Tuesday, October 25, 2011
“What does it take to be a great or even good psychiatrist? What are our criteria as patients? What are the criteria that psychiatrists value to be good, even great?"
Kathy added: “I would really value an exploration of Smitty’s questions ...”
You got it.
Smitty and Kathy were responding to my Sunday rerun post, Smart Meds Strategies - No This is Not an Oxymoron. The post was based on three reader polls that found eight in ten of you reported that your meds were not working “very well.” As I concluded:
The meds are the one constant in this equation. The two variables are you and your psychiatrist. First imagine a smart patient working with a smart psychiatrist. Now picture a naive patient placing his or her trust in a lazy and indifferent psychiatrist. Are we likely to see dramatically different outcomes? I rest my case.
I’ve made numerous comments on psychiatrists in past posts. Perhaps now is a good time to organize them into a sort of Patients’ Bill of Rights. Let’s get started:
The Right to a Psychiatrist Who Listens
Literally every complaint I get from readers boils down to the fact that their psychiatrists refuse to listen. The most common cases involve doctors who downplay their patients concerns about the side effects of their meds. I remember pointing this out to a group of clinicians in my first and last-ever grand rounds that I delivered in 2008. “Trust me,” I said. “When your patients complain to you about feeling like fat stupid zombie eunuchs on the meds you prescribe we are not doing this to ruin your day.”
My audience reacted as if I had just ruined their day.
A year later I was in the audience at a psychiatric conference as a prominent doctor told us how psychiatrists are trained to listen. I stifled my derisive outburst of shocked disbelief just in time. The comment was too much even for the psychiatrist sitting next to me. He whispered something to me, and we just shook our heads in amazement.
There is no question that a clear disconnect exists between patient and psychiatrist. According to a 2003 study by Scott and Pope, clinicians felt their patients quit lithium owing to "missing highs." Patients who quit, on the other hand, cited other reasons.
More egregious - and still fairly common - are cases where a psychiatrist will insist on prescribing a med over the patient’s strenuous objections. Typically the patient will inform the doc that the med has caused an extremely bad reaction in the past. Typically, the doc will prescribe the med anyway.
Even a psychiatrist who wants to listen is disempowered, thanks to the demands of managed care. The standard ten-minute meds check militates against a concerned physician probing beneath the diagnostic label to find out what is really going on. We get lumped and categorized and prescribed to. But are we being treated?
The Right to a Psychiatrist Who Values Us as Human Beings
Three years ago, I heard a prominent psychiatrist tell a class of psychology undergrads that the worst stigma to be found anywhere comes from psychiatrists. Blow me down - a candid and honest psychiatrist. I have no reason to dispute him.
Too often, we hear from psychiatrists and other clinicians that we lack insight into our illness, that we refuse to take their advice, and that we go off our meds for no reason. Okay, there is some merit to these claims, but when you hear them mindlessly repeated with no regard to the actual facts, then the result is to devalue us as human beings.
Xavier Amador PhD, author of “I am Not Sick, I Don’t Need Help,” is the foremost proponent of the lack of insight hypothesis, which he insists is a brain disease in its own right (“anosognosia,” is the label he applies). I happened to run into him at a poster session of a psychiatry conference a few years back.
“Patients lie,” was his parting shot, as he walked away from me. He obviously didn’t realize I was a patient.
Dr Amador, I think you just proved my point.
The Right to a Psychiatrist Who Values Our Uniqueness as Human Beings
Back to my first and last-ever grand rounds. Regular readers here have heard this a million times, but it bears retelling:
"Keep in mind," I told my audience, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."
It was as if I had let rip a roof-rattler and everyone was too polite to laugh. Then I blurted out: "To me, you all have flat affect."
Kelvin grade frozen stony cold silence.
Really, why would I want to be like my psychiatrist?
The Right to a Psychiatrist Who Is Committed to Getting Us Well, Not Just Stable
Here is how I phrase the issue in an article on bipolar treatment on mcmanweb:
You are stable, no longer in a state of crisis. You are looking ahead - to the whole rest of your life - to returning to your normal life. Your doctor, on the other hand, is looking back - from the days or weeks that you emerged from crisis - at preventing another hospitalization. Already, there is a major disconnect between you and your doctor. ...
Your doctor tends to call it a success stabilizing you into a state of being clinically “undead.” But is that where you want to be? And if you bring this to your doctor’s attention - is that just you, another patient who lacks insight?
Wrapping It Up
Obviously, these four rights are interconnected and related. A psychiatrist who refuses to listen, for instance, is obviously someone who devalues us as human beings, fails to recognize our uniqueness, and is not committed to getting us well.
Unfortunately, there is little incentive for bad doctors to change their behavior. Legally, their asses are covered, professional discipline is non-existent, and they are removed from the pressures of the free market. Basically, even if their patients fail to get better - or even if they get a lot worse under their care - they still get paid.
Six months ago, I had lunch with two out-of-town visitors. The topic turned to psychiatrists. I twirled my pasta with my fork and looked up at the person facing me. If you had to take a guess, I asked, how many psychiatrists would you say are bad ones? From the look on his face, I could tell he was formulating the same answer as mine.
Two-thirds? I suggested.
He nodded his head. Two thirds, he replied. My other visitor was also nodding her head in agreement. Two-thirds sounded right to her, too.
Two-thirds. Does that sound right to you? Just asking ...
Further reading from mcmanweb:
The Problem Clinician
Problem Patients, Problem Meds