Why Finger-Pointing and Self Flagellation Don't Work

This post is an effort to address some of the rhetoric that is focused on psychiatrists by other psychiatrists. It can be traced back to some of the replies posted here on this blog. But the real impetus today is a thread on Twitter. Twitter is an interesting format for studying dynamics during discussions. It has significant limitations but some of the highlights are interesting. The thread of interest started out as an exchange between myself and another clinical psychiatrist on the issue of the intensive treatment of patients with psychotic disorders specifically early intervention. My responses noted below.

In my experience two groups are overlooked that result in chronicity:
-post partum psychosis
-bipolar disorder with psychosis

Have seen both groups poorly stabilized and rediagnosed as schizoaffective and then schizophrenia.

Both need very intense effort at first diagnosis.

— George Dawson (@dawso007) July 26, 2019

What followed was a fairly rapid deterioration in this exchange. There were the usual comments about how diagnoses are really “labels” and wouldn’t it be nice if we had a different name for the label. From there things progressed to talk about stigma and how it was a significant problem that we need to address. There was also the question about the “dark past” of psychiatry and how there needs to be some kind of atonement for that. I made the basic point that I don’t come from a dark past of psychiatry and there are more positive ways to proceed. From there, one of the posters who was a psychiatrist put up references to what he meant about a “dark past”.  His references were both highly problematic. For example, in the first reference he discusses drapetomania as one of the dark chapters in psychiatry without realizing that the term has nothing to do with psychiatrists. The term is straight out of the anti-psychiatry playbook.  In a second reference (1) there is a chapter from the Schizophrenia Bulletin on the political abuses of psychiatry. There are no references to the political abuses psychiatry in the United States. I might be concerned if I was practicing psychiatry in Russia or China.  It seems that if more countries had the patient safety and civil rights safeguards in place like the United States has - the political abuse of psychiatry would be far less likely.  The arguments about atoning for the “dark past” on the basis of the provided references appear to not apply to my statement about not needing to atone for anything.

As a person who understands rhetoric and who knows psychiatry, there are plenty of historical problems that can be characterized as problematic. That is true of any medical specialty. What is difficult to understand is why a person who is practicing psychiatry is criticizing the field using anti-psychiatry rhetoric. I criticize the drapetomania reference in this post that was written by a psychiatrist defining the field of critical psychiatry (par 10).  I will attempt to summarize the arguments and illustrate my approach.

1. Everyone is biased including psychiatrists- 

My position has always been that psychiatrists receive more extensive training in recognizing and eliminating bias than anyone. That is not a popular position to take in today’s political climate where the fastest way to win an argument is to suggest than someone has an unconscious bias that only you can recognize. The overwhelming evidence that what I am saying is true is basically the training of current and previous generations of psychiatrists. Psychiatrists learn how to talk to people from all backgrounds and cultures. They learn how to communicate with people who have difficulty communicating with other doctors or even their family members. They are trained in aspects of the interpersonal relationship that allow them to analyze that relationship both diagnostically and from a therapeutic standpoint. Beyond that it should be very clear that this communication process happens every day and multiple times a day. Psychiatrists are consulted for difficult analyze problems and they make medical diagnoses - in addition to psychiatric diagnoses - based on these communication techniques.  This is the the work of psychiatry and everybody I know in the field is there because they know it and they are interested in it.

2. Psychiatrists are biased against patients with particular diagnoses-

 One of the concerns that came up was that there are certain diagnoses specifically personality disorders that psychiatrists would prefer not to treat. In clinical practice no matter what your specialty, one of the professional goals is to find a certain niche. I preferred to treat patients who were very ill and many of them had significant personality disorders. There are different approaches to personality disorders and treatment can occur without using that diagnosis as long as there is a specific problem list. The other factor is the number of resources necessary to provide treatment. It is common these days for people to be referred for dialectical behavior therapy (DBT) whether they have the requisite diagnosis or not. That explanation will not suffice for people who believe that personality disorder diagnoses are inappropriate labels that should be eliminated and that they have a problem that has no specific treatment. The reality is that current treatments work and that is what psychiatrists are focused on.

I have had other physicians tell me that they wanted to go into psychiatry, but they experienced intense emotional reactions when talking with people who had certain diagnoses. That could be a specific personality disorder diagnosis or extreme affects associated with other conditions. It highlights the fact that psychiatrists want to be able to communicate with people that others avoid and they are successful at doing so.

3. Psychiatrists should listen to people who are critical or in some cases abusive because there needs to be an “atonement” with the past-

I got a reaction from some people because of my matter-of-fact statement that there is nothing for me to atone for. Interestingly, most of the psychiatrists holding this opinion are all from the United Kingdom. Irrelevant rhetoric aside, additional analysis might be useful. The first has to do with the way the criticism is presented. In a public forum it is common for people to attack psychiatrists and suggest that they are “arrogant” because they refuse to listen to a long list of complaints. At one point, a reference was made to problematic treatment in some institution. The poster referred to the fact that a patient had died from a bowel obstruction and alluded to gross mistreatment. The problem with that type of argument is - were psychiatrists involved? What were the specifics? Where are the authorities?

Whenever people have anonymously complained about psychiatrists and mistreatment I typically ask them why they have not filed a complaint with regulatory authorities. At least I used to do that until I realized they really don’t want an answer or solution. They just want to make psychiatrists look bad. I realize that I was dealing with a lot of people from the UK, but let me discuss how things go in the United States. There are federal and state regulations on the practice of medicine. The ultimate authority and whether a physician is disciplined up to and including loss of license is the state medical board. In the state where I practice, any complaint is thoroughly investigated. That means the complaint does not have to be accurate or even coherent. If any complaint is filed against a physician, the medical board contacts them and requests all of the relevant records and a response from that physician within two weeks. A failure to respond results in disciplinary measures that may include loss of license and the ability to practice medicine. There are independent entities that report on how many physicians are disciplined in every state and encourages people to file complaints. They have rating systems that suggest whether or not enough complaints are filed against physicians. That is a very low threshold for dealing with complaints about physicians.

All physicians must apply for a new medical license every year. On that medical license physicians must attest to the fact that they do not have any substance use problems, medical problems that impair their ability to practice, and have not committed any crimes. They also have to attest that they are not under investigation by any hospital, clinic, professional organization or the board of medical practice. All controlled substance prescriptions are tracked by physician and patient. In the state where I work there is also an Ombudsman who is located in the Governor’s office and is charged with investigating complaints against the vulnerable adults. Vulnerable adults by definition include people with mental disorders, addictions, and developmental disabilities. An Ombudsman investigation is totally independent from the medical board.

I can’t say what happens in the UK, but patient safety is a priority in the US rather than the reputation of any doctor. With all the safeguards in place,  I don’t know why anyone would post information on social media about being injured or abused by any physician without going through this process.

Since most physicians in the US are employees, that is another area of oversight. Practically all medical organizations solicit physician ratings from patients being seen and aggregate those ratings around each physician. They are used to “incentivize” physicians to get more optimal ratings. They are also used to intimidate physicians into doing what their administrators want them to do. Any significant complaint from a patient or a fellow healthcare professional would result in a physician needing to meet with an administrator.  That internal employer investigation must be reported to the medical board and credentialing agencies.

In the extreme, malpractice litigation is another source of oversight but there is an admittedly a mixed agenda. Malpractice litigation occurs both in the United States and the UK, suggesting to me that with some of the extreme scenarios described in social media this litigation would be an obvious approach.

These levels of physician oversight, suggests that the complaints leveled against psychiatrists in social media have either not been brought to the responsible authorities or they don’t exist. These processes also suggest that there is no room for a “dark” present at least not without discipline or loss of license. Physicians have a fiduciary responsibility to their patients and very clear accountability. Specific responsibility is a much clearer way to approach the problem than suggesting that everyone atone for some vague injustices.

 4. There are no unique psychiatrists and you don't have to be unique to do good work –

 The final bit of rhetoric that I encountered was in the form of a hashtag #NotAllPsychiatrists. The discussant in this case was another psychiatrist from the UK who suggested that using that hashtag as an argument to counter the blanket condemnation of psychiatrists “gets us nowhere”. He was suggesting that psychiatrists should listen to all possible complaints and that by using this hashtag “it suggests we are interested in listening”.  Unless you believe that most or all psychiatrists harm patients this is an argument based on a false premise.  The hashtag itself is as rhetorical as well as the statement that all complaints should be listened to by all psychiatrists.  Each psychiatrist listens to  the patient sitting directly in front of them. They have responsibility to that person.  The psychiatrists I know are preoccupied with not making mistakes and they generally do a good job of that.   A more appropriate hashtag to counter the blanket condemnations might be #PracticallyNoPsychiatrists.

This idea is not productive in other ways.  Direct observation of my colleagues suggests that we are all uniformly trained and the idea that one psychiatrist is “better” than another is a convenient illusion subject to context. I have seen more than one mistake made when a psychiatrist was blamed for something beyond their control and their colleagues were not supportive. That seems to be the dynamic operating here when discussions among colleagues suddenly become forums for complaints against psychiatrists. It is also a convenient way to just win an argument. In other words, there is no good reason for a psychiatrist to not want to listen to complaints about the profession in a conversation that started as a professional discussion about psychiatry. Case closed!

This is some of the rhetoric used against psychiatrists in social media and unfortunately much of the finger-pointing and self-flagellation is from psychiatrists themselves. I pointed out clear reasons why it is unnecessary. There are currently plenty of more functional avenues for complaints against physicians and they should be utilized.

And no psychiatrist out there should be suggesting that they have a superior position when it comes to caring for patients or endorsing blanket criticism of the field.



George Dawson, MD, DFAPA


References:

1:   van Voren R. Political abuse of psychiatry--an historical overview. Schizophr Bull. 2010 Jan;36(1):33-5. doi: 10.1093/schbul/sbp119. Epub 2009 Nov 5. PubMed PMID: 19892821
.

Supplementary:

One of the qualifiers for this post is that psychiatric practice is being compared between the US and the UK.  Reading literature written by psychiatrists from the UK for decades I can't imagine the practice there is much different.


Graphic Credit:

The "words have power" graphic is from Shutterstock per their standard user agreement.  The artist is gerasimov_foto_174.  I thought it was very appropo for this post because many of the intense critics and in many cases maligners of psychiatry have power as their predominate focus. Most psychiatrists don't see the world that way and in fact realize that in most cases we are lucky to be able to secure the most appropriate treatment for our patients.

Current Treatment of Respiratory Viruses - More Homilies

With Permission: SIB Swiss Institute of Bioinformatics,
Philippe Le Mercier, ViralZone.

My Facebook feed got me going today.  I get the Mayo Clinic feed since I consider their clinical care and some of their research to be the best in the world.  Of course social media is much less rigorous and sometimes it comes down to just advertising and promotion.  That was my assessment of the link to this document this morning.  It is a business document that purports to give advice on how to decrease your chances of a respiratory infection this winter.  Some of that advice is given by a Mayo Clinic Infectious Disease specialist and a Cleveland Clinic family physician.  There was one number I had not seen before and that is the Number Needed to Treat (NNT) for the flu vaccine is 40.  Forty people need to be vaccinated to prevent one case.  The advice is the usual set of homilies about respiratory infections including get the flu vaccination, wash your hands, sneeze into your sleeve, take care of yourself and stay home of you are sick.  In other words, there is no way in hell that you are not going to get sick at least once this winter.

Our continued 1950's approach to viral infections remains a mystery to me.  Certainly there are technical problems with trying to design vaccines for over 200 viruses that can cause the common cold.  But the reality is, vaccine design for influenza virus - easily the most lethal of these viruses is obviously not so hot.  As far as I know, vaccines for the most common of the cold viruses - Rhinovirus - is non-existent.  Anti-viral medications for respiratory viruses are more controversial.  Looking at the most popular one Tamiflu or oseltamivir.  The NNT to prevent one death may be 1,800 - 3,200.  The NNT to prevent one hospitalization may be 97 to 142 depending on criteria.  The NNT group suggests somewhat better NNTs of 36 and 83 for preventing a culture positive case of influenza and preventing pneumonia respectively.    Contrast that with the NNT for antidepressants of 5-10 as determined by Leucht, et al (2) in their comparison to other medications for various medical conditions.  And you thought antidepressants were ineffective?

Infectious disease respiratory virus research is a goldmine for all of the Luddites out there.  There are a number of web sites that provide free access to just about everything you ever wanted to know about every virus known to man.  The viral particle shown at the top of this page is the order that contains Rhinoviruses one of many common cold viruses and one of the viruses that may be responsible for the expression of asthma in predisposed individuals or exacerbations of asthma in asthmatics who are asymptomatic.   This illustration is from the ViralZone, one of many free online databases with detailed information about the molecular biology and genetics of viruses.  If I was an aspiring Luddite wanting to be provocative about the field of medicine being stuck in the 1950s despite the availability of all of this advanced information - this would be a logical place to start.

In previous posts here I have also critiqued the lack of attention given to environmental approaches to respiratory viruses and the fact that the airborne nature of some of these viruses is not acknowledged - possible because airborne viruses are not contained by hand washing and other direct contact techniques.  It s well know that viruses can be collected in the heating and air conditioning systems of public buildings and that altering the humidity and air flow characteristics in those buildings can change the viral concentrations in the air.  Whenever I have mentioned this to the administrators of buildings where repeated respiratory epidemics swept through the staff - I got the same response that I received from an airline after I reported a severe respiratory infection after one of their flights: "We are really sorry that you had flu-like symptoms after your flight and look forward to your future comments to help us improve our service."

What?!

 Time to get serious about respiratory infections and come up with some effective interventions.  Effective medication to prevent viral replication and spread in the infected and to create barriers to infection would be ideal and so would environmental methods to reduce the infection rate.  Considering the strong incentives in America to work while sick and considering that the average worker is going to get 2 to 3 respiratory infections per year that can last up to 3 weeks in duration means that very few of us and the patients that we treat are not going to be exposed and infected.  With the current advanced knowledge of the pathogens and modern heating and air conditioning systems it seems like a lot more could be done right now.


George Dawson, MD, DFAPA


References:

1:  Postma MJ.  Re: Tamiflu: NNT to prevent a pandemic flu death may be a million.  BMJ 2005; 331:1203.

2:  Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012 Feb;200(2):97-106. doi: 10.1192/bjp.bp.111.096594. Review. PubMed PMID: 22297588.


Attributions:

Graphic at the top of this post is courtesy of: SIB Swiss Institute of Bioinformatics, Philippe Le Mercier, ViralZone.  http://viralzone.expasy.org/  licensed via Creative Commons Attribution- NonCommercial 4.0 International License.

Cochrane Distances Self from Critic

The Cochrane Collaboration came out with this press release to point out that one of their collaborators was posting his psychiatric criticism outside of his role in that organization.  The critic mentioned in this release has written this blogger in response to my critique of his criticism of psychiatry.  My response elicited a significant amount of derision directed at me from his apparent supporters.  That led me to modify my policy on posting comments. I believe that he posted a response to my response on another blog or blogs that I never read.

While I am no great supporter of Cochrane and consider their site to be somewhat redundant, non-productive, and lacking creativity and innovation, it is obviously in their interest to distance themselves from statements that they do not consider to be in their best interest.  For links to the exchanges on this blog with this critic, they are included in these two posts:

http://real-psychiatry.blogspot.com/2014/02/an-obvious-response-to-psychiatry-gone.html

http://real-psychiatry.blogspot.com/2014/02/the-proud-critics-of-psychiatry.html

Apart from the obvious, the more I thought about the last sentence in this release, the more it bothered me:

"There is a wide range of views within Cochrane on the benefits and harms of psychiatric drugs...."

That is an interesting perspective from an organization that is supposed to objectively interpret the evidence.  Are there an equally number of "wide range of views" on other types of medication or just the ones used by psychiatrists?  It leads to questions about whether there are psychiatric experts and people who actually prescribe the medications writing these reviews or if anyone can do it?  I could make the argument that many if not most of the summary statements seem like they are written by the same person or committee.  It also leads to the question about the political nature of these documents.  Could the specified critic for example reformulate his criticism according to the Cochrane format and publish it in their library?  Are Cochrane documents ever a compromise of a "wide range of views"?  Is there anyone at Cochrane who is aware of the additional levels of criticism that psychiatric practice is subject to and the rhetorical nature of that criticism?  I think that these are all important questions if you are concerned about being perceived as having a partisan position.  Of course most critics of psychiatry could care less about being partisan or even the appearance of being partisan, but they are generally not selling objective analysis.

Just this year, I lost access to a library database that I had previously accessed for years. I had to try to access Cochrane Reviews directly through a large publisher's web site. I was confronted with the prospect of purchasing the individual articles or an entire year long subscription through that publisher. They also have an open access model where authors can pay significant fees to have their articles published in an open access mode.   The Cochrane Library is a published product just like anything else, subject to all of the conflicts of interest of a published product.

That is an additional perspective to have when reading the release.


George Dawson, MD, DFAPA

Evidence Based Urgent Care

I went in to urgent care today after battling an influenza-like illness that I got on a trip to Alaska, most likely in the flight home.  The symptoms are charted in the above graphic.  Without providing too much graphic detail on the symptoms, my concern was in whether or not I might have pneumonia and needed a chest x-ray.  Although I knew this was most likely not an influenza virus, the symptoms were fairly severe.  As an example, on last Saturday August 15, I had diffuse muscle pain that was so severe, I could barely move.  In the two days I took time off from work August 18 and 19, the muscle pain was restricted to chest wall muscles.  The cough had also become productive over the past 5 days.  I thought it was reasonable to get it checked out, especially against a backdrop of asthma and chronic asthma therapy.

I took my graphic along with me and showed it to the nurse and the physician.  I told her that I had bronchitis that was probably caused by a respiratory virus.  The nurse was overtly uninterested and at one point said that all she needed was a single symptom to write down and that symptom would be cough.  As she continued writing, she kept glancing at the graphic and taking additional notes.  I wanted to say: "Just scan it in and you can stop writing.  It contains almost all of the information that you need to know."  But I didn't.  I maintained standard medical office decorum.  As Seinfeld once said: "You go from the large waiting room to the smaller waiting room and wait again to see the doctor."  The nurse took all of my vitals including an oxygen saturation and stated matter-of-factly: "They're all normal."  My enthusiastic reply of "Good" was met with dead air.

The doctor walked in and I gave him a brief history.  He looked at my graphic and wrote down a few words.  He listened to all of my lung fields with a stethoscope and then listened to my heart sounds - both through my shirt.  The entire history and exam took about 5 - 10 minutes.  And then:

"You have bronchitis.  There is probably a lot of inflammation in there.  I am going to prescribe prednisone and an antibiotic.  Levaquin is a good one for this.."

At that point, I told him that I was already on two QTc interval prolonging drugs and that Levaquin might not be a good idea.

"OK then I will look up another antibiotic.  Doxycyline is one that should work.  Yes - there is no interaction between doxcycline and your medication.  Any other questions?"

I asked him about the issue of a chest x-ray.  I had three in the last two years and it seemed like the decision was a coin toss.

"I don't think so.  You have sounds all over your lungs and not in one place in particular.  If it doesn't get better I would do a chest x-ray.  Right now it is not going to change what I do."

I walked out with scripts for doxycycline 100 mg BID x 10 days and prednisone 40 mg QDAY x 5 days.  Entire length of the visit with the RN and MD about 15 minutes and I was the only patient in that clinic.

Of course all during this time, I was comparing the topology of this medical visit and medical care to the common uniformed criticisms of psychiatric care.  Just this morning and totally out of the blue somebody sent me a link to their letter in the British Medical Journal about the fact that 70% of clinical trials of paroxetine were unpublished.  He sent it in response to a post that I had made here some time ago, and apparently was unaware of the fact that I figured out that paroxetine was not a drug that I cared to prescribe by the time I had prescribed it to a second patient.  It should be obvious that unpublished clinical trials have been a significant problem in medicine for some time and that is nothing new in psychiatry.  Seems like the prevalent bias against psychiatry rearing its ugly head again.

How about the longstanding claim that psychiatric diagnoses are not valid because there is no "test" for them.  What was the "test" I got for bronchitis?  Of course there was none.  A diagnosis of bronchitis pretty much depends on the symptoms that I walked in with.  The same symptoms on the graphic that seemed to be shunned by the RN and casually interesting to the MD.  None of the measurements in the office had anything to do with bronchitis.  They were all essentially measures to look at whether or not I had any more significant disease - actually a more significant syndrome.  When I was an intern, we thought we had a more scientific way to analyze the problem.  We would obtain sputum samples and Gram stain the samples and culture them.  Once the integrity of the respiratory epithelium is disrupted there are all kinds of bacteria that colonize the area.  The sputum samples were not useful - either in terms of pathogenesis or guiding antibacterial therapy.  Thirty years later, antibacterial treatment of bronchitis is still empirical.  No specific pathogen is identified.  The thinking used to be that sputum indicated a bacterial infection, now we know it is just sloughed epithelium from the cytotoxic effect of viruses.  Empirical treatment of bronchitis is really no different than empirical treatment of any symptom defined mental illness.  Ignoring a couple hundred specific respiratory viruses is reminiscent of a hostile criticism of psychiatric nomenclature: "It is all one disease."  By comparison, acute bronchitis is also one disease.

Another interesting comparison is symptom severity.  I spend a lot of time discussing and documenting this with psychiatric disorders.  In the case of bronchitis, there was no particular interest in severity.  No questions about subjective experience, patterns of the cough, or sputum production.  You either have it or you don't.  Of course, I know that pattern recognition was in place and the physician was looking for signs of more significant illness like tachycardia, tachypnea, diaphoresis, and cyanosis.  But there were not any questions about functional capacity and how I was being affected (again more info in the graphic.)  Psychiatric diagnosis and treatment requires close attention to severity, impact on functional capacity and sleep, and whether the symptoms are in remission.

What about the "evidence basis" of the treatment?  A charitable interpretation of the e-mail about paroxetine would suggest that author was critical of the evidence basis for its use.  It is well known that over half of the drug studies from ClinicalTrials.gov are unpublished and that a significant number of the published trials omit details of interest (3) like side effects.  That same study looked at trials in 7 different medical specialties, none of them psychiatry.

It turns out that in clinical trials those adults with acute bronchitis treated with antibiotics are less likely to be rated as improved at follow up.  Some studies show a shorter duration of cough by 1/2 day but the trade off is a significant increase in antibiotic side effects with 19% of emergency department visits for adverse drug effects being due to antibiotics (1, 2).  A direct quote from UpToDate:

"Patients with known asthma may develop superimposed acute bronchitis.  It is common that such patients seek treatment and are inappropriately prescribed an antibiotic even though they usually have a viral illness."

The UpToDate review also looks at the associated issues of overprescription of antibiotics, the 20 year CDC initiative on antibiotic overprescribing that has essentially failed and the dire consequences of developing multiple antibiotic resistant bacterial strains.  My purpose here is not to imply anything about my treatment, but to illustrate that these practices are common and there is no equivalent amount of criticism similar to that targeted at psychiatric care.  In fact, if I wanted to take on the role of pseudopatient, I could walk in to any clinic or emergency department and walk out with the same prescriptions - even in the absence of acute bronchitis.  I could simply lie about the symptoms.  Nobody is going to ask me for a sputum sample, and 6/7 asthmatics have residual wheezing that can be picked up on a cursory exam.  Of course there would be public outcry.  I would be accused of lying to hard working physicians and wasting their time.  But that same poorly conceived idea is still cited as evidence against psychiatric diagnosis.

Unlike the unrealistic critics of psychiatry, my goal here is not to embarrass anyone, or illustrate that I am better than anyone.  But how is nonpublication of clinical trials of paroxetine (a drug that I have not prescribed in over 20 years) a problem with psychiatry?  Nonpublication of clinical trials is obviously a problem for everyone.  The poor quality of current clinical trials technology is a problem for everyone and unlike the Cochrane database, I don't see the point in the exhaustive documentation of predictable low quality results - at least not much of a point.

I am also not about to attribute the differences in practice and clinical trials to the art of medicine.  This is a problem of analyzing huge amounts of data in biological systems.  There are widespread problems with clinical trial design in every area of medicine because they cannot analyze that data.  Contrary to being a "gold standard" there needs to be better stratification of heterogenous diseases whether that is depression or bronchitis.  We can only have more specific treatments when we have better characterized molecular pathology and the treatments to target that pathology.  That includes markers that would suggest which patients would respond to drug treatment and which would not.  There is a promising biomarker for bronchitis that should be treated with antibiotics right now, but it is not widely studied or widely available.

The highlights of this post have really not changed since I began pointing out that psychiatry is singled out for criticism by various people with various motivations.  Looking at the facts in this post should leave little doubt that this is merely a continuation in this trend of unrealistic and unfair criticism consistent with the dynamic I outlined in the past.

Some things just don't change.


George Dawson, MD, DFAPA



References:

1:  Thomas M. File.  Acute bronchitis in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 23, 2015.)

2:  Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014 Mar 1;3:CD000245. doi: 10.1002/14651858.CD000245.pub3. Review. PubMed PMID: 24585130.

3: Riveros C, Dechartres A, Perrodeau E, Haneef R, Boutron I, Ravaud P. Timing and completeness of trial results posted at ClinicalTrials.gov and published in journals. PLoS Med. 2013 Dec;10(12):e1001566; discussion e1001566. doi: 10.1371/journal.pmed.1001566. Epub 2013 Dec 3. PubMed PMID: 24311990



Supplementary:

Graphic updated daily for the course of the illness:

This illness finally cleared at about Midnight on August 28, after 16 days.  The "common cold" typically lasts 2 - 3 weeks and is a significant cause of morbidity in this country.  I hope that I have also illustrated that it is also a problem in terms of treatment and a lack of real public health measures to reduce the spread of these viruses.

I Don't Need Your Vote

Apple’s CEO Tim Cook came up with quote last week and I thought it was a good one:

“I’m not running for office.  I don’t need your vote.  I have to feel myself doing what’s right. If I’m the arbiter of that instead of letting the guy on TV be that or someone who doesn’t know me at all, then I think that’s a much better way to live.”

The original article began with an introduction about how Steve Jobs took a lot of heat and a lot of praise to protect the executives focused on Apple’s business and products.  Observers also note the activities of so-called “activist investors” trying to influence the management of the company into buying back stock for a quick short-term gain.  Cook is clear that he is all about long-term results and he is accountable for those results.  The same logic applies to what I do and have done for the past 30 years.  On the financial message boards there is constant noise with news and analysis of whether the stock price is going up or down.  After watching those trends it is clear that nobody knows the trends and that far fewer people know anything about the technology.  Many of those posts are placed there to manipulate opinion.  The critics don't know Tim Cook and the critics don't know me and clearly seem to have never met the psychiatrists that I know and work with.  Let’s take a look at how the so-called critics of psychiatry compare with the critics that Cook is addressing.  They can be broken down into several classes:

1.  The professional critic – criticism generally takes the form that I have special knowledge that no other psychiatrist has.  That knowledge can vary from the totally absurd (there is no such thing as mental illness or I am the only person to keep psychiatry honest) to more plausible exaggerations (I am the only person who can do this therapy, detect this side effect, prescribe this medication, etc.).  There is some legitimate criticism but it tends to be very rare.  I think the sheer number of internet articles by the same author saying the same thing may be an indication of volume substituting for quality.  The obvious message in many of these articles is that I am unique and everyone else is either ignorant, crooked, or stupid.   There are varying levels of conflict of interest (books, speaking engagements, the hero worship of various hate groups).  These critics are magnets for the haters of psychiatry who see them as modern day heroes and generally ignore the conflict of interest issues that their heroes use to criticize others.

2.  The journalist looking for an angle – the overall bias of journalism against psychiatry is well documented and wide spread.  Looking to sell papers or in these days mouse clicks is an obvious motivator.  In some cases the journalists just jump to books and web sites as sources of revenues and fame.  Even the most charitable interpretation of their work will note the obvious flaws.  Considering the DSM-5 a treatment manual or overestimating the impact of the DSM-5 when in fact most primary care physicians never use it are good examples.   While telling psychiatrists what their problems are when they have completely ignored the biggest stories in mental health for the past three decades that really have nothing to do with psychiatrists.  Those stories are how managed care companies and state and local governments have decimated the care for people with severe mental illnesses and addictions.  They have only recently picked up on stories related to incarcerating the mentally ill and trying to provide them psychiatric services in jail.  Not a stellar job of mental health reporting over the past 30 years.  As in the first category, some rare legitimate criticism exists.   

3.  The injured patient – certainly the treatment of psychiatric patients has the potential to cause injury like any other medical treatment and injuries do occur.  As I have posted several times on this blog, anyone who takes a medication that is FDA approved is at risk for side effects up to and including death.   As I have pointed out here (where you will not see in many other places) – the FDA decision can be purely political rather than scientific.  As a result, any medical or psychiatric treatment should be entered into very cautiously.   I have also posted here (and you will not see this in many places) that nobody wants to take a non-addictive medication and that people are generally hopeful that it will provide relief from a miserable condition.  I do not believe that people take any medications, especially psychiatric medications lightly.  I have outlined my clinical method to minimize side effects and adverse events.  Even with that high level of caution, side effects and adverse events will occur.  There are no shortage of remedies that can be pursued at multiple levels.  Most people resolve the problem immediately with their physician.   In the case where medical organizations are involved there can be direct complaints to the medical administration, hospital authority, or patient advocates.  At the state and licensing level complaints to the state medical boards and in some cases complaints to a mental health ombudsman can be made.  There are obviously malpractice attorneys.  Injuries caused by medical treatment are legitimate reasons for complaints and criticism but at some point I would hope that it would lead to a solution to a real problem.  I would also hope that nobody is compelled to sacrifice their medical confidentiality for the purpose of a complaint.

4.  The severely personality disordered – there is no good way to say it, but there are people who are very hostile to other people.  In many cases they aggregate around psychiatrists because that is where everyone else tends to send them when they cannot be dealt with.  Like any group of people in contact with psychiatrists, the vast majority of people with personality disorders are able to work on their problems in a productive way and do not turn treatment into a series of personal attacks.  But there are also the small fraction that do.  In many cases they target psychiatrists (and others) and their anonymous criticism is frequently irrational, heated and in some cases threatening.  They can attract like-minded people.

5.  The professional critic who is not a psychiatrist.  I posted my earliest experience of an irrational response by an attending physician when he learned that I was going into psychiatry.  In today’s politically correct landscape it would be classified as harassment and abuse.  Practically all of the psychiatrists I know have similar stories.  In fact, I personally have several more.  The unexamined irrational hatred of psychiatrists is just a fact that any psychiatrist has to deal with.  But when I hear a medical professional come up with some blanket statement about psychiatrists that is what it is all about.  I have examined in a previous post the basis for these generalizations.  Most physicians are at least are circumspect about why they did not go into psychiatry.  Most of them tell me they don’t want to deal with lethal violence or deal with the severely personality disordered.  Unless somebody points out this unexamined irrational thought pattern for what it is – it will never be corrected.  See my previous comment about it.  Or as the kids say these days haters be hatin' and leave it at that.

6.  The people who bristle when psychiatrists speak out against irrational criticism or even offer an alternate explanation are an interesting lot.  Some blogs seems to attract a lot of them, but I don’t frequent the more hateful blogs.  They are a self- righteous lot that looks as far as their own information.  They generally ignore any contradictory information and stick to their story or accusations.  They will attempt to bury any psychiatrist pointing that out with righteous indignation and sophistry usually by invoking victimhood  ("Noooo we are not antipsychiatrists – stop calling us that name!"),  hero worship ("You just aren’t as good as the psychiatrists who we agree with!") or the usual appeals to emotion ("It is so pathetic that these psychiatrists are just so (ignorant, evil, etc) and they just can’t accept our “facts”").  You can apparently say anything and really believe it is true.  Just so nobody forgets – it is true that psychiatrists are bogeymen.

Boo!

I am an experienced psychiatrist with 30 years of experience.   I have specialized in treating the toughest problems and the problem of lethal violence and severe mental disorders, often with significant medical comorbidity.  Like a neurosurgeon said to me at a serious point: “You guys treat the toughest problems that nobody else in medicine wants to treat.”  I have treated many more people than are mentioned in “case reports” and at this point in entire clinical trials.  I have as much experience as anyone in the safe and effective treatment of these disorders.  I encourage people to not tolerate side effects, use psychotherapy, and to be comfortable with the idea that I should be able to answer any questions they might have about my assessment or treatment recommendations.  Like all physicians I have much higher levels of accountability than most other professionals.  Like all physicians there is a rare day where I am not being harassed by someone who thinks they know how to do my job better than I do usually because it suits their business interests.  And I am the one with no conflicts of interest.  This is a non-commercial blog.  I have no books to sell.  I have no financial connections to any industry.   I couldn't care less if anybody ever paid me for my opinion.  So it should not be too surprising when I say:

I don’t need your vote.  I know what I am doing and that has been substantiated time after time – tens of thousands of times.  Further, I know how to read research and interpret the findings as opposed to the general lack of scholarship from those who assume they know more about my job than I do.  There are a handful of psychiatric experts that I consider to be authoritative and none of them are the usual media critics.  In fact, some of the media critics aren’t even psychiatrists and it shows.  But the best part is I am no different from my other colleagues that I consult and collaborate with every day.

They don’t need your vote either.

George Dawson, MD, DFAPA

Marketing, Advertising, and Safeguarding Objectivity

blame (third-person singular simple present blames, present participle blaming, simple past and past participle blamed)

1.     To censure (someone or something); to criticize.  [quotations ▼]

2.     (obsolete) To bring into disrepute.  [quotations ▼]

3.     (transitive, usually followed by "for") To assert or consider that someone is the cause of something negative; to place blame, to attribute responsibility (for something negative or for doing something negative).

To provide context for this post, I refer any interested readers to the previous post and the comment by Steven Reidbord, MD.  I started typing up a response and decided to just continue it into this post.  I like to post things in regular blog format, because the comment section is uneditable and I make frequent spelling and grammatical errors.  My intent is to provide my perspective rather than disprove any of Dr. Reidbord’s points which are basically critical points about assigning blame, the standard of proof that physicians are affected by marketing and advertising, assertions about the connection between all of the marketing components and the profits of pharmaceutical companies and the need for physicians to “safeguard” their objectivity.

On the issue of blaming Big Pharma, of course they have done all of those things.  I would expect them to because that is typical behavior of corporations.   There are some people that believe this indicates that all corporations are evil.  There is also a blanket level of condemnation of the industry independent of any specific legal charge or incident.  You can certainly find rhetoric against all industrial sectors.  Nobody seems to acknowledge that governments have developed this landscape, including a regulatory landscape that encourages individuals to take risks without worrying about any personal or criminal penalty.  Litigation for large corporations is seen as the cost of doing business.   It seems that if anything, the law is written to incur legal activity and legal fees.  It is probably no accident that most lawmakers are attorneys.   I am no more outraged about Big Pharma corporate behavior than I am about any other industry. 

Before anyone tells me that medical industries are somehow different because they deal with peoples’ lives, if you think about it numerous industries deal with peoples’ lives.  Some are actually toxic to peoples’ lives.  Others  (like medicine) have affiliated professionals with professional responsibilities but unlike physicians those professionals (who also work with industry and receive benefits from the industry) are seldom scapegoated because of it. 

On the issue of marketing, I have made the same arguments that Dr. Reidbord makes to Big Pharma critics for at least a decade.  I am usually met with the response that physicians have a higher calling and that we must somehow place ourselves above advertising so that we are not commercially influenced.  The corollary is all of the “proof” that advertising and marketing influences purchasing and therefore prescribing behavior.  There are many problems with the analogy and that argument.  First, the proof generally refers to a fairly loose body of literature with poorly stated hypotheses and experimental designs that are either nonexistent or inferior to any clinical trial designed by Big Pharma.  I am happy to entertain any evidence for this connection in the event that I have missed something.   Apart from lack of the experimental evidence, it defies common sense.  I am unaware of any multi-billion dollar product-based industry that thrives on advertising an inferior product and not backing it up with anything.  To use the automotive example, if I unwittingly purchase a Toyota based solely on a flashy ad and discover it is a lemon, I may conclude that this is an aberrancy or that all Toyotas are lemons.  Either way they are unlikely to find me as a future customer.   That is not a sustainable business model.  The general assumption about pharmaceuticals is that physicians don’t seem to be able to self-correct by noting deficiencies including a lack of efficacy during hundreds or thousands of prescriptions.  I find that to be much more likely that noting your car is a lemon.  With prescriptions physicians are professionally accountable to purchasers.  That is a higher standard than losing time or money on a car.  Second, if I respond to marketing and go down to my car dealer for a $500 cash rebate, 0% financing, or some other incentive, I will not be placed in some national database that can be used to suggest that I am morally inferior to physicians who are not in that database.  Oh sure,  there will always be the usual disclaimers that being listed in the database is really an appearance of conflict of interest rather than actual conflict of interest, but the implication of wrongdoing is palpable and usually evident by what is being written about this list.  Third, the reality of a general lack of effective medications is never really acknowledged.  I have never seen a study about marketing pharmaceuticals that takes that into account.  It is common in clinical practice even before the advent of DTC advertising to see patients who were desperate to try the next new drug on the market.  In many cases we are still looking for a reliable car in a field of Yugos.  We are not looking for a Corvette.  Does that mean we have been influenced by advertising?  Does that mean that the patient/consumer has been influenced by DTC advertising?  It may simply mean that we are faced with a large number of drugs with a lack of uniform efficacy and significant toxicities.  Fourth, there is an overgeneralization of an imaginary boundary problem between pharmaceutical companies and physicians that seems to flow from the marketing rhetoric.  Suddenly companies are not only marketing drugs, they are selling medical diagnoses and treatment guidelines.  Managed care companies and PBMs get a complete pass on this issue and the idea is that the Big Pharma-Physician alliance is in lock step to sell as many drugs as possible.  That is a rather pathetic characterization of the problem and the pat solution of cutting all industry ties is an equally pathetic pseudosolution.   I do consider the business end of Big Pharma to be marketing and advertising.  I think the effect of that marketing and advertising is a vastly overstated political argument.  I think it is hubris to imagine that physicians can’t self correct in the way that any consumer self corrects when purchasing any advertised product.

With regard to what is necessary – like most criticism of Big Pharma nobody is ever really explicit about their meaning.  Practically all articles written about Big Pharma marketing/advertising tactics especially those that involve physicians imply that everyone in that chain of events is working to enhance the bottom line of the pharmaceutical company.  Working for the monied interest of a pharmaceutical company is the conflict in conflict of interest. If you are asking the question: “Who said this was necessary?” I guess my answer would be; “Just about everybody.”

The last question that I hope to address is the idea of “safeguarding” one’s objectivity.  In the previous response the idea was that the physician psyche is so frail and easily persuaded that we need to avoid all contact with Big Pharma advertising.  If that is the case there are many other sources of discordant special interest information that we should avoid like the plague including less competent attending physicians and colleagues, less dynamic medical school lecturers, all forms of managed care, most hospital and clinic administrators, most media outlets and most federal regulations on billing, coding, and documentation.  Off the top of my head I could add previous standard medical practices like the Swan Ganz catheter,  massive back surgeries for back and neck pain, chronic high dose prednisone for COPD,  and meperidine injections for migraines.  The list is endless.

If my objectivity was that tenuous I would be sitting in a dark room somewhere practicing psychiatry the way it is described in the New York Times.   I would be depending on a blog or pious journal editors to keep me honest!  
   

I have no conflict of interest to declare.  I have rigorously avoided Big Pharma advertising and detailing long before it was fashionable to do so.  My interest in avoiding Big Pharma advertising was that I found it to be disruptive, annoying, and demeaning - largely to the reps seen lugging food up and down hospital and clinic hallways.  I will probably never consider myself too stupid to figure out advertising even at the purported mind-control levels.  If anyone reading this disclosure doubts this statement – feel free to look for my name in the database of corrupted (or not) physicians.
 

As a further point of disclosure, I drive a Toyota.  I have a general policy of driving a car until the 150,000-200,000 mile mark and then buying a new one.   I find that by that time most cars have multiple systems that start to fail and it becomes a long series of expensive repairs and safety problems.   I have been driving Toyotas for 10 years and that follows a long line of Chevrolet, AMC, Plymouth, and Pontiac products.  Irrespective of the advertising, my personal experience is that it is the most reliable and cost effective ride for the money. 

Those are my only interests in both Toyotas and new pharmaceuticals. 

  

George Dawson, MD, DFAPA

Supplementary 1:  Posted definition at the top is from Wiktionary per their open access agreement. I intended to use it here more as a graphic than text as a lead in to the article.  

Supplementary 2:  For anyone considering a post here as a comment - please consider composing your comment in a word processor and cutting and pasting it in here.  The comment section on Blogger is not a reliable area to compose and edit comments.  I have lost several myself and the text may be too small to edit.  If the comment appears to have been posted but it does not appear - please send me an e-mail.  It occasionally gets diverted to a spam folder and I can still retrieve and post.