Posted by Dr. Vollmer on December 18, 2014
Why go to medical school, if all you want to do is talk to people? I used to ask myself that question, and at times, I still do. Yet, periodically I am enormously grateful for my medical education, as is my patients. LuAnne, seventy, comes to mind. Knowing her for many years, I saw a healthy and vibrant woman who ate well, slept well, and exercised regularly. She has friends, a husband, children and grandchildren. Her family of origin is mostly healthy. Her mother is going strong at 95. She has no known risk factors, with a normal blood pressure, normal glucose levels and her thyroid is intact. Suddenly, I get a call from her husband that she has undergone a procedure for a pulmonary embolus. She had trouble breathing, went to the Emergency Room, was admitted and then devices were put in her veins so that the clot did not stop her breathing. Sure, a non-medical person can read Dr. Google and educate himself on the issues, but for me, with my background, I instantly knew what she went through and I could instantly talk to her husband about the details of her medical care. Moreover, having gone through these emergencies with many patients, I could imagine the psychological trauma which might ensue. The new-found vulnerability. The tremendous fear for the future. The immediacy of the present. Cycling through medical emergencies has given me the perspective and the wisdom to know both from a technical point of view about what the next steps are going to be, but also from a psychological point of view about the game-changing experience this will be for LuAnne’s mental interior.
At first, LuAnne was in denial. “I am lucky” she tells me, meaning that she did not die. “Yep” I say, “I see that, in the midst of being unlucky,” I remind her, to suggest that she was struck by lightning, and as with all traumas, there is initial pull for gratitude, sometimes followed by a tremendous sense of victimhood. Over time, LuAnne’s anxiety has sky-rocketed. She is afraid to go far from home, as that is where she feels safe, even though her trauma began at home. The downstream experience of this medical emergency has yet to flow, but together we are prepared for a lot of discussions about what this all means for her. Understanding the pathophysiology helps us a lot. We can work with her known versus her feared limitations. I can comfortably communicate with her other physicians. I can help her understand her new medications and I can help her ask good questions when she sees the doctor. I can also point her towards mindfulness classes to help her cope with her fears. LuAnne appreciates my medical background, so maybe for that alone, it is good I went to medical school.
Posted by Dr. Vollmer on December 17, 2014
“Consider these numbers. While 37.6% of practicing physicians are age 55 or older, in psychiatry nearly 55% are in this age range, ranking as the second oldest group of physicians, surpassed only by preventive medicine. Part of this aging cohort effect is the low rate of medical school graduates choosing psychiatry. Only 4% of US medical school seniors (n = 698) applied for one of the 1097 post-graduate year one training positions in psychiatry2. As Dr. Roberts noted, it is troubling that the area of medicine addressing the leading source of medical disability is also facing a shortage of new talent. Indeed, over the past decade the number of psychiatry training programs has fallen (from 186 to 181) and the number of graduates has dropped from 1,142 in 2000 to 985 in 2008. In spite of the national shortage of psychiatrists, especially child psychiatrists, 16 residency training programs did not fill with either U.S. or foreign medical graduates in 20113.”
So, Shelly is right! Fewer medical students are going into psychiatry, creating a shortage of psychiatrists in this country. And yet, on the Westside of Los Angeles, there is no shortage. In addition to declining numbers, psychiatrists clump together in affluent areas, so they are not evenly distributed throughout the country. My “club” is smaller and older than it used to be for reasons that make me speculate about the changing nature of psychiatry. Seeing quick-fixes, not only does not hit the deeper issues of mental health, it also does not satisfy the deep craving, in many prospective psychiatrists, to drill down into the mental apparatus, curious about motivation, feelings, and thoughts.
Who are these four percent of medical students opting for a career as a psychiatrist? Do they, like the joke implies, hate blood? Or, are they the “humanities type,” who only went to medical school to please a parent, and once there, wanted to revert back to their primary interest in literature, which psychiatry most resembles. Or, are they are neuroscientists of the future, studying nematodes as a window into the human brain? Or, do they see a “lifestyle choice,” as a physician who by and large has little on-call duties? Or, maybe they have had their own psychic trauma, pushing them towards helping others, and maybe helping themselves at the same time? I wonder. I talk to prospective psychiatry residents on a weekly basis, as they tour around the country looking for their next step, their residency. I see the “best and the brightest,” meaning that the students I chat with have impressive accomplishments and strong verbal skills. They all seem like a wonderful addition to my field, but my field needs to utilize their intelligence to its maximal good for patient care, not minimize the need for intelligence, and propose superficial treatments for deep problems.
Posted by Dr. Vollmer on December 16, 2014
The old days, before my time, psychiatrists had few patients, relatively speaking, saw patients one or more times per week, and occasionally, very occasionally prescribed medication, which was usually a benzodiazepine for anxiety. These were the pre-Prozac days of psychiatry where most psychiatrists furthered their education with psychoanalytic training, and as such, were drawn to an in-depth exploration of the human psyche. 1988, Prozac appears on the scene, and suddenly psychiatrists are transformed into psychopharmacologists, seeing patients every fifteen to thirty minutes, maybe once a month, maybe once every three months.
Psychoanalytic training, meanwhile, was the purview of psychiatrists, until the 1980s when psychologists sued to be part of the club http://www.nytimes.com/1992/08/19/health/md-s-make-room-for-others-in-ranks-of-psychoanalysts.html. The perfect storm. Psychiatrists saw a niche in fast-paced, sporadic visits, pushing medication, and psychologists and masters level clinicians could now enter, what was seen as, the privileged class of psychoanalysts. The storm continues as Electronic Medical Records (EMR) enters the scene in the teens of our current 2000 decade. More clicks mean more “thought” and more “thought” means a better billing situation. With the caveat that EMR will help many millions of patients with their health care, specifically in terms of mental health, EMR furthers the distance between the doctor and the patient. Narrative history, the holy grail of psychoanalytic work, is minimized, and exchanged for checklists and binary questions. Discussions are relegated to “lower level professionals” as the jargon goes.
There are many perspectives here: the patient, the doctor and the population. The patient misses out on a clinician who both manages medication and does psychotherapy. The doctor misses out on having a family of patients who he deeply cares about. The population may be the rub, in that I can imagine that the good news with these changes is that more people will have access to a psychiatrist, however briefly, and maybe, just maybe, this will prove helpful to millions of sufferers. As I want to further this discussion, I recognize the potential benefit on population statistics, but what about the doctor who wants to really know his patients? Should he turn to another profession or, as some like to say, “go concierge”? What about the trainees caught in the transformation? Those, who entered the field before Prozac (myself, here), and yet graduated into a field post-Prozac. Or, those who entered medical training before EMR (2010 about), but graduate in a world of clicks and mouse. How are they supposed to cope? Adapt or die, or maybe rebel? For me, I am going to adapt, rebel and post.
Posted by Dr. Vollmer on December 15, 2014
Does “Community Psychiatry” mean low-income pill mills or can Psychiatrists have a larger impact on community mental health, without going through the avenue of public policy change? In other words, can a graduating psychiatrist, one with ten years of training, four of which are specialized in psychiatry, find an employment opportunity in which they are not asked to be a medication dispensing machine? Can they find a job where they are responsible for program development or psychoeducation, where they educate large numbers of people about positive mental health, or how to live a happier life?
My impression is that to be employed as a psychiatrist means you are forced into a narrow role of prescription writing, without the benefit of deep relationships with patients, or the psychological benefit of implementing system change. What if graduating medical students do not understand this horizon? What if they think they are going into a world in which mental health can be promoted by psychiatrists, not just by teaching about medication, but by promoting healthy living and healthy lifestyles, for the body and the mind? What if they come to learn that psychoeducation is mostly done by professionals who do not have medical licenses, and with the shortage of providers, the medical license is seen to be optimally used only for medication management. All other activities, such as groups, wellness activities, vocational coaching, are done by those with Master’s level degrees. I can imagine the disappointment new graduates might feel as they discover that “Community Psychiatry” does not mean helping the community, but rather it means medicating the community. which may help some, but not in a more global way which is more fulfilling, and a greater justification for years and years of training.
Psychiatry, as I frequently say, needs to re-gain its foothold into the “whole person” and not just the “medication piece.” It is possible that medical students are not exposed to this limitation until late in their training. I think we need to tell them, so the field can re-boot. Community Psychiatry should mean the psychiatrist is helping the community function in a way that decreases the mental health burden on the individual and his family. This can only happen though if psychiatrists are paid to run and design programs, not just write prescriptions. This is my rant. I am not letting it go.
Posted by Dr. Vollmer on December 15, 2014
I am trying to persuade you…
Posted by Dr. Vollmer on December 11, 2014
“Loyola Marymount University’s Marital and Family Therapy Department offers students an innovative program that leads to a Master of Arts in Marital and Family Therapy with specialized training in Clinical Art Therapy.
Students are trained to integrate their visual art backgrounds with psychotherapeutic skills as they work with a variety of clients, including children, adolescents, adults and families. The training fully prepares students to become practicing marital and family therapists committed to utilizing art processes in their work as psychotherapists.”
“Do psychotropics change the art?” I ask my students as I teach these LMU students about psychopharmacology. “What about the clock test for dementia?” I ask, wondering if they can decipher how one’s brain deteriorates as evidenced by the deterioration in their clock drawing. http://www.ncbi.nlm.nih.gov/pubmed/10861923 . It is my privilege to ask these questions of eager students, artists, who want to coach artistic output in their patients in order to ameliorate the suffering they see in kids, adolescents and adults, many of whom are underprivileged and have little access to mental health interventions. The students, endlessly interesting themselves, seek the inner world of their patients through an artistic expression, allowing a springboard to deeper exploration and mental healing. As a psychoanalyst I would say that these therapists are bypassing the conscious, heading towards unconscious thought processes, through artistic expression.
Some of these patients are on medication, or need to be on medication, so these students need to understand who to refer for psychotropic medication, and they need to know how to communicate with the prescribing physician, about the impact of the medication, on the art, on the therapy, and on the mental apparatus of the patient. That is where I enter into the curriculum. It is my job to help them understand the armamentarium of drugs that we use to help people with their mental distress. Moreover, it is my job to give them confidence to call that doctor and to weigh in adamantly about their impressions of the treatment. Empowering my students to communicate with physicians is a distinct challenge, because medical care, as it is in this country, is a hierarchy, and as such, these student therapists often worry about being humiliated. “You know this patient better than anyone,” I say, knowing the hours and hours they spend with their clients, working on their art, talking to them about themselves, their families, their traumatic experiences, and their hopes for the future. “I am a psychiatrist, and I am busy, and I may be short with you, if you call me, but it is helpful if you, in a nice way, can get to the point quickly and assertively.” I say, trying to break down this invisible wall between the MD and the therapist. “Drugs can change the art, and art can change how the drugs are perceived. You are on those front lines. Don’t forget that.” I say, thrilled to be a part of their education.
Posted by Dr. Vollmer on December 10, 2014
Blame the parents, a simplistic way to think about adult psychopathology. On the one hand, we can all agree that childhood sets the stage for adulthood in which relationships are formed, leading to happiness and fulfillment, and/or pain and suffering. That relationships in childhood, that is, those with the caretakers, create a paradigm for how relationships should be, create an imprint which can be growth-promoting and/or psychologically destructive is the premise behind the “blame the parents” approach. Some psychoanalysts reframe the “blame the parents” with the language of “psychic trauma”. Clearly, on a broader level, there are multiple layers of psychic functioning and “psychic trauma” only affects one layer. Siphoning out this layer to teach about “mental schemas” does not mean that there are not biological factors which impact resilience such as IQ and temperament.
Brett, fifty-two, comes to mind. He is lonely, unemployed and burdened by the care of his disabled brother. He states that he cannot form relationships with women because he is “sure” they are going to hurt him, so what is the point? Where does this certainty come from? I wonder. It stands to reason that Brett’s saying “sure” means that historically speaking, women have hurt him terribly and he, in his mind, was not able to mend that wound. Does this mean that his mother did not respond to him, in the way that he needed to be responded to, and hence now, in middle age he is lonely and depressed? Maybe, but that is not the whole story. It does not mean that Brett’s mother is “bad” or unempathic, but it could mean that the fit between mother and child was poor, meaning that Brett’s mother did not tune into his needs in a “good enough” way, as per Winnicott. Maybe, at a tender age, Brett had a relationship with a woman that “traumatized him for life,” as some people might say, but in fact, if every relationship brings up prior relationships, then we can assume that “traumatized for life” implies a lack of resiliency, making me as a therapist, think about his early relationships.
So, can we “blame the parents” and forgive them at the same time? This is the option that each patient has, that understanding one’s needs, and perhaps the lack of attention to those needs, does not necessarily make the patient angry at his caretaker, but often, the patient becomes compassionate for how hard it is to take care of a child, who has needs that are demanding a deep and wide skill set of compassion, empathy and patience. In essence, psychic trauma is inevitable in childhood. The issue is how that trauma becomes integrated into the mental state of the adult. Does the trauma inhibit the ability to work and love, as Freud would ask, or does the trauma deepen one’s commitment to work and love in a meaningful way?
Posted by Dr. Vollmer on December 8, 2014
Doctor, you are awfully defensive!
Posted by Dr. Vollmer on December 5, 2014
“Memory is so complicated,” a psychiatrist-in-training, said to me, in talking about the Ferguson case. “Oh yes, doesn’t that explain why cookbook therapies, which only address cognition and not the emotional component to symptom formation are of limited utility?” I say, to a student who looks back at me with shock and thoughtfulness. If we agree that memory is complicated by predispositions, the need to fill in gaps, and social pressures, then can’t we also agree that symptoms such as anxiety and depression are also complete with backstories and family context which make understanding the complexity of the symptom more important than proposing a quick treatment? This is my thesis and this is why I continue to blog. The contradiction between marveling at the many aspects of memory and, at the same time, proposing that deeply held symptoms are simply treated in 12 sessions seems outrageous to me. Having said that if 12 sessions brings relief, I have no issue, but what happens when the patient does not respond to 12 sessions? Do we say they are untreatable? Do we refer them to a higher level of care, such as medication management or hospitalization? No, I say. We should understand that for some people, given the complexity of their situation, more therapy is needed, not necessarily with medication, and not necessarily requiring hospitalization or intensive outpatient programs. Complex brains require complex treatment. At the very least, we should all agree to that.