Monday, August 2, 2010

Whatever You Say, Doctor

"The brain that is innately fearful and angry has been selected for by evolution."

"My holy of holies is the human body, health, intelligence, talent, inspiration, love and absolute freedom--freedom from violence and falsehood, no matter how the last two manifest themselves."


Two years ago tomorrow appeared the first post of this peculiar A. P. blog; 361 posts later, it still seems as good a rationale as any. Happily, I have little more to say about the activity of blogging itself--it is an intellectual hobby, full stop.

I am forever casting about for serviceable metaphors for what it is that psychiatrists do. Well, psychiatrists are doctors--what do they do? Arguably they have a dual role, one scientific/technological and the other dramatic/emotional. Taking the latter first, the clinical encounter is a carefully scripted and staged act of caring which grounds the endeavor in the aim of healing rather than, say, exploitation. And yet it cannot be only drama; medicine functions legitimately only if there is real technical know-how beyond the layman's scope that doctors are privy to. The two act in concert to produce a clinical outcome.

It is the technical basis that Daniel Carlat has, to some scandal, questioned in his recent book Unhinged. If the science of medicine comprises diagnosis and treatment, both come under intense scrutiny in that volume. As the "debate" over DSM-V has grown into the kind of ad hominem free-for-all that would seem typical of the U. S. Congress, psychiatric diagnosis is considered by many to be as much hearsay as real science. And as alleged technical breakthroughs like vagus nerve stimulation and transcranial magnetic stimulation have turned out to be relative duds, some of psychiatry's most powerful somatic treatments remain at the level of mid-20th century technology. Carlat concludes that psychiatrists should no longer have to be physicians by training--the implication is that our technology, such as it is, does not justify it.

Undeterred, Henry Nasrallah, M.D. extols the "futurology of psychiatry," laying out the technical revolution that is just around the corner--we have been hearing that for 25 years, but this time it's apparently for real. I think of a sonorous voice from my childhood: "Gentlemen, we can rebuild him; we have the technology." But while other physicians are replacing knees and stenting coronary arteries, psychiatrists are...prescribing Valium. But Lee Majors looking mellow for an hour wouldn't have made for much of a show--even in the 1970's.

Granting the profession's shortcomings yet decrying the infighting and self-doubt, Ronald Pies advocates the "prescriptive bond" as the essence of the medical mission of psychiatry (one that, presumably, could not be performed by psychologists with prescribing privileges). Basically, he is writing about the drama of the white coat, that is, a seemingly trivial prescription has the history and authority of several millenia of medical tradition behind it. The caduceus. The Aura of the Doctor. And yet what good is that if the prescription is for sugar pills, or for something that may do more harm than good?

I think of the psychiatrist as a weird hybrid of the philosopher, the priest, the legislator, and the pharmacist. All of these must grapple with inherently ambiguous and contentious issues corresponding to crucial human needs. All must deal with the man on the street, whose opinions on these matters often exceed all in intensity if not in wisdom. But what ensues when the community loses faith in the shaman is...debates like these. Everyone feels he knows best about his body and what to put into it, about right and wrong, about God, about what policies to enact. And yet society sees fit to appoint "experts" for these roles not really befitting the title of "expert." Psychiatrists should not be glorified druggists, but those with enough perspective and wisdom to usefully frame human suffering. In that sense, pace the futurologists, there will be "nothing new under the sun."

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