Tailoring Treatment

It’s great to be back at the MARRCH Annual Conference & Expo after a several year hiatus. This year, I’ll be speaking on tailoring treatment using the transtheoretical model (26 October, 12:30 p.m.). You can find my PowerPoint here.

The transtheoretical model is seemingly central to addiction treatment, but do we effectively use it?

  • Do we accurately stage patients upon admission and during their course of care?
  • Does our interpersonal stance match each patient’s stage of change?
  • Do we use appropriate processes of change for each patient’s stage of change?
  • Does it even matter?!

I’ll tackle these questions and much more. ✸

They Might Be Faking

It was great to gather again for the Minnesota Sheriffs’ Association’s annual Correctional Health Division conference. This year, I presented on non-psychiatric (“medical”) malingering. Here’s my PowerPoint:

We could perhaps tackle psychiatric malingering next year (hint, hint). In some ways, this is easier to deal with as presentations seldom require urgent off-site transport. Standardized tests also make determinations more secure.

Many thanks to Holly Compo, Tom Wells and Randy Willis for inviting me to participate, and for onsite support. ✸

This Is Water

Last weekend, I lead a residential wellbeing retreat at the Dan Anderson Renewal Center on the Center City, Minn., campus of the Hazelden Betty Ford Foundation. We examined the origin and nature of suffering, and some potential solutions.

We used David Foster Wallace’s This Is Water as our core text. Here are my PowerPoints that explore some related ideas:

Many thanks to Paul Anderson for inviting me to lead the retreat. And a huge thanks to Peg Schroeder for assistance with planning and onsite support.

Based on positive evaluations, it seems likely that we will offer the retreat again to all comers (not just health professionals). ✸

Top Doc 2022, and Some History

I’ve been practicing addiction medicine since 2005. A lot has happened between then and now, including regional recognition of our specialty by Minnesota Monthly in 2014.

“Top Doctors” Issue: 2014, left; 2022, right.

You can trace the history of the specialty back to at least 1954. That’s when the New York City Medical Society on Alcoholism, progenitor of the eventual American Society of Addiction (ASAM) formed. In 1983, it began awarding a certificate of added qualification (CAQ), which was still available when I entered the profession. My certificate—December 6th, 2008—is probably from the final CAQ cohort.

The American Board of Addiction Medicine (ABAM), an independent medical board, formed in 2007. I was a member of its inaugural class in 2009. This eventually gave way to the American Board of Preventative Medicine (ABPM), of which addiction medicine has been a subspecialty since 2018.

I was surprised when Minnesota Monthly notified me that I was going be included in its 2014 “Top Doctors” issue. The letter didn’t indicate which specialty, so I e-mailed the publisher. They replied, “You have been nominated in the field of Addiction Medicine.” This was a new category. Our specialty had finally achieved mainstream recognition—grocery stores, gas stations, home mailboxes!

Five of us were listed in 2014. The number has grown over time and this year includes 17 addiction medicine physicians.

Mpls.St.Paul Magazine publishes a competing list. I hope that it discovers addiction medicine before I retire. I’m only 52, so there’s still lots of time. ✸

Postscript. We intentionally run a very small practice—it’s just my longtime assistant, Kris Jamieson, and me. She’s the one answering the phone and e-mails, chasing down labs results and medical records, calling pharmacies, completing prior authorizations, and offering constant encouragement to patients (they tell me “I love Kris” and “Kris is great” all the time). Behind every top doctor there’s a top assistant. This recognition is just as much hers.

Adjust Your Own Mask

No, not *that* kind of mask! I’m thinking about the airline safety announcement. It’s a great metaphor for health professionals—it’s hard to help others when we’re struggling ourselves.

Please join me for a weekend retreat at Hazelden Betty Ford Foundation’s aptly named Renewal Center, located on its beautiful Center City, Minn., campus. I’ll be bringing together a decade of work on burnout, resilience and wellbeing, with a big emphasis on acquiring new self-care skills.

Anyone working in healthcare welcome. And, yes, Hazelden Betty Foundation is known for addiction treatment—but you don’t need to have a personal history of addiction to attend the retreat. ✸

Postscript. The retreat’s title—This Is Water—is a riff on a small but profound book by David Foster Wallace.

The 700 Club

As a preacher’s kid, I just couldn’t resist the pun!

June 30th marked my 700th day of Musing. Many thanks to InteraXon for bringing this amazing technology to consumers.

For more on my Muse journey, please see here and here. Please also see this video beginning at around 26:00.

I’m planning to lead some meditation retreats in 2022 (Covid got in the way the past two years). Each attendee will receive a Muse S and meditation instruction over the course of a weekend. More to come after I work out the details. ✸

Mosquito Forecasts

Here’s a quirky chapter from my early professional life. I worked for Multidata, a small company then based in Minnesota, before, during and after medical school. Our main products and services dealt with pollen—the stuff that causes allergies. More on that perhaps in future posts.

In the early 1990s, we sought to diversify and landed on mosquito forecasts. Go ahead and chuckle, but there was actually a decent market for the product.

Our first media appearance was in The Wall Street Journal on Friday, June 30th, 1995—right before the Independence Day holiday. This led to a lot more media, both that weekend and in the years that followed.

So here’s a tribute to Dennis Gebhard, Multidata’s founder, and his business partner, Bill Erickson, for urging imaginations to run wild. Those were truly magical years! ✸

Family First

Somewhere between 2001 and 2004 (when I was a family medicine resident), I had the great fortune of rotating with Tom Okner and Stuart Cox at Midwest Ear, Nose & Throat Specialists. During that experience, I acquired a slim volume, Primary Care Otolaryngology, that immediately acquired a place of honor in my bookcase.

The authors included life advice and musings about science in the margins of various pages. This one stopped me in my tracks then and remains a guiding principle today.

In the spirit of Father’s Day, I thought that I’d share Dr. Fischer’s wisdom with other parents who are doctors. ✸

J. Gregory Staffel, et al. Primary Care Otolaryngology. Alexandria, VA: American Academy of Otolaryngology—Head and Neck Surgery Foundation, 2000, p. 64

Beginner’s Luck

I’ve written a lot of stuff over the years — journal articles, book chapters, opinion pieces — but I don’t think that I’ll ever top my first publication.

Our family had just moved to Brainerd, Minn., and I had the good fortune of taking Berteil Mahoney’s 8th grade composition class. She submitted one of my pieces to the Minnesota Star & Tribune (as it was called then) and it appeared in the paper’s “Neighbors” section on May 26th, 1984.

Mrs. Mahoney ignited what has become a lifelong love for writing. But, more importantly, she demonstrated the early importance of a good editor! ✸

SIMS Season — 2022

I’m privileged to serve as faculty for another season of Hazelden Betty Ford Foundation’s Summer Institute for Medical Students (SIMS). This page contains links to my teaching materials and some additional resources.

Many thanks to Kari Caldwell for involving me in SIMS and also the Professionals in Residence (PIR) program!

Screening, Brief Intervention & Referral to Treatment (v. 05/11/2022)
Motivational Interviewing Skills Session (v. 11/09/2022)

Key Readings [Mindy & Kari will provide copies]
Alcohol Use Disorder (textbook chapter)
Taboo Topics in Addiction Treatment: An Empirical Review of Clinical Folklore (J Subst Abuse Treat 1993;10(3):303-16. PMID: 8315704)
The 10 Most Important Things Known About Addiction (Addiction 2010;105(1):6-13. PMID: 19712126)

Patient Assessment
The ASAM Criteria Assessment Interview Guideline (Adult)
Tailoring Treatment (transtheoretical model)

Patient Resources
DBT Skills Training Handouts and Worksheets (see: Chain Analysis of Problem Behavior, p. 31)
Motivational Interviewing Workbook
REBT Pocket Companion for Clients
Rethinking Drinking (consumer health website)
Tips for Cutting Down on Drinking

I’ve long advised medical students and residents to acquire some psychotherapy skills, regardless of their eventual specialty. Motivational interviewing (MI) and cognitive behavioral therapy (CBT) are relatively easy to learn and have broad clinical utility.

Some MI resources include:

  • Miller WR, Rollnick S. Motivational Interviewing, 3d ed. New York: Guilford Press, 2013 [classic textbook]
  • Sim MG, Wain T, Khong E. Influencing behaviour change in general practice. Part 1—brief intervention and motivational interviewing. Aust Fam Physician 2009;38(11):885-888 (PMID: 19893835; and here)
  • Sim MG, Wain T, Khong E. Influencing behaviour change in general practice. Part 2—motivational interviewing approaches. Aust Fam Physician 2009;38(12):986-989 (PMID: 20369152; and here)
  • Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques—facilitating behaviour change in the general practice setting. Aust Fam Physician 2012;41(9):660-667 (PMID: 22962639; and here)
  • Searight HR. Counseling patients in primary care: evidence-based strategies. Am Fam Physician 2018;98(12):719-728 (PMID: 30525356)

In terms of CBT, I highly recommend the professional trainings at the Albert Ellis Institute, starting with the primary certificate practicum. Some other resources include:

  • DiGiuseppe RA, Doyle KA, Dryden W, Backx W. A Practitioner’s Guide to Rational Emotive Behavior Therapy, 3d ed. Oxford: Oxford University Press, 2014 [classic textbook]
  • Harden M. Cognitive behaviour therapy—incorporating therapy into general practice. Aust Fam Physician 2012;41(9):668-671 (PMID: 22962640; and here)
  • Stuart MR, Lieberman JA. The Fifteen Minute Hour, 6th ed. Boca Raton: CRC Press, 2019 [please see, in particular, Chapter 4]
  • Frenz DA. Another Arrow for Your Quiver: REBT for SUD. Minneapolis: David A. Frenz, M.D., 2018 [PowerPoint presentation]