I passed a pamphlet for a conference on Compassion Fatigue today and thought to myself: "Why haven't I ever encountered the term compassion in medical school or at any point in my medical or professional training?" If you look it up in a real dictionary there seems to be multiple meanings ranging from: "A feeling of wanting to help someone who is sick, hungry, in trouble, etc." to "a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate suffering." None of these definitions seems to capture what happens in medicine and how physicians are trained. It seems like an undisciplined emotional reaction to human suffering. That may seem a bit calloused to someone outside the field but would you want your surgeon operating on you in the throes of an emotional reaction? Would you want your internist or psychiatrist recommending medication for you during an emotional episode? On the other hand, depending on what part of the definition I focus on, I have already pointed out that in my opinion the overprescribing of medications is motivated at some level by "a strong desire to alleviate suffering." More evidence that compassion may not be the best basis for medical decisions.
I can still recall the first patient that I was responsible for. The very first patient I evaluated on Internal Medicine as a third year medical student. He was not much older than me, but at that point he had a much harder life. As he explained his symptoms to me and we did the examination, I found myself getting more and more anxious. I realized that he had a very serious illness that he was not going to recover from. I pulled all of the test results and x-rays together so I could present it in our team meeting in the morning. I could barely get the information out to my chief resident and attending. I was overcome with emotion. My voice cracked. I was tearing up. My head was spinning. I was focused on how unfair life was. He was a young guy, just like me with the usual hopes, dreams, and relationships that we all have and through no fault of his own, he had developed a terminal illness. I certainly wanted to help him, but there was nothing that could be done. That happens so frequently in medicine, using the most emotional definition of compassion would render most physicians nonfunctional. It tends to alter your focus. The focus has to be on what is happening right here and right now and not the unfairness of the process. The focus needs to be on the technical details or you can't provide competent care and tell people what they need to know. As I have gotten older, I have an image for the process of unpredictable disease and death. It reminds me of the war movie where the fleet is sunk and everyone is bobbing in the Pacific Ocean wearing life preservers. Suddenly the sharks appear and people start to die on a random basis. Whoever the sharks decide to kill. A random horrific process. That is my image.
It may explain the reaction of one of my attendings when I was a resident on a busy inpatient psychiatric unit. I was reading the description of one of our consultants to him and the consultant used the adjective "unfortunate" to describe all of the medical problems the patient had sustained. My attending glared at me and said: "Why is he unfortunate?" It seemed like an obvious descriptor to me. Anyone with all of these severe medical problems could be described as unfortunate, but I could not respond to him at the time. It seems to me if the sharks get you or there is a near miss, unfortunate in the bad luck sense may be a good description. He may have been thinking of another definition. But I think he was most likely giving me the message that it is best to not even recognize the random walk through life and the fact that the shark can eat you at any time. Without that element of denial, how can you function? How can you function as a physician?
After you have talked with thousands of people about their traumas and adversities, you realize that most people suffer. Personal biases make some people want to alleviate the suffering of some more than others. Nobody wants to see children suffer. There are some people who attract the ill wishes of others. They are generally unlikable or they have perpetrated some kind of shocking crime. There seems to be a likeability bias with compassion and that also makes it less useful for physicians. Physicians are obliged to perform competent medical care irrespective of how well the person is liked. There are often errors on the side of people who are very likeable. Sometimes physicians and medical staff get very attached to person based on their personality, physical characteristics, or demeanor. You may want to help that likeable person more, but that doesn't translate into whether you can or not.
If you are trained to render assistance, save lives when you can and alleviate suffering where does the compassion that you had before medical school go? Without invoking defense mechanisms it gets converted to other things that are adaptive in the profession. Empathy and technical skill are good examples. Empathy is probably a more accurate emotional appreciation of what is occurring in a person you are trying to help. It is focused on that person and their emotional state and if reflected back to that person they would agree with the observations. A better measure of burnout for physicians especially psychiatrists would be empathy fatigue rather than compassion fatigue. Seeing people as collections of symptoms and having no appreciation for the emotional side of their experience would be one example. Seeing patients as an endless stream of problems that you need to fix rather than unique individuals would be another. As the days get longer there are also the comparisons physicians make about how much time they spend taking care of others compared to how much time they spend with their families. As the family time gets shorter it may be harder to empathize with increasing numbers of patients.
Whether it is compassion fatigue or burnout, these seminars all seem to teach the same things. It is fashionable to refer to the skills as "tools". Mindfulness techniques, cognitive behavioral therapy. relaxation techniques, meditation, diet, sleep, and exercise are all parts of the "toolkit." Nobody ever seems to address the severely deteriorated work environment as a cause and ongoing factor. Productivity demands on physicians in terms of the number of patients seen, the amount of documentation that needs to be done and the other aspects of being a good corporate citizen are a recipe for burnout and that is probably the most common job scenario for physicians these days. Professional organizations seem to ignore that fact that if physicians are going to function the way they should and treat the whole person, a work environment without adequate time to talk with patients in one of the fast paths to burnout.
No amount of "tools" can reverse that.
George Dawson, MD, DFAPA
Supplementary 1: In talking with people over the years and trying to help them stay on the job, the most significant problem is unreasonable employers. People work in jobs where the job directly impacts their health. The best example is alternating shifts and never being able to establish a regular sleep routine. Hospitals are some of the worst offenders. They have adopted policies that allow them to tell nursing staff that they need to work "mandatory doubles" when there are shortages. The policies that have hospitalists working 7 days on and 7 days off are no better. I have interviewed hospitalists about their cognitive efficiency on day 6 and 7 and have been told that it generally plummets. They are taking twice as long to do the documentation and it is difficult to think. I was in a similar position one year when I was running a 20 bed inpatient service with assistance of a physician's assistant. I had to see everyone, everyday and managed both the medical and psychiatric diagnoses. When I decided to stop doing that, I was replaced by two full time psychiatrists and an internal medicine specialist to take care of all of the medical problems. Eventually those two psychiatrists felt it was too much work and a third psychiatrist was added to cover 4 of the 20 patients. The adverse effect of a business model on employee health that operates on personnel expenses cut to the bone can not be overemphasized. Hospitals and clinics will happily work medical staff to the point that it adversely impacts their health and lifestyle, adversely impacts their cognitive abilities at work, leads to burnout, and leaves them in a state where empathy is a thing of the past.
The only reason I quit running a 20 bed inpatient unit by myself was a colleague of mine who told me he did it for years - right up to the point he had his first heart attack.
Showing posts with label burnout. Show all posts
Showing posts with label burnout. Show all posts
Friday, March 21, 2014
Monday, November 4, 2013
Accountability - The Last Refuge of a Scoundrel
On April 7, 1775, Samuel Johnson said: "Patriotism is the last refuge of a scoundrel." His biographer had to clarify that Dr. Johnson was not talking about love of country but "pretend patriotism which so many have made a cloak for self interest". We see the rhetorical application in American elections where politicians spend more time on discussions of their military records rather than issues relevant to any kind of plan that they have for the nation or solving any real problems. Nunberg makes the observation that that the term can also mean an irrational bias favoring one's country and that Americans have applied the term indiscriminately at times. He also points out that it can be a word designed to put people on the defensive.
If I had to pick a word in the medical field that has similar uses - it would be "accountability". There has probably been no single word more responsible for facilitating managed care and recent government intrusions into the practice of medicine. If you think about the premise of physicians being "accountable" to politicians and businesses - it is absurd on the face of it. Taking a professional who has been trained to be accountable to an individual patient and who operates in a professional environment that specifies behavior toward that person and telling them that they are now going to be monitored by businesses with a goal of maximizing profits or politicians with numerous conflicts of interest and a clear interest in getting re-elected - is an ongoing disaster. So how has it happened? I would suggest that most of it has to do with rhetoric.
Before I point out the medical applications of the accountability rhetoric let me say that I don't consider this to be specifically applied to medicine. Accountability rhetoric is broadly applied by any person or group seeking some kind of political advantage. An obvious example is education and teaching. Politicians everywhere get a lot of mileage out of the idea that they are going to hold teachers accountable usually through standardized test scores. It has become a pat answer to taxpayers concerns about the money being spent on education and low graduation rates. In some states, the test scores are marched out every year and used to rank schools and teachers. Never mind the fact that the school system that produces the top international performance scores does not work that way. In Finland, a professional teaching culture is by far and away the most significant factor in their academic excellence. In the book written about this the teachers say they would not tolerate the kinds of intrusions that are common in the United States. These intrusions are all based on accountability rhetoric.
In preparing for this post, I searched my e-mails from the past three years and found 1800 e-mails containing the word accountability. Most of those hits were due to the Health Insurance Portability and Accountability Act (HIPAA). If you read the long title of this act it was clearly doomed out of the box. The major impetus for the PPACA (Obamacare) was health insurance portability suggesting that HIPPA was already a failure. That did not deter legislators from including a Privacy Rule under HIPAA to supposedly crack down on privacy violations. My read of the bill is that is actually broadens the use of anyone's medical information among all "covered entities" affiliated with your health plan. In the meantime, the Privacy Rule was so threatening that it almost immediately made it more difficult for the doctors doing the work to get access to data. Was it necessary for physicians? Absolutely not - physicians are trained in medical privacy and all broad breaches of medical privacy have been due to either hacking or business people losing computers with significant amounts of data. Make no mistake about it - politicians will be there to make the most accountable people accountable and greatly decrease their efficiency. A great example of the title of this post.
I have recently posted a number of examples of accountability rhetoric being used for political leverage against physicians. It can be used by medical boards, advocacy organizations, state agencies, federal agencies, and specialty boards in addition to politicians. I am going to focus on a single example and that is Medicare. All of the information that follows is public and can be accessed through the Medicare link on the American Psychiatric Association's web site. I picked it up on my Facebook feed but it disappeared and I had to call APA staff to figure out where it went. I am very familiar with the history of Medicare quality initiatives because I was one of their quality reviewers for inpatient hospitalizations in Minnesota and Wisconsin in the late 1980s and 1990s. If you look for inpatient psychiatry measures you will find that many of them (polypharmacy, multiple drugs from the same class, discharge planning) are unchanged from that era, despite the fact that the review organization was disbanded because it did not find enough quality or utilization problems to justify its ongoing existence.
The APA points out that Medicare now has a fee scale that takes into account "quality of care measures instead of just paying a standard fee for every procedure (CPT) code". They have a Physician Quality Reporting System (PQRS) that requires psychiatrists to report on one measure in order to avoid a 1.5% penalty. For 2013 that report has to be made on one Medicare patient. This is described as an "incentive" to report on quality performance measures and of course a "penalty" for those who fail to report. A managed care company would call it a "holdback" in that it is technically work that has been done, but the no cost way to turn it into an "incentive" is just to take it from the people doing the work and make it seem like they are rewarded with it later.
The document goes on to document "measures identified as pertinent to psychiatrists (along with their designated codes)". If you are a psychiatrist read through these reporting measures and marvel at the morass of initial codes that I am sure are going to grow as this administrative nightmare continues. The further problem is that Medicare/CMS clearly has the goal of comparing physicians and holding them accountable based on the fantasy that these measures actually mean something in clinical practice or even the world. And if this list of measures is not enough, there are also 50+ page guidelines online like: "The American Medical Association-convened Physician Consortium for Performance Improvement - Adult Major Depressive Disorder Performance Measurement Set" that describes an additional set of performance measures. The AMA is involved and if you click the link 2013 PQRS Quality Measures you can search on Major Depressive Disorder and find the following links. You can download the 50+ page document from the top link.
Most people realize that physicians currently have some of the highest burnout rates of any group of professionals. Those burnout rates are directly related to micromanagement even before we get to the level I just described in the above paragraphs. The paradox that every physician is aware of is that these reportable measures are not valid objective markers and they are being promoted by bureaucrats who not only have no accountability but in the case of the mental health system of care are some of the same people who destroyed it in the first place. Don't forget that Congress skewed insurance coverage of mental illness and addictions so badly that Senators Wellstone and Domenici had to write legislation in an attempt to correct that. At this time the final form of their legislation is still pending.
So accountability has become the last refuge of scoundrels. Be very skeptical of any politician or bureaucrat waving that flag. It has little to do with reality and more to do with promoting their own self interests while creating a tremendous and unnecessary burden for the doctors they regulate.
George Dawson, MD, DFAPA
Nunberg G. Going Nucular: language, politics, and culture in confrontational times. Cambridge: MA Perseus Books Group, 2004.
For a complete analysis of political doublespeak as applied to medicine see:
Robert W. Geist: Hot Air Index: Political/Commercial Double-speak Lexicon for Medicine
If I had to pick a word in the medical field that has similar uses - it would be "accountability". There has probably been no single word more responsible for facilitating managed care and recent government intrusions into the practice of medicine. If you think about the premise of physicians being "accountable" to politicians and businesses - it is absurd on the face of it. Taking a professional who has been trained to be accountable to an individual patient and who operates in a professional environment that specifies behavior toward that person and telling them that they are now going to be monitored by businesses with a goal of maximizing profits or politicians with numerous conflicts of interest and a clear interest in getting re-elected - is an ongoing disaster. So how has it happened? I would suggest that most of it has to do with rhetoric.
Before I point out the medical applications of the accountability rhetoric let me say that I don't consider this to be specifically applied to medicine. Accountability rhetoric is broadly applied by any person or group seeking some kind of political advantage. An obvious example is education and teaching. Politicians everywhere get a lot of mileage out of the idea that they are going to hold teachers accountable usually through standardized test scores. It has become a pat answer to taxpayers concerns about the money being spent on education and low graduation rates. In some states, the test scores are marched out every year and used to rank schools and teachers. Never mind the fact that the school system that produces the top international performance scores does not work that way. In Finland, a professional teaching culture is by far and away the most significant factor in their academic excellence. In the book written about this the teachers say they would not tolerate the kinds of intrusions that are common in the United States. These intrusions are all based on accountability rhetoric.
In preparing for this post, I searched my e-mails from the past three years and found 1800 e-mails containing the word accountability. Most of those hits were due to the Health Insurance Portability and Accountability Act (HIPAA). If you read the long title of this act it was clearly doomed out of the box. The major impetus for the PPACA (Obamacare) was health insurance portability suggesting that HIPPA was already a failure. That did not deter legislators from including a Privacy Rule under HIPAA to supposedly crack down on privacy violations. My read of the bill is that is actually broadens the use of anyone's medical information among all "covered entities" affiliated with your health plan. In the meantime, the Privacy Rule was so threatening that it almost immediately made it more difficult for the doctors doing the work to get access to data. Was it necessary for physicians? Absolutely not - physicians are trained in medical privacy and all broad breaches of medical privacy have been due to either hacking or business people losing computers with significant amounts of data. Make no mistake about it - politicians will be there to make the most accountable people accountable and greatly decrease their efficiency. A great example of the title of this post.
I have recently posted a number of examples of accountability rhetoric being used for political leverage against physicians. It can be used by medical boards, advocacy organizations, state agencies, federal agencies, and specialty boards in addition to politicians. I am going to focus on a single example and that is Medicare. All of the information that follows is public and can be accessed through the Medicare link on the American Psychiatric Association's web site. I picked it up on my Facebook feed but it disappeared and I had to call APA staff to figure out where it went. I am very familiar with the history of Medicare quality initiatives because I was one of their quality reviewers for inpatient hospitalizations in Minnesota and Wisconsin in the late 1980s and 1990s. If you look for inpatient psychiatry measures you will find that many of them (polypharmacy, multiple drugs from the same class, discharge planning) are unchanged from that era, despite the fact that the review organization was disbanded because it did not find enough quality or utilization problems to justify its ongoing existence.
The APA points out that Medicare now has a fee scale that takes into account "quality of care measures instead of just paying a standard fee for every procedure (CPT) code". They have a Physician Quality Reporting System (PQRS) that requires psychiatrists to report on one measure in order to avoid a 1.5% penalty. For 2013 that report has to be made on one Medicare patient. This is described as an "incentive" to report on quality performance measures and of course a "penalty" for those who fail to report. A managed care company would call it a "holdback" in that it is technically work that has been done, but the no cost way to turn it into an "incentive" is just to take it from the people doing the work and make it seem like they are rewarded with it later.
The document goes on to document "measures identified as pertinent to psychiatrists (along with their designated codes)". If you are a psychiatrist read through these reporting measures and marvel at the morass of initial codes that I am sure are going to grow as this administrative nightmare continues. The further problem is that Medicare/CMS clearly has the goal of comparing physicians and holding them accountable based on the fantasy that these measures actually mean something in clinical practice or even the world. And if this list of measures is not enough, there are also 50+ page guidelines online like: "The American Medical Association-convened Physician Consortium for Performance Improvement - Adult Major Depressive Disorder Performance Measurement Set" that describes an additional set of performance measures. The AMA is involved and if you click the link 2013 PQRS Quality Measures you can search on Major Depressive Disorder and find the following links. You can download the 50+ page document from the top link.
Most people realize that physicians currently have some of the highest burnout rates of any group of professionals. Those burnout rates are directly related to micromanagement even before we get to the level I just described in the above paragraphs. The paradox that every physician is aware of is that these reportable measures are not valid objective markers and they are being promoted by bureaucrats who not only have no accountability but in the case of the mental health system of care are some of the same people who destroyed it in the first place. Don't forget that Congress skewed insurance coverage of mental illness and addictions so badly that Senators Wellstone and Domenici had to write legislation in an attempt to correct that. At this time the final form of their legislation is still pending.
So accountability has become the last refuge of scoundrels. Be very skeptical of any politician or bureaucrat waving that flag. It has little to do with reality and more to do with promoting their own self interests while creating a tremendous and unnecessary burden for the doctors they regulate.
George Dawson, MD, DFAPA
Nunberg G. Going Nucular: language, politics, and culture in confrontational times. Cambridge: MA Perseus Books Group, 2004.
For a complete analysis of political doublespeak as applied to medicine see:
Robert W. Geist: Hot Air Index: Political/Commercial Double-speak Lexicon for Medicine
Saturday, October 26, 2013
No - I Don't Have Generalized Anxiety Disorder
I was reading a copy of JAMA the other day and a story written by a transplant surgeon Jeremy M. Blumberg, MD. It was an excellent description of surgical training to the point of autonomy and then the nagging uncertainty of whether the surgery you have trained for years to do will go well. Will you avoid mistakes? He describes his first transplant as an attending:
"This operating room was new to me; the nurses were friendly but foreign. The instruments were familiar, but somehow felt different - was there just a barely palpable increase in tension in the muscles of my hand causing this effect? The patient's blood vessels were hard, thickened from years of dialysis and diabetes. She bled more than usual when we reperfused the kidney. It felt as if every last molecule of epinephrine had rushed out of my glands and nerves, squeezing my blood vessels and taunting my intestines to detonate...." (p. 1676)
I hear you brother. I thought that level of anxiety over the balance between doing the impossible and not doing harm might fade away over the years but it has not. In psychiatry a lot of it depends on the level of complexity that your patients have. It can be an acute situation but more often than not - it is a problem throughout the day that you take home with you. Additional medical conditions, non psychiatric medications, polypharmacy, and difficult to treat disorders all compound the problem. I have designed a hierarchy to illustrate what I mean. It turns out that when I think about it, the acute problems seen by psychiatrists are not at the top. The problems at the top are typically problems where there is no good guidance, where you are on your own, left with biologically determined probabilities and you need to come up with your best estimate of what will happen given current circumstances. The problems encompass both psychiatry and the medicine associated with psychiatry.
Let me provide an example of both. In the case of the psychiatric problem the usual scenario is a case of impaired judgment. Is the person at risk for death or self injury? Are they able to cooperate with the assessment and treatment plan. Do they seem changed to the point that you can no longer accept their responses as being accurate? Are you treating them for acute and chronic suicidal ideation and behavior? Any acute care psychiatrist ends up assessing thousands of the situations across the course of their career. It is often much more complex than an acute assessment. Many of these scenarios unfold in the context of ongoing psychotherapy and in order for the patient to be able to improve some risk is taken. In other cases there are calls to warn people and in extreme cases - calls to the police to check on a person who might be in trouble. I have not seen it studied but the stress of these situations for the psychiatrist involved is well known. Overthinking the situation in order to avoid the unexpected call that one of your patients has suicided or killed someone is common. In my conversations with medical students over the years, one of the main deterrents to psychiatric residency is the worry about suicide prediction.
The medical situations are as complex and they frequently have no clear solution. A common scenario is that the person has a severe mental illness and they develop a problem that leads to to rethinking the medication they are taking. A common scenario is a person on maintenance therapy who suddenly develops a renal or hepatic problem necessitating a change in therapy. The best example is bipolar disorder and lithium therapy. Lithium remains the drug of choice for many people with bipolar disorder and it can be highly effective. When I first started to practice it was common to see people who had repeated institutionalizations for bipolar disorder suddenly stabilized on lithium. Their functional capacity was restored and they were able to return to work and establish families. In those early days, the issue of lithium nephrotoxicity was not clearly observed. There was a major study of people on lithium maintenance for decades that showed no difference in renal function. In the last 15-20 years most nephrologists agree that lithium can lead to renal insufficiency and failure in a minority of patients on lithium therapy. In the case of a person that lithium has been working well for 30 years, there is no guarantee that anything else will work as good. That translates to no hospitalizations in a long time to frequent hospitalizations every year. Monitoring that therapy and in some cases following the patient while they are in dialysis or after transplantation is on example of a situation that you can't leave at the office.
In many ways, the stress and anxiety in psychiatric practice is a measure of attempting to predict the unpredictable. Psychiatry has accurately said that psychiatrists can't predict future behavior or rare events to explain why all suicides and homicides cannot be prevented. But some sort of probability statement is inherent in all medical practice. I would estimate it still happens to me about every three weeks. Something isn't right and I don't have an exact answer. It becomes an obsession to an extent. Laying awake in bed. Getting up to do some additional research but realizing ahead of time that the yield is low. Realizing that no matter what decision you make - all of the outcomes are probably going to be suboptimal. You always get to the point where you can feel the adrenaline molecules rushing and your heart pounding. You know you are tense and starting to break into a light sweat. You readjust yourself in bed and realize your back and shoulders are as tight as a frozen hydraulic jack. You might actually check your pulse and blood pressure and find that they are elevated. It goes on like this until something happens and the intellectual crisis abates. Sometimes that takes a while - at one point months and a beta blocker to break up the stress induced tachycardia and hypertension.
No I don't have generalized anxiety disorder - I am a doctor trying to deal with the uncertainties of being human.
George Dawson, MD, DFAPA
"This operating room was new to me; the nurses were friendly but foreign. The instruments were familiar, but somehow felt different - was there just a barely palpable increase in tension in the muscles of my hand causing this effect? The patient's blood vessels were hard, thickened from years of dialysis and diabetes. She bled more than usual when we reperfused the kidney. It felt as if every last molecule of epinephrine had rushed out of my glands and nerves, squeezing my blood vessels and taunting my intestines to detonate...." (p. 1676)
I hear you brother. I thought that level of anxiety over the balance between doing the impossible and not doing harm might fade away over the years but it has not. In psychiatry a lot of it depends on the level of complexity that your patients have. It can be an acute situation but more often than not - it is a problem throughout the day that you take home with you. Additional medical conditions, non psychiatric medications, polypharmacy, and difficult to treat disorders all compound the problem. I have designed a hierarchy to illustrate what I mean. It turns out that when I think about it, the acute problems seen by psychiatrists are not at the top. The problems at the top are typically problems where there is no good guidance, where you are on your own, left with biologically determined probabilities and you need to come up with your best estimate of what will happen given current circumstances. The problems encompass both psychiatry and the medicine associated with psychiatry.
Let me provide an example of both. In the case of the psychiatric problem the usual scenario is a case of impaired judgment. Is the person at risk for death or self injury? Are they able to cooperate with the assessment and treatment plan. Do they seem changed to the point that you can no longer accept their responses as being accurate? Are you treating them for acute and chronic suicidal ideation and behavior? Any acute care psychiatrist ends up assessing thousands of the situations across the course of their career. It is often much more complex than an acute assessment. Many of these scenarios unfold in the context of ongoing psychotherapy and in order for the patient to be able to improve some risk is taken. In other cases there are calls to warn people and in extreme cases - calls to the police to check on a person who might be in trouble. I have not seen it studied but the stress of these situations for the psychiatrist involved is well known. Overthinking the situation in order to avoid the unexpected call that one of your patients has suicided or killed someone is common. In my conversations with medical students over the years, one of the main deterrents to psychiatric residency is the worry about suicide prediction.
The medical situations are as complex and they frequently have no clear solution. A common scenario is that the person has a severe mental illness and they develop a problem that leads to to rethinking the medication they are taking. A common scenario is a person on maintenance therapy who suddenly develops a renal or hepatic problem necessitating a change in therapy. The best example is bipolar disorder and lithium therapy. Lithium remains the drug of choice for many people with bipolar disorder and it can be highly effective. When I first started to practice it was common to see people who had repeated institutionalizations for bipolar disorder suddenly stabilized on lithium. Their functional capacity was restored and they were able to return to work and establish families. In those early days, the issue of lithium nephrotoxicity was not clearly observed. There was a major study of people on lithium maintenance for decades that showed no difference in renal function. In the last 15-20 years most nephrologists agree that lithium can lead to renal insufficiency and failure in a minority of patients on lithium therapy. In the case of a person that lithium has been working well for 30 years, there is no guarantee that anything else will work as good. That translates to no hospitalizations in a long time to frequent hospitalizations every year. Monitoring that therapy and in some cases following the patient while they are in dialysis or after transplantation is on example of a situation that you can't leave at the office.
In many ways, the stress and anxiety in psychiatric practice is a measure of attempting to predict the unpredictable. Psychiatry has accurately said that psychiatrists can't predict future behavior or rare events to explain why all suicides and homicides cannot be prevented. But some sort of probability statement is inherent in all medical practice. I would estimate it still happens to me about every three weeks. Something isn't right and I don't have an exact answer. It becomes an obsession to an extent. Laying awake in bed. Getting up to do some additional research but realizing ahead of time that the yield is low. Realizing that no matter what decision you make - all of the outcomes are probably going to be suboptimal. You always get to the point where you can feel the adrenaline molecules rushing and your heart pounding. You know you are tense and starting to break into a light sweat. You readjust yourself in bed and realize your back and shoulders are as tight as a frozen hydraulic jack. You might actually check your pulse and blood pressure and find that they are elevated. It goes on like this until something happens and the intellectual crisis abates. Sometimes that takes a while - at one point months and a beta blocker to break up the stress induced tachycardia and hypertension.
No I don't have generalized anxiety disorder - I am a doctor trying to deal with the uncertainties of being human.
George Dawson, MD, DFAPA
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