How I Write This Blog….
I have had some people ask me about how I pick topics to
write about recently so I thought I would elaborate on this a bit. There are several recurrent themes on this
blog that are difficult to miss. Medicine and psychiatry have been an immersive
experience for me over the past 40 years.
I cannot imagine having a more interesting career focus and am grateful
every day for the people who got me there and helped me maintain over all those
years. It was a difficult job even with
that support largely because of the patient population I chose to work
with.
I wanted to focus on people with the most severe problems
and that led to a 25-year period in acute care and community psychiatry. The
difficulty was generally not due to the patients, but the way mental health
services are funded and managed in the United States. If you happen to be an employee (like I
always was) rationing by payers meant that you had to spend your time seeing
more people for less reimbursement. Eventually it meant performing the additional
work of 2 – 3 people that used to assist with documentation
and billing
and coding. I was told that I always
had a choice about spending less time with patients – but I never took
that route. Any translation of the time
constraints meant spending an absurdly short amount of time with patients.
I was always very enthusiastic about patient care. I did a lot of research on individual
problems and how they could be approached.
I focused on a lot of problems like the psychotherapy of psychosis,
movement and other neurological disorders, medical problems in the mentally
ill, dental problems in the mentally ill, reading the brain imaging studies I
ordered, traditional and quantitative EEG, and screening for rare causes of
neuropsychiatric disorders and treatment resistance. That care would put me in
touch with many researchers over the years because I had a habit of emailing
who I considered to be the top experts in the world about the clinical problems
I encountered. To cite 2 examples – I
emailed an expert in QTc prolongation who was a psychiatrist and a cardiologist
and another expert in ECT about post ECT aphasia. They both talked with me by phone and I was
reassured that my treatment recommendations had expert backing.
Expert opinion and evidence is required to do a professional
job in any medical specialty and psychiatry is no exception. In making
recommendations to people – I think it is important to be able to discuss the
rationale and strength of evidence. I
would commonly discuss on and off-label uses of medication and existing
evidence for off label use. On occasion I
would do a Medline search of the evidence while the patient was in the office
with me so they could see it. I also had no problem referring anyone to the
most technical information available about their problem or treatment. That
included detailed information on medication and side effects as well as
psychotherapy references. I did find
that given the choice – most people opted for my translation of the evidence and
if I was practicing right now my question would be if that was still true in
the era of AI.
Since retiring from clinical practice, I am still inspired
every day to think about biology, medicine, and psychiatry. I also frequently think about science. I was a biology and chemistry major as an
undergraduate and still read about both of those fields as well. I have many questions
that I have been thinking about for years and if I see a paper about it – I am
off to the races for a while. To give a recent example – I have been
researching inflammatory mechanisms in rosacea – the biochemistry and potential
mechanism of action for medications.
Most people think of rosacea as a purely cosmetic problem, but it can
complicate other organ systems and people with the disorder are more likely to
have cardiovascular disease and mental disorders.
From the diagram at the top of this post these are
additional sources of ideas for posts:
1: The science of
psychiatry - this is the most straightforward source of ideas. I read the American Journal of Psychiatry,
the Journal of Clinical Psychiatry, and many others looking for
interesting papers. I try to avoid the
pattern of just posting reports on papers and I am more attracted to papers
that I have associations to and am interested in. I don’t have academic access to online journals,
so it costs me extra – but at this point I can justify it as a hobby of sorts.
The science of psychiatry covers the basic science (neuroanatomy,
neurophysiology), epidemiology, genetics, pharmacology, classification,
clinical trials and associated technology, and preclinical research. It also
encompasses evolutionary biology, anthropology, and sociocultural determinants
of behavior and disorders.
2: Science and
clinical practice of medicine - readers
may notice that I have a vivid recollection of my training and try to keep up
on the specialties that I consider to be the most relevant. They are basically Internal Medicine,
Neurology, Endocrinology, Allergy and Immunology, Rheumatology, Perinatal
Medicine, and Infectious Disease. That
sounds like a lot – but I have a search system that scans the new literature by
authors and topics of interest. Just going through all those emails is a lot –
but it pays off in about 5% of the searches.
AI seems to do a lot better with these topics and I consider it to be a
better (more focused) search engine.
3: Basic science –
exploring the connections - While reading papers there are branch points. A familiar branch point is more detailed
basic science. A recent example is researching the enzyme 5-alpha-reductase
while writing a blog about post finasteride syndrome. I have been reading about enzymes for the
past 40 years and am interested in the structures, cofactors, where they fit in
metabolism, the genetics associated with it, and the reaction kinetics. Over the past two years I have been following
the electrochemistry use to analyze neurotransmitters in vivo and some
of that work had me rereading Michaelis-Menten
kinetics from undergraduate physical chemistry and med school biochemistry.
4: Culture and
psychiatry - I review films, poems, and books that I think are culturally
relevant from a psychiatric perspective and in the genesis of stress and mental
disorders. I am currently reading
Margaret Atwood’s Oryx and Crake because of what I learned about her
fiction writing technique and the effect it has had on some aspect of culture –
it is apparently the most banned book in high schools. I have several pieces of
creative writing where I present my personal history to make a point about
mental functions like transgenerational
effects of trauma or an association to something
in the past that seems relevant in the present. I have written about overtly political topics
that I think adversely
affect the physical and mental health of the nation. I frequently write about gun
extremism as being one of the most malignant factors in our culture. People often forget about the social and
cultural determinants of human behavior or seem to think that psychiatry is
outside of that sphere. Human biology is
inseparable
from human culture and society.
5: Psychiatric practice – I have broad experience in the
field treating very serious mental disorders.
To do that requires more than just picking a medication and hoping for
the best. It takes knowledge in how to
communicate with people, how to make diagnoses, how to change course when
things are not going well, and how to provide an adequate environment for
discussion and psychotherapy. There is not any aspect of psychiatric
treatment that I am not interested in.
6: Psychiatric
criticism - as I have posted on the blog – psychiatric criticism is a cottage
industry in the US. There are people out
there who consider it to be their full-time job. I respond to some of that criticism based
on its absurdity and have probably spent too much time on it on the
blog. In additional to the usual critics
– some psychiatric
journals have also published criticism that
I consider to be inaccurate and have posted corrections about that. Any time a new DSM is being developed – I
anticipate a mountain of criticism. It
seems to be an easy way to make provocative posts with the usual accusations of
technical problems, conflicts of interest, limitations, and many others. It
will be difficult to not respond to the new wave of DSM criticisms – and may
console myself that I have far fewer readers than the New York Times. Dealing with largely inappropriate
criticism has led me to be a student of rhetoric and I have an addition to my
library on that subject. 35 years of
experience on the Internet has also led me to have a no trolls policy.
Any one of these sources can get me focused on a topic but
it is not a linear process. For example,
this post on post-SSRI
sexual dysfunction (PSSD) resulted in additional research on herpes
infections (HSV-1, HSV-2) and the effect on sexual function between episodes
and additional research on post finasteride syndrome that I will
probably post in the next few days. I was able to ask that question directly
during a teleconference by an infectious disease specialist who was discussing
sexually transmitted infections. She was
sure it did occur but agreed there were no good studies of the topic.
I write about quality medical care and the practice
environment. In the 1990s and early
2000s I was a quality reviewer for Medicare psychiatric admissions in Minnesota
and Wisconsin. We have a rigorous protocol
that we used to determine quality care and provide feedback to hospitals on how
they could improve. Most people are not aware of the fact that at some point –
quality assurance was turned over to healthcare organizations rather than
independent contractors with no conflict of interest. It is no accident that healthcare managed
care has led to both a deterioration in quality care and the practice environment
for physicians. Quality has been transformed
into high productivity low quality rationed care with more resources diverted
away form physicians and patients to middle managers. There are plenty of posts on this blog about
how that has happened and continues to happen.
I do not hesitate to post my personal experience with health
care and have included the experiences of my family. Self disclosure is avoided in the clinical
practice of psychiatry. I have certainly
done that and teach that in psychotherapy seminars. As a free-lance writer, it serves a different
function. I have covered the real experience of vaccine
reactions, cardiac
ablation procedures for atrial fibrillation, my first COVID
infection, and my wife’s experience getting treatment for acute
appendicitis compared with my experience 50 years ago. I am typically making points about less-than-ideal
conditions, the real experience compared with how it is portrayed and in some
cases the science that it still unknown. In every case I hope I am making the
point that every treatment experience is unique and what happened to me is not
what will happen to you. Uncertainty and
heterogeneity are two of the favorite concepts I emphasize on the blog.
And finally, I get suggestions from readers on what topics
they would like to see. That led to the
PSSD post and the future post finasteride post. But I am always open to
more. And if you see a post or a graphic
that you are interested in writing a paper about – feel free to contact me
about collaboration. About 10 years ago
– I was at a conference where one of the lead speakers presented using some of
my custom graphics and he did not give me any credit. This was a graphic that only exists on my
blog because it was made by me.
Everything on my blog is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives
4.0 International (CC-NY-NC-ND
4.0). All you must do to use it is
to reference my work.
There is an element of creativity. As far as I can tell that depends on your
conscious state, memories, and associations.
I am thinking all day long and often long into the night. I can think about what happened 50 or 60
years ago alternating with something that has my focus on any given day. It is not strenuous – it seems more like a
preferred activity especially now that I have no work demands. When you think and interact with the
environment all day long – you are bound to get some novel combinations of
thoughts that can lead to a good blog post.
And that is about the last thing I can say…
George Dawson, MD, DFAPA
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