Highlights From The Comments On Telemedicine Regulations
Table Of Contents: 1: Isn’t drug addiction is very bad? 1: Comments About How Drug Addiction Is Very Bad Some people countered that drug addiction was very bad, and preventing it is worth some inconvenience. For example, Michael van der Ruyt:
I hope my point didn’t come across as “addiction doesn’t matter”. My point was - well, suppose the DEA passes a regulation saying that, because addiction matters so much, from now on only doctors with ground-floor offices can prescribe medication. You might ask questions like “Are doctors with ground-floor offices really better at controlling addiction than doctors with higher-up offices?” or “If there are bad doctors overprescribing meds, can’t they get ground-floor offices and keep doing that?” or “Doesn’t this just inconvenience everyone with a one-time office relocation fee, without shifting patients from worse to better doctors?”. These are the same questions I wanted people to ask about the telemedicine regulations, not “is addiction really bad?” Also, for Lela, see eg here, here, and here: most research suggests that childhood use of ADHD medication decreases future risk of substance abuse; a minority of studies find no effect, but AFAIK no credible ones find an increase. ADHD treatment is correlated with substance abuse, because ADHD itself increases risk, but it’s not a causal relationship. 2: Comments Debating If Telemedicine Is Worse Than Regular Medicine Some people did try to argue that telemedicine is worse than regular medicine, either along some axis related to addiction risk, or some other axis. For example, Freddie deBoer:
In response to Freddie, I wrote that I’m face-blind and bad at body language, so maybe I’m missing some kind of really subtle cues that other people can notice, but to me seeing a good image of a person’s face and upper body captures 99% of what I would get from seeing a patient in person. There are very few psychiatric signs happening in a patient’s feet! (yes, ankle clonus for serotonin syndrome, very nice, I bet you aced your USMLEs). I’m not in person has no value, just that “drive a hundred miles and pay more so that I can get the extra 1% information” is a pretty big ask. Belobog writes:
I will never get tired of citing this tweet: Why idly theorize when you can JUST CHECK and find out the ACTUAL ANSWER to a superficially similar-sounding question SCIENTIFICALLY? There are many studies of telemedicine, which mostly find it’s as good or better than regular medicine. See for example here, here, here, etc. These suffice to get a vague sense that telemedicine is usually good and not bad, which I think is accurate. But nobody knows how well a study showing telemedicine is good at one thing in one specialty translates to being good at another thing in another specialty. For example, consider this study showing that telemedicine improves care in opioid use disorder. The clearest way it improved care was by patients being more likely to attend their appointments and continue care. This led to various other good things, like lower risk of overdose. Did doctors deliver equally good care per appointment? We don’t know. If you’re sure you won’t miss any of your appointments, will teleheath be better or worse for you than in-person? We don’t know. Does “telemedicine treats opioid use better” generalize to “telemedicine treats ADHD equally well?” I don’t know. Is the sample size large enough to notice if telehealth doctors did 1% worse at treating some specific easy-to-miss but dangerous condition? I don’t know. Does telehealth increase addiction risk in other patients who aren’t already addicted? I don’t know. Certainly nobody has ever done studies on the point relevant to this particular regulation: whether making patients see a doctor in person once before receiving controlled substance prescriptions from them decreases addiction rates. It wouldn’t even make sense to study this, since part of the effect would be from patients self-selecting into the treatment population to begin with. In the future, if you want to know whether I know of studies in some area, please just ask me nicely. You don’t have to speculate on which of my personal failures have caused me to hate Science and Evidence. 3: Comments About “Pill Mills”: Some people express concerns about “pill mills”, unscrupulous companies that hire doctors to prescribe to anyone who asks. These are pretty common for Adderall in particular. Michael:
I agree that these pill mills exist and Cerebral is one of them, but I have trouble figuring out how to think about them. As I wrote here, the official definition of ADHD is so fuzzy as to be meaningless. It requires a patient to meet five vague criteria off a list with items like “often has difficulty sustaining attention” and “is often easily distracted”. Some doctors diagnose with a gestalt impression: they take a history, they hear things that seem to satisfy those criteria, and they diagnose with ADHD. Others use questionnaires that ask “on a scale of 1-5, how much trouble would you have paying attention in such-and-such a situation?”. A few use sophisticated video-game-style tests, but these are expensive, inconvenient, and probably less than 20% of diagnoses, plus they come with big warnings saying NOT TO BE USED TO DIAGNOSE ADHD, YOU CAN ONLY DO THAT BASED ON WHETHER THEY FIT THE CRITERIA. I bet pill mills like Cerebral spend thirty seconds asking patients “Do you often have difficulty sustaining attention?”, and the patients say yes. Maybe they even give a questionnaire. So in a purely formal sense, there’s nothing that good doctors are doing that they’re not. You would hope that the good doctors dig deeper, try to make sure they’re understanding the situation and telling the truth - but the exact amount to do that is a judgment call. As I discuss here, I usually err on the side not making them jump through too many hoops - most of the hoops are security theater, and the most severe ADHD patients get distracted and fail to jump through the hoops and then I have to decide if I really want to deny them medication on that basis or not. So the difference between good doctors and pill mills here is really thin. Or to put it another way: even in a world without any pill mills or telepsychiatrists, you will always be able to get Adderall through the following process:
Since everything about ADHD diagnosis and treatment is already security theater, it’s hard to say what pill mills are doing except kind of smirking under their breath while going through the rituals - as opposed to real doctors, who go through the rituals with sincere faith. Don’t get me wrong, I do think there’s a difference here. But the regulatory state isn’t set up to say “And you have to sincerely believe in the rituals or they don’t count”. So instead they punish unrelated groups, like telepsychiatrists. See also my old post Bureaucracy As Active Ingredient. The security theater doesn’t work because it’s effective. It works because it’s inconvenient enough to weed out the less motivated fakers, and some of the remaining fakers get cold feet about lying to a nice sincere psychiatrist who seems to be trying to help them. Pill mills remove the inconvenience, and seem to be nod-and-wink cooperating with liars, so the theater stops working. The only solution is to inject some inconvenience and shame back into the process somewhere, which the DEA has chosen to do by restricting telepsychiatry. They could accomplish the same goal by making you attend your appointments naked, but I guess clothing companies have better lobbyists than telepsychiatrists do. 4: Comments About Forcing Blind People To Fill Out Forms Before They Can Access Braille I analogized forcing patients to see an in-person doctor before they could access a teledoctor to forcing blind people to fill out forms before they could access Braille. Several blind people and their friends pitched in to say this was a real problem. For example, Mikolysz:
5: Comments About My Caricature Of A Doctor Who Refuses To Prescribe Psych Drugs Because People Just Need Jesus Jon Cutchins writes:
Mike writes:
On the other hand, fluxe writes:
Unfortunately I only mention this possibility because it’s happened to several of my patients. The best I can offer in terms of being unbiased and apolitical is to signal-boost posts like this one about overly woke therapists being another big problem. Alien on Earth writes:
I agree that there are many reasons people recommend against psychiatric drugs (a few are even good). Psychiatric drugs have lots of side effects and are clearly imperfect options, and I see people object to them more often when they think they have a perfect option as an alternative. Sometimes that option is Jesus. Other times it’s the trendy new somatic yoga reprocessing kundalini trauma dianetics therapy. Other times it’s LSD or ketamine or Dr. Bob’s 24-In-One Internet Nootropic. All of these work for some people, but not as much as the people pushing them think - which I guess is also true for psych drugs. I’m nervous about people who think they’ve found the answer and pressure people towards one alternative or another without presenting evidence. I’ve seen this happen enough in religious contexts that I think it was a fair thing to use as an example. 6: Comments About Which Part Of The Government Is Responsible For This Regulation ProfessorE writes:
I mostly accept this correction, although I’m still a bit confused - a lot of the analyses by lawyers I read said things like “Unquestionably, the DEA’s proposal is not what most industry stakeholders were anticipating. The initial reaction is the rules are more restrictive than necessary and impose concerning limitations and burdens on clinicians and the patients they treat”, and I’m confused why industry stakeholders weren’t anticipating it if the DEA had to do it in order to follow the law. And JR writes:
Based on that comment and this, my best guess about what’s happening is:
I’m not exactly sure who to be angry at, but I think “the government” is a fair albeit vague target. 7: Comments About How Other Countries Do It Coagulopath writes:
A few years ago I was told this was how it worked in the US too. As far as I can tell, the currently proposed restrictions remove the 12 month requirement (if it even ever existed), which I think is a positive step.
California has a centralized database of all controlled substance prescriptions (it’s called CURES). I don’t know how carefully the government monitors it. I often hear stories of doctors who overprescribe controlled substances getting in trouble, but I don’t know the details. You have to understand, there’s more medical law than any human can read, and doctors don’t have the skills to know where it is or how to interpret it. So the regulatory state mostly rules by fear. Everyone has a vague sense that if they overprescribe controlled substances, according to some inscrutable criterion, something bad will happen to them. What counts as overprescription? How bad is the bad thing? Surely you would have the right to a jury trial first, right? Surely there isn’t some DEA Star Chamber where judges wearing expressionless masks condemn you to death via forced amphetamine overdose as a suitable yet ironic punishment, right? These are among the many questions none of the doctors I’ve ever asked about this know the answers to. You're currently a free subscriber to Astral Codex Ten. For the full experience, upgrade your subscription. |
Key phrases
Older messages
Open Thread 270
Monday, April 3, 2023
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MR Tries The Safe Uncertainty Fallacy
Thursday, March 30, 2023
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The Government Is Making Telemedicine Hard And Inconvenient Again
Wednesday, March 29, 2023
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Turing Test
Monday, March 27, 2023
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Open Thread 269
Monday, March 27, 2023
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