Tuesday, March 4, 2014

Can You Trust Your Physician?

I could not help but respond to the Psychiatric Times article with the same title that they e-mailed me this morning.  Trust in an interesting concept when you live in a country that is politically managed for laissez faire capitalism and the only protection that the average citizen has against various cartels is caveat emptor.  The vocal irrational biases against psychiatry should discourage blind trust of psychiatrists even further.  Early in my career, I stayed away from any interpretive approaches to a lack of trust and took a simple cognitive behavioral therapy (CBT) approach.  That goes something like this: "I don't think there is any basis for you to trust me or not trust me.  I would encourage skepticism and taking a look at what I actually do for you.  If you find the recommendations, discussions and treatments that I recommend are useful, that is more clearcut evidence that I might be helpful to you.  If not, certainly let me know and we will figure out what to do  about it".  Many of the people I have worked with over the years who had "trust issues" have found that to be a useful approach.

In reading the article, I find out that it is about the legal requirements involved in informing women about abortion. specifically the fact that in some states physicians are now required to tell women that a fetus will feel pain as it is aborted.  Additional states require women to pay for an ultrasound evaluation and view the fetal image before the abortion, advise women that abortion leads to an increase in breast cancer, and refer women for counseling after advising them that an abortion places them at risk for adverse mental health consequences.  The authors cite the scientific evidence to the contrary in all cases.  Can you trust a physician who is reciting abortion law boilerplate when they are advising you about that procedure?  Probably as much as you can trust a physician doing a safety assessment in a situation where they are prohibited by state law from discussing firearms that the patient may have at home.

 I don't think anyone should be surprised about the lack of science involved when politicians decide to manipulate physicians to do their bidding.  I currently live in one of the most liberal states in the United States and every year I get a letter informing me of the number of abortions performed every year and reminding me of my obligation to report if I perform an abortion.  It is a state law that all physicians receive this letter, even if they are psychiatrists who don't do any surgical procedures.  The intent of the letter is to clearly intimidate physicians into not performing abortions.

To quote the downside from the authors:  "These politically motivated laws undermine the concept that medical decision-making is based on scientific evidence. They force physicians to act as agents of the state government rather than put their patients’ interests first. They are intended to intimidate women so that they will not have abortions. They are corrosive to honesty in the physician-patient relationship, interfere with the physician’s responsibility to the patient, and violate medical ethical principles."

I think that any reasonable physician would agree.  I have been pointing out for decades that physicians have been agents of the state for a long time.  Colluding with managed care and all of its governmental variations is a clear example.  The entire managed care manual on when to discharge people from hospitals and how to do that has nothing to do with science.  The entire concept that all medications in the same drug class are equivalent has nothing to do with science.  Practically all of the rationing that occurs by the government and managed care companies has nothing to do with science.  But it doesn't stop there.  All state statutes having to do with the duty to warn have nothing to do with science and more to do with where the deep pockets are located.  In the original case precedent the perpetrator was detained and interviewed by the police and released before the homicide.  It was a clear example of the failure of the police to protect the victim and yet that was spun into the responsibility of clinicians to warn potential victims.  How much legislation is out there to create work for trial attorneys?

I was at a conference a few years ago where hospice care was being discussed as the latest innovation in hospital care.  When I thought about how people are assessed and discharged from acute care hospitals my question seemed obvious:  "Since there are care managers forcing discharges, isn't there a potential conflict of interest if hospice care is seen as the fastest way to discharge somebody from a hospital?"  The result was dead silence, a moment of confusion ("He really didn't ask that question did he?"), and then I was ultimately ignored as the speaker moved on.  With all of the focus on what are really trivial conflicts of interest in psychiatry, think about that for a moment.  A care manager representing the business interests of the hospital, the MCO/ACO, and the political interests of the politicians interfering with the practice of medicine has options available to them with the potential to short circuit care and provide less intensive care than might be recommended by a physician.

I was in a clinic recently where I was given an impressively long list of exceptions to patient privacy.  I picked up one of my electrical engineering journals the other day and was warned about how the Internet of Things (IOT) will be collecting all sorts of data on the average citizen, but that the owners of the data (Google, Facebook, etc), hope that the average citizen will see the worth in all of this information being in their hands.

Turning over all of this information and power over to the political and business classes is an obvious mistake.  Eliminating what has been described as a mandarin class - the physicians is another.  Unfortunately physicians and their professional organizations are completely inept at dealing with this problem and we are left with these inappropriate political intrusions and physicians acting like agents of the state and business cartels.

That means that politicians will not only try to manipulate who is born based on their ideology, but more importantly who has access to medical care and the level of intensity and who dies.  It is happening right now and it should be a lot scarier than a fictional robot time-traveling back from the future.

Remember the CBT approach to your physician, your health plan and your insurance company and make sure they are doing what you want them to do and not what some politician or business manager wants them to do.

George Dawson, MD, DFAPA


  1. How much trust do you place in the patient's experience vs what the current scientific literature states? And, in the case where you lack trust in it, how much autonomy do you acknowledge the patient has a right to? I'd say in general, not in psychosis or when they are a threat or in harm's way.
    Two simple examples. I commented here that modafinil helped my driving. Not 24 hrs later, I came across a recent scientific paper that confirmed this. Second example, abortion may not cause an increase in depression in the literature, yet it most certainly would have in my life. So, in both examples, the literature was inconsequential to me; I knew my own experience.

    In regards to the autonomy, I love the truth and seek it out, but the more everyone seems to know what is best for me the less I am given the opportunity to follow what I deduce is correct for me.

    1. Your post highlights the difference between the goal of treating individual patients and what has come to be known as "population based medicine". The government and the managed care industry have the grand idea that all treatment and treatment guidelines can be focused at the level of the population or more generally what you might find in a large clinical trial.

      Physicians on the other hand treat individual patients and have to be alert to the fact that what might be a great medicine for 50% of people in the field trials can be toxic or worse for anywhere from 1 person in 50-100,000 or even higher percentages. On that basis, the only logical conclusion is that the patient must be aware of rare side effects, encouraged to report them as well as any unusual experience they have and that both the patient and the physician need to be alert to any potentially new but unreported side effects.

      The same thing is true of clinical phenomenon independent of medication and there is no better example than the issue of abortion. Several years ago both APAs came out with statements about how research shows that abortion does not increase the risk of depression or other disorders. On the other hand it is not uncommon to encounter women who attribute some or all of their anxiety or depression to abortion. It would be completely inappropriate to discount that experience based on a population survey of symptoms and their relationship to a previous abortion.

      Any physician will ideally function to recognize the autonomy of the person and meaningfulness of their life experience and come up with options for them. The business and political trends of one size fits all members in society and all of the physicians treating them is an insult to human biology.

  2. What a great answer. One that I am pleased to see stated in this age of evidence-based medicine where I am expected to fit the evidence and not just by doctors, but by insurers, gov't, and most of society. And, yes, politics only adds to this burden.

  3. The AMA and APA have been promoting big government intervention for years to promote parity and mental health funding. So they got big government and are now surprised that government tells them how to practice. All of which was predictable from the beginning.

    1. Could not agree more. One of the political issues that physician organizations seem oblivious to is the big tent effect. We don't want to risk alienating minority factions because we don't want to lose any dues paying members. There is perhaps no better example than not wanting to lose the managed care proponents in either the APA or the AMA. The corrosive effect of those decisions are evident to people who have been around for a while, but I think they are lost on newer generations when that is all they know.

      The corollary for me is also abdicating medical quality for some ideas cooked up by somebody from business school. I notice that the current APA President came out with a statement on collaborative care today. In his statement he talked about how insurance companies decided long ago to pay psychiatric services according to a different scheme. I guess the gurus in charge believe that it will be harder to NOT pay psychiatrists embedded in primary care clinics.

      I see it as a way that psychiatrists can be permanently shuffled out the door.

    2. I see it as a way that psychiatrists can be permanently shuffled out the door.

      I do too. You read my response to Dr. Moffit where I stated that "I am 100% behind your vision" regarding embedding them in GP offices. I choose my words carefully as I know the odds are high that this will not work out well for either patients or psychiatrists in actual practice. Too bad really.

  4. It's appalling that people who claim to be experts in human behavior can so often be duped over and over again and not learn from their experience. Or maybe they don't care because the end game doesn't affect their tenure or economic future personally.