Friday, December 30, 2016
Breakfast With My Old Mentor
I have some other posts ready to go, but I wanted to end the year on a positive note. I could not think of anything more positive than my old mentor being back in town and suggesting that we meet for breakfast. I would not be where I am today without mentors. Mentors who told me what to do and silent mentors who I could just identity with. Both types have been invaluable to a guy who did not have a clear idea of what he wanted to do in life. When it comes to people who carefully plan their life and people who are on kind of a random walk - I was firmly in the latter camp until some time after college.
The only reason I went to college was to play football. I got a scholarship. It did not take long to discover that was a bad idea. That discovery was facilitated by a gangrenous appendix. During the hospital stay, one of my professors came in to visit. He basically told me to snap out of it, drop the idea of coaching and a physical education minor, and do something more rigorous academically. He literally told me that I was wasting my time. He was very animated about it. When he left I wondered why an unpopular professor with a reputation for eccentricity would visit a freshman who he had only known for about a month and tell me that my life trajectory was wrong. And why would I immediately see that he was right?
It was not long before I had met chemistry and biology professors that I could identify with. I also had very positive experiences with the English and Philosophy professors. That led to increasing motivation and academic rigor. Medical school was not much different. It was natural to gravitate to neuroanatomists, biochemists, neurosurgeons, neurologists, internists, endocrinologists, nephrologists, cardiologists, and infectious disease specialists. Learning medicine and psychiatry in medical school and residency was an exciting immersive educational experience. Not all of the professors were stimulating or inspiring. I did not consider those fields for a second. After the computer match of several specialties psychiatry was the next step.
I met my mentor in my PGY2 year in 1984. He had just left private practice to do research. There was never any doubt that he was extremely knowledgeable in psychiatry. At the time there was an active debate between the so-called biological psychiatrists and the psychiatrists who were more psychotherapy oriented. The biological psychiatrists were basically phenomenologists in search of biological paradigms at the time. Some of the more prominent paradigms at the time were psychopharmacology, genetics, primate research and neuroendocrinology. In many cases, residents were split by identification with some faculty or alienation from others. My mentor was comfortable in all areas. We could discuss biological theories and then how to introduce and conduct psychodynamic psychotherapy. He explained how he did it and it made things possible. He highlighted our discussions with with examples from his own experience. He asked me questions about what it was really like to be a psychiatrist: "Suppose you are at a cocktail party and a person approaches you. That person appears to be acting out. Do you react to them like psychiatrist or not? Do you think that you can put being a psychiatrist on hold?" Questions that most PGY2s have not had time to contemplate when doing night call on psychiatric units full of transplant patients - many with difficult to control diabetes. All of this was worked in between seeing patients and doing the usual patients presentation in the clinic and the hospital.
I moved on to a different program for the last two years. The same biological psychiatry versus psychotherapists going on in the new program where interestingly there were biological researchers with strong interests in both psychodynamic and behavioral therapy. It was the only program where I have ever seen pharmacotherapy contingent on whether or not the behavior therapy was attempted or successful. Even more psychiatrists with the same orientation as my original mentor.
We ordered breakfast and settled in. It was the first time we would be talking for an hour in 32 years. I had talked with him briefly outside of a lecture that he was getting ready for at an APA meeting. He brought me up to speed on what he was doing. He got in on the ground floor of psychiatric research in a particular specialty and it was apparent that he knew most of the field cold. He e-mailed me several papers later. We discussed a few medical problems and the morbidity of the aging process. We discussed some issues that come up teaching residents and I remembered some of the things he told me about my personality and style that were dead on. We talked about my concern over the FDA contraindication for bupropion in active or resolved eating disorders and what needed to be done about that. We discussed the historical development of the DSM and its limitations. He told me something I had never heard there - organized psychology tried to come up with an alternative to the DSM-III and failed. I informed him about the Psychodynamic Diagnostic Manual (PDM) and my experience discussing it with some East Coast clinicians. We made a few jokes - technically we were peers, but he was always easy to relate to. As the hour wound down we settled on a few truths that we had come to over the years about psychiatry and I thought I would include them here as a positive jumping off point for the new year:
1. It is all about the biology -
I have always reflected on my teachers of clinical psychiatry and concluded that I was very fortunate to be taught by the best from two very different programs. That all started with my mentor. About two thirds of the way into our conversation he made this statement and I found myself in complete agreement. When I was in medical school psychiatry was in a very primitive state and a lot of that was due to the nature versus nurture argument. The psychiatric assessment and mental status exam has not changed since that time. There are generally 200 - 300 data points gathered in a standard assessment and the goal is to come up with a formulation of the problem and a separate list of diagnoses. If you are a resident of course they need to be DSM diagnoses. The problem then as now is that the explanatory power of the formulation is not necessarily robust. At the end of that presentation somebody in the crowd could always say: "So is it nature or is it nurture?" On either end of that spectrum the formulation could encompass - "Who cares if it is nature or nurture - I just prescribe medication for specific diagnoses." to "I only do psychotherapy - this is repressed narcissistic rage. I prescribe a little amitriptyline if needed for sleep." Hardly robust explanatory paradigms and the old Popperian baggage that psychoanalytic theories were not falsifiable.
The biggest missed opportunity during residency was not capitalizing on the neuroscience of the day. The academic centers where I was studying were firmly into primatology, neuroendocrinology, and psychopharmacology. Nobody seemed to pick up on Kandel's early work for about a decade. There was much debate about what biological psychiatry was and the definition I was picking up on at the time was treatment with medications. There was a focus on neurotransmitters and neural transmission. But my entire residency occurred before the advent of selective serotonin reuptake inhibitors (SSRIs) and atypical antipsychotics (AAPs). The most effective medication for the indication was lithium and that is still probably the case. Over the intervening decades neuroscience has taken off. We now have an early appreciation of the complexity of the brain and nervous system with advances every year. We are very close to the point where we are able to investigate putative neuroscience based mechanisms for stress, psychological trauma, environmentally determined epigenetic changes that cause important changes in behavior, common psychiatric syndromes, genetically determined changes in drug metabolism, and primary genetic transmission of mental disorders. There has been an explosion of information about the molecular biology of addiction and dementias. It seems that many people have discovered in the last 10 years what Kandel was writing about in 1979 - psychotherapy changes biology. How else would it work? All of this information is immediately relevant for psychiatrists.
2. The last thing that we need is another research proven psychotherapy -
I found that I had psychotherapy training in residency that was second to none. As a resident that occurred primarily as one hour of direct supervision for every hour that I was in session with a patient and that was about 450 hours per year for three years. The psychotherapy supervisors were diverse in terms of their orientation. I picked up additional training on inpatient services from psychoanalysts and others. It seemed obvious to me that you have to say something useful to people when you see them and that typically flowed from one form of therapy or the other. In psychiatry due to the severity of the problem and the general lack of medical care - flexibility was necessary. I can recall making a diagnosis of probable partial complex seizures in a patient I thought that short term psychodynamic crisis oriented therapy might be useful.
Over the years, psychotherapy research led to more manuals for standardized approaches. I remember getting an early copy of Linehan's Dialectical Behavior Therapy mailed directly to me from the inventor herself. I accumulated a library of psychotherapy texts on supportive, psychodynamic, behavioral, cognitive behavioral, and the more recent modifications. But the problem with psychotherapy was never a lack of useful models. There was fairly good evidence that psychotherapy may not be all that specific. Therapists from different schools could both get good results. There was a general lack of adequate research of psychodynamic/psychoanalytic therapy. There were also some clinical trials that may have left the wrong impression. I recall an early partially negative trial of psychotherapy in schizophrenia that seemed counter to older anecdotal literature. More recent cognitive behavioral therapy of schizophrenia and other severe mental illnesses seems to correct the idea that psychotherapy is not useful.
In our discussion of psychotherapy we both agreed that there is really no research based psychotherapy available largely due to managed care environments. I thought the average number of sessions for most managed care patients was 3. He had just read an article suggesting it was 1. Either way the practical limitations for psychiatrists in these settings is that they are scheduled for brief medication focused visits and long intervals. A person with a severe mental illness who is not in a crisis situation may be seen every 3 months for 15 - 20 minutes. But even in that rationed and sparse setting, I worked with a psychiatrist who established incredible relationships with people. I had people asking me for years after he left, if I knew what had become of him.
We both agreed that it was futile to keep doing psychotherapy research on heterogeneous populations and inventing different psychotherapies when the results are generally the same (and probably limited by varying subject characteristics) and research proven psychotherapy cannot be provided due to managed care rationing. The therapeutic alliance and useful discussions with patients need continued application. Nothing useful tends to happen unless the patient believes they are clearly understood and that is communicated by the psychiatrist.
3. Residents have to care about the DSM - we don't -
Through all of the fake news about the release of the DSM-5, I maintained that all of the hype was hardly necessary for a very imperfect classification system that is slightly important to psychiatrists - but nobody else. We agreed it was useful for residents to learn but really not that important for practicing psychiatrists. The basis of that agreement and the need for the residents to learn it is that we know all of the deficiencies and the few strong points better than anybody else. It caused me to recall the electronic medical record that I use. Each major diagnostic category has about 240 listed diagnoses or nearly the total in the DSM-5. There are so many that I can have difficulty finding the correct one. Like most psychiatrists, I am using about 1/4 of the diagnoses and recognize the limitations not only of those diagnoses - but limitations of the idea that simple verbal descriptions can parse the most complicated organ into a large number of useful diagnoses.
All in all it was a good breakfast. I was happy to see my mentor and he was happy to see me. Along the way I think I evolved into a competent clinical psychiatrist with a very similar skill set (except the extensive research). I know that the other residents in my class did the same.
I feel privileged and elevated by acquiring those skills directly from my mentors and colleagues along the way. It transformed my early random walk into academics into a focused professional life.
And I am very grateful for that.
Happy New Year!
George Dawson, MD, DFAPA
Eggs Benedict picture at the top is By balise42 (http://www.flickr.com/photos/ipalatin/5261997126/) [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons at https://upload.wikimedia.org/wikipedia/commons/2/2b/Eggs_benedict.jpg