Tuesday, June 28, 2011

Marcia Angell on the Corruption of American Psychiatry

Dr. Marcia Angell, perhaps the leading critic of the pharmaceutical industry, has written a powerful two-part critique of American psychiatry in the New York Review of Books.

The articles review three books that cast major doubt on the effectiveness of psychiatric medications and the hypothesis that disordered neurotransmitters cause psychiatric ailments. "The Emperor’s New Drugs: Exploding the Antidepressant Myth" by Irving Kirsch carefully analyzes research on antidepressant medications and concludes that virtually all of the impact comes from the placebo effect. "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America" by Robert Whitaker goes much further. Whitaker argues that the enormous increase in diagnosis of serious psychiatric illness is caused by the deleterious impact of medications. In Whitaker's view the problem isn't that medications don't help - it's that they exacerbate the conditions they're being used to treat!

The second article moves beyond medications to take on psychiatry itself, taking off from discussions of "Unhinged: The Trouble with Psychiatry — A Doctor’s Revelations About a Profession in Crisis" by Daniel Carlat and the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" - the world-famous "DSM."

When I did my psychiatry residency in the mid 1960s, medications were just coming into use. The predominant model was psychoanalytic - that mental disorders were caused by psychological conflicts ultimately derived from childhood experience. But fom the 1980s to the present, and especially since the introduction of Prozac in 1987, the paradigm has shifted to one that sees "chemical imbalances" as the cause of mental disorders. In the wise words of the late Dr. Leon Eisenberg, psychiatry went from being "brainless" (conflict was everything) to "mindless" (neurotransmitters are everything).

It's difficult, however, to find clinicians who've been deeply immersed in treating people with psychiatric ailments who don't believe in their hearts that nature and nurture are both involved. Quite apart from the question of whether the neurotransmitter hypothesis holds water, twin studies definitively show that inherited physical mechanisms contribute to the causation of mental disorders. And quite apart from whether psychoanalytic hypotheses about the causative role of childhood experience pan out, it's easy to observe that emotions and relationships influence the way symptoms are expressed and treatment proceeds.

What Dr. Angell's discussion brings out is the role of money. There are enormous profits to make from the sale of branded psychiatric drugs. Pharmaceutical companies have invested hundreds of millions in marketing. Angell details just how much leaders in my profession, alas, have earned from these marketing efforts, all-too-often at the cost of integrity, and how the psychiatric profession has reclaimed its role as a medical specialty by emphasizing brain over mind.

But the financially-driven corruption that has demonstrably occurred has ready receptor sites in our wish for simple explanations for why we are the way we are. Ambiguity and uncertainty invite anxiety. Certitude and closure reassure us. The combination of huge profits to be made, professional status to be enhanced, and what the poet Wallace Stevens called our "blessed rage for order" to be satisfied by decisive answers, have driven a powerful medicalization of the human psyche.

The pendulum had swung way too far in the psychoanalytic direction in the post World War II period. The necessary correction has swung way too far in the direction of "chemical imbalances" at present. I may be a cockeyed optimist, but I believe the books Dr. Angell reviews, and her own writing, are steering us towards a more complex, balanced view of human nature that respects both "brain" and "mind" without limiting our choice to oversimplified, rival pseudo-truths.

(I'm lucky to have Marcia Angell and Danny Carlat as colleagues and friends. I've written posts about Danny Carlat's work here and here. For Marcia Angell's New York Review articles see here and here.)

Sunday, June 26, 2011

Medicare Policy Needs Viagra

This post is about policy dysfunction, not erectile dysfunction.

Medicare reform is so complicated that it's easy to get lost in arcane minutia. But if we take a big picture view of the two main approaches to containing Medicare costs - the Sustainable Growth Rate (SGR) formula and Paul Ryan's voucher proposal - we see the cost problem for what it is - a symptom of policy dysfunction.

Both approaches embody a basic truth. The U.S. must get a grip on Medicare costs, and accomplishing that won't happen without setting limits. The SGR does that by pinning the tail on physician fees. If per capita Medicare costs rise too much, fees have to come down correspondingly. The Ryan plan pins the tail on Medicare recipients - if costs rise faster than the vouchers they receive, it's their problem to solve.

Both approaches deserve respect for not indulging in the delusion that "waste, fraud and abuse" will do the job. But both are profoundly wrong.

It's not primarily physicians' fees that drive Medicare costs. It's the services we physicians order. Lowering fees across the board puts prudent and profligate physicians in the same boat. The SGR is a make-believe "solution" that Congress repeals every time the formula prescribes a massive fee reduction.

The Ryan plan is similarly misguided. Medicare recipients aren't "consumers" of health care. When shopping for clothes we (I'm Medicare eligible) can choose between Walmart and Nieman Marcus. That's consumerism. But when cancer or heart disease occur we don't "shop" at a cancer or cardiac mall - we seek doctors and nurses we trust and put ourselves in their hands. The negative reaction to Ryan's proposal shows that U.S. society won't accept putting the risk of cost overruns onto Medicare recipients alone any more than Congress accepts putting that risk uniquely onto physicians.

The SGR and the Ryan plan both try to solve a cultural and ethical problem with a simple technical fix. In part because of our reluctance to accept the inevitability of aging, decline, and death, and in part because the medical-industrial complex has sold us on the idea that ever more medical intervention will make us younger, healthier and happier, we haven't yet accepted the fact that we ("we" = physicians, patients and the wider public) must collaboratively manage Medicare (and the entire health system) in a more parsimonious, evidence-based manner.

The fact that a wise and compassionate proposal to pay doctors for visits in which they discuss their patients' goals triggered an eruption about "death panels" demonstrates the depth of the cultural and ethical challenge. Sarah Palin and Newt Gingrich almost certainly knew they were lying in crying "death panel," but the fact that the public responded as strongly as it did shows that the very idea of discussing values about the goals of health care is seen, by many, as an assault on life itself.

The result of Medicare policy dysfunction is a program that too often harms seniors by overtreatment, creates ever-increasing out-of-pocket costs for Medicare recipients, and robs the next generation of opportunities they would otherwise have.

Medicare reforms that are guided by clinical evidence ethical reflection will better serve seniors and society. I continue to believe that advocacy for this approach from within the community of Medicare recipients will embolden political leaders to be more courageous. That kind of advocacy may serve as Viagra for policy dysfunction!

(See here and here for previous posts about Medicare advocacy.)

Friday, June 24, 2011

Dr. Marsha Linehan and the Sources of Creativity

An article in yesterday's New York Times told how Dr. Marsha Linehan, developer of Dialectical Behavioral Therapy (DBT), a profoundly innovative and uniquely effective approach to chronically suicidal patients, "came out" about her own history of chronic suicidality.

As a teen-ager in Tulsa, Oklahoma, Dr. Linehan, who is now 68, experienced increasing depression and self-injuring behaviors, leading to hospitalization at the Institute for Living in 1961, at age 17. She spent two years at the hospital, often cutting herself, burning herself, and banging her head against the wall when she was put into seclusion, which happened often. She was treated with psychotherapy, medication and two courses of electroconvulsive therapy. Nothing helped.

On discharge Dr. Linehan was older, but not yet healthier. She was, however, determined. Here's what she says in retrospect: "I was in hell. And I made a vow: when I get out, I’m going to come back and get others out of here." Where that spark of resilience came from is a mystery. But wherever it comes from, it's something we need to cultivate in ourselves, and, as physicians, in patients who suffer from chronic conditions, whether of mind or body.

Dr. Linehan returned to Tulsa, then went to Chicago to try to find her way. She experienced more depression and suicidality, and was hospitalized again. She frequently went to church to pray. One night in her mid 20s she had a remarkable experience: "I was kneeling in there, looking up at the cross, and the whole place became gold — and suddenly I felt something coming toward me. It was this shimmering experience, and I just ran back to my room and said, 'I love myself.' It was the first time I remember talking to myself in the first person. I felt transformed." She went back to college, studied psychology, got a PhD, and subsequently made history!

I've never met Dr. Linehan or trained in DBT, but I've referred many patients to DBT programs and saw it through their eyes. This post isn't the place to try to summarize the DBT method, but as I see it, the components of DBT were familiar and on hand - behavioral therapy, cognitive therapy, meditation, and psychoeducation. Dr. Linehan's unique contribution was to show how the pieces could be orchestrated together to achieve outcomes that none were able to accomplish alone.

My guess is that what enabled Dr. Linehan to do this - in addition to her brilliance and skill - was her empathic understanding for and deep commitment to the patient population she developed DBT to serve. She understood, from within, how pained and vulnerable these patients are, and, at the same time, how they need to be pushed. In other words, tough love. And perhaps from empathy for the many therapists who struggled, initially ineffectively, to help her, Dr. Linehan has focused as well on helping therapists develop the skills and supports they need to do the difficult clinical work.

In the "coming out" lecture she gave at the hospital she spent two years at as a teen-ager, Dr. Linehan said - "So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward." I found this very moving. She has already created an objective legacy by developing a clinical approach and subjecting it to rigorous evaluation, but she wanted to bring in the subjective component of her own life experience as well.

Outcome studies speak to evidence based medical practice. Her life story speaks more widely to hearts as well as minds.

In William Butler Yeats's late poem "The Circus Animal's Desertion" the poet starts by lamenting a period of emptiness, and then reviews the great poems he'd written. In the final stanza he asks where these creative achievements came from. Here's the question and his answer:
Those masterful images because complete
Grew in pure mind, but out of what began?
A mound of refuse or the sweepings of a street,
Old kettles, old bottles, and a broken can,
Old iron, old bones, old rags, that raving slut
Who keeps the till. Now that my ladder’s gone,
I must lie down where all the ladders start
In the foul rag and bone shop of the heart.
In her late teens and 20s Dr. Linehan was down and out, but she had the courage to "lie down where all the ladders start," with truly inspiring results!

Wednesday, June 22, 2011

The Right to Die from Mental Illness

Rachel Aviv has a superb article - "God Knows Where I Am: What should happen when patients reject their diagnosis?" - in the May 30 New Yorker.

The story takes off at a sprint. I dare the reader to put it down. Here's the first paragraph:
On October 5th, 2007, two days after being released from the New Hampshire Hospital in Concord, Linda Bishop discarded all her belongings except for mascara, tweezers, and a pen. For nearly a year she had complained about the restrictions of her psychiatric unit, but her only plan for her release was to remain invisible. She spent two nights in a field she called “Hoboville,” where homeless people slept, and then began wandering around Concord, avoiding the main streets. Wary of spies, she cut through the underbrush behind buildings, walked through gullies beside the roads, and, when she needed to rest, huddled in the bushes. Her life was saved along the way, she later wrote, by two warblers and an owl.
Linda, who was 51, had been a healthy, cheerful, intelligent child. She graduated from college, married in her late 20s, had a daughter, Caitlin, in 1985, but separated from her husband shortly after Caitlin's birth. A psychiatric illness, with paranoid delusions as the main feature, emerged gradually. In 1999 she and Caitlin fled from the persecution Linda feared from the "Chinese Mafia." At first Caitlin shared her mother's fear, but as she said in an interview with Rachel Aviv - "at some point, I just thought to myself, I know better than this." Later that year Linda abandoned Caitlin, explaining in a note that she was going to meet the governor.

For several years Linda was itinerant - often homeless, and occasionally staying with her sister Joan and her parents. After 9/11 Linda went to New York City for a time and patrolled the edge of ground zero, speaking to visitors about the importance of what had happened. In 2004 Caitlin moved back with her mother. She and Linda's sister Joan tried to get Linda to see a psychiatrist, but Linda felt she was perfectly healthy, only suffering from various forms of persecution.

In 2005 Linda was arrested after a motor vehicle accident. The authorities recognized that she was unwell and not competent to stand trial. In 2006 Linda was committed to New Hampshire Hospital. She refused medication and consistently rejected the suggestion that she had an illness. The hospital tried to make Linda's sister Joan her guardian, which would (with Joan's consent as guardian) have allowed them to give Linda antipsychotic medication, but Linda spoke rationally to the judge, who turned down the guardianship proposal.

Shortly thereafter the hospital, which felt hamstrung in their effort to treat Linda, discharged her. Four days after discharge Linda broke into an abandoned farmhouse. The diary she kept details her life from October 9, 2007 until a final note on January 13, 2008, shortly before her death from starvation.

In the house Linda lived on apples she collected. A cloud formation that looked like the number four convinced her that a delusional lover would come to rescue her on December 4. When this didn't happen, Linda gradually resigned herself to whatever God might have in store for her. The heartbreaking quotes from her diary show a sensitive, intelligent, thoroughly deluded person, struggling to deal with imaginary persecutors while starving to death.

Dealing with people like Linda Bishop, who are (a) profoundly ill but (b) do not see themselves as ill, (c) have their own version of reality, and (d) do not meet the typical criteria for involuntary detention of being an acute danger to themselves or others, is (e) the most difficult challenge for psychiatry and an unsolved ethical conundrum for society. Over the years I've spoken with innumerable concerned family members like Linda's daughter Caitlin and sister Joan. They've asked - "why can't you do something - isn't it obvious that X is deeply unwell?" I explained that X's condition was indeed obvious, but that we in the U.S. have chosen liberty over allowing imposition of control, however benevolent the intentions might be.

I see the standoff between liberty values and caretaking values as a dead heat. We've seen how totalitarian societies have abused the power to declare who is insane and in need of external control. In the 1975 film "One Flew Over the Cuckoo's Nest," Jack Nicholson embodies the spirit of rebellious liberty fighting (and losing to) Nurse Ratched, who embodies totalitarian domination. We in the U.S. place a supreme value on individual liberty. Years ago, in a visit with psychiatrists in China, I asked how they would deal with patients like Linda, who are seen as needing medication but refuse to take it. The psychiatrists did not understand the question. In China the local authorities would be told that Linda needed medication, and it would be given to her.

But stories like Linda Bishop's challenge another basic value - our sense of decency. If we saw a drowning child and had the ability to rescue it, it would be unthinkable to ignore the situation. Antipsychotic medication might not have "rescued" Linda, but not being able to try seems comparably unthinkable.

When two values - here, liberty and caring for others - deserve equal respect, it's a mistake to make one the winner, entitled to trump the other. That's what happened with Linda. The hospital felt constrained by privacy laws not to tell Caitlin and Joan that Linda was being discharged. Had I been consulting about Linda, I would have advised a discreet form of civil disobedience, as by saying - "we know how eager you are to leave the hospital, and the judge concluded you don't need a guardian, but we can't in good conscience let you leave without contact with your daughter and sister..." The situation would have been messy - Linda would have refused and insisted on leaving, to which the response would be "we want you to be be able to leave - you're an intelligent and capable person, but our conscience requires us to contact Caitlin and Joan as part of the leaving plan."

In a court trial, the outcome is binary - the defendant is either innocent or guilty. In a situation like Linda's, binary reasoning doesn't work. Linda was profoundly ill, but also impressively capable, which is what led the judge to turn down guardianship.

Death from her illness might have been inevitable, but in the final three months of her life, no one was able to try to rescue Linda from her delusions. The state motto in New Hampshire is "Live Free or Die." As applied to Linda it should be reworded - "Live Free and Die."

Monday, June 20, 2011

The Ethics of Practicing Medicine Part Time

Dr. Karen Sibert, an anesthesiologist in Los Angeles and a mother of four, created a major brouhaha with her tough op ed, in which she inveighed against part-timers in medicine, and told women contemplating medical practice that they "can't have it all." Here's the essence of Dr. Sibert's argument:
Medical education is supported by federal and state tax money both at the university level — student tuition doesn’t come close to covering the schools’ costs — and at the teaching hospitals where residents are trained. So if doctors aren’t making full use of their training, taxpayers are losing their investment. With a growing shortage of doctors in America, we can no longer afford to continue training doctors who don’t spend their careers in the full-time practice of medicine...

Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve...

Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work.
Dr. Sibert has taken a lot of abuse for the politically incorrect argument she makes. But she makes five incontestable points: (1) the public makes a substantial investment in medical education, and is entitled to a return on that investment in the form of medical service; (2) with the aging of the baby boom, we anticipate a shortage of physicians, especially in primary care; (3) women make an increasing portion of primary care; (4) women choose part time careers more often then men do; and, (5) medicine should be seen as a calling, not a job.

That said, I believe Dr. Sibert is wrong. She's identified real problems, but the remedy she offers - a moral requirement for full time practice - puts the solutions onto the backs of individual physicians. In a time of epidemic, exhaustive labor is expected and required. But as a solution to chronic system failures, it's the wrong way to go.

There's been lots of writing about how to fix primary care, with the Medical Home being the chief current model. Some physicians have turned to concierge practice, in which they practice full time (as Dr. Sibert calls for) but limit their panel to a small number of patients who can pay the enrollment fee (which undermines the aim of providing wider access).

Over the years I've observed what "part time" practice means to my primary care colleagues. By ordinary work standards, "part time" is VERY "full time." Being part of a team that provides 24/7 access in a coordinated manner can offer excellent service to patients and allows for a sustainable career. I've been a patient in this kind of practice for the past 25 years, so I know first hand that it can work.

(For a rich picture of Dr. Sibert's analysis and reactions to her proposals, here's a link to "On Point," the excellent NPR program.)

Thursday, June 16, 2011

Should a Convicted Rapist be Allowed to Practice Medicine?

In 2008, a military court convicted Dr. Mark Seldes, a Flight Surgeon serving in South Korea, for raping a civilian colleague. Dr. Seldes served three years in prison. When he emerged from incarceration he applied for reinstatement of his Florida license. Two weeks ago, the Florida Board of Medicine voted to allow Dr. Seldes to return to medical practice.

Here's the gist of the Health News Florida article about the board's decision:
Board members wrestled with the question of whether a rape conviction precludes a health professional from being able to practice with skill and safety, as Florida statutes require.

The rape victim was not a patient, and thus Seldes's attorney, Kenneth Haber, said the case had nothing to do with the practice of medicine. Haber also said that the rape offense was not violent and that Seldes had previous sexual contact with the victim before the rape. An account of the case in Stars and Stripes said the rape victim was asleep, under medication, at the time the assault occurred.

“He was a man who made a terrible mistake to engage in a relationship with an individual who was not his wife, and has destroyed his career and has certainly brought dire consequences on his marriage,” Haber said.

Seldes's wife sat next to him as the Board went back and forth over what conditions Seldes must meet in order to return to practice.

"Anytime the word rape is used, it rises to a level that gives me great concern, and I'm unwilling to say that this doctor should keep practicing in Florida," said Don Mullins, a consumer member of the board.

"I take a different view," Dr. Zach Zachariah shot back. "In my personal opinion, he has paid his penance."

The board ultimately agreed that Seldes could practice, as long as he works in a government facility while he is under supervision by PRN, a monitoring program for troubled physicians.

He must also complete at least 300 hours of community service within the next three years and give all patients a questionnaire that asks how they had been treated. Seldes requested not to be placed on official "probation," since that might prevent him from being able to get a job with the VA or some other agency, and the board agreed.
If the only question the board had to answer was whether Dr. Seldes would be able to "practice with skill and safety," they could examine him the way candidates for board certification are examined and see if he passed.

But that's not the criterion physician Zach Zachariah and consumer Don Mullins were using.

Zachariah believed that by serving his jail sentence, Seldes had "paid his penance." From the perspective of justice, Zachariah is right. We should help ex-convicts reenter society and become constructive citizens. Jesus's teaching - "let he who is without sin cast the first stone" - deserves universal respect.

Mullins didn't challenge the idea that Seldes had "paid his penance," but he believed it simply didn't make sense to give a rapist a medical license. He was also right.

From the perspective of ethics, predicting Dr. Seldes's ability to perform with "skill and safety" isn't the only question. The Hippocratic oath includes this sentence: "In purity and holiness I will guard my life and my art." Anyone who has committed rape has not guarded his life "in purity and holiness." This is the value Mullins guided himself by, and he was right to do so.

If medical practice were simply a form of body repair, analogous to plumbing, tiling and painting, the Hippocratic precept would not apply. But medical care is built on a relationship and stands and falls with trust. And it isn't just the individual physician who must be trusted - it's the profession itself.

The Florida Board of Medicine made a serious error when it concluded that rape doesn't disqualify a physician from being part of the medical community.

(For a post about the question of whether someone who had been convicted for murder should have been accepted into medical school, see here.)

Wednesday, June 8, 2011

Dialysis, Immigration, and U.S. Law

Since 2007, I've written a series of posts about safety net care issues - most notably, the problem of providing dialysis to undocumented persons.

This week's New England Journal of Medicine has an article from Baylor in Houston describing in some detail what happens when the undocumented are blocked from having scheduled dialysis and rely on emergency room treatment. It's a classical lose/lose situation. The patients suffer, the taxpayers pay more than would be required for "regular" treatment, and the physicians providing care are distressed by the substandard care they are forced to provide.

The authors are not naive. Here's how they pose the basic problem for clinical care, public policy and ethics:
This issue lies at the intersection of debates over the soaring cost of health care and the need for immigration reform. Do we have an ethical duty to provide the same standard of care for all sick patients within our borders? Or would mandating the provision of health care (and of maintenance-dialysis treatments) create an incentive for illegal immigration and worsen the current situation?
There's no easy answer. But we're better off for facing the problem squarely. Thanks to Drs. Rajeev Raghavan and Ricardo Nuila for helping us do that!

Tuesday, June 7, 2011

Anthony Weiner and Medical Ethics

Representative Anthony Weiner's tearful confession of having (a) sent lewd photos to women over the internet and then (b) lied recurrently after the first photo emerged, is the news of the day. (For overseas readers and the rare U.S. reader who do not follow U.S. gossip, here's a link to a New York Times article and editorial on the story.)

Weiner's ridiculous internet photos and messages were immature. He clearly violated the House ethics rule that representatives should conduct themselves “at all times in a manner that shall reflect creditably on the House.” And his baldface lies were reprehensible. He says, however, that he will not resign.

For two reasons, I hope Weiner can tough it out.

First, U.S. political process has a deeply hypocritical double standard. When Sarah Palin and Newt Gingrich lie about "death panels" in the health reform law, they cause profound public harm, but suffer no disgrace for the damage their mendacity causes. But when Elliot Spitzer consorts with a prostitute, and Anthony Weiner struts his physique on Twitter and Facebook, we are shocked, shocked, and pillory the perpetrators.

Spitzer and Weiner have simply made fools of themselves. Palin and Gingrich have caused widespread harm. If we want to get serious about destructive public conduct, let's address the what's truly harmful!

Second, Weiner's press conference confession is a refreshing antidote to the more characteristic political stance of evading responsibility and blaming others, as in Donald Rumsfeld's lame "stuff happens" response to the fiasco of looting we allowed to go on in Iraq. Weiner spells out the embarassing behavior he carried out on internet, and clearly acknowledges his lies.

In medicine we often care for people who have done wrong. In my psychiatry residency I was startled when one of our teachers (using an old fashioned word) asked a patient who had treated others very badly - "how does it feel to be a bum?" The question led to a serious exchange. The patient had indeed acted in a reprehensible manner. The challenge he faced was whether he could make amends, learn from his experience, and become a decent human being. That's what our teacher suggested we try to help him with. The phrase "tough love" wasn't in use then, but that's what he was recommending.

AA's 12 steps apply tough love to the effort to recover from alcoholism. The AA member is asked to make "a searching and fearless moral inventory" (step 4), to make "a list of all persons we had harmed, and became willing to make amends to them all" (step 8), and then to make "direct amends to such people wherever possible, except when to do so would injure them or others" (step 9).

If Weiner follows the wisdom of these steps he could improve our political dialogue by (a) continuing to take full responsibility for his actions and (b) working to promote higher standards of responsibility-taking in our culture. If he can do this he will be helping us improve our capacity to follow Gandhi's teaching, that we should hate the sin but love the sinner.

That's a capacity that health professionals must develop. Our patients need to know that we love them even as we confront the destructive behaviors they may manifest.