Happy Labor Day 2023!

 

Over the years of writing this blog I have put out a Labor Day message to describe any progress in the physician workspace in the past year.  The practice environment for physicians has deteriorated significantly over the past 3 decades and those changes are generally locked in by the healthcare business managers backed by both Congress and state governments. I have used the following graphic several times on this blog to illustrate what happened over specific time frames and it is probably time to add some additional details.

The impact of managed care on medical practice has been clear for the past 30 years.  In many cases that model is being adopted by physicians in private practice settings. For example, it is common now to see a specialist initially but in follow up see one of the physician extenders working with them. That can make health care a lot less personal and it leads me to think about the reason why physicians are trained to provide continuity of care in the first place.

But even more than that issue is the explosion of online services provided for flat rates that focus on seemingly basic problems in exchange for payment. On my streaming services that typically involves a company that offers prescriptions for depression, anxiety, hair loss, and erectile dysfunction.  A second company offers beta blockers for performance anxiety.  Given the side effect potential for these medications – I am curious about how comprehensive the initial evaluations are and the follow up visits.

I was recently hospitalized and had a first hand look at what the modern hospital workplace looks like.  When I was in training there were discrete teams by specialty and they consisted of physicians at all levels of training.  A typical team might have 1-2 med students, 1-2 interns, a resident, a senior resident or fellow, and the attending. The work load would depend on whether your service admitted people to the hospital (typically internal medicine, surgery, neurology, renal medicine, cardiology, psychiatry) or consulted to those teams (infectious disease, endocrinology, pulmonology, rheumatology, cardiology, psychiatry).  The admitting services were the most intense because of irregular admissions and complicated unstable patients. Teams generally had places to meet, where patients were presented to the attending and there were formal didactics. Bedside teaching occurred on rounds.

During my hospitalization, I was not seen by a single physician in my room. When I went out into the hallway, both sides of the hall were lined by people facing computer screens. There was one consulting team standing outside a patient door – visible only because it was obvious the fellow and attending were discussing cases. The level of crowding was striking and it left me with the impression that all these people could not possibly be physicians.  Managed care shaped the form of these teams and who was in that hallway. First, they eliminated the usual admitting services and replaced them all with hospitalists. Then they replaced at least some physicians on those teams with non-physicians. Those moves benefit business decisions but I have not seen a single adequate study on the impact it has on medical care.

Training physicians in hospitals has typically involved hands on learning, consultation from senior and expert physicians, and active learning environment, and in many cases the opportunity for research.  All these areas need to be preserved in the practice environment in order to stimulate practicing physicians to maintain high standards. An environment that leads to burnout, sleep deprivation, and moral injury is not adequate to the task. The question always has been whether physicians have any kind of leverage that could lead to appropriate modifications. That question has never been put to the test and in fact, healthcare organizations in the United States generally flaunt their power over physicians rather than attempting to negotiate with them.

Will a union make a difference? My experience with unions started out in my family of origin.  My father was a member of the Brotherhood of Locomotive Firemen and Engineers (BLFE). He worked as a locomotive fireman and then an engineer.  He had to be a union member in order to work.  He generally was not very happy about it. The railroad industry was run on a seniority system and as railroad utilization decreased – younger workers like my father had a difficult time finding job assignments. Even though they were technically employed by a railroad and reimbursement for the work was good, it seemed like only the most senior engineers benefitted to the point that they could make a good living.  As a result, the contracts negotiated by the unions did not mean that much to my father. He also tended to see the union as corrupt because, the union officials clearly made far more than he was making trying to work in their system.  Railroads unions were also compartmentalized - so a strike against one railroad did not mean a strike against all.  As a result, workers from the railroad that was the object of the strike could work for competing railroads during the strike. If similar rules apply to physicians a uniform practice environment is no guarantee, but the onerous aspects might be eliminated.   

Unions for physicians and residents are becoming increasingly popular but they have more restrictions that in a blue-collar environment. The National Labor relations Board (NLRB) enforces the National Labor Relations Act (NLRA) and decides what public sector employees can form unions (1). Independent contractors, supervisors, and managers are excluded because the focus of the act was on laborers. The general categories are loosely defined so it takes an NLRB investigation to determine who can be in the union. Tenure and tenure track employees were eliminated by a Supreme Court ruling. Only salaried employees who do not do a significant amount of supervision are allowed to be union members. If a union is allowed, the goals in terms of collective bargaining, representation, and impact on hospital policies need to be determined.  Although the momentum for unions is building, there is a considerable amount of inertia from the managed care era. During that time, we had many physicians who were eager to escape a deteriorating practice environment to become administrators and basically enforce business policies. It remains to be seen if unions can have a favorable impact on local health care policy and practices – but just establishing more is a step in the right direction.    

More resistance to Maintenance of Certification by various boards and the American Board of Medical Specialties is also growing. I went to the alternate system National Board of Physicians and Surgeons (NBPAS) certification in 2018 and have not looked back. At the same time, I realize that I was outside of any system demanding that I recertify through an ABMS board and as a result – in a unique situation relative to younger colleagues. A petition was started in July to end ABMS MOC and so far there are 20,000 + signatures. There was an initiative in the APA to stop MOC about 10 years ago, but the administrative process prevented it from being put on a ballot. The basic problems with MOC is that there is no evidence it is necessary for quality care, in fact most health care organizations have abandoned true quality programs. Second, it is not reflective of clinical practice. Most physicians – even generalists end up in a niche and focus their educational efforts and mastery in that area. It makes no sense to keep taking examinations outside of that area. Third, it is a substantial time and financial commitment and it clearly generates a lot of revenue for ABMS specialty boards. Fourth, there is some suggestion that MOC should be tied to state licensing (Maintenance of Licensure or MOL). This would allow states and health care organizations even more power in controlling physicians – even during their private times when they would need to spend time studying for barely relevant examinations. Elimination of MOC is another positive step in the direction of restoring a more reasonable practice environment.

Beyond a better practice environment and what it takes to make that politically – the profession of medicine is at stake.  I have written about a lot of the technicalities – but this is deeply personal. Going to medical school and studying medicine was the best thing I could have done with my life. By identifying with the practicing physicians in my various training programs I learned how to live and breathe medicine and psychiatry 24 hours a day. Always thinking about it, never far from a journal article that I wanted to read, and always focused on how that translated to clinical practice – usually a very hard problem I was seeing in practice. From the very first patient contact, the importance of communicating with people in an empathic, unhurried and comprehensive way was obvious.  We cannot afford to lose that transformative effect that medicine has on people.  We cannot dumb things down for the business world and make human biology less complex. I know there are many docs out there that think like me.  Whether we can unionize or cancel MOC – we can never lose sight of the fact that we need to preserve a transformative profession for the sake of future generations of physicians and their patients.

 

 

George Dawson, MD, DFAPA

 

References:

1:  Bowling D 3rd, Richman BD, Schulman KA. The Rise and Potential of Physician Unions. JAMA. 2022 Aug 16;328(7):617-618. doi: 10.1001/jama.2022.12835. PMID: 35900755. 

The True Big Pharma Backers Show Themselves

 

Here is a hint – they are not psychiatrists or even physicians.  They are Republicans.  That may come as a shock to those of you who have absorbed all of the pharma conflict of interest stories about physicians over the past 20 years. Psychiatry in general was selected for much of that criticism. The average physician in the US had no significant conflict of interest even when trivial compensation like meals during continuing medical education (CME) courses were tallied. Some members of Congress even went so far to investigate some psychiatrist’s personal employment arrangements to point out any potential conflicts of interest when it came to pharmaceutical manufacturers.

Today we finally have some clarification on who really backs Big Pharma and wants to assure their large profits.  It should come as no surprise that it is Congress – specifically members of the pro-business GOP.  For years, Congressional conflict-of-interest has been sanitized by their disclosures as if that somehow prevented them from passing pro-Pharma legislation and regulations. For the record the amount of lobby money to the major parties varies from year to year.  For 2022 a total of $26,297,445 was donated from the pharmaceutical industry with $15,175,518 to the Democrats and $10,994,723 to the Republicans. That is an average donation of $29,159 to $105,910.  By contrast the Open Payments site recording payments to health care professionals claims that drug and medical device companies gave physicians $12.59 billion in 2022, but they are counting funds used to pay for research as well as profits from ownership of patents and medical devices (a total of $8.87 billion).  Looking at general payments alone, the physicians receiving any type of reimbursement averaged about $441. The current reporting rule is that any amount exceeding $10 or an aggregate of $100 in the case of meals must be reported.

I previously asked the question whether a slice of pizza given to a doctor at grand rounds was more likely to get results for the pharmaceutical industry than the average donation to Congress ($46,579 at the time).  I made the point that despite the continuous criticism of psychiatrists, they happen to be way down on the list of physicians getting these donations with about 37% receiving general payments and 3.6% receiving payments totaling more than $10,000.

But all the corruption by trivial payments discussion was based on shaky research. It is quite easy to demonstrate that physicians want to try new drugs as they come into the marketplace and show that marketing efforts correlate with prescriptions. We had a No Free Lunch movement to prevent corruption by pizza slices. We had a great deal of agitation about ghost writers, pharmaceutical companies not publishing negative studies, faulty research, side effect reporting, etc. Almost all of that involved psychiatry and often several self-appointed critics from the field.  There are undoubtedly problems with clinical trials in all specialties, but during that 20-year span from about 1998-2018 it seemed as if there was an active conspiracy to sell psychiatric medications.  To some extent that continues but it has less legitimacy in the field particularly since drug detailing and sales have been eliminated from most clinics and hospitals.

All of that commotion was probably good cover for Congress who was actually receiving payments that could make a difference.  And during that time pharmaceutical companies recorded record profits.

What is different now?  The Biden administration has decided that it wants to negotiate prices for Medicare Part D prescriptions. They are on solid ground. The Veterans Administration (VA) negotiates drug prices and has 399 drugs on their formulary.  A GAO study showed that they paid 54% less per unit than Medicare. HHS has already selected the drugs that will be negotiated in the initial round and as expected most of them are the high expenditure drugs in the plan.

The Republicans claim that these negotiations will decrease access to care and raise drug prices although there is no evidence that the VA negotiations have done that. They also claim that there will be reduced innovation, research and development, and job losses. They seem to have missed the overall picture that pharmaceutical companies in other countries succeed – even when there are negotiated prices with the health plan in those countries. Of the top 15 pharmaceutical companies in the world 8 are in the United States and the remainder in Switzerland, UK, France, Denmark, and Japan. The numbers given for fewer new drugs, fewer new indications, and drop in R&D spending seem highly speculative to me.  For example, the drop of $663B in R&D spending is the equivalent of about half of the total revenue for the top 15 companies.   I seriously doubt they are spending that much on R&D. During the 20 year period that I am referring to companies left entire therapeutic areas and it was common knowledge that marketing was going to drive pharmaceutical sales. There is an entire section about decreased jobs.  Are the Republicans really suggesting that Americans should pay (by far) the highest amounts for prescription drugs in order to fund a jobs program? And finally, the suggestion that the plan is “legally dubious”.  Apparently Congress is set up to help industries optimize profits rather than protect people who can’t pay a thousand dollars or more for a Medicare Part D copay.         

This post also has implications of pharmacy benefit managers or PBMs.  You remember them?  They are the business entities charged with “managing” your pharmacy benefits allegedly to make medications most “cost effective”.  PBMs make about $315 B annually for doing nothing more than managing prescription drug programs for employers and other large entities with health insurance programs. In practice they are a price multiplier rather than a price reducer.  PBMs control the spread or difference between what the insurance pays for a medication and what they reimburse pharmacies. In some cases, their reimbursement for pharmacies is lower than the actual cost of the medication. Since they are leveraging large number of patients, local pharmacies typically do not have much of a choice if they expect to do business – even though an affiliation with a PBM is draining. PBMs can own their own pharmacies and reimburse those pharmacies more than community pharmacies.   For a physician the most onerous aspect of PBMs occurs with prices for drugs and their positions on formularies for hospitals and clinics.  A formulary is a restricted list of medications available for physicians in that health plan to prescribe for their patients.  That can mean a patient has to change their prescription for it to be covered or some newer medication may not be covered at all.  During negotiations with manufacturers, PBMs can get a rebate from the manufacturer if they get their product exclusively in the formulary. That rebate is kept by the PBM rather than shared with the people paying for the drug.  

The pharmaceutical landscape is a minefield that is set up to optimize corporate profits. Pharmaceutical companies are essentially guaranteed high margins based on patent exclusivity and high prices.  PBMs generate a lot of revenue, add no value, and many pharmacists would add are a drain on their businesses. Let's face it - these businesses like most of healthcare in the US were essentially invented in Congress.  If they are not a recipe for making money - I don't know what is.  The Medicare Part D price negotiations through the Inflation Reduction Act is the first bright spot I have seen in a long time.  Republicans clearly want to maintain the status quo and that means extremely expensive medications and copays for anyone who is in the Medicare Part D coverage gap. If you were ever surprised by one of these copays like I was recently – support the Biden Administration’s attempt to control high drug prices.

George Dawson, MD, DFAPA

Supplementary 1:  An obvious point that I forgot in the original post in terms of backing Big Pharma is the idea that any physician would back limited access to a needed medication because of financial (rationing) restrictions.  Toward the latter half of my career, if anything physicians have made extraordinary efforts to get medications for their patients including having to manage large collections of samples and try to supply some patients from those samples.  Incredibly - some critics saw that as another perk from pharmaceutical companies that was corrupting physicians.  Some politicians on the other hand who are getting very large donations from pharmaceutical companies have no hesitation in suggesting that American patients should continue to pay exorbitant costs for pharmaceuticals - even if it means not being able to afford medication and compromised health.   

Supplementary 2:  Must watch video on regulatory capture or how Congress profits from disrupting free markets and establishing monopolies. Pharma and electronic health record (EHR) companies are cited examples, but there are additional examples including broadband and AI:

 https://www.youtube.com/watch?v=F9cO3-MLHOM

  

The Donut Hole Gets Real

 

Like most people my age I am taking some medications regularly and got the text message today from my pharmacy that I could pick up one of those prescriptions. The medication is a commonly prescribed medication from a group of medicine called  Non-Vitamin K antagonist oral anticoagulants or NOACs.  The medication is apixaban or Eliquis. People commonly take it to prevent blood clots or emboli and the complication including stroke, thrombosis, and pulmonary emboli. I have been taking it for about 2 years.

I usually get a prescription for 180 – 5 mg tabs and the last time I picked it up was on May 25, 2023.  At that time there was a copay of $94.  I am on Medicare A and B and a Medicare Supplemental Policy.

This time as I drove through the line the pharmacist told me the copay was $500. I asked him to clarify what had happened, but he had no idea.  Even though I had all of my previous refills at this pharmacy he had no idea what had happened and advised me to call the insurance company. When I got home that is exactly what I did. They advised me that this was the standard coverage gap for prescription drugs also known as the donut hole.  The insurance company pays for $4660 worth of medication (in my case almost all apixaban) and at that point copays stop and the patient is responsible for a flat 25% of the total cost of the medication or the $500).  When the patient incurs a total of $7,400 in pharmaceutical costs the number falls to 5% of the total, but by then it is probably a new year and the running tally resets. The customer service rep told me that I might be able to apply for assistance through company or state program, but they all had low-income requirements.

The donut hole started in 2006 as a result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. All Medicare Part D plans have it. It initially required patients to pay 100% of the drug cost during the coverage gap.  That was reduced to the current 25% by the Affordable Care Act (ACA) passed in 2010. By 2025 there will be a cap of $2,000 for costs incurred in the coverage gap. 

It turns out that apixaban is number 10 on the list of 17 most expensive drugs purchased through Medicare programs.  In 2019, the average person taking it spent $7,234 for 12 refills per year and $2,172 in out-of-pocket costs.  A reform of this pricing has been suggested but obviously has not been done since I am paying about the 2019 list price.   The top drugs on this list are easily not affordable for many people. The cost of the top 5 agents are $16,348 to $182,162 per year with out-of-pocket costs ranging from $3,242 to $11,532 due to the coverage gap (1).  Apixaban in the single largest Medicare Part D expenditure at $12.5 billion per year (last filed in 2021).

Flashbacks of my work in acute care. For 22 years, I treated low to no income people in acute care settings. I was lucky to work with excellent social workers who would exhaust every available resource to help them with funding for medical care and housing.  Getting their medications funded was a chronic problem.  People on Social Security Disability do not get a lot of money each month.  At one point the state instituted a spenddown.  That meant if you were hypothetically making $1,000/month in disability payments, the state could demand that you spend a significant portion of your disability on medications before they would add any additional money for that purpose.  It is not possible to live very well – if at all under those financial constraints.

One of our attempts to adapt was to use the company scholarship programs to get them assistance from pharmaceutical companies. With many patients that took a great deal of coordination and filling out forms.  It also required nursing time for both the paperwork and an additional effort to manage free samples of medication. We were often scrambling to find medications in urgent situations or because one of the authorizations had lapsed.  All the samples also had to be catalogued by lot number in case there was a recall of that medication. I did not look forward to dealing with the forms or samples but realized we had to do it or some people would not get the medication they needed.

Today the tables were turned and I was looking at an arbitrary payment or I would not get the medication.  I have also heard this story many times. People unable to pick up a needed medication because of the copay – leading to an abrupt discontinuation or attempting to stretch out an existing medication until the first of the year. You really cannot stretch out an apixaban prescription.  I have read many news stories about people trying to stretch out their expensive forms of insulin resulting in medical compromise and death. I was lucky enough to have savings to cover the $500.

What are the problems with the donut hole?  I can think of at least 4:

1: It kicks the can down the road (also known as cost shifting). When confronted with these large payments, I can imagine a lot of people tell the pharmacist to forget about it and drive away. In the case of this medication that can lead to strokes, pulmonary emboli, thrombosis of large blood vessels, and/or death.  Treatment typically involves hospitalization and possible nursing home placement.  Worst case scenario might involve death, prolonged rehabilitation and the hospital or nursing home eventually seeks all of a patient’s assets to cover the accumulating bills.  All of those events could have been prevented with the prescribed medication.

2:  The structure of this billing is an incentive for pharmaceutical companies to increase prices since that will cause benefits to hit the wall earlier and cause the patient to enter the coverage gap and to pay more cash.  In fact, it is an obvious way to extract the maximum payment from both the insurance company and the patient. 

3:  It is another classic example of how politicians work to subsidize businesses in a non-transparent way.  I know more about medical billing than most people but I had no idea I was turning over $500 today until I was advised by the pharmacist.  

4:  This is a clear example of why the Republican and Libertarian ideas about "free market" healthcare are false.  In other words, we would choose to pay for what we really wanted in a free market and pay those market prices.  Obviously, anyone would pay $500 (or more) to prevent a stroke - but not if it means not eating.  The politicians involved will say: “well yes – but there is no free market.”  Of course, there is no free market. The market is actively manipulated to optimize profits for health care companies and minimize guidance from physicians.  That is the political system in the US. No doctor that I know of wants to prescribe a medication and hear at some point that the patient could not afford to take it. Sometime that news is very slow and the prescribing doctor does not find out until they see the patient back in a couple of months.

Don't ever think that American "free market" capitalism is a big deal in health care.  It is a big deal when politicians work with businesses to give them access to your assets and allows other businesses with more focal products like pharmaceuticals to charge whatever they want. There is no better example than the donut hole.  The cost savings that these companies promised is not from cost containment, but from rationing and that is a big difference. 

 

George Dawson, MD, DFAPA

 

References:

Dusetzina SB. Relief in Sight - Estimated Savings under Medicare Part D Redesign. N Engl J Med. 2021 Dec 23;385(26):e93. doi: 10.1056/NEJMp2116586. Epub 2021 Nov 10. PMID: 34758246.

Supplementary 1:

I downloaded this list of medication arranged by total Medicare Part D expenditure from the CMS web site on 8/26/2023.  The most recent data they have is for 2021.  Medications for psychiatric indications do not appear until # 24 Invega Sustenna and #31 Latuda.  More than a little interesting because psychiatrists have endured medication based attacks for over 20 years - primarily on grossly inflated conflict of interest concerns, pharmaceutical company profits concerns, and drug safety.  Many of those attacks continue today even though most of these medications are inexpensive generics and much of the rhetoric has lost its punch.  These same critics apparently have no similar concerns about significantly more profitable and higher risk medications.  That adds to my commentary in this post. 

Supplementary 2:  The Medicare Part Drugs selected for HHS negotiations with manufacturers include the following.    There is some overlap with the most expensive medication listed above but Farxiga, Entresto, Enbrel, and the list of diabetes mellitus medication are not on that list. For more information on the list click on the link at the bottom of the table. 

Medicare Drugs Selected by HHS for Price Negotiations

Eliquis

Jardiance

Xarelto

Januvia

Farxiga

Entresto

Enbrel

Imbruvica

Stelara

Fiasp; Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill

https://www.hhs.gov/about/news/2023/08/29/hhs-selects-the-first-drugs-for-medicare-drug-price-negotiation.html

 

 

Graphic Credit:

Evan-Amos, Glazed Donut Public domain, via Wikimedia Commons"

Link:

https://commons.wikimedia.org/wiki/File:Glazed-Donut.jpgalt="Glazed-Donut

File:

https://upload.wikimedia.org/wikipedia/commons/thumb/a/a5/Glazed-Donut.jpg/512px-Glazed-Donut.jpg

 

 

 

 

 

 

 

 

The Whale

I finally saw this movie as it hit my subscription networks. It is an interesting story from many perspectives that is expertly told and acted. It raises several perspectives relevant to psychiatry but thankfully that explicit connection was left out of the production.  As the final credits rolled – I noticed that it was adapted from a play.  This is the closest I would come to seeing a play.  I do not think that I am constitutionally able to watch plays. They all seem contrived, overacted, and at times require a level of immediate and shared imagination that I do not possess.  I prefer solid ground as a jumping off point – even if things go awry from there.

The stark reality of this film is the home of Charlie (played by Brendan Fraser).  We meet him as he is teaching an online course in creative writing and see a typical Zoom interface. Charlie is the only one without a visual display.  He explains that his camera is broken. The scene cuts to his home. It is a dismal setting.  We see that Charlie is massively obese, barely able to ambulate and then with great effort, and in very poor health. At one point his nurse and friend Liz (played by Hong Chau) enters and tells him that he has hypertension and congestive heart failure to the point he needs to be seen emergently or he will be dead in a few days.  His poor health is displayed many times as he starts laughing but that rapidly turns into a cough and then chest pain. Over the course of the story, we learn that Charlie was not always like this but after losing his lover Alan to suicide he began overeating and gained a massive amount of weight. We see him binge eating at several points in the film – in one case biting off a fourth of a large meatball and cheese sub sandwich and obstructing his own airway to the point that Liz had to jump on his back to dislodge the food. After chastising him she picks the remaining sandwich off the floor and hands it to him.

The food theme is prominent over the several days duration of the film. Charlie gets a pizza delivered every day and he leaves the money in the mailbox.  The delivery driver talks with him through the door and eventually they address each other by their first names. At the last delivery the driver asks Charlies repeatedly if he is OK and appears to walk away.  As Charlie opens the door, he notices the driver is off to his left looking at him and appearing mildly shocked. Neither of them speaks but Charlie goes back in the house obviously upset and binge eats the pizza along with several additional items he adds from his refrigerator.

Charlie’s self-destructive eating and the associated self-loathing is a prominent theme throughout along with the expression of disgust.  He actively seeks confirmation that he is disgusting on a physical basis but only gets it spontaneously from his daughter Ellie (played by Sadie Sink).  Ellie is an angry teenager, performing suboptimally in school and she directs much anger at Charlie for abandoning her at 8 years of age when he left for the relationship with Alan.   Charlie actively seeks a relationship with her and at one point promises her a large sum of money just to spend more time with him, even though the time he has left is measured in days. He repeatedly apologized for his “bad decisions” in the past and emphasizes that he wants to try to make things right.  He would go as far as helping her write essays that might allow her to pass to the next grade in high school.

Two other characters are introduced over the course of the film.  Thomas (played by Ty Simpkins) shows up at Charlie’s door one day as a Christian missionary. He presents himself as a person intent on saving Charlie through God and Christianity.  He comes into dialogues with both Liz and Ellie.  Liz pointedly tells him to stay away from Charlie - that there are people who do not need to be saved.  She also points out the significant flaws in the local church that Thomas is affiliated with. Her father is the pastor of that church and Alan was her brother. Her father tried to arrange a marriage for Alan and described his suicide as a tragic accident. In his conversation with Ellie, Thomas discloses enough details of his life and why he might be estranged from his parents that Ellie is able to track them down. That eventually leads to reconciliation.

Charlie’s ex-wife Mary (played by Samantha Morton) appears toward the end of the film. There is a detailed discussion of the mistakes that were made and Mary’s chance meeting of Alan in a WalMart parking lot.  Even though there is a lot of tension, there is still an obvious level of caring between Charlie and Mary. Mary discusses Charlie’s unflagging optimism as one of his attributes that she misses. At some point it becomes obvious that the large sum of money that Charlie intends to give to Ellie may have come at a cost to his own health.  He has no health insurance and Liz points out what additional services he could have received.  Charlie refuses medical care and emergency services based on the cost, although that refusal is also consistent with his self-destructive path. He hears Liz describe the stress that he is putting her through but is unfazed.

Throughout the film, an essay about Moby Dick is referred to. The basic message of the essay is that the author can deny aspects of his own life and introspection about it – by focusing on killing whales. We eventually learn that this essay was written by Ellie when she was in the 5^th grade.  Charlie asks people to read him the essay when he is in a medical crisis with chest pain, shortness of breath, and diaphoresis.  He finds it comforting.  He also retypes the essay and gives it to her for school and she becomes enraged when she finds out. Charlie emphasizes that he only meant to show her that he appreciated her intelligence and creativity.

At a psychological level, Charlie is dependent and self-effacing. His motivation appears to be trying to correct past mistakes, especially abandoning Ellie, even though that was a complicated process that he was only partially responsible for. His reaction in these problematic scenarios is to accept the blame and go far beyond that to see himself as a disgusting person and ultimately a physically disgusting person (his characterization) that he produced by excessive eating.   

Several reviewers commented on the empathy in the film, but I really did not see any. Nobody seems interested in what happened to Charlie and how he got into this predicament – only that he is in it. They are attached to Charlie for various reasons but also out of their own self-interest.  As in real life, a lot of emotion happens in those settings as people are frustrated with Charlie when he does not accept their advice.

A relevant psychiatric dimension is the issue of involuntary treatment. In these last days of his life we see that Charlie has very high blood pressure, congestive heart failure, and possible angina that necessitate emergency care. Liz confirms that she has discussed his situation with an emergency medicine physician who concurs with her opinion.  Charlie even Googles his numerical blood pressure to confirm that it is an emergency. And through the film, he says he will not be treated and Liz agrees that she will not force the issue. But suppose that she wanted to.  What might happen in this situation?  Charlie could be transported to the ED, treated, and agree with admission for stabilization. He has no apparent psychiatric diagnosis, but it does not take too much imagination to see how any extended dialogue would get into the area of self-care and self-destruction to the point that the attending physician would consider an emergency hold. It is not uncommon to see people who have secluded themselves and not taken care of themselves admitted to inpatient psychiatric units with as many medical problems as Charlie. Suicide by food or lack of self-care is less dramatic than other methods but it can produce the same result.

Would Charlie be seen as depressed?  Probably – but is that the real problem? Moral injury seems to be a more proximate cause superimposed on a man who accepts all of the bad things happening in his life as his fault and reacts according. It allows him a veneer of optimism, while never having to confront the realty that human relationships are more complicated than that.  

Psychiatric speculation aside, this is a complex film that you must see.  The writing and acting is excellent.  The interpersonal drama has unique dynamics and is first rate.  I hope to see all these actors in other projects. It is a well thought out story line – right down to Charlie’s Zoom exit from his creative writing class. And importantly there is a clear message that there are all kinds of people out there struggling through life as best as they can every day. Those struggles may prove resistant to the insights and best advice from others.   

 

George Dawson, MD, DFAPA