other words, American clinicians have the extraordinary freedom to prescribe unnecessary antibiotics with impunity but are barricaded from a psychiatric admission for a young person in immediate distress.

 

Looking forward

  1. There is consistent evidence that prior authorizations are always approved, so the process serves no purpose.
  2. Allow patients to be admitted for 24 or 48 hours without prior authorization. This eliminates delays in care but still allows insurers to collect information they deem necessary.
  3. Streamline phone trees and online systems. Overseas call centers may save on labor costs, but the amount of time spent on language clarification, dysfunctional voice recognition software, and multiple transfer upon transfer to different representatives probably exacerbates the cost to the insurer.

 

 

References

Funkernstein, A, Harstelle S, & Boyd JW. Prior authorization for child and adolescent psychiatric patients deemed to be in need of inpatient admission. American Journal of Emergency Medicine. 2016: 27 February. http://dx.doi.org/10.1016/j.ajem.2016.02.027

 

©2016

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Andreas Lubitz and the Ethics of Confidentiality

Matt Freeman DNP, MPH

“How are things at home?” It can jumpstart a conversation about emotional health, giving the patient a chance to have control over how little or how much he or she would like to disclose. My own variation has been, “How is your mood and your stress level?” Patients often say, “the usual amount of stress.” Others become tearful. Others find an unexpected opportunity to share what is happening in their lives.

I do not know what Andreas Lubitz would have said. Perhaps he would have talked about his dashed hopes to marry Kathrin Goldbach, or his reported frustration with flying shorter fights rather than the more prestigious long-haul routes with Lufthansa. But he might have said nothing at all.

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I think back to the handful of patients I have had in my career who have been commercial pilots. I even remember chatting with one of them about his mood. He was exhausted by his schedule, his pay was abysmal, and his wife was also a pilot, thereby putting a great strain on their marriage. As is the standard of care with a patient with a mood disorder, I asked, “Have you had any thoughts of hurting yourself or others?” He said no.

 

What if he had said yes?

The rules for breaching patient confidentiality vary by country and—in the US—by state. But there is a consistent theme: plan, means, and intent. If my own patient had been specific with his plan and time range, I would have probably been able to get him admitted to mental health facility, and—in collaboration with others—most likely able to contact the airline’s medical department.

But what if he just said, “Sure, I have thoughts of hurting myself? Sometimes I wonder what would happen if the plane I was flying crashed.” I would be asking a lot of questions at that point, probably consulted with a mental health provider, but if he expressed this in vague terms—a melancholic fantasy—it would have been inadequate to sever our private doctor/patient relationship. I could urge him to see a therapist, encourage antidepressants, invite a short-interval follow-up, discussed what actions to take if he felt increasingly suicidal or homicidal, but my powers would have ended there.

All of us fear another Germanwings 9525 or Egyptair 990, but suicides are notoriously difficult to predict. If the European or American governments suddenly required all pilots to answer the question, “Are you having thoughts of hurting yourself or others?” before flying, the answer would be “no.”

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Egyptair Boeing 767-300, similar to the aircraft that crashed near Nantucket on 31 October 1999

 

Actively suicidal patients, particularly men, typically keep their plans closely guarded.  It is not too difficult for a severely depressed patient to outfox a standardized depression inventory, even the probing questions of a therapist or primary care provider.

Although the details of Andreas Lubitz’ medical history are still blurry, he could have just said, “No, I do not feel like hurting myself or others.” There is no polygraph, “trick question,” nor blood test that would have predicted a murder-suicide. Psychologists usually have the ability to estimate behavior within a 48-hour window, but that depends on the patient disclosing a lot of information.

From media reports, Andreas Lubitz had some red flags: a previous history of a mood disorder, recent treatment, a trigger (the breakup), and reportedly erratic behavior. How many pilots, truck drivers, those whose jobs require firearms or access to explosives would meet a similar description?

 

Who is the client?

My first practice out of school was in occupational medicine. I often saw truck drivers, firefighters, police officers, air traffic controllers, and others who needed medical examinations for employment. In the overwhelming majority of cases, the goal was to ensure that I “rubber stamped” the paperwork.

US law requires that any medical examination be conducted post-offer. In other words, the patient had already been given the job, and it was my responsibility to ensure that there were no barriers. The medical examination did not serve to address health concerns, prevent illness, nor screen for disease. It served an administrative purpose.

Although most patients take it in stride, some view it as a marked invasion of privacy with no benefit to public safety. It is indeed awkward, unpleasant, or threatening to answer detailed health and mental health questions, disrobe, get poked and prodded, all because an employer requires it.

Regulatory bodies, like the Federal Aviation Administration and Federal Motor Carrier Safety Administration stipulate guidelines for these examinations. But healthcare providers are faced with a dilemma: if pilot, driver, firefighter, or other examinations are part of one’s livelihood, it would be dangerous to have a reputation for saying “no.” This could lead to unemployment for the patient and a vacancy for the employer.

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The client for these examinations is not the patient himself or herself. The client is the employer and/or the government agency. Patients therefore lack the comfort of a private and established doctor/patient relationship. When a patient comes to see me on his or her own for routine medical examination, it is a “health-seeking behavior,” and he is or she is perhaps more likely to share more extensive thoughts about mental health, substance abuse, and other problems.

There is one further problem: patients can sometimes shop around. Pilots and drivers seeking medical certification can go to any FAA or DOT-approved healthcare provider. If the first examination does not go well for some medical reason, the pilot or driver can merely hope that the next examiner does not ask the same questions, conducts a less thorough examination, or the patient might just be a bit less truthful in his or her responses.

 

There is no clear flight path ahead.

Loosening confidentiality laws raises many ethical concerns. Psychological screening may be helpful but has the peril of self-disclosure: an affirmative answer to a screening question can cost one his or her livelihood.

Environmental mitigation, such as ensuring two personnel in the flight deck has the rather obvious dark side: Lubitz could have incapacitated a pilot or flight attendant seated to his left and continued to crash the plane. In the US, pilots and flight attendants do not pass through checkpoints to detect weapons in many airports since they travel through “Known Crew Member” (KCM) ID checkpoints.  In fact, many pilots are Federal Flight Deck Officers (FFDOs), who are permitted to carry firearms on board.

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Amid the grief and fear in the aftermath of the crash and its investigation the most salient call is one for dialogue. Ethicists, mental health professionals, occupational health providers, and primary care providers need to open a greater discussion about suicidal and homicidal behavior. Although a statistical rarity, the consequences are catastrophic. Now is the time to talk more about protecting privacy while protecting the public, ensuring access to care, and guaranteeing further research in suicidology.

 

 

 

Pseudoscience at Gate B6

Matt Freeman DNP, MPH

It was mid-morning on a Saturday. I had only hand luggage, and had checked in online the day before. I arrived at the small airport exactly one hour before departure. I was a bit annoyed that the flight was delayed, but otherwise not expecting too much trouble. It was a 90-minute flight on a 70-seat regional jet. Only one other flight, also a small regional jet, was departing from the same section of the airport.

By my best estimate, there were 80 passengers in line for the security checkpoint. Most seemed to be leisure travelers: families with little kids, older adults. There was an abundance of sunburn and golf shirts.

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The queue inched along. As I looked around, anxiety was escalating. There was a lot of chatter about missing flights; several people were in tears knowing that they would certainly have their travel plans fall into disarray.

Twelve Transportation Security Administration (TSA) staff were working: one checking identity cards, two on either side of the x-ray machine, one operating the metal detector, seven chatting with each other, and one walking his way through the increasingly antsy crowd.

“What is the province of your destination?” He asked the woman next to me.

“Province?”

“Yes, which province? British Columbia? Ontario?”

Confused, the woman replied, “I’m going to Houston. I don’t know what province that’s in.”

The TSA agent scoffed. He moved on to the next passenger. “The same question for you, ma’am. What is the province of your destination?”

The woman didn’t speak, handing over her driver’s license and boarding card, assuming that was what he wanted. He stared back with disdain.

 

There are no flights from this airport to Canada.

 

When it was my turn, I volunteered, “I’m going to Texas, not Canada.”

“What are the whereabouts of your luggage?” He asked.

“Their whereabouts? My bag is right here next to me.”

“Yes, what are its whereabouts?”

 “It’s right here.”

“And that’s its whereabouts?”

This was seeming like a grammatical question.

“And about its contents? Are you aware of them?”

“Yes,” I replied, quizzically.

He moved on.

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I missed my flight. The woman next to me met the same fate. She cried. I cringed. We pleaded with the airline agent for clemency. The plane pushed back from the gate with many passengers waiting to be asked about the whereabouts of their belongings or their province of destination.

The agent asking the strange questions and delaying the flights was a part of  “SPOT.”

 

The SPOT Program

In 2006, the TSA introduced “SPOT: Screening Passengers by Observational Techniques.” The concept was to identify nonverbal indicators that a passenger was engaged in foul play. Two years after the program started, the US Government Accounting Office (GAO) declared that, “no scientific evidence exists to support the detection of or inference of future behavior, including intent.”

The absence of evidence did not dissuade the TSA. Neither did another study in 2013, in which the GAO reported, “the human ability to accurately identify deceptive behavior based on behavioral indicators is the same as or slightly better than chance.”

The Department of Homeland Security, which oversees the TSA, has its doubts as well. The DHS inspector general reported in 2013 described the SPOT as follows: “[We] cannot ensure that passengers at United States airports are screened objectively, show that the program is cost-effective, or reasonably justify the program’s expansion.” It is now three years since that statement, but the TSA is still playing the game, aware that they have no data nor agency backup to support their efforts.

SPOT is expensive too. The GAO reported that the program has cost more than $900 million since its inauguration. That is just the cost of training staff and operating the program, not the costs incurred by delayed or detained passengers.

 

The “Science” Behind Behavioral Techniques

The SPOT program was developed by multiple sources, but there is one most prominent psychologist in the field: Paul Ekman PhD.

Ekman published Emotion in the Human Face, which demonstrated that six basic human emotions: anger, sadness, fear, happiness, surprise, and disgust, are universally expressed on the human face. Ekman had travelled to New Guinea to show that facial expressions did not vary across geography or culture.

Ekman’s theory was undisputed for 20 years until Lisa Feldman Barrett PhD showed that Ekman’s research required observes to select from the list of six emotions. When observers were asked to analyze emotions without a list, there was some reliability in the recognition of happiness and fear. The other emotions could not be distinguished.

When confronted with skepticism from scientists, Ekman declined to release the details of his research for peer review. Ekman claims that his work is on the radar of scientists from China, Iran, and Syria, so it would be dangerous for him to disclose his findings. I guess I should not publish here that the atomic weight of hydrogen is 1.008 atomic mass units. Syrians could find out! Everyone, hide your physics and chemistry textbooks!

Charles Honts PhD attempted to replicate Ekman’s findings at the University of Utah. No dice. Ekman’s “secret” findings could not be replicated. Maria Hartwig PhD, a psychologist at City University of New York’s John Jay College of Friminal Justice, described Ekman’s work as, “a leap of gargantuan dimensions not supported by scientific evidence.”

The TSA’s own adaptation of Ekman’s work into SPOT is scientifically challenging because it can only be tested on those pretending to be terrorists. In other words, any attempt at scientific application of SPOT evaluation is based on those who are already engaged in deception. Even Ekman himself describes the TSA’s testing of his research as “totally bogus.”

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Maybe I can boil this down: we have a psychologist whose research was refuted. And even the defamed psychologist has argued that the TSA’s application of his already dubious evidence is “bogus.”

When asked directly, a TSA analyst pointed to the work of David Givens PhD, an anthropologist and author. Givens has published popular works on body language, but Givens explained that the TSA did not specify which elements of his own theories were adopted by the TSA, and the TSA never asked him.

 

The TSA’s Response

When asked for statistics, TSA analyst Carl Maccario cited one anecdote of a passenger who was “rocking back and forth strangely,” and was later found to have been carrying fuel bottles that contained flammable materials. The TSA described these items as, “the makings of a pipe bomb,” but there was no evidence that the passenger was doing anything other than carrying a dangerous substance in his hand luggage. There was nothing to suggest that he planned to hurt anyone.

A single anecdote is not research, and this was a weak story at best.

When the GAO investigated further, they analyzed the data of 232,000 passengers who were identified by “behavioral detection” as cause for concern. Of the 232,000, there were 1,710 arrests. These arrests were mostly due to outstanding arrest warrants, and there is no evidence that any were ever linked to terrorist activity.

 

What Criteria Are Used in the SPOT Program?

In 2015, The Intercept published the TSA’s worksheet for behavioral detection officers.

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I was obviously in deep trouble.

“Stress Factors” (one point for each)

  • Avoids eye contact with security personnel (why do I need to make eye contact?)
  • Excessive clock watching (yep; it was getting late.)
  • Face pale from recent shaving of beard (I shaved that morning.)

 

“Fear Factors” (two points for each)

  • Constantly looking at other travelers or associates (People were crying. Why would I not be looking around to see what was going on? Was I supposed to stare straight ahead? Nope. Can’t do that; staring also racks up points on the worksheet.)
  • Scans area, appearing to look for security personnel (I was wondering why they weren’t working.)

 

“Deception Factors” (three points for each)

  • Appears to be confused and disoriented (I was asked bizarre questions that required clarification)

 

I earned eight points, which assigned  me to the highest risk category. If one followed the paperwork, I should have been referred for extensive screening and law enforcement was to be notified.

It would have been hard to find passengers in the line who did not exceed five points required to warrant a referral for additional screening.

Considering that the criteria include yawning, whistling, a subjectively fast “eye blink rate,” “strong body odor” and head turning, just about everyone reaches the SPOT threshold.

Mercifully, I was sent on to the screaming TSA agent at the metal detector and the man who was angry that I did not have a laptop. I was spared further scrutiny.

 

The Risk of Scoring

Looking past the absence of evidence, there are further problems with the SPOT worksheet. “Scored” decisions can detract common sense. For example, I have often lectured on suicide assessment. There are several analysis tools to help a clinician determine if a patient should be admitted to the hospital or allowed to go home. I always teach, “whatever you do, do not assign a score.” This offers a false sense of security without real clinical application. It doesn’t matter if a patient only gets a five out of 20 if he takes his own life after you discharge him or her.

 

The Fourth and Fifth Amendments

The Fourth Amendment protects Americans from “unreasonable” search and seizure. But airport security falls under the category of a “consent search,” which is voluntary. The Fourth Amendment does not apply because the search is conducted outside the setting of an arrest, and the passenger has “consented” to a TSA search.

  1. The courts ruled that a passenger consents to inspection either by presenting his or her identification and boarding card to the TSA, or by placing his or her belongings on an x-ray conveyor belt. The SPOT interviews take place before either of these steps, when passengers have not yet entered the TSA’s “custodial” area.
  2. The extent and detail of the search is not explicit. A reasonable passenger would have the expectation that he or she will be subject to some form of inspection of their hand luggage, a metal detector, or a full body scanner. Is it reasonable to assume that passengers can expect to be interviewed?

 

What about the Fifth Amendment? Since the Bill of Rights does not apply at the checkpoint, a passenger could easily self-incriminate.

  1. TSA staff are not law enforcement officers and have no powers of arrest. But they use the term “officer” and wear badges. (This has been subject to controversy by bona fide law enforcement officers.) The notion of a “consent search” is by no means explicit at any checkpoint.

 

Conducting an interview with the appearance of a law enforcement role exploits a loophole. There is no Fourth Amendment because the interview is not conducted by a law enforcement officer. There is no right to an attorney, no right to remain silent because the interviewer merely has the appearance of a police officer.

The bottom line: the TSA is not actually law enforcement but they do have the power to prevent a passenger from boarding an airplane. One has to submit to SPOT investigation in order to fly. Even if one has not even begun the screening process on constitutional grounds, and even if the nature of one’s consent is by no means informed.

Above all, the “search”—the interview—has not been shown to be any better than chance alone at detecting a dangerous passenger.

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Low-Hanging Fruit

My friend Grace is a great physician. She is a warm, brilliant, and talented colleague. We have been friends for decades. She grew up in the Midwest to all-American parents. She has an amazing sense of humor and a charming personality.

Grace went to visit her parents in Michigan, and flew there without incident. On her way home, a SPOT agent saw her in line at the entrance to the security checkpoint.

She was pulled aside, taken to a separate room, and interviewed by two TSA staff with seemingly meaningless questions. Her boarding card had not been flagged; she was taken out of line before she had even entered the screening area.

She missed her flight.

Rattled and confused, Grace called and asked what could have happened. We agreed that she was a target for several reasons: attractive, thereby capturing the interest of male TSA agents, who could have her alone in a room and get to know her. And we agreed that she was “low-hanging fruit:” someone who would be articulate enough to answer questions, unlikely to unleash anger, and unlikely to question the TSA’s judgment.

The TSA denies that SPOT agents have a quota to follow. But SPOT agents have stated that they were under the impression that a promotion was more likely if they pulled more passenger aside.

This was not about security, not quite in line with a “consent search,” and really had to do with either getting a promotion or perhaps scoring a date.

 

SPOT Around the World

Since the 1980s, the US Government has required US air carriers to conduct profiling techniques for flights destined to the United States. This applies to flights form designated “higher risk” points of origin: anywhere mostly Europe, South America, and the Middle East.

Using techniques comparable to the SPOT program, security contractors conduct interviews at the check-in counter and boarding gates. Many European carriers use the same system for flights from the developing world to Europe.

The largest contractor, ICTS, and its affiliates, claim to follow an Israeli model of threat detection: behavioral analysis. The company was founded by Israeli security “experts,” and theoretically models its behavioral profiling system following an Israeli model.

Their track record abysmal.

In 1988, passengers checking in at Frankfurt Airport for Pan Am flight 103 were questioned by security staff, supposedly looking for behavioral profiles akin to SPOT techniques. The staff spoke inadequate English to understand responses. They were given stickers to identify passengers who should be subject to further scrutiny (“selectees,”) but the screening staff did not even know what a “selectee” was, so they just assigned the stickers at random. Two hundred forty-three passengers and 16 crew died when a bomb exploded aboard the second segment of the flight.

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On 21 December 2001, Richard Colvin Reid checked in at Terminal 2A at Paris Roissy/Charles de Gaulle Airport. American Airlines’ contract security agents were wary of Reid’s appearance and evasive answers to their questions. After consultation with the French Police, Reid was given a ticket for a flight the following day. He boarded American Airlines flight 63 with his shoes loaded with plastic explosives.

Seven years later, Umar Farouk Abdulmutallab passed through a document inspection and security interview by KLM contract security staff in Lagos. He was then interviewed and searched by Delta Air Lines’ contract security agent, ICTS, at Amsterdam Airport Schipol. The interview did not arouse enough suspicion to warrant further search or inspection, and Abdulmutallab boarded Delta Air Lines flight 253 with explosives in his underwear.

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At least Reid and Abdulmutallab did not harm anyone.

 

Can this Work? Common Sense Behavioral Detection

On 14 December 1999, “Benni Antonie Noris” arrived in Port Angeles, Washington in a green Chrysler 300M. Customs officer Diana Dean asked where he was headed. In broken English, Noris stated that he was headed to Seattle for a “business trip.” This made little sense since there are far more direct ways to travel from Vancouver to Seattle. Noris was fidgeting, jittery, and sweating. He began fidgeting and squirming, hiding his hands. His form of identification was a Costco Card.

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Port Angeles, Washington

It did not require a SPOT form to give Diana Dean an indication that this driver’s behavior was atypical.

The driver was unable to articulate his plans in Seattle nor where he was staying. Dean described him as acting “hinky” (I had to look that word up in a dictionary. It should clearly be in wider use.)

Inside the trunk of his car, Dean kept the conversation going as she and a colleague inspected his car. It was loaded with nitroglycerine.

The driver turned out to be Ahmed Ressam, known as “The Millennium Bomber.” Ressam was on the verge of executing a plot to blow up Los Angeles International Airport on New Year’s Eve.

Diana Dean did not need a SPOT training notice a problem. This is a man who used his Costco card as identification and hid his hands. No need for “behavioral detection” techniques. Dean modestly claimed it was “dumb luck.”  It was not luck; she just identified remarkably aberrant behavior. This was not a checklist of someone blinking too fast or having shaved recently. This was a wise customs agent thinking, “This guy just used a Costco card as identification.”

 

The Israeli Method

As an Israeli national, I became accustomed to the envied security techniques employed at Israel’s four commercial airports.

The agents employed by the Israeli Airports Authority (IAA) do indeed “profile” passengers, but their efforts are often quicker, easier, and seem far more like the “Diana Dean Technique.”

IAA staff rank passengers from “1” to “6,” with the higher then number indicating the greatest amount of suspicion. I have only ever earned a number “1,” so I speak from the least intrusive end of the spectrum.

Instead of attempt to ensnare me in a trap with questions about the whereabouts of my bags or my province of destination, the questions are usually reasonable and fast. “Where have your bags been since you packed them?” “Did anyone give you anything to take with you?” “Are you carrying anything that could be used as a weapon?”

In some cases, the agents attempt to asses if a passenger is Jewish, but this is conducted in a roundabout way so as to circumvent religious profiling. Foreign travelers are asked, “Do you belong to a religious congregation?”

But the question is partially helpful as there are many Christian and Muslim tourists in Israel. Those travelling with a Christian tourist group are unlikely to arouse much suspicion.

In fact, I have only seen a few passengers earn a number “6.” These were American Christian young adults, who mentioned that they had travelled to Jordan, and they were given CDs by an acquaintance to bring back to the United States. They did not know was on the CDs. That is a case for Diana Dean. “You do not know the guy who gave these to you, nor do you know their what is on them?” I would have been skeptical too.

The IAA is cautious about race and religion. The worst attack on Israeli air transportation took place in 1972 at Ben Gurion Airport. Twenty-six people were killed. The assailants were Japanese, posing as tourists. Since that attack, the IAA has attempted to include ethnicity and religion only as components of its screening process.

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Although many have published horror stories, the overwhelming majority of passengers do not encounter anything extraordinary at Israeli airports. The agents are usually young, bubbly, right out of their army service, and eager to show off any language skills they may have acquired.

There is no “show.” There are no badges, nobody is called “officer,” and the goal is clear: keep the airport and flights safe.

The staff joke, make small talk, and are typically make an effort to help those who are elderly, infirm, or traveling with small children. The goal is to screen for problems but do so expeditiously and without pretending to be anything other than airport security.

I have heard stories, especially from non-Jewish tourists, who were subject to greater questioning or detailed searches of their hand luggage. But I have never heard of a missed flight due to semantic tricks about the whereabouts of one’s luggage.

Although I do defend every aspect of Israel’s government, racial tensions, or the Palestinian conflict, I can say with certainty that I would not have missed my flight due to trick questions about the whereabouts of my bags or to which province I was headed. If I was running late, I am confident that the IAA staff would have done their best to mitigate the problem.

 

Is There a Better Answer?

Israel does not publish statistics, and I could not tell you if their system is any better. The difference is one of attitude: most of the IAA staff are kind, calm, and not interested in hassling anyone.

Moreover, Israeli airports protect their perimeters. There are two checkpoints before even entering Ben Gurion Airport. This reduces the risk of one of the TSA’s glaring loopholes: long lines of passengers waiting to enter a security checkpoint. It seems like a situation ripe for an attack. And it has happened before: in 1985, 19 people were killed and 100 wounded when terrorists attacked the TWA and El Al check in desks at Rome and Vienna Airports. The TSA lives in the strange assumption that only “sterile” areas of the airport are subject to an attack, thereby ignoring enormous public spaces.

Given the amount of air travel to, from, and within the United States, I doubt that questioning passengers would ever work. The TSA lacks the organization, multilingual skills, and service mentality of the Israel Airports Authority.

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A crowded checkpoint at Seattle/Tacoma International Airport: mobs of people who have not been screened for weapons

The TSA already has one answer, but they chose not to use it in my case. I am a member of the Department of Homeland Security’s “Global Entry” program. This means that I was subject to a background check, interview, and fingerprinting. The Department of Homeland Security vetted my credentials and deemed that I did not present any extraordinary risks, and could therefore use its “PreCheck” lane. But this airport had decided to close its PreCheck lane that day. And their SPOT agent had no knowledge that I had already been vetted through databases and fingerprints… arguably a more reliable system than having him determine if I blinked too rapidly.

Until 2015, the PreCheck program also meant that one need not pass through a full-body scanning machine, in part because the machines are famously slow and inaccurate. They are particularly problematic for those with disabilities and other medical conditions. But the TSA decided that it would switch to random use of full body scanners even for those passengers who had already been vetted. Lines grew longer; no weapons have been discovered.

 

Looking Forward

  1. The SPOT program has been proven to be ineffective. There is no rational reason to keep it in place.
  2. There must not be quotas or incentives for detailed searches and questioning in the absence of probable cause.
  3. Passengers consenting to a search should have the right to know what the search entails, particularly if it involves odd interrogation techniques that can lead to missing one’s flight.
  4. The TSA should respect previous court rulings that the search process begins when a passenger consents to being searched. Asking questions outside of the TSA’s custodial area of the airport is questionable for legal reasons.
  5. Reduce lines. The attacks in Rome and Vienna were more than four decades ago, but that has not dissuaded the TSA. Get the queue moving quickly, thereby reducing the opportunity for an attack.
  6. Stratified screening, such as he PreCheck program, makes sense. But it TSA staff elect to ignore the program, then it is no longer useful.

 

 

References

Benton H, Carter M, Heath D, and Neff J. The Warning. The Seattle Times. 23 July 2002.

Borland J. Maybe surveillance is bad, after all. Wired. 8 August 2007.

Dicker K. Yes, the TSA is probably profiling you and it’s scientifically bogus. Business Insider. 6 May 2015.

Herring A. The new face of emotion. Northeastern Magazine. Spring 2014.

Kerr O. Do travelers have a right to leave airport security areas without the TSA’s Permission. The Washington Post. 6 April 2014.

Martin H. Conversations are more effective for screening passengers, study finds.  The Los Angeles Times. 16 November 2014.

The men who stare at airline passengers. The Economist. 6 June 2010.

Segura L. Feeling nervous? 3,000 Behavioral Detection Officers will be watching you at the airport this thanksgiving. Alternet. 23 November 2009

Smith T. Next in line for the TSA? A thorough ‘chat down.’ National Public Radio. 16 August 2011.

Wallis R. Lockerbie: The Story and the Lessons. London: Praeger. 2000.

Weinberger S. Intent to deceive: Can the science of deception detection help catch terrorists? Nature. 465:27. May 2010.

U.S. Government Accountability Office. TSA Should Limit Funding for Behavioral Detection Activities.  GAO-14-159. Washington, DC, 2013. http://www.gao.gov/products/GAO-14-159.

US House of Representatives. Behavioral Science and Security: Evaluating the TSA’s SPOT Program. Hearing Before the Subcommittee on Investigation and Oversight. Committee on Science, Space, and Technology. Serial 112-11. 6 April 2011.

All images designated as public domain

©2016

Diet Coke with Two Straws: The Story of an Armchair Stalker

Matt Freeman DNP, MPH

 

“This is hard to talk about,” said Tony, looking toward the floor.

It was Tony’s second visit. He had come in with a somewhat benign visit a month prior, complaining of shoulder pain. He was perhaps “testing the waters,” and had come back to discus his true concerns.

I recall him as largely nondescript: a 30-year-old manager of a large retail store. He had a condominium in a solidly middle class neighborhood, proud to be close with his family and wife. He told me how he was looking forward to playing football with his brothers.

“It’s so personal.” Tony gazed at the floor. His eyes starting to tear.

This was familiar territory for me. I had my money on erectile dysfunction, a diversion from marital fidelity, a gambling problem, sexual thoughts about about other men. None of the above. I was entirely unprepared.

“I wear women’s clothes.”

This was still not an overwhelming story for me. I had worked with heterosexual cross-dressing men before.

“My wife’s clothes.”

This just got a bit more complicated.

 

“It’s because of Jill. Jill Payne.”

“Who?

“Jill Payne. WNTN?”

 

I was stumped.

 

Exasperated, Tony explained that Jill Payne was a local news anchor. He was shocked that I had never heard of her.

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Tony explained that he had been going with his wife to purchase clothes for her that matched those of Jill Payne. She rarely watched the news, so she did not recognize that her clothes matched those of the news anchor.

In his wife’s absence, he would wear the dresses and suits while scouring the internet for photos and videos of Jill Payne.

Tony shared a small scrapbook of Jill Payne photos. Almost combusting with anxiety, he began to spill endless details of Jill Payne’s life: where she was born, her favorite restaurants, the names of her children.

As he composed himself, I asked a few critical questions. Tony had no interest in hurting Jill Payne. He knew her neighborhood but not her house, and he did not have sexual thoughts about Jill Payne. He also had no thoughts of being “trapped” in a man’s body. Tony just wanted to feel as close to Jill Payne as possible.

Tony initially seemed to hope that I would help facilitate further connection with Jill. He explained that Jill’s husband was a physician, and perhaps I knew him. Furthermore, was under the impression that Jill’s husband was Jewish, and he began questioning me about my religion, hoping to glean as much information as possible. I deflected.

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My first concern was for Jill Payne’s safety. Tony denied any plan, intent, or means to hurt her. He denied any attempts to visit her home or the television station. The action of stalking was not part of his life, at least not for the moment.

I felt desperate to call Jill Payne. But I could not. From a confidentiality standpoint, I had no grounds to breach the provider/patient relationship. To make a call to Jill Payne, Tony would need to have expressed a clear intent to harm her. Tony did not meet the legal criteria for a so-called “Tarasoff Warning,” or duty to warn a potential victim of violence.

I was unsettled, and I collaborated with a physician and two psychologists. They all agreed that the best course of care would be to find a therapist for Tony, maintain rapport, and monitor his stability.

 

“Most Likely to Be Stalked”

Jill Payne has probably gone through this before. Amy Jacobson, a news broadcaster, said, “Everyone has a crazy guy. It’s expected.”

Although statistics are hard to find, women on local news channels have been described as the “most likely to be stalked.” It has been described as a “job-related hazard.”

Park Dietz MD, PhD, MPH is a forensic psychologist known for his testimony in high profile murder and stalking cases, including John Hinckley Jr. and Jeffrey Dahmer. Dietz’ view is that those who stalk news reporters are seeking status, fame, and glamor… a means of compensating for his own sense of self.

Dietz characterizes the typical news reporter stalker as single, male, under- or unemployed, lacking intimate relationships, and with a poor sense of self.

Indeed, Tony was a lonely man. Although married, he worked at night while his wife worked during the day. Lacking intimacy and purpose, he did not just aspire to have Jill Payne’s possessions. He aspired to be Jill Payne.

 

Artificial Intimacy

I remembered an ad for the local news when I was a child. The female half of a news anchor team spoke of her adoration for the male anchor. “He always brings me my Diet Coke the way I like it… with two straws.”

A neighbor was visiting a city across the country and was taken by an ad for the local news team. “He always brings me my Diet Coke the way I like it… with two straws.” The two straws were an invention of the national network’s marketing office.

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Local news anchors are touted as part of the community. They are neighbors.  They have the illusion of being friendly, familiar, and approachable. And all of this is engineered through advertising. The “two straw” preference was somehow a way to make the anchors seem nonthreatening and amiable.

This is not to say that Jill Payne is anything but pleasant; I would have no way of knowing.

Family TV

 

The frequency of exposure compounds the situation. The local news anchor is in one’s living room or bedroom at least five days a week. She closes her broadcast with “Thanks for joining us. See you tomorrow.”

Tony knew that Jill Payne could not see or hear him. But she was a part of his everyday life. In fact, her current broadcasting schedule is weeknights at 5:00, 5:30, 6:00, and 11:00.

Michael Zona MD, a psychiatrist in Boulder, Colorado, explained that the most beautiful women are not typically the objects of such affection. Instead, it is the “girl next door.” The obsessed stalker may find that it would be within the realm of possibility that this woman would want a relationship with him.

A higher-profile celebrity in Manhattan or Hollywood might have appeared to be “off limits” to Tony. Jill Payne’s hometown sensibility and geographical proximity made her a more appealing target.

Stations

Obsession as a Function of Narcissism

Reid Meloy PhD, a forensic psychologist, describes a “narcissistic linking fantasy.” This can actually be a part of healthy human behavior: the thoughts of love, admiration, being liked, and complementing one another. The self-serving need for love and admiration are not pathologic.

Narcissistic linkage fantasies become troublesome when the fantasy involves someone who cannot reciprocate. Jill Payne never knew that Tony existed. But he could view this as a form of rejection. Although—to my knowledge—he never contacted her, he might find a postcard from the news channel to be dismissive. Jill was not recognizing the depth of his affection. He had spent a major proportion of his life devoted to Jill; she would not reciprocate.

Jill Payne comprised Tony’s sense of self, so anything that could be perceived as a slight by Jill would be an attack on Tony’s already damaged self worth.

 

From Obsession to Stalking

Tony was an “armchair stalker.” He never admitted to following Jill Payne, meeting her, or making plans to do so. But there was certainly a risk.

Although the prediction of future violence is almost impossible, I doubt that Tony would have ever tried to harm Jill Payne. In fact, I think that his fear of rejection was somewhat protective (for Jill) since he would do everything possible to avoid a slight from Jill.

But if his life disintegrated further: if his marriage dissolved, he developed a mood disorder, or other instability, he was certainly at risk for irrational or dangerous behavior.

ActionNews

After the News

I doubted that Tony was struggling with his gender identity nor with wearing women’s clothes. His true distress was about an impossible love, and obsessional  behavior. But he was at ease talking about his obsessional behavior as a function of cross-dressing. It was tangential way for me to get him connected with a psychologist. I consulted by phone with a psychologist who specialized in gender issues, and he was willing to consult with Tony. The psychologist was out of Tony’s insurance network, and he could not afford the cost of the visit.

I moved to a new city not long after I started working with Tony. I transferred Tony to the care of a colleague. He never followed-up.

I searched the internet for news stories under Jill Payne’s real name and the word “stalker.” No hits. She is still an anchor ten years after I worked with Tony.

 

References

Meloy R. The Psychology of Stalking: Clinical and Forensic Perspectives. Cambridge, MA: Academic Press. 2001.

Wise J. Most Likely to Be Stalked. Psychology Today. 8 October 2010.

 

©2016

All images public domain

The names “Tony,” “Jill Payne” and the station “WNTN” are pseudonyms.

 

 

 

 

 

In and Out of Network: The $900 million annual cost of provider credentialing

Matt Freeman DNP, MPH

“Are you ‘in networkwith Blue Cross? Cigna? Humana? UnitedHealthCare?”

My office gets these calls all day, every day. According to The Washington Post, the average wait time to see a family practice physician is 66 days in Boston, 24 days in Atlanta, and 23 days in Seattle. Dallas was the lucky city with an five-day wait.

New medical schools have scrambled to open; there have been increased enrollments in physician assistant and nurse practitioner programs. Professional schools are working harder than ever to recruit, educate, and graduate primary care providers.

Unfortunately, new primary care providers face massive barriers with insurers.

A licensed healthcare provider cannot just send a bill to an insurance company and expect a check in the mail. Insurers require that the provider undergo a credentialing process, which officially takes about 90 days, but it can take 180 days or more. Or the insurer may be “closed” and not allow the physician, physician assistant, or nurse practitioner to join the network at all.

 

Why Being “In Network” Matters

Even if seeking care for myself, I look to see if the healthcare provider I wish to see is within my insurance network. I am well aware that I have a $4,500 deductible and “in network” providers, and a $6,900 deductible and 50 percent co-insurance for “out of network” providers. In other words, I have to pay half the cost of the patient visit up to $6,900 if I see someone outside of my insurer’s network.

For the first time, the federal government is helping consumers find this information as well: beginning in January 2016, www.healthcare.gov will now allow consumers to find specific clinicians before deciding on a health plan to join.

waitingroom2

 

What is Credentialing?

Credentialing is the process used by health insurers to permit a healthcare provider to become a part of their “network” or “panel.” It involves a review of the provider’s credentials and approval of a committee. It is estimated to cost $900 million annually. (That figure is limited to physicians, and does not include physician assistants or nurse practitioners, who go through the same process.)

Insurers rightfully want to provide their enrollees with high-quality care. They seek to verify that the providers “empaneled” in their networks are appropriately educated, board certified, and do not have licensure sanctions or malpractice cases indicative of a pattern of poor quality of care.

The insurers state that they depend on “primary source verification,” meaning that they will not accept a photocopy of a diploma, transcript, or board certification. They want the information directly from the academic institution or certifying body.

Although this appears to be a logical step to prevent fraud, insurers are overlooking the fact that state boards require this information in order to issue a license. For example, my state licenses required a copy of my transcripts, proof of an internship, proof that I passed all my of board exams, written letters from the academic programs from which I graduated, fingerprints to be processed by the FBI, and a search of the National Provider Data Bank for licensure sanctions and malpractice cases.

If all of this is required to be licensed, why would an insurer need to repeat the process? Thus far, nobody has been able to answer that question.

 

The Process Starts Over Every Time a Provider Moves.

After months of “primary source verification,” a provider faces the same process from the beginning if he or she moves practices. Insurers tie each provider to a federal tax identification number. The minute that changes, credentialing has to start over.

Insurers may have specific requirements like hospital admitting privileges, “on call” services, accommodations for disabled individuals, and so forth. Likewise some practices offer a wider array of services than others, but these are small changes. Why would an insurer need to re-verify that a degree, certification, or license have been issued just because a provider moved to a new practice?

I have been re-credentialed by insurers at least three times even though my degrees, certification, and license did not change.

 

The Failed Solution

In 2002, the Universal Provider Datasource began. This gave healthcare providers and insurers are central databank of credentialing documents: certifications, employment history, diplomas, licenses, and so on.

The idea was that a provider has a unique code with the databank, and he or she then grants insurers access to his or her information. No need to fill out page after page of the same questions.

But it actually serves no clear purpose. The Universal Provider Datasource, now part of the Council for Affordable Quality Healthcare is a self-report system. Clinicians submit their information, attest to its legitimacy, but it is not verified.

Instead of streamlining the system, it just adds an additional step to a cumbersome process.

 

Even “Primary Source Verified” Information is Wrong

I am “in network” with one particular large insurer. Patients can select me as their primary care provider, and I show up in their list of available PCPs. But the information listed is wrong. Despite careful “primary source verification,” I am listed in the wrong specialty, and the system shows me as having been in practice for three years (I have been in practice since 2004.) Perhaps their “primary sources” included imagination and fuzzy math.

I suggested that they change my specialty in particular (they listed in my family practice, which I am not.) They did not change anything. It is unfortunate that I appear less experienced than I am based on their web site, but perhaps I should be willing to accept that as a compliment to my youthful appearance.

 

Pills

 

The Closed Network

A number of large insurers have shut the door to new primary care providers. Despite the shortage, these companies have decided that their patients should pay more.

For example, two insurers in my area are “closed” to new providers. The refrain I often hear is, “I called my assigned primary care doctor, and the wait to get in was three months.” It’s just as common as, “The office said that they will not see me because I have not been in for 18 months.” That leaves the patient with the option of paying the higher costs of an urgent care, the emergency department (for a non-emergency), or the expense of seeing an “out of network” provider, which is typically double the out-of-pocket cost.

When I looked at one particular “closed” network, I searched on their web site for primary care providers within 15-mile radius. Most of the names were listed two or three times, so it took a while to filter the list. Then I cross-checked the names against the state registry: one had a cancelled license and lived more than 2,000 miles away, one specialized only in geriatrics, another was a kidney specialist, several were cardiologists. Good luck finding an actual primary care provider.

 

Closed Networks Erroneously View Primary Care Providers as Interchangeable

The relationship between a patient and his or her primary care provider is reassuring, potentially life-saving, and a critical component of disease prevention and management. Everyone has different needs: some primary care providers specialize in certain areas: women’s health, people with HIV, patients who speak a primary language other than English, the elderly, LGBT populations, the hearing impaired, etc.

Although insurers claim that they “consider” providers with special skills or experience for closed networks, this is—at least anecdotally—untrue.

 

Is this this Anticompetitive?

Yes. The system favors large conglomerates.

The balance of power lies with the largest provider groups and healthcare institutions. For example, when hospitals merge, they end up with two departments offering the same service: two groups of surgeons under the same umbrella holding company. The two provider groups have greater bargaining power with insurers.

Established practices do not want the networks to be open either. For example, a study of Florida hospitals demonstrated marked price increases beyond inflation and without accounting for changes in quality of care.

Insurers could also argue that they may open networks based on patient quality data. A closed network might be swayed into accepting a new primary care provider if he or she demonstrated high marks for meeting the standard of care for diabetic patients. But what if the practice has comparatively few diabetics? Or what if the practice inherits a large number of poorly controlled diabetics, and the patients’ data will give the illusion of substandard care.

 

 

Financial Motivation for Fewer Credentialed Providers

Insurers have great interest in keeping their networks small. If there are too many providers, the insurers might face the threat of demand for higher compensation. In 2002, a law suit against Aetna, Anthem BlueCross/BlueShield, and Humana was filed by physicians in Cincinnati. The physicians argued that they were reimbursed below acceptable rates. Humana settled for $100 million and agreed to increase its reimbursements by up to 30 percent.

An even larger network would have meant even greater bargaining power against Humana, and an increased threat to their ability to reimburse below the market rate.

 

Failure of Antitrust Legislation

The courts have been reluctant to take action against anti-competitive action by insurers. Some states enacted “Any Willing Provider” legislation, which mandates that any qualified provider must be allowed to participate in a network. But a decision by Justice Scalia argued that the Employee Retirement Income Security Act (ERISA) pre-empts “Any Willing Provider” laws. Therefore “Any Willing Provider” laws in 27 states apply only to state-regulated policies, not self-funded insurance plans (those typically offered by large employers.) Furthermore, in many cases, the “Any Willing Provider” legislation is limited to pharmacies and pharmacists.

 

How Could This Be a Threat to Public Health?

1. Delays in diagnosis and treatment

Imagine that you or a loved one has an early, brewing pneumonia: fever, chest pain, maybe a little short of breath, profound fatigue. If treated promptly with inexpensive antibiotics, it will not be pleasant, but it is certainly a survivable condition.

If the wait time is anywhere from five to 66 days, that could mean delayed diagnosis, delayed treatment, and the results could be life-threatening.

2. Excess Cost as an Impediment to Care

In the pneumonia scenario, one could argue “that’s why there is urgent care.” True, urgent care clinics and “convenient care” clinics (like those inside pharmacies and supermarkets) should be able to diagnose and treat pneumonia.

I had a look at the cost of going to one of these clinics. I searched on www.healthcare.gov for unsubsidized plans available within my ZIP code. I picked the first three plans from three different insurers.

  • Plan one: urgent care is not covered at all. It is considered a “non-emergent” use of an emergency facility.
  • Plan two: 20 percent co-insurance (in-network urgent care) 50 percent co-insurance (out-of-network.) The same service in a primary care office has a $10 copay.
  • Plan three: $50 copay per visit. The same service in a primary care office has a $30 copay.

Walgreens Healthcare Clinic lists its prices as $89 to $129 for evaluation and management of an illness. Depending on one’s insurer one may or may not be able to recover some of the expenditures from a visit to a “convenient care” clinic.

UrgentCare

 

3. Fragmentation of Care

Since credentialing starts over every time a provider moves, a healthcare provider cannot necessarily take his or her patients along. For example, say that a family practice physician is in a struggling group practice. She decides to break off from the group and open her own practice. Patients will have to wait until the physician is re-credentialed in her new practice. Even worse, if networks are closed, her patients will have to find a new family doctor, and they may face delays in finding the care they need.

4. Misused Funds

$900 million per year in credentialing costs is an unthinkable expenditure of healthcare dollars. The expenditure is often redundant, incorrect, and needlessly time-consuming. A “Gold” health insurance plan is estimated to cost $4,360 annually for the average person. If we standardized credentialing, we could translate that $900 million to “Gold” coverage for two million Americans, or reduce the deductibles and copays for those with high deductible plans that individuals and families cannot afford. We would also provide those consumers with access to a wider network of providers, offering timely care and—one hopes—fewer complications.

 


Potential Solutions

1. The infrastructure already exists.

The CAQH system already collects the requisite data for credentialing, but it is self-report. External verification companies, like Optum, could actually partner with CAQH to flag sections of a provider’s profile as independently verified.

My diplomas, therefore, would always have green check mark next to them, thereby eliminating the need for an insurer to check every time I move. After all, the day I earned by bachelor’s degree, my board scores, and my grade in pathophysiology are not going to change.

 

2. Centralize the “primary source verification” process.

Although insurers do not say so, it would be reasonable to assume that many contract with the same companies—like Optum—to conduct “primary source verification.” Why not allow transparency? Once a provider has been “verified” by one of these firms, there should be no need to repeat the process.

3. Charge an application fee.

Although I would hate to give even more money to insurers, motivated providers could be asked for—say–$100 or $150 for an expeditious review of their credentials.

Insurers concede that their “network” and “credentialing” meetings are held monthly. So this would meant that a new provider could be “verified” and ready to work within six weeks rather than six months.

 

4. Closed primary care networks imperil public health and impair consumer choice. Open the networks.

The shortage of primary care providers is well-documented, and this problem is going to get worse. Insurers should not be fearful of having to pay providers fairly if their networks grow.

Two of the “closed” networks had estimated operating revenues of $15.1 billion and $12.33 billion in 2015. Their financial security is not at risk.

 

References

Bernstein, L. US Faces 90,000 doctor shortage by 2025, medical association warns. The Washington Post. 3 March 2015. https://www.washingtonpost.com/news/to-your-health/wp/2015/03/03/u-s-faces-90000-doctor-shortage-by-2025-medical-school-association-warns/. Accessed 31 December 2015.

Bonfield T. Humana settles doctors’ lawsuit. The Cincinnati Enquirer. 24 October 2003. http://www.enquirer.com/editions/2003/10/24/loc_choicecare24.html. Accessed 30 December 2015.

Noble A. Any Willing or Authorized Providers. National Conference of State Legislatures. 5 November 2014. http://www.ncsl.org/research/health/any-willing-or-authorized-providers.aspx. Accessed 2 January 2016.

Porter ME & Treisberg E. Redefining competition in health care. Harvard Business Review. June 2004. Accessed 2 January 2016.

Potter W. Health insurers watch profits soar as they dump small business customers. The Center for Public Integrity. 25 January 2015. http://www.publicintegrity.org/2015/01/26/16658/health-insurers-watch-profits-soar-they-dump-small-business-customers. Accessed 2 January 2016.

ValuePenguin. Average Cost of Health Insurance (2015). http://www.valuepenguin.com/average-cost-of-health-insurance. Accessed 2 January 2016.

 

All photos public domain

©2016