Why Be A Psychiatrist?

Who becomes a psychiatrist? Many would say those that can’t stand the site of blood. I always took issue with that half-joke, half-truth comment, because for me, I really really like blood. I like organs. I liked my surgery rotations. I liked drawing blood. I became a psychiatrist because I never wanted to get bored. At the time, all other specialties were following algorithms, meaning that once these were mastered, there seemed to be little challenge. With psychiatry, talking to people, is always new and different. I like that. I wonder if that same principle applies to my younger colleagues. Were they drawn to listen to stories, or were they drawn to the fun of psychopharmacology? Psychopharmacology is fun, in that people get better from medication and this, of course, is very satisfying. Still, I wonder how young people decide their specialty these days. A psychiatry rotation in medical school deals with chronic mental illness. It would be hard to extrapolate from that, my daily life as a private practice psychiatrist. I am sure there are the practical considerations of paying back loans, controlling one’s hours, and the amount of overnight call. I think I should ask my students. Stay tuned.

Anniversary Reaction

A reader writes:” My brother and I were like twins growing up: 14 months apart and inseparable. When I was 25 and he was 26, he died of cancer. At the time, I didn’t grieve hardly at all, as I was raised not to talk about intense feelings much. So…I put a lot of these painful feelings away, and didn’t realize until this past year, when I was going through other stresses, that there was even something called delayed grief. The pain has been overwhelming. I am going through counseling with a really good therapist who is helping, but I am dreading my brother’s death anniversary date that is coming up next month. It is always an extremely difficult month for me. I am especially dreading it this year. I had been doing better lately but the past two days I started crying just thinking about my brother. I miss him so much. He was my best friend in the world and no one can ever replace him. On top of everything else, I have guilt feelings that I didn’t do enough to help him get diagnosed earlier. It has been so many years since he died but it feels like just yesterday.”

 

From…http://www.griefhealingblog.com/2012/05/coping-with-anniversary-reactions-in.html

 

In cruising the internet, I found this tale, helping me pinpoint my curiosity about this idea of the “anniversary reaction.” There is something, for some folks, like this reader above, that I will call Zach, in which the anniversary becomes the focal point for grief. It is almost as if Zach’s mind has given him permission to grieve around the anniversary time, whereas at other times, he would feel foolish or “too sensitive”. On the other hand, maybe the anniversary, the time of year, the length of the days, the holidays, bring back a flood of memories which bubble up causing this psychological pain. Either way, and of course, it could be both, Zach expresses this sentiment that “the pain has been overwhelming,” leaving us, the reader, to wonder what he means by that. He is “dreading” his brother’s death anniversary, but what is he afraid of? One imagines that he is afraid of the despair, the heart-wrenching feeling, of helplessness that he cannot bring his brother back. What is “overwhelming,” I think, means that he is fearful that his ego will be taxed beyond it’s typical coping skills, leaving him with no means to soothe himself. In the event that he cannot soothe himself, he fears he will be left feeling agitated and alone, perhaps with a temptation towards conscious or unconscious self-destructive behaviors,  in order to help him escape from his psychological state. All egos, no matter how strong, or well-developed, can face circumstances which exceed it’s ability to find healthy coping skills. On this level, Zach’s fears are understandable. His “good therapist” can help him understand his fears, but by no means, can this “good therapist” protect him from his anticipated need to escape his psychological state. On the other hand, maybe understanding that the ego might, in fact, be stressed in ways that it has never been stressed before, might help Zach be more thoughtful about developing new, and deeper ways of managing, what at this time, seems to be an unbearable reality. Maybe that is what I do.

What Do Psychiatrists Do?

Private practice, county jobs, VA jobs, academic jobs, are all examples of how psychiatrists jump into a career. As I have ranted in this venue before, most psychiatrist jobs, these days, are what I call “psychopharm” jobs, meaning the institution hires the psychiatrist to be a “pill-mill”. “What’s wrong with this?” My imaginary readers ask, to help me launch into my current post. What’s wrong, is the psychiatrist should be the thought leader, the one who designs programs for the mentally ill or creates systems of care in which problems such as homelessness and substance abuse can be approached in a comprehensive, and compelling way. Checklists are not the answer, and yet, there is a large push, particularly in the public sector, for the practitioner to check off boxes, signaling that important issues are discussed. Yet, the issues of the mentally ill, be they anxiety or psychosis, is that the individual needs to feel deeply understood, and then there needs to be services which connect with their underlying pathology. Psychiatrists are in a unique position to both understand patients, as well as help other mental health professionals understand the deeply disturbing experience of mental illness. As such, psychiatrists understand the kind of social services that patients need. They also understand the kind of individual work a patient needs. Putting these two skill-sets together, creates a thought leader who should run agencies, direct programs, or design curriculum. Yet, in most institutions, those jobs are done by non-MDs. The psychiatrists fill the check-box of “psychopharmacology evaluation” and that is usually all they do. This is the big picture/small picture issue. We, as a field, have bought into the ‘small picture,’ without feeling the responsibility of the ‘big picture.’ For this, I think, my field needs to reflect and re-group.

Women And Opiates: My Rant

Pills of hydrocodone, also known as Vicodin, are shown. Drug overdose is one of the few causes of death in the United States that is worsening, eclipsing fatal traffic accidents in 2009. (Toby Talbot / Associated Press / February 19, 2013)

“About 15,300 women died from overdoses of all kinds in 2010, more than from car accidents or cervical cancer, according to the CDC.

Overdose deaths rose most rapidly among middle-aged women who, previous research has shown, are more likely to suffer from chronic pain and to be prescribed painkillers.

“Mothers, wives, sisters and daughters are dying at rates that we have never seen before,” Frieden said. ‘These are really troubling numbers.’ ”

http://www.latimes.com/news/local/la-me-rx-painkillers-20130703,0,916397.story

 

I highly suspect that many of these “middle-aged women” taking opiates, overdosing from opiates, complaining of chronic pain, are suffering from disappointments, psychic pain, and frustration with their lives, particularly their relationships. This “middle-age” for women, as we all know, is associated with launching children, coping with elderly and disabled parents, menopausal body changes, along with mid-life relationships which range from long-term marriages to being new to the dating scene to perpetuating a single life, which may or may not feel satisfying. Where do these women turn? The psychiatrist? Nope. For both social and financial reasons, these women, generally speaking,  turn to their trusted primary care physician. However,  complaining about their husbands, children or their parents, seems like a “waste of time,” so they focus on the very real pain of aging. Joints do not work as well. Injuries are more common. The fluidity of the body is slowly declining and so they complain. Exercise, of course, should be the first line of defense, but primary care physicians are usually coached to get rid of pain quickly, rather than telling patients to exercise, as primary care doctors often feel that the exercise  recommendation is unlikely to be understood as helpful, but rather the patient responds with  “yea, I know, but I won’t.” The culture of doctors wanting to please their patients, encourages physicians to give them opiates for pain that is not clearly understood, but complained about. “What is going on with your life, right now?” is the question that I wish happened in that eight minute office visit. Primary care doctors could venture an educated guess, that the pain of aging is exacerbated by disappointments in relationships. Middle-age is a hard time for women. The culture seems to understand the “mid-life crisis” of men, but women, too, examine their choices, sometimes with feelings of deep regret and despair. Maybe opiates numb that despair, and over time, as the feelings mount, so does the opiate use, leading to tragic and preventable death. My solution: Exercise and psychotherapy for these women who come complaining of body pain, while working them up to make sure that they do not have an underlying disease process which requires medical intervention. Opiates are wonderful drugs for those facing the end of their lives due to a debilitating disease. By contrast, opiates ruin the lives of those who could have a lot to look forward to, but who need to get over a major hurdle in their lives.  Physicians need to understand that. Women deserve it.

Changing Face of Medical Care

 

There is change mentioned at every lecture I attend, every lunch time discussion, every committee meeting. I hear these discussions in primary care and in psychiatry, but I think it is likely that every corner of health care is struck by the feeling that we have reached a pivot point. Today’s angle was delivered from an esteemed Duke primary care physician, director of the Family Medicine Residency, and a former student. Family Medicine, he says, will no longer focus on why patient A does not take his blood pressure medication, but the physician will look at a bigger picture of how can he/she implement a system which facilitates compliance. We changed the name from compliance to adherence and back to compliance, but that is another story. This system is going to involve using technology, nursing and administrative staffs, wellness groups and community outreach. It sounds like Kaiser to me. In fact, it is the Kaiser model. Have lesser trained folks work on the patient interface, while the physician does what he is trained to do; decide what the problem is and how to treat it. After that, the can gets kicked down the road, and the health care team deals with the details of implementation. Theoretically, this makes a lot of sense. Practically, Kaiser, as the model, does a good job, mostly. My issue, as my readers have heard before, is that the reward system for the physician has changed drastically. It used to be that the implementation of the details, understanding why patient A does not want to take his medication, his resistance, if you will, to making his life better, was where the deep relationship developed, and hence the career satisfaction. Now, unless a physician “goes concierge,’ as my colleagues like to say, that connection is lost, leading to a more technical job of diagnosis and treatment recommendations. More technical means that patients, on average, will get good care, but the physician will only be using his left brain. The integration of the right brain, the understanding of how human emotion interfaces with disease management, will no longer be in the physician’s scope. As a policy maker, this makes sense. As a physician, well, the world is changing.

Graduation Time

 

Tonight the UCLA Child Psychiatrists are marking the end of their fourteen year journey to professionalism. There are eight 30ish men and women who will begin careers for the first time, without the mandatory supervision of faculty members. Many folks see this as a prolonged adolescence in that despite their age, they have yet to experience the responsibilities of adulthood. Although they are licensed physicians, and perhaps board certified in adult psychiatry, they have never had the experience of being an employee. Thus far, they have been in this in-between land in which they are working under supervision, similar to an apprentice, while still learning their trade. They are graduating at a time in which the Affordable Care Act will soon change the landscape of medical practice. Access to mental health care will explode, leading to a high demand, but at the same time, the providers of this care will likely be primary care physicians and nurse practitioners. Psychiatrists, the experts project, will be consultants, helping those on the front lines deal with the issues of mental distress. Yet, their training has not been embedded in primary care so the jobs they jump into will not resemble their apprenticeship. This reminds me of my training where psychotropic medications were yet to explode, so I launched into a world of “psychopharmacologists” thinking that word was for those with PhDs in psychopharmacology and not clinicians. As I have often said in these posts, I was caught in a world in which my younger colleagues became great enthusiasts for the wonders of medication, whereas  my older colleagues had deep skepticism, and I could see both sides. This is the dynamics of medical training, where the embryonic development is so long, that the field one enters is not the field one exits. Excitement and apprehension ensue. These folks have had multiple graduations, from college, medical school and residencies, but “this is the one that matters” I tell my students. “This graduation means you are entering into a world in which you are now responsible for your own career.” I say, remembering the weight of this crossroads.

The Joys of Medicine

Leadership

Fungible

 

Health care is moving to assembly line medicine which means that physicians are completely interchangeable, or fungible, entities. This does not mean that people will get poor care, but it does mean that the role of the physician has changed from cultivating relationships to following algorithms. In the long run, those attracted to a medical career will be a different personality type than those in the past, as following algorithms is a different skill set than feeling the pleasure of healing relationships. I understand the value of fungibility, yet I am sad about this change.  Adapt or die, comes to mind, and so I will adapt.

 

 

 

 

Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, shares in a company, bonds, precious metals, or currencies.

It refers only to the equivalence of each unit of a commodity with other units of the same commodity. Fungibility does not describe or relate to any exchange of one commodity for some other, different commodity.

As an example: if Alice lends Bob a $10 bill, she does not care if she is repaid with the same $10 bill, two $5 bills, a $5 bill and five $1 bills or bunch of coins that total $10 as currency is fungible. However, if Bob borrows Alice’s car she will most likely be upset if Bob returns a different vehicle–even a vehicle that is the same make and model–as automobiles are not fungible with respect to ownership. However, gasoline is fungible and though Alice may have a preference for a particular brand and grade of gasoline, her primary concern may be that the level of fuel be the same (or more) as it was when she lent the vehicle to Bob.

 

http://en.wikipedia.org/wiki/Fungibility

 

 

Women Doctors

Last night I had the privilege of speaking to a group of women physicians, mostly psychiatrists, leading to the inevitable topic of how quickly the field of medicine is changing in that it is unrecognizable from our field twenty years ago. We were middle-aged women who remember when it was a big deal for a woman to become a physician; gender atypical, one might say. Now, over half of most medical students are women. As a group, our daughters, not our sons, are entering medical training. “What does this mean?” one woman asked. “Women will earn the money and men will take care of the household,” one woman answered. “Or women will do both, like they have been doing for generations,” another woman said. “Women are twice as likely to get depressed as men,” I say, adding in a well-established psychiatric statistic. “Is this related?” I ask out loud. “Yes, but women are twice as likely to get depressed from menarche to menopause, so that makes it seem hormonal,” one knowledgeable woman answered. “Yes, but those are also the years where women have to juggle a lot of competing responsibilities,” another well-informed woman chimed in. “Men are more likely to be alcoholics,” another woman said, implying that maybe men deal with their psychological issues through substances and not through talking about their mental state. As usual, we had no answers, but many questions. Our worlds,  the world of knowing a “woman’s role” and the world of medical practice, is confusing to us. We want to help people, but how best to do this, is not completely clear. We want to be role models to our younger colleagues, but we do not understand their world and they do not understand ours. All in all, it was nice to be together to chat about common concerns. My job was to keep the conversation going. They did not need me for that. The passion for this topic generated the energy in the room.