Friday, December 7, 2012

Paradigm Shift or Typical Rhetoric?

"Humanism and science cannot be based on rhetoric and wishful thinking. They require hard work and dedication to both scientific methodology and humanistic concerns."  - Akiskal and McKinney - 1973  

Well I decided to interrupt a post I was working on to respond to more noise about everything that is wrong with psychiatry - at least according to one blogger and an author that he is reviewing.  The basic argument is that there is a push to "remedicalize" psychiatry because of pressure on psychiatrists from non physician providers.  Apparently psychiatrists are an expensive commodity- especially if they really don't know anything.  That argument is so poorly thought out - it is difficult to know where to start.

The medical basis of psychiatry is well recorded starting in European asylums.  At one point German psychiatry was firmly focused on brain studies and Alzheimer, Nissl and others were searching for the neuroanatomical basis of mental illnesses in the late 19th century.  Psychiatrists were the first physicians responsible for the large scale treatment of epilepsy and neurosyphilis.  Whenever a previously intractable condition became more treatable it seems like it was no longer under the purview of psychiatry.

If anything there was a push to demedicalize psychiatry with the advent of Freudian and later therapies - that for the most part were good literary efforts but seem to offer very little in terms of modern treatment apart from a few very broad guideposts. It probably persisted right up to the heyday of biological psychiatry in the US and I would put that sometime in the early 1980s.  A well read friend of mine suggested that when Freud was waiting for a call from the Nobel committee, it probably should have been the committee on Literature rather than Medicine.  Given Freud's subsequent impact on English literature - I think that was a keen observation.  It certainly had little to do with medicine.

The medical basis of psychiatry is well documented and all I have to do is  spin around in my chair and look at the texts I have on my book shelves.

The original work on delirium by Lipowski.  Three editions of Lishman's Organic Psychiatry.  Countless texts on consultation liaison psychiatry, geriatric psychiatry, addiction psychiatry, sleep medicine, psychosomatic medicine, and specialty volumes on Alzheimer's disease and other brain conditions.  Classic chapters in Lahita's Systemic Lupus Erythematosus on the cognitive and psychiatric aspects of SLE.  Every psychiatrist needs to know if there is a medical cause for the psychiatric problem being evaluated, if it is safe to treat a person given their medical comorbidity, and how to assure the medical and psychological safety of that patient they are treating.  That has always included the ability to make common and rare medical diagnoses, interpret physical findings, and interpret test results.  That last sentence is frequently minimized but it requires the ability to recognize patterns and manage information that is on par with any other specialist.

The idea that psychiatry requires "remedicalization" or has been "remedicalized" is another myth of the ill informed, but it does have a basis.  The basis is in how the managed care cartel has taken over and dumbed down the field.  Managed care companies would like nothing more than psychiatrists sitting in offices doing cursory interviews and handing out antidepressants.  Reviewers from managed care companies have essentially disclosed this to me over the years with comments like: "Psychiatrists are not supposed to manage delirum".   My reply:  "That's funny because the Medicine service transferred me this patient as 'medically stable' and with no delirium diagnosis."  Who in the hell else is going to manage delirious bipolar patients with hepatic or renal failure?

Of course I realize that managed care companies really don't care about my patients and in this case it was fairly explicit that they could save the "behavioral health" cost center a lot if they could shame me into transferring the patient back to Medicine.  My response was basically - you convince them to accept the patient and I will transfer them back.  It never happened.

The only "paradigm shift" required here is to let psychiatrists practice medicine at the level they are competent to provide, rather than rationing their services.  The quality of care will dramatically improve and that includes associated medical care and diagnoses determined based on the ability of psychiatrists to communicate with patients.  What is probably difficult to accept by the "paradigm shifters" no matter who they may be is that psychiatry is a difficult field.  You do have to know plenty of medicine and like all other medical specialties you need to know the theory.  When I trained in in medical school there was plenty of theory that we had to learn that never made it into mainstream practice.  Much of the neuroscience and genetics that applies to psychiatry already exceeds the applicability of what I was taught about theophylline in medical school.

The most difficult part about psychiatry is that you always have to be patient centered and know how to talk to people.  That falls flat if you don't have the expertise to recognize all of their their illnesses and help them get better.  The only real crisis in psychiatry is that it is being starved into non existence by the government and managed care companies.  They don't care what psychiatrists know and what they can do.  They don't want you to see one.

George Dawson, MD, DFAPA

Akiskal HS, McKinney WT Jr.  Psychiatry and pseudopsychiatry.  Arch GenPsychiatry 1973 Mar;28(3):367-73.

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