Wednesday, October 22, 2008

Doctoring



"Everyone complains of a poor memory, no one of a weak judgment."


De La Rochefoucauld



Two psychiatry posts caught my eye yesterday, one by Peter Kramer, M.D. on the vagaries of prescribing, the other by Richard Friedman, M.D. on the strange phenomenon of patient-blaming. Between them they capture much of the art of the profession: balancing reported evidence against individual idiosyncrasy, and exercising patience leavened by humility.

Kramer points out that unless or until we have a much more advanced understanding of the genetics of drug metabolism, we will remain unable to predict how an individual will respond to any given drug with respect to both side effects and therapeutic effects. Doctors are guided by recommended ranges of doses, but patients vary wildly in their tolerance and reaction. One patient sleeps 24 hours after 25 mg of Seroquel, while another patient doesn't blink after 1000 mg. As someone somewhere said, the only difference between a medicine and a poison is the dose.

Many patients openly state they don't want "to be a guinea pig," but in a sense each singular clinical interaction must involve some "guinea pig" element because that particular constellation of factors--the doctor, the patient, the drug, the time, the diet, the other medications taken--have never occurred before in the history of the universe (and never will again). Of course, medications have been tested on large groups of other people such that we do have useful guidelines; we pretty much know that the person taking it won't drop dead 15 minutes later, and we know a lot more besides. But those large groups of other people are not exactly this person, so the potential for serendipity is considerable.

In choosing a medication we are hypothesizing that the range of remotely likely outcomes of taking it is preferable to the range of remotely likely outcomes of not taking it. We do not, of course, really know what will happen in either case; life is like that. A crystal ball would be a tremendous conversation piece in the office, but it would convey exactly the wrong idea (and of course few would get the irony anyway).

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Friedman delivers a message psychiatry seems in need of again and again: because of persistent crucial gaps in our knowledge we usually err in blaming patients for not getting better. It is true that factitious disorders and "secondary gain" exist, but these are vastly outnumbered by the cases in which people do not get better (or "fail" to get better, a frequently encountered word choice that itself speaks volumes) for physiological reasons we do not yet understand.

This is so problematic in psychiatry because we do not yet have access to the physical pathology involved. In other areas of medicine we can, via testing and imaging, witness the metastasizing tumor, the high blood sugar, the positive blood cultures. But in psychiatry all we usually have to go on is subjective report and observed behaviors. As Friedman describes, the bipolar who becomes refractory easily becomes, in the eyes of clinicians, the borderline.

Of course we also can't just treat people as physical phenomena; we must engage them as responsible agents as well. And the gray areas are fascinating: hysteria, personality disorders, addictions. We think now that addictions have a strong biological component, but what about willingness to attend AA or other appointments, or willingness to take medications? How do we decide when we are dealing with the illness and when we are dealing with the (accountable) person? We tack back and forth, I think, trying to find a fair and just middle way. But psychiatry teaches nothing if not humility, so when in doubt, which is often, it seems wise to spare the person and not the illness. I try not to be gullible either, but I'd rather be a little gullible than a little (or a lot) cynical--I seem to sleep better that way. Oh, and I try not to be sanctimonious either...

5 comments:

s said...

Great post.

worthen said...

When you are at the mercy of a disease that is making you so miserable you want to die, experiencing side effects is worth the chance of salvation. You're grateful if your shrink is someone who is willing to keep trying if the side effects are too much or if the drug simply isn't working.

John J. Coupal said...

Psychiatry doesn't have a lock on those physicians having patients who fail to get better.

Surgeons have their failed back syndrome, aka, the failed back surgery syndrome. The patient's back or legs remain defiantly painful or symptomatic despite the best efforts of the surgeon.

My favorite is the hateful patient. To any speaker of English, that obviously describes the patient who hates...er, something. au contraire, in doc speak it indicates a patient whom the PHYSICIAN does not like to be around, for one or many reasons. Talk about projection having a quaint medical orientation!

Novalis said...

Right, while psychiatry and psychopharmacology have plenty of flaws, those who reflexively condemn the whole enterprise and endorse NOTHING BUT therapy, nature walks, etc. have no idea of the magnitude of what some people are dealing with.

And yes, I agree that chronic pain conditions are a close analogue of psychiatric syndromes in general medical practice--there is the same refractoriness both to understanding and to treatment.

Anonymous said...

It seems that the biopsychosocial model of psychiatry is becoming much more bio to the detriment of patients' psychological and social needs or dysfunctions.

Speaking from the patient perspective, medication has been (for me) an indispensable part of the equation, but not the entire answer.

Therapy is also useful, but there are too few "good" therapists available, and psychiatrists, who used to be the best trained providers of psychotherapy, are now often relegated to the role of psychopharmacologist.

Now, many of us have split treatment teams who may or (usually) may not communicate with each other. We also see more therapy providers with only a year or two of post-grad training and an insubstantial depth of knowledge of mental illness and its treatment.

I am definitely posting this anonymously.