Tuesday, August 19, 2008

Rules for Psychiatrists

Not long ago the NYT reproduced some "rules for doctors" devised by Dr. Rob in his blog "Musings of a Distractible Mind." They are worth reading, and I pondered what some rules for psychiatrists might be; at the risk of being presumptuous, I offer some off-the-cuff thoughts:

1. Even for "med management," take the time (it needn't take long) to get a sense of the patient's unique life story--its stages, its successes and failures, its hopes and goals. Doing so will help him or her to feel more understood, and it should help make the interaction more interesting to you (if it doesn't, this may be a hint that you're in the wrong specialty). I think of this as a mini-biography, distinct from diagnostic formulation.

2. Given the still very ambiguous state of psychiatric diagnosis, spend less time on hair-splitting (bipolar II vs. bipolar NOS?) and more time on what has pragmatically been helpful for the patient over time.

3. Regarding patients who seem rather annoying or downright detestable, in addition to trying to figure out how much this implies about the patient as opposed to the psychiatrist, actively try to find something to like about the patient. If you can't find anything at all, someone else probably ought to be treating him or her.

4. Be alert and don't be naive, but also don't assume you are a mind-reader as regards suspicions of "med-seeking," functional complaints, or whatever. Studies suggest that no one group of people, including psychiatrists, is better at detecting lies than any other. Take the patient's reports at face value until you have uncontrovertible evidence not to.

5. Be on the lookout for "psychopharmacological Calvinism." Substance abuse is real, and it can of course be iatrogenic, but it is also the case that benzodiazepines and stimulants are uniquely helpful for substantial numbers of patients. "Med seeking" is actually a misnomer; if you knew a particular medication to be helpful for your symptoms, wouldn't you "seek" it as well?

6. If the patient can't afford the medication, you're wasting everyone's time.

7. Take side effects seriously. Use every opportunity you can to reduce numbers of medications and dosages--but some people really do seem to need five drugs.

8. Regarding psychiatry's ability to intervene significantly in disorders over time, the discipline is still where medicine and surgery were perhaps a century ago. While the patient must have hope, beware of overconfidence and excessive expectations (particularly since these days the patient often comes in with the latter already). Diagnosis, prognosis, management, solidarity, comfort: these should be possible, even when treatment and potential for recovery are quite limited.

Okay, soapbox complete. I'm open to subtractions and additions.

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