Impossible Profession

I mean impossible in the good sense, of course. Time is limited tonight, so I enthusiastically recommend a fine brief commentary I came across today on the strange, agnostic difficulty of psychiatry. Written by Rachel Dew, M.D. in the American Journal of Psychiatry, it is by a psychiatrist and intended primarily for other psychiatrists, and it conveys nicely the mind-boggling nature of the undertaking.

The piece speaks for itself, but no blogger can resist a few comments. When Dr. Dew claims psychiatry as "the hardest specialty," I assume she means "hard" in a moral and not a simplistically cognitive way. For the very reason that so much ambiguity does still prevail in psychiatry, there is not nearly as much of the kind of mental calisthenics--the grand connect-the-dots-game involving obscure diseases, symptoms, and physical and lab findings--pertaining to much of the rest of medicine.

If much of medicine is, cognitively and sometimes physically, a kind of triathlon, perhaps with elaborate obstacle courses thrown in, then psychiatry might be more akin to...meditation. Obviously aspiring to mindfulness, psychiatry at its best tries to slow things down, to notice things otherwise unnoticed, to accept an emptiness at the heart of things without giving in to despair. It attends to suffering, knowing that pain often cannot be eliminated but that pain need not be shrouded in affliction.

Psychiatry is not just that, obviously. There are a number of things we do know, even if only in a pragmatic and not a metaphysical or in a purely scientific way. No triathlon perhaps, but one can meditate while walking.

In addition to the inherent difficulty here, there is the added complication that, these days especially, many patients show up to psychiatry looking for a triathlon (to watch, that is). Increasingly, practicing psychiatry is like offering a meditation class in which people keep showing up, asking "Where does the race start?" Well, I don't know, but tell me what you're looking for.

How Much is a Psychiatrist Worth?

As I've thought about some of psychiatry's recent pharmaceutical research scandals, the broader role of money in medicine has naturally come to mind. After all, there is no way to be totally free of conflicts of interest. Any physician in private practice, or any physician who gets credit of any kind for sustaining a volume of clinical work (such as in academia, where physicians often are salaried but must accrue billings to justify that salary from year to year) has an interest in providing services that may conflict with doing what is medically and ethically justified.

The old joke goes that if you walk into a barbershop and ask if you need a haircut, chances are the answer is going to be yes. But we hold physicians to a higher standard than barbers; even when a surgeon or a psychotherapist could use the business, if a procedure is not indicated in a certain case they are obviously expected to honestly say so, despite their own pecuniary interest. Needless to say it doesn't always play out that way.

According to a list I randomly looked up, the average psychiatrist income in this country is $134,000 (I don't know how specifically reliable that particular survey is, but all the figures are on par with other surveys I have seen various places in the past). In terms of all specialties psychiatry is at the low end, but it is comparable with the other office-based, non-procedural specialties. As this list notes, many physicians put in well more than 40 hours per week, including night and weekend hours.

Perhaps it is puritanical of me, but even apart from the general corruption of psychiatry's already fragile knowledge base that I've already written about, I have also been bothered by the sheer tackiness of psychiatrists augmenting their income in a big way essentially by auctioning off their degree-related expertise to the highest bidder (that is, by giving highly lucrative "educational" talks or obtaining drug company research funding that is more about funding than about research).

Obviously physicians should be and will be paid well in the overall scheme of things. It is a demanding and stressful profession requiring prolonged (7-12 years depending on specialty, usually 8 or 9 for psychiatry) education and training beyond an undergraduate degree. And nowadays medical students often graduate with over $100,000 in student loan debt.

A medical degree is earned through a great deal of hard work, but it is also a privilege granted by society for the general health and welfare, not for the enrichment of individuals. Physicians obviously live comfortably, but the great majority of them are not CEO's-with-three-homes-and-a-yacht kind of rich (maybe a nice home, a superfluity of books, a menagerie of high-maintenance pets, and a canoe).

Some people seem to think it's obscene for a baseball player or a rock star to make many millions of dollars, but in a capitalist society one can hardly object. If one is providing entertainment or any other discretionary product, then one deserves whatever income one can pry out of the market. But short of high-end psychoanalysis and cosmetic procedures, health care is not a discretionary product, unless life itself is discretionary.

Some of the high-profile academic psychiatrists who have generated the recent opprobrium (detailed in the link in my post two days ago) earned seven figures over several years from drug companies, above and beyond their already hefty clinical and academic reimbursements. In a field that, due to the potentially devastating effects of mental illness, frequently serves the most socioeconomically dispossessed members of society, that strikes me as being unseemly. For individuals making six figures to have fancy meals bought for them by drug companies soliciting their services seems to me to be in equally poor taste.

Any opinions out there--do psychiatrists and other physicians make too much money, too little, or just right?

Handicapping

For well you know that it's a fool who plays it cool

By making his world a little colder.

The Beatles

Polonius: My lord, I will use them according to their desert.

Hamlet: God's bodkin man, much better. Use every man after his desert, and who shall scape whipping?

1. Nassir Ghaemi, M.D. has another thoughtful post on his Psychology Today blog about psychiatry's financial and pharmaceutical imbroglio. As he argues, it is impossible to expel drug companies from psychiatric research and education altogether; too much of value would be lost. Rather, analogous to Wall Street overreach in general, what is needed is much stricter regulation, oversight, and cultural change.

He contends that individual psychiatrists and patients ought to reform themselves by resorting to drugs only for clear-cut "diseases" and not for vague symptom management. It sounds great; the problem is the persistent ambiguity of psychiatric diagnosis. So long as mental disorders are not natural kinds but have elastic boundaries shading into normality, the inclination to use more medication rather than less will persist. Psychiatry has always had an identity problem inasmuch as there is no lasting social consensus about what psychiatrists should be doing. This is due to lingering scientific and philosophical confusion that doesn't appear likely to be settled to general satisfaction anytime soon.

2. The New York Times has an intriguing article today about self-handicapping, or engaging in self-defeating behavior in the interest of maintaining self-esteem. This is obviously usually unconsciously motivated; an academic example would be skipping class or failing to study for an exam so that, if or when failure occurs, one can explicitly or implicitly have the consolation, "It's not as if I really tried."

This is a fascinating process because it rings so true and yet feels so, well, self-defeating. As the article notes, this kind of behavior "works" well in the short term (with respect to maintaining self-image) but not so much in the long term, when routine practitioners come to be viewed as whiners and slackers. And yet we seem to know people who undertake this strategy not merely as regards specific tasks, but also with major life projects. If one sabotages significant relationships or careers, one escapes ever "really" being tested.

If, as seems unlikely, one wins out despite apparent attempts at self-defeat, then things look great. Actually, one of the evolutionary hypotheses for substance abuse frames such behavior as an attempt to demonstrate one's fitness despite evident impairment. Just as a peacock sends the message, "Look how tough I must be if I can pour this much energy into a glorious tail," risky intoxication sends the message, "Look how tough I must be if I can get things done despite being falling down drunk half the time." Both phenomena are extreme versions of showing off, in unconscious and evolutionary senses. Like much of evolutionary psychology, this substance abuse hypothesis may not be true, but it's interesting nonetheless.

How would one go about managing self-defeating behavior?. Life entails risk and the possibility of failure; there is no getting around that. But the self-defeatist arguably does what he does either because his self-esteem is too fragile for either modest failures or because, due to narcissistic inclinations, he consistently attempts tasks beyond his ability. The process would involve fortification of self-esteem with supported and gradual exposure to appropriate risk. Then--carpe diem. As always, this is a "day" easier talked about than "seized."

Psychiatry and its Problems

Prince: I see a good amendment of life in thee, from praying to purse-taking.

Falstaff: Why Hal, 'tis my vocation. 'Tis no sin for a man to labour in his vocation.

A couple years ago I saw a great New Yorker cartoon featuring a deeply dorky-looking fellow wearing a t-shirt emblazoned with the motto "I love my problems." That may have nothing to do with this post--I just thought I'd mention it.

No, this post is about the strange relations between psychiatry and the world's oldest profession. Forgive me, I repeat myself. Or so one might think from the most concise yet complete review I have yet found of psychiatry's troubling ties to the pharmaceutical industry, by Marcia Angell (former editor of the New England Journal of Medicine) in the current New York Review of Books.

As her article notes, the ties between big pharma and medicine are now deep, far deeper than patients suspect (reaching depths compared to which the recent decision to stop giving pens and other trinkets to doctors is nothing short of laughable). To my mind, the most profound issue is the corrupting bias of published research involving effectiveness of medication, as this endangers the knowledge base resorted to even by physicians who willfully bypass all other interactions with drug companies. In that sense there is no escaping the distortion.

The great hazard here for physicians is nihilism regarding published research, mirroring the nihilism one sees in others regarding the general news media. If reporting is demonstrably biased in significant numbers of cases, how can one believe anything? Barack Obama may well be indistinguishable from Osama bin Laden, and all antidepressants may be no better than placebo--who is one to believe in this crazy world? It takes care and attention to separate the trash from what is real--care and attention not likely to be in evidence at a boozy pharma-funded Continuing Medical Education program. I'll pay for my own wine, thank you.

Classical Tragedy

My smile is stuck,

I can't go back t'yer Frownland.

Captain Beefheart and his Magic Band

"I have come," he said. "But I do not choose now to do what I came to do. I will not do this deed. The Ring is mine!"

Frodo

I read an interesting profile by Jason Zengerle in The New Republic today of Brent Cambron, an anesthesiologist who developed an opioid addiction to which he eventually succumbed. As the article describes, anesthesiology is a high-flying, ambitious specialty, but one whose practitioners develop substance abuse disorders at an alarming rate. Cambron's was a sad story.

The presumed explanation is access--anesthesiologists are the only physicians who regularly and literally handle controlled substances (as opposed to merely prescribing them, at a remove). However, apparently pharmacists, who have similar access, do not seem to be so high-risk. Why? The article proposes two possibilities. One, admittedly far-fetched, is that small but significant quantities of opioid medications may accumulate in vaporized form around anesthetized patients, enough so that the anesthesiologists hovering over them could experience enough exposure and even tolerance to develop subtle craving for the drugs.

Zengerle suggests that the more likely reason may be that anesthesiology attracts candidates that are particularly high-strung "control freaks" who gravitate toward self-medication. However, the pharmacists whom I have known have been similarly enamored of meticulous control, perhaps even more so--why would it be that they would be less likely to "self-medicate?"

The question raises the perennial issue of what motivates drug use--pleasure or need, and is there ultimately a difference? The article suggested Cambron's belief, like that of many drug users, that he needed substances to feel "normal." However, an alternative explanation is that anesthesiology attracts candidates who are highly inclined toward both novelty-seeking and mastery. Drug experimentation, like the professional drug administration of anesthesiology, satisfies both. In other words, drugs are exciting and pleasurable, and some are less able than others to resist the lure. To be sure, once an addiction develops, volition decreases greatly, but there are always initial crucial choices.

The article points out that Cambron's drug use, in the beginning, was far from impulsive. Indeed, it seemed to have been deliberate and carefully weighed, a virtually pure act of hubris--he was highly intelligent and capable, and sincerely believed that he could master the kinds of substances that had conquered countless others. He fell, like Icarus and like Macbeth. I don't mean to speak ill of the dead--Cambron was a highly talented individual with many virtues.

There was some question as to whether his death via overdose was recreational or intentional--but it involved vecuronium, which, as Zengerle pointed out, is a highly lethal, non-narcotic drug that no anesthesiologist would confuse with an opioid. High-potency opioids, like automobiles, make available more power than we are, evolutionarily, able to wield without significant risk. We must continue to optimize protections and limits, but it seems there will always be casualties.

Now That's Mania

For Mercy has a human heart

Pity, a human face:

And Love, the human form divine,

And Peace, the human dress.

William Blake

One advantage of workng inpatient psychiatry is that diagnoses present as closer to black or white, rather than as the infinite shades of gray encountered in outpatient practice. On an acute ward, to put it bluntly, the schizophrenics may be actively hallucinating and paranoid, the borderlines are flaming, and the melacholics are mired in despondency.

A floridly manic patient, pacing the halls 22 hours per day and talking non-stop, definitely shapes the ward milieu for better or worse, depending on whether the mania is irritable or euphoric. Like anyone who ever did much inpatient work, I recall any number of mornings when, even before turning my key in the lock, I saw or heard some ruckus through the unit door and instantly thought, "A manic came in last night." Mania is a force of nature; like a tornado, it is, when fully formed, unmistakeable.

But the last few years I have chosen outpatient settings, where diagnosis is endlessly slippery. Much has been written and protested recently about the alleged over-diagnosis of bipolar disorder, particularly in children, and presumably fueled at least in part by pharmaceutical advertising. I treat the 18 and over crowd only, but in coming years more and more young adults will obviously start coming in, trailing their dubious diagnoses behind them.

There are a few major clinical matters any psychiatrist wants not to screw up. Overlooking or minimizing suicidality is obviously a big one; missing bipolar disorder is another. The problem is that outpatients rarely present with unambiguous past diagnoses or crystal clear symptom reports. A chief obstacle is that several of the possible symptoms of mania are so common as to be, in psychiatry, what headache or heartburn is to primary care.

Consider the diagnostic criteria for bipolar disorder. Generally speaking, I don't know that I have ever evaluated someone with mood symptoms who, when asked, did not confirm "mood swings." Even those who clearly are recurrently depressed and not bipolar will report a subjective sense of mood instability (no one is equally depressed all the time).

So what constitutes a potentially manic mood swing? Unfortunately three of the possible symptoms--difficulty falling asleep, a sense of "racing thoughts," and distractibility (which could be experienced as poor concentration)--are ubiquitous in psychiatric work and can characterize depressive and anxious disorders as much as mania.

A hilarious aspect of a manic diagnosis is the duration component, described as more than a week or any duration if hospitalization is necessary. Herein lies the infamous circularity of psychiatric diagnosis, for in this instance a clinical treatment decision--to hospitalize someone--itself shapes the diagnosis.

Imagine that two people, each with a four-day history of obvious manic symptoms, come to the emergency room. They are clearly impaired and urgently in need of treatment, but they are not imminently dangerous to anyone and therefore do not warrant involuntary commitment. Patient A consents to voluntary admission and therefore "wins" the manic diagnosis; patient B refuses admssion and cannot technically be considered manic until three more days pass. In this case patient A, in granting, "Okay, I need to be in the hospital," is essentially and officially diagnosing himself with a manic episode. He needs to be in the hospital because he has a manic episode, but we know for sure that he has a manic episode only because he needs to be in the hospital.

What originally prompted this post was a fellow I saw a while back who, surprisingly and in a euthymic state, described what I consider a classic "outpatient mania." He was fiftyish and had no psychiatric history apart from a depressive episode of some kind a decade ago, in the context of specific marital and job issues. He had been hospitalized then but had pursued no outpatient treatment in the ensuing years. He functioned well and was asymptomatic.

In September he had the relatively acute onset of severe insomnia, but insomnia of a peculiar kind. He claims that over a ten day period he may have slept only four hours in all. Tired of lying in bed in vain, he got in the habit of getting up and working around the house all night.

He began to feel very productive at work, outperforming men who were decades younger. People started mentioning that he seemed to be talking a lot and was not himself. Finally he lost his job because his boss observed that he was plainly high on something, although crucially this patient had no substance abuse history (the latter frequently both complicates undisputed cases of bipolar disorder and muddies the diagnosis at other times).

This went on for three months, until at a certain point he developed the notion that the world was coming to an end in some Rapture-like event. He was variously wandering in roadways and speeding around in his car until he came to the attention of the police somehow, after which he was jailed briefly because of old issues pertaining to a failure to appear in court. By the time he saw me he was back to himself.

Obviously bipolar disorder is an immensely complex issue and beyond the scope of a post, a blog, or a book. It increasingly seems that like the vast and amorphous phenomenon of depression, bipolar disorder probably comprises multiple distinct disorders that we cannot yet sufficiently discriminate, and these are mediated by both biological and cultural pathways that are very difficult to fathom. It will be interesting to see how bipolar disorder looks in DSM-V.

There are a few moves in psychiatry that at times are absolutely essential, and yet that should be undertaken only when one is unequivocally sure. I would include among these: hospitalizing someone, particularly if involuntarily; recommending ECT; diagnosing schizophrenia; and diagnosing borderline personality disorder. Diagnosing bipolar disorder belongs with these as well.

For the many ambiguous cases one doesn't know after the first appointment, or after the third or perhaps even the fifth. One gets to know the person, and tries a few things to see what happens. At some point a provisional diagnosis inevitably, if implicitly, takes shape. Let's see, my motto should be: pragmatism, empiricism, contingency...

January Juxtapositions

Hamlet: The air bites shrewdly; it is very cold.

Horatio: It is a nipping and an eager air.

The blogging muse is still on the road, away from the work that imposes at least some form and discipline upon rumination. Actually, the blogger really doesn't have access to the literary muse, but rather perhaps to the muse's somewhat shady, disreputable nephew. This nephew wastes time, doesn't shave regularly, may have had some minor run-ins with the law. It is doubtful that he is going to amount to much; however, it's also unlikely that he will cause serious trouble. The grand literary muse herself, to paraphrase Nietzsche, may have had an untimely cultural demise a long time ago, at our hands.

If one keeps a journal, there is some pressure to write consistently. If one looks back and finds weeks without entries, there is the question Wasn't I alive during that time? Perhaps only externally so. Or perhaps I was intensely alive, so much so that I felt no need to write. Is writing a vital form of life itself, or a compensation for the lack thereof? The ancient aesthetic conundrum, never to be cracked.

Doesn't every month of the year have its own qualia, to borrow the highfalutin neurophilosophical term for the (arguably) ineffable subjectivity of experience? Or maybe I get the idea from Maurice Sendak's sublime calendar book Chicken Soup with Rice, one of my early childhood favorites.

Just to mention the northern hemisphere winter months, January unsurprisingly appears in the mind as a barren field, frosted, with a few trees austerely left at the edges. It has its own stark beauty, but only in the way that emptiness itself does: a very Buddhist month to my mind. February, owing to its end-rhyme with January and its relative brevity, is a tacky little annex added onto the first month, sort of like a trailer haplessly abutting an overcrowded elementary school. March is limbo, a kind of demilitarized zone scoured by blustery winds; nothing much happens there but the hope of something better. But lo and behold every year something better does come.

In a week devoted to travel and family my very modest reading has consisted mainly of James Wood's brief How Fiction Works. I enjoy his writing, which in its limpid efficiency reminds me of Edmund Wilson's: reading it is like coasting downstream in a canoe--one feels the power carrying one and need only to steer now and then.

For the bookworm the volume is a compressed reminder of things long known, but a few points struck me especially. Wood is impatient with the impatience some have for the artifice of literature, in a couple of respects. Since Flaubert writers have aspired to impersonality, to the removal of every possible trace of the author in the work. Wood reminds us that while this may be a helpful practice, it is never possible to do absolutely. Literature is always the refraction of reality through a specific and necessarily idiosyncratic eye. Just as the psychotherapist, while she may try to eliminate individual details from the office, nonetheless has her character reflected back for all to see in every choice of furniture, item, and paint, so the author's identity fairly screams, no matter in what subtly mutated form, from the text.

Wood is also impatient with the impatience that some have with realism in literary form. He sees the fads of postmodernism and other experimental adventures as being impatience with literature itself, as being an attempt to make writing more than it can or should be. Writing is not life, but a combined reflection and refraction of life. All writers aspire to realism; the problem is deciding what realism is.

Wood points out that so-called "flat" characters, those defined by just one or two characteristics (the famous example he uses is Dickens's Mrs. Micawber), can be every bit as valuable as essential as "round" characters that enjoy depth and multi-dimensionality (think of Tolstoy's Pierre). After all, as Wood argues, this is so because we meet real people who are "flat" all the time, who, free of ambivalence and ambiguity, are consumed by one or two primary passions in life. Being flat has its enviable advantages.

Neither January nor 2008 is all bad. There is, after all, January 20 to look forward to. Cynicism too shall pass.