Science and Politics…..With A Lesson from Psychiatry

 

I started reading this week’s edition of Science and was surprised to find several editorials about the relationship between science and politics. In addition to the editorials, news items like “Will Trump upend public health?” and “Trump picks lawyer for EPA.” Were no less alarming.

Marcia McNutt, President of the National Academy of Sciences wrote the first essay (3).  She correctly discusses science as a rational neutral process that by its very nature is apolitical.  She describes the peril of citizens ignoring scientific reality by quoting a 26% increased mortality rate in areas of the US where political leaders dismissed the importance of the COVID-19 vaccine.  She makes the point that science must define the body of information that policy should be based on - but it should not actually dictate policy.  She advocates for a role of listening to the affected people and fighting the disinformation that affects them.  Unfortunately, the process of active listening will not do anything toward fighting misinformation – especially when things get to the wide dissemination and meme stage. 

H. Holden Thorp, Editor-in-Chief of Science journals wrote the second essay (4) and it was more specific to the current political situation.  After commenting on the win for Trump he provides the following qualifier:

“Although his success stems partly from a willingness to tap into xenophobia, racism, transphobia, nationalism, and disregard for the truth, his message resonates with a large part of the American populace who feel alienated from America’s governmental, social, and economic institutions.”

The first clause in this sentence is accurate – but there are problems with the second.  Are xenophobia, racism, transphobia, nationalism, and dishonesty really symptoms of an underlying problem or do they represent the real problem of an opportunistic politician successfully scapegoating a portion of the population to gain the support of the electorate with these biases?  That has immediate relevance for the author’s proposed solutions of decreasing scientific misconduct to enhance public trust.  He points out that an animated defense on X/Twitter by scientists was not successful (how could it be based on the platform’s structure, biases and conflicts of interest?). He ends by correctly predicting that the attacks on science and scientists will go on unabated into the future and would like to see a response by the scientific community that makes them less successful.

The essay by Jaffrey Mervis (2) highlights concerns that research advocates have for the Trump agenda that is described at one point as defunding research to reduce taxes.  Any analysis of the tax plan shows that the savings are disproportionately awarded to the top 1% of wage earners.  A research physicist points out that there is no good news for science in the Trump agenda and that also translates to no good news to the tech industry that depends on government funded research for innovation.  Three areas from the Biden administration that may suffer are the Chips and Science Act, climate change, and research collaboration with China. 

The essay by Jocelyn Kaiser (1) focuses on the possible impact on the National Institutes of Health (NIH).  In this essay there is clear focus on Robert F. Kennedy, Jr. as a danger to the NIH and health related basic science research.  That danger on the one hand describes him with the euphemism “vaccine skeptic” and on the other quotes former NIH Director Harold Varmus as saying: ”enormous risks especially if [Trump] placed someone as unhinged as [Kennedy] into a position of responsibility.”  There is a lot of room between skeptic and unhinged.  Trying to present an even-handed description in this case is a clear error when responding to RFK’s rhetoric. It is not a stretch to say that his rhetoric may replace science as the guiding principle behind the NIH.  That is a problem regarding the role of science advising policy makers and a boundary problem on the part of rhetoricians.  Simply put – if you are an administrator with no science background and you are making science up – stay in your lane.

Another clear example of potential problems with a Republican Congress is still based on the COVID-19 pandemic and insistence that the bat coronavirus research was the source of the pandemic virus.  This has reached meme status in the MAGA community fueled by rhetoric from both Trump and members of Congress who have directly attacked NIH scientists.  In some cases those verbal attacks have resulted in threats of violence to those same scientists. All of that happening even though the origins of SARS-CoV-2 are not settled science - but most recent reports suggest origins in the wild like practically all pandemic viruses. Some politicians want to reform the NIH and that is typically a code word for changing an institution to something more like the one they want.  In the case of the Trump administration that can include banning fetal tissue research and I would expect other issues related to women’s reproductive health that the religious right objects to.

The final essay by Rachel Vogel (5) is focused primarily on the implications of Trump’s threat to leave the World Health Organization (WHO). The author reminds us that Trump started this process in July 2020 based on the false claim that “WHO had helped China cover up the spread of the virus in the early days of the pandemic.”  The Biden administration came in and stopped that process.  WHO member states are bracing for a second withdrawal or a reduction in funding to key programs that many think would be catastrophic.  Cuts could also be made to the US Agency for International Development (USAID) that administers many of these programs and other agencies funded to research and treat tuberculosis, malaria, and AIDS.  Political and religious ideology may also be a factor.  A program for AIDS relief started by George W. Bush is a possible target for indirect support of abortions and the use of language that right wing religious groups consider offensive including “transgender people” and “sex workers”.  It is likely that a “gag rule” on the dissemination of abortion information will be reinstated and the penalty will be withdrawal of funding.  Like aspects of the other essays, the author is hopeful that there will be ways to compensate for the Trump worst case scenario. Reform of the NIH has been talked about in the past.  Europe and other countries could compensate for the lack of US support.  Competitive funding sources like the BRICS group (Brazil, Russia, India, China, and South Africa) could also come to the forefront.  The amount of funding available from BRICS and what those countries would require in return is speculation at this point.    

The 5 essays highlight real problems and given Trump’s current nominations for the Director of HHS and NIH probably minimize them.  Suggested solutions to the problem seem to be the time-honored stay out of politics, present the data, and take the high road.  This is really an inadequate plan.  How do I know this?  The valuable lesson is that this is what psychiatry has done for decades.  Ever since Thomas Szasz began his repetitive rhetoric that there was no such thing as mental illness, or that psychiatric diagnoses were like drapetomania (later modified to drapetomania was somehow a psychiatric diagnosis) we have had to tolerate nonsensical criticism while major physician and psychiatric groups were silent.  The many leaders in the field who did respond and had excellent responses were eventually ignored as the neo-Szaszians continue to repeat this nonsense decades later.  An experiment by Rosenhan that was exposed as fraudulent continues to serve as an anchor point for antipsychiatrists – even though what happened clearly did not impact the field (deinstitutionalization had already started and the neo-Kraepelinians were already at work on reliable and valid diagnostic criteria).  The result of this rhetoric is significant hangover on the field. It is difficult to make a direct connection but common sense dictates that psychiatric resources probably takes a hit from all the repetitive negative rhetoric. That is the risk to all of medicine, public health, and scientific research with the current MAGA rhetoric.

Science typically considers itself above rhetoric and politics at least until the competition for grant funding heats up.  The editorials all fail to comment on this.  Instead, they suggest that leading by example, being available for consultation, and generally taking the higher ground will somehow correct corrosive politics.  That is both a naïve and losing strategy.  We currently have a party that has lied and misinformed the public repeatedly and at record levels.  It is supported by a large mainstream media organization with the same goals providing a constant diet of misinformation. It is funded by billionaires. The effects of all those dynamics are easily observed in attitudes toward real science and scientists.  Experts on autocracy and authoritarianism point out that the effect of constant lies on any group of citizens is that eventually they don’t believe anything – even if it happens to be the truth.  A standard authoritarian tactic is to attack expertise and pretend that it does not exist.   

At no recent point in history have legitimate scientists, physicians, and public health officials been threatened with violence by people who have no clear idea of what they do.  In many cases these professionals have been responsible for saving thousands of lives. That situation should be intolerable to any scientist or modern citizen who can evaluate the effects of science.  Furthermore, it should not be supported at any level by the government, but it currently is.  The same party that that supports lies also supports threats and violence at various levels up to an including an attempt to overthrow the US government. With the current election there is the expectation that attempt will be whitewashed as a protest further eroding the rule of law.

The curious aspect of this process is that it is right out there in the open. The repetitive lies are picked up by social media.  Proxies of that ideology begin to amplify them to the point that they become memes rapidly assimilated by true believers in the same ideology.  At that point they become part of that culture and resistant to change from rational arguments and additional information. There is no evidence that I am aware of that change is possible at that point and the most recent Presidential election is solid evidence.     

There is a semi rational basis to politics at best.  The current election illustrates this at many levels.  Major questions of character, intellect, and policy were ignored. The fact checking mode of the fourth estate was minimized.  Some media outlets were mere propaganda arms and provided no information for voters to make an informed decision. 

The only rational course is to continuously counter the repetitive propaganda being put out in social media.  There is no comprehensive strategy for doing this but it must be done.  It will take more than a few editors from Science journals.  A starting point may be a coalition of editors of science and medical journals with their own website dedicated to refuting misinformation and posting the real science. The time has come to stand up for what is science and what it not and protect people under attack for doing the right thing.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Kaiser J. Trump won. Is NIH in for a major shake-up? Science. 2024 Nov 15;386(6723):713-714. doi: 10.1126/science.adu5821. Epub 2024 Nov 14. PMID: 39541475.

2:  Mervis J. Research advocates see 'no good news for science'. Science. 2024 Nov 15;386(6723):712-713. doi: 10.1126/science.adu5820. Epub 2024 Nov 14. PMID: 39541473.

3:  McNutt M. Science is neither red nor blue. Science. 2024 Nov 15;386(6723):707. doi: 10.1126/science.adu4907. Epub 2024 Nov 14. PMID: 39541446.

4:  Thorp HH. Time to take stock. Science. 2024 Nov 15;386(6723):709. doi: 10.1126/science.adu4331. Epub 2024 Nov 7. PMID: 39508752.

5:  Vogel G. 'America first' could affect health worldwide. Science. 2024 Nov 15;386(6723):715. doi: 10.1126/science.adu5822. Epub 2024 Nov 14. PMID: 39541476.

The Most Important Thing I Learned in the 8th grade….

 

I grew up in the northernmost regions of Wisconsin on the shore of Lake Superior. I also grew up a relatively long time ago. There were no wealthy people around – you were either a working-class family with a regular pay check or a working-class family with an irregular paycheck. It all depended on the work.  My father was a railroad fireman (he shoveled coal in steam engines) and later an engineer on diesel locomotives.  Even though he was in his forties work was very irregular due to the seniority system used by railroads.  The oldest people got their selection of jobs and there were more people than jobs. Many people at the top refused to retire creating a lot of anger and controversy by younger people wanting to work more hours.

The entire population of my home town was from European ancestry – everyone was white. Irish and Scandinavian derived families clustered on the west side of town and eastern European, German and Polish families on the east side of town.  We lived on the east side about 7 blocks from the lake.  

The town was located between two reservations inhabited by the Red Cliff and Bad River Tribes of the Lake Superior Chippewa. It was rare to encounter anyone of Native American ancestry unless you played sports and competed against some of those teams or until you were in middle school or high school. I used to fish on the Bad River Reservation with my grandfather and we got to known some of the men who ran a local boat landing.

Racism was overt and it was everywhere.  That may sound odd given my description of the place, but it would not take much to set people off.  An image on television like Muhammad Ali talking in his usual provocative manner or Willy Mays showboating in center field was all that it took. Racial epithets followed at a rate and intensity that was quite unbelievable.  There were a few cooler heads.  My grandmother was one.  All that she could do was to insist that people not talk like that in her presence.  As a boy – it was a mystery to me that the rest room facilities on trains were segregated – even though we were practically in Canada and there were no black people around.  I asked my father why the porter had to have a separate bathroom and he could not give me an answer.  At the time I had never seen a porter.    

The time frame of my youth coincided with the American Civil Rights Movement (1954-1968) but there was no discussion of it in schools, churches, or the public discourse.  The only place where it came up at all was in my 8^th grade biology course.   On a day back in 1965 – I learned the best lesson I ever learned in high school and possibly in my life.

I was a definite nerd back then and extremely interested in science – especially biology.  It was the only class that seemed to be interesting.  That was probably fueled by being a neurotic kid and always wondering if I had an undiagnosed disease or not.  My imagined symptoms at the time seemed limitless and I would find myself in the library researching rabies and various cancers primarily.  It seemed that cancer was always a dinner table topic for my parents.  A relative with exploratory surgery and the ultimate ending: “They just sewed him back up – there was nothing more they could do.”  There was not a lot available to an 8^th grader with those interests so I ended up picking up a lot of biology on the side. That could be useful or not depending on who the teacher was – so I kept most of it to myself.

I can still recall the excitement of learning that our biology course had been changed to Modern Biology and there was a new textbook (1). Our teacher told us the course would be more relevant and it could also form the basis for a college trajectory.  All I can remember about it today is frog dissections, the genetics of taste testing and tongue rolling, and the idea that race was a social construct that had nothing to do with biology.

That’s right – the social construct bomb was dropped in the middle of the Great White North in 1965 and it did not make a sound. There was no emphasis about it.  There were no lessons seeking to connect it to the culture at the time and the Civil Rights Movement.  There was no controversy at school board meetings. It was right there in the book.  A biological definition of races and a description that the isolated groups that were called races would probably intermix at some point and the artificial, color-based designations would just disappear.  We would all be one big happy Homo sapiens family. That information was as rational as it was profound when I read it the first time and witnessed how the idea was repeatedly violated over the next 50 years.  I had seen it violated so many times I went back and found the original biology text that I read in the 8^th grade.         

Some of the key quotes from that text are on the following graphic.  The basic idea is that the species originated and subpopulations migrated over thousands of years and were geographically isolated. During that isolation mutations occurred in those populations that led to some alterations in physical appearance but the genome wide similarities were still much greater than any between population differences. One standard species definition is the ability to interbreed between populations and that was sustained.  Even though populations were named by different physical characteristics they were biologically identical. In the modern era, the longstanding physical barriers to population mixing are no longer present and we should expect a more homogeneous population over time.

Flash forward to 2024.  I just read a paper (2) that should be read by everyone and combined with my personal experience is the impetus for this post. The additional impetus is the recent election in the US and a political cultural movements that are overtly racist, anti-racist, and anti-anti-racist. There are some common interests.  As a clear example, the overtly racist and anti-anti-racist movements coalesce around the central idea that the white race will be “replaced” by non-white races and this will result in significant loss of political advantage. That theory is called the Great Replacement Theory and it plays out at several levels not the least of which is the claim that one party seeks to use it to their advantage to get more voters and they will do this by illegal immigration. Never mind the fact that non-citizens cannot vote.  And never mind the fact that the current political landscape is a small blip in geological time. 

The paper is written by two evolutionary and theoretical biologists.  Expectedly it contains an abundance of modern theory about human genetics, evolution, and most importantly modes of transmission between individuals in populations. The most interesting focus for biologists and physicians is that there are ways to transmit behaviors between generations that are outside genetic transmission and that there are potential interactions between these modes and individual genetics.  The authors use an example of dairy farming and the persistence of lactase alleles.  Dairy farming can select for those alleles in the population but cultural adaption like the use of milk fermentation can also be successful in the absence of lactase persistence.  The main drivers of non-genetic inheritance are depicted in the graphic at the top of this post from the authors’ paper. 

In the body of the paper, they discuss cultural evolution (CE) and gene culture coevolution (GCC) models.  The lactase allele in the context of dairy farming is an example of GCC.  They discuss common errors made in suggesting that race is biologically based and introduce how cultural factors explain some of the differences attributed to genetics.  Intellectual differences are cited as one early example that was attributed to genetics – but modern genetic studies and combining cultural factors shows that there are no clear genetic differences between comparison populations and that all of the differences in educational achievement can be attributed to cultural factors like cultural role models, parental expectations, resources, social roles, and environmental niche.  Negative factors like racial discrimination and adverse life experiences can also play a role.  This paper is a reminder to carefully look for other sources of variance in large in genome wide association studies (GWAS) and whether cultural factors were studied.  My speculation is that the commonest cultural factor in play these days is childhood trauma because the Adverse Childhood Experiences (ACE) checklist is available and considered a measure. This paper would suggest that is only part of the story.      

So here it is nearly 60 years after I read that race has no biological basis and that it is a social construct - it is still being used to divide citizens, suppress the vote, ration resources, stereotype people, direct violence at people, and actively discriminate against them.  I don’t know if reading this paper will be helpful at all so I provided the slides comparing my 8^th grade biology text and a current state of the art paper in abbreviated form.

I did not touch on the rhetoric involved and that is long, detailed, and discussed in other places on this blog.  Very briefly – philosophers and other rhetoricians have taken an anti-science stand in the past because they believed that science was given too much power.  That came about as philosophical musings gave way to more predictable scientific explanations. The problem is that science is an evolving process rather than a book of clearcut answers with some areas less evolved than others.  Eugenics and even more recent claims that race and associated cultural characteristics and endpoints are genetically based could be considered part of that process.  But many of these arguments still persist and like other areas of science have been politicized.  The authors here present all the reasons those arguments about race as a biological property are wrong.      

It was known in 1963 and it’s even more well known today.

 

George Dawson, MD, DFAPA

Supplementary 1:  In terms of cultural factors and educational attainment I was reminded of one from my background - the Medical College Admissions Test (MCAT).  Back when I took it there was a general knowledge section that was supposed to show that the applicant had a knowledge base outside of science.  It was heavily weighted to the arts and humanities.   It was eventually eliminated because it was shown to favor students in large cities where there was access to art galleries and museums.  The closest museum was 200 miles away.  My family rarely left town.  When they did it was usually to pick up my father from a train station about 30 miles away.  

Supplementary 2:  It is interesting to consider the political rhetoric of the last election as it applies to the concept of race as a social construct.  It was common to see minority groups that in some cases were extremely small being scapegoated for political purposes.  Some of it had to do with long standing racism and some of it had to do with cultural factors.  The whole point of this blog post is how can any of that be acceptable if we are all members of the same race with trivial differences in appearance and behavior.      

 

References:

1: Botticelli CB, Erk FC, Fishleder J, Peterson GE, Smith FW, Strawbridge DW, Van Norma RW, Welch CA (Biological Sciences Curriculum Study). Biological Science: Molecules to Man. Revised Edition. Boston: Houghton Mifflin Company, 1963: 671-674.

2: Lala KN, Feldman MW. Genes, culture, and scientific racism. Proc Natl Acad Sci U S A. 2024 Nov 26;121(48):e2322874121. doi: 10.1073/pnas.2322874121. Epub 2024 Nov 18. PMID: 39556747.        

3:  Creanza N, Kolodny O, Feldman MW. Cultural evolutionary theory: How culture evolves and why it matters. Proc Natl Acad Sci U S A. 2017 Jul 25;114(30):7782-7789. doi: 10.1073/pnas.1620732114. Epub 2017 Jul 24. PMID: 28739941; PMCID: PMC5544263.

 

Graphics Credit:

From reference 2 Copyright © 2024 the Author(s). Published by PNAS. This open access article is distributed under Creative Commons Attribution License 4.0 (CC BY).

 

The Wait In The Emergency Department….

 

I just got back from the hospital.  My wife was admitted with acute appendicitis and is scheduled for an appendectomy in the morning. That sounds like a routine occurrence.  There are after all about a quarter of a million appendectomies done in the US every year.  I had a complicated case myself at age 18 with a perforated appendix, sepsis, and a weeklong stay in the hospital with a drain in my side. It was one of the sickest episodes in my life – even after the appendix was removed, I could barely talk with my friends who came to visit due to the pain and intense malaise – but mostly the malaise - an intense feeling like you have the flu but many times worse.

The problem started at about 2PM today when she noticed some nausea and abdominal pain.  She thought it started after drinking some coffee at her health club along with a protein drink.  Over the next hour she became intensely nauseated and started to get increasing pain.  She asked me to examine her and she had tenderness with some slight rebound tenderness in the right lower quadrant but no abdominal wall rigidity.  I suggested we go to the emergency department to get assessed for appendicitis.  She declined because she knew the process would take hours.  She preferred Urgent Care – but I reminded her it was the place of no urgent lab results and over penetrated x-rays.  There was nothing urgent about any of the Urgent Cares we had been to in our health plan.  I finally convinced her that the ED was the only place where things get done and I was worried that she had an acute abdomen that would only get worse. 

That is exactly what happened over the next two hours – increasing pain and nausea.  She was eventually vomiting continuously and in severe pain.  So, we headed down to the ED and got there at about 7:10 PM.  The check-in was excruciating slow.  An RN asked her about 50 questions while she could barely sit in the chair.  She kept saying that she had to lay down.  The nurse finally said – “I wish we had a bed to offer you but we don’t.  You can lay down over there on the waiting room chairs.”  The chairs she referred to were in the triage area.  My wife laid across two normal sized chairs and covered herself with a blanket we brought from home.  We were interrupted by a nurse who took her down the hallway gave her medication for nausea (Zofran) and pain (hydromorphone).  She came back to those chairs but we were eventually asked to go to the general waiting area.  I took this picture of her laying across a larger bench style chair that was too short for her to lay flat.  The blanket is our own.

By 3 hours she was finally given a bed in the ED low acuity area and more Zofran and hydromorphone.  That stopped working a lot sooner.  She was sent for a CT scan of the abdomen at the 3 ½ hour mark.  That was preceded by a visit by an ED resident and later the attending physician. We got the final CT result about 1 ½ hours later when I went out to report she was continuing to get worse and the medications did not seem to be doing anything.  The Zofran was changed to Compazine and more hydromorphone was given.  Eventually a new ED physician came in and explained that surgeons had been called and that an appendectomy would probably be recommended.

At that point it was after midnight and I discussed me going home after I had said my piece with the surgeons.  I had two specific concerns about antibiotic coverage.  My wife was out of it by then but whispered: “Just behave yourself.”  When you have been married as long as we have - that snappy repartee develops.

On the long drive home, I had time to reflect on a number of things.  First, I was an intern at this hospital in 1982 and at that time we had a trauma wing and a non-acute wing.  Interns would rotate from one side to the other every other night.  The attendings on each side wanted to get people in and out as quickly as possible and they emphasized that point to us.  There were no bottlenecks and people were triaged based on acuity.  There was a sign there tonight saying that was still the rule.  Of the 30 or so people in the ED waiting room are, there was possibly 2 other people as ill as she was.  They were all laying on waiting room chairs.  Second, the pace was leisurely with a lot of down time. I still don’t understand why it takes 6 hours to get a diagnosis of acute appendicitis when I could do it as an intern in 15 or 20 minutes without a CT scan (we were told the CT scan results took 30 minutes to get back.)  Third, if EDs are that inefficient why not offload some of the front-end work to Urgent Cares.  That would entail making an Urgent Care urgent – a place where you can get a rapid assessment and the necessary tests and (hopefully) get directly admitted to a hospital and treated.  Fourth, the bottleneck suggests to me that beds are being rationed at some point.  We were in the second busiest ED in the Twin Cities. At some point – ED demand has been well defined and it should be accommodated.  Fifth, the place is run down. When I was there the argument could be made that it was worse, but this is a brand-new addition to the front of a brand-new addition to an old hospital.  It had the gestalt of a bus depot. People were milling about coughing and sneezing around the people laying on chairs waiting to get a bed.  Not a good look for either patient satisfaction or infection control.

All things considered it is an ongoing suboptimal experience. Nausea and pain were tolerated far too long with little follow up on the initial results.  It highlighted to me the need for an advocate when you go into a hospital these days – not just to prevent major problems but also to troubleshoot around routine decisions like: “Should I press this call light because not only does the medicine not seem to be working but I feel a lot worse.” Or “Maybe you should ask that doctor again if they have the CT results – it has been an hour.”   And of course, if you know additional history as an advocate that is valuable information.

Were there bright spots?  Both the ED and surgical residents had a great interpersonal style.  They gathered all the relevant information, were personable, and the surgery resident did a great job with the informed consent for the surgery. That’s about it.  It took 5 hours to get to the two physicians who could do something and then another hour to do it.  I told the surgeon I was in the same ED as an intern and then went into psychiatry.  She said that her experience on psychiatry was “heartbreaking” and she thanked me for my service.  Not the first time that has happened.

That is all I know at this point other than the fact that my heart rate was up the entire time I was part of this process – probably by 30 or 40 beats per minute.  I got home at about 1:45 AM and got about 4 hours of sleep.  A call to her nurse this morning for an update resulted in me finding out that she is still in the ED at 9 AM.  She is now getting IV fluids, antibiotics, anti-nausea medication, and pain medication. Her surgery is not scheduled until 3:45 PM today.  The nurse reassures me that she will be in a hospital bed after the surgery and may be able to go home the same day.

This is state of the art health care in the US.  After 40 years of micromanaged health care by managed care organizations we have a system that is less efficient and patient centered than the one I was trained in back in the 1980s. The only real innovation has been the use of CT scanning for the diagnosis and that was scientific innovation rather than business management.  Despite all the patient satisfaction surveys we have a system that no patient should be satisfied with.

 

George Dawson, MD, DFAPA 

Update 1:  My wife had surgery today approximately 23 hours after presenting to the emergency department with acute abdominal pain.  It occurred at about 6:15 PM.  I have highlighted what happened over the first 24 hours in the timeline below. I have not filled in the medications yet – but she was taking an anti-nausea medication (Zofran or compazine) and pain medication typically hydromorphone or oxycodone.  She was getting IV fluids at a rate of 50 ml/hour and at one point became hypotensive and the rate was increased. 

The surgeon discussed the results of the surgery with me. The appendix had perforated and as a result they had to clean the area to clear away that debris.  The procedure was maintained as a laparoscopic appendectomy despite the area of infection.  The surgeon quoted a 20% abscess formation rate with this complication.  We discussed the importance of the right antibiotic combination to prevent infection and secondary infection of a recent hip arthroplasty.  The surgeon emphasized that despite previous statement – my wife would not be going home because she continued to need IV antibiotics and oral antibiotics at the time of discharge.  When I left the hospital, my wife was alert and had some continued nausea and abdominal pain.  She was in good spirts and the nurses were discussing how she would start the night out with frequent monitoring and how that would taper off into the next day.

The issue of antibiotic coverage for a hip or knee arthroplasty is somewhat controversial in terms of antibiotic coverage. Most sources suggest a first- or second-generation cephalosporin and metronidazole.  I will put the medications on the timeline if I can convince the nurses to print out a copy of the MAR (Medication Administration Record). Hoping that discharge is imminent if there are no complications tonight.

 The antibiotic issue in appendicitis is also controversial.  There is a debate about just how good a purely medical/antibiotic approach to appendicitis is.  For example, there is a high recurrence rate of symptoms after treatment with just antibiotics.  There is some uncertainty about whether the risk for perforation is reduced and there is currently a protocol to study that problem.  It seems fairly straightforward if you consider that a partial mechanism is that the infection causes circulatory compromise and this leads to tissue damage including necrosis and leakage of the appendix contents.  The CT imaging may also be predictive.  The first surgery resident suggested that if a pattern of obstruction was visible there would more likely be perforation and disseminated infection.  My wife’s CT scan had that pattern and she did sustain a perforation.       

Update 2:  My wife was discharged today (11/15/2024).  Nobody explained the rationale – but I am speculating it was because her blood pressure stabilized (she was hypotensive), she did not have a fever, and her physicians thought the current level of pain and nausea that she has will resolve in the next week.  She was discharged with 4 doses of a cephalosporin and 4 doses of metronidazole after receiving an undetermined amount of antibiotic.  I say undetermined because she requested a printout of the medications administered (MAR) and were told they would not give it to us.  Instead, we should go down to medical records and sign a release to get this printout.  That made no sense to me but I have encountered this resistance at this hospital before that included having to pay for a third party to send me many irrelevant records from my own treatment.  I would think that the world’s most expensive electronic health record would have no difficulty with this task.  We were given an incomplete discharge instruction sheet instead that highlighted some of the problems with this EHR – not the least of which is reconciling the discharge medications.

We were told that follow up will be with my wife’s primary care physician.  No mention of the 20% chance of an intrabdominal abscess or what to do about that.  Just instructions on how to inspect and care for the laparoscopy incisions. My wife also has a 6-week-old arthroplasty of the right hip. I emphasized the need for antibiotic prophylaxis to prevent infection of that hip to the surgical team.  Her orthopedic surgeons advised her not to get any dental work done for 6 months (it is 80% healed at 3 months) and in terms of bacterial exposure a perforated appendix is probably as problematic as dental work.  I will need to confirm with orthopedics about whether a longer course of antibiotics is needed.

She is currently ambulatory, in good spirits, and has pain, and nausea.  No nausea medications were given on discharge. A limited amount of oxycodone was given for pain at half the dose she was taking in the hospital (10 mg). The bulk of the pain treatment was a combination of ibuprofen, acetaminophen, and methocarbamol.  This polypharmacy approach to postop pain seems common these days.  I will be assisting her with the medications and helping her monitor her condition.  I will also be researching the antibiotic issue and trying to get in touch with her orthopedics team.

Supplementary 3: I am adding this note on the third day after discharge (post-op day #5).  It appears that my wife has made significant progress today with a marked reduction in pain and improvement in other gastrointestinal symptoms.  She did have a temperature of 99.5 F last night but none today.  She continues to take several pain medications, a medication for muscle spasm, and a medication for gastroesophageal reflux.  I messaged her orthopedic surgeon about the antibiotic prophylaxis to ask if he thought it was adequate to prevent infection of the hip prosthesis and he did. She has a follow up with him next week but none with general surgery.  Her discharge paperwork clearly states: "We recommend that all non-essential contact with health care facilities be avoided."  Apparently that includes discharge follow up appointments.

Supplementary - more on malaise - I use the term frequently on this blog and often interchangeably with "flu-like illness".  It probably correlates with systemic inflammatory components released during infection like cytokines.  Watching my wife go through this course of appendicitis - I was reminded of what I went through 50 years ago.  At that time I became acutely ill in a period of hours, met my primary care physician in the ED, and he took my appendix out and placed a drain in my side in a period of 2 hours.  I was in the hospital for the next week.  I can recall an intense sick feeling that was not associated with pain or nausea.  It was so intense - it was the only time in my life that I did not care if I lived or died.  I just wanted it to stop.  Friends visited and I could barely talk with them.  This is my understanding of malaise at the severest level.     

Flashbacks on Election Night...

 

Well – the 2024 election is over and I thought I would bring it to a close with this final post on the issue.  As previously stated, I am a small “I” independent and have never registered as a Democrat or a Republican.  Except for Barack Obama and Joe Biden - I have voted for Ralph Nader in nearly every other Presidential election that I have voted in.  As you can see from recent posts, I absolutely did not want Trump or his minions anywhere near the White House again.  It is astounding that it has happened.  To make sense of it – sometime last night the media started to spin it as Trump being some kind of genius or popular hero.  That lacks any real explanatory power. The media has done an incredible job during this election making Trump seem to be a normal Presidential candidate when he is far from it. It was quite a spectacle this morning watching the morning TV gang falling all over themselves making this seem like a miracle – when they essentially staged it.

You do not have to be a psychiatrist to see the obvious problems here but apparently it helps. I have listened to Trump voters interviewed and during those interviews they can provide no rationale for their vote.   I have listened to young voters interviewed and it was not clear that they knew anything about how voting works in the United States.  Young voters are criticized for being ideologically self-centered as if older voters are not.  The only voters that made sense were self-identified Republicans who could not vote for Trump based on his attempt to overthrow the elected government of the United States.  You would think that would be a hard stop for any law-abiding citizen.  Back in the day when I took civics, I think it was referred to as treason.  Beyond that small problem, nobody seems to recall all of the other the legal problems that would keep the average person from getting an interview just a few years ago.  Somebody posted that Americans need to stop pretending that they are superior to everyone else when they put a guy like Trump in the White House.  Trump could not get a job at Piggly Wiggly and he is now President of the United States.  That personifies everything that is currently wrong with the United States.

There has been no discussion of the rhetoric used in this campaign particularly Trump's.  To cite one example, in a previous post about the initial debate with Biden - Trump suggested Biden had “destroyed” the country (he used the word destroy 22 times) and he is the “worst” President – (he used the word worst 22 times). All that despite the fact that Trump produced no useful content on policy and did not respond to Biden's comment that in a scholarly ranking of presidential achievement - Trump was dead last (Biden was 14 out of 45 and that has probably improved).  This has been Trump's strategy in every speech.  No content and irrational personal attacks.  He attacked Harris' ethnicity and called her a "bitch" several times (2-4) as well as many other derogatory names and insults.  And there was no criticism of this by anyone apart from Biden in the debate, who was characterized instead as old and feeble by the press.

Of course, Trump opponents are also issuing conciliatory statements acknowledging the win and wishing him the best.  They are doing everything he would not do and ignoring all his vicious name calling along the way. I have not heard the usual platitudes about how he is the President for all Americans yet – but it will be coming.  Let’s face it – he is not the President for all Americans.  He is the President for the powerful and the gullible.  OK - I will acknowledge that maybe there are still a few loyal Republicans caught in the headlights who don't realize the party of Reagan has been transformed into a cult. 

He was described as a transactional President by the BBC today (3).  In other words what does he get out of what he gives in negotiations?  It came up in a conversation with a Ukrainian Prime Minister Kira Rudik reminding everyone that Trump said he would solve the war in Ukraine in one day.  And later that he would solve the war in Ukraine before he was in office.  Those are the first of many failures that I will be looking for and pointing out.  Trump is completely disingenuous and I expect to see a long list of failures.

One major point that seems to be missed about this election outcome is that it is a textbook example of how rhetoric alone can carry the day – even when there is a complete lack of substance.  This is a critical point that I have not seen analyzed by anyone. If anything – the press is still reacting to Trump’s rhetoric as though it is true. The economy is a clear example.  Trump has described it as a disastrous failed economy due to Biden and Harris. The press still accepts that despite the recent edition of the Economist pointing out it is an outstanding economy as far as economies go.  There is the other reality piece that Presidents don’t have that much of an effect on the economy anyway – but the economy persists as a top explanation why Trump won.  It really wasn’t the economy – it was false rhetorical ideas about the economy. 

The second most common narrative to explain the results is that Trump sold himself to the commoners as someone who would attack the “elites” and either burn the system down or take them all down a notch. I heard Mark Cuban on Sam Harris’s podcast describing the elites as basically anyone Trump wanted to criticize – generals, doctors, etc. So the elites are basically the rhetorical targets of Trump. They don’t really meet any unique definition of elites.  And the definition of elites is quite wide ranging from people with special abilities to the wealthy class. Is a general concerned about Trump’s treatment of military veterans and war casualties an elitist?  What about the billionaires all circling around Trump and Trump himself?  What about the richest man in the world giving over $100M and intensive media coverage on his social media site to the Trump campaign and other MAGA candidates?  What about people who are clearly above the law compared with the rest of us? Any application of the elitist explanation must leave out the fact that Trump is one of the biggest elites of them all.   

The failure to see Trump as the character and intellectual failure that he is seems matched by rationalizations that equate him to your eccentric old uncle who shows up once a year at the family gatherings.  During the past months where his style was equated to autocracy (which it is) and Naziism (which it is not) – several excuse makers came out and said that Trump could not possibly be a Nazi because he is only interested in himself and not promoting any long-lasting ideology. So, if he moves on the dark cloud will go with him.  In another case, the Wall Street Journal stated: 

“We don't buy the fascism fears, and we doubt Democrats really do either. Our own concern is whether he can successfully address the country's urgent problems. Most second presidential terms are disappointing, or worse, and Mr. Trump hasn't mapped out a clear agenda beyond controlling the border and unleashing U.S. energy production.”

And

“The authoritarian rule that Democrats and the press predicted never appeared. Mr. Trump was too undisciplined, and his attention span too short, to stay on one message much less stage a coup. America's checks and balances held, and Democrats benefited from the political backlash.”

Yes – they really are suggesting that we can rest reassured that their candidate's cognitive limitations and complete lack of an agenda should be reassuring that he can sit in the White House and not try to fashion an autocracy with staying power when he has a raft of Mini-Mes at his disposal.  He has after all demolished the Party of Lincoln to the point where it is no longer recognizable as a legitimate political party and rendered it into a cult.

The other problem with all of this is that there is an expectation somewhere that all Americans will accept this atrocious set of affairs, reconcile with the people who voted for this man, and we will all be one big happy family.  That is very unlikely to happen.  What is likely to happens is that Trump and his cronies are likely to “double down” on all their intrusions into private life, functional government, and public safety.  Even today we are hearing about how Kennedy wants to eliminate FDA departments and Musk wants to impose a new austerity standard on all Americans. The Rolling Stone quoted several proponents of Project 2025 saying that they no longer must pretend that there is distance from Trump and they can now own the connection.  All of that translates to direct harm to the people who voted for Trump thinking that he is somehow interested in them.

There needs to be resistance to this at every level.  When the harm occurs it needs to be documented whether that is maternal mortality because some politician thinks they know how to manage pregnancy or increased infant mortality due to vaccination limitations or worsening asthma as a direct result of lax air quality standards.  I think that violence, gun violence, and violent crime will increase just because it is part of the MAGA culture.  Their standard response that they are the law-and-order party no longer applies – because they are not.  There is a long list that I will record over time.  Expect a PowerPoint.

As all of this was churning in my brain last night – I realized that Trump getting elected was just like me working on my acute care unit just before I quit.  I was lying in bed wide awake and feeling like an electric current was running through my body. It was impossible to relax.  My heart rate was elevated. It reminded me of why I can never go back to that kind of work again. Although I did it for 22 years, at the end it was intolerable.  I did not mind when the stress was due to trying to help people resolve severe psychiatric problems.  It was very problematic when the environment became politicized and I was one of the targets.  It also reminded me of the current danger, a dangerous man, and a dangerous party and why it is more important to be loyal and true to the idea of a country than a candidate.  Stay vigilant and don’t let this extremely bad turn of events get you down.

In the most basic final analysis – a vote for Trump was a vote for lawlessness, resentment, dishonesty, greed, corruption, and disrespect. It was a vote for big business managers and CEOs, misinformation, income inequality, climate change, pollution, government intrusion in your personal health care, and autocrats worldwide. 

How can that possibly end well?  

 

George Dawson, MD, DFAPA

References:

1:  Bensinger K, Yourish K, Gold, M.  Failing to Provoke Harris, Trump Turns to Tried and True: Vulgarity.  New York Times.  August 31, 2024.  https://www.nytimes.com/2024/08/29/us/politics/trump-crass-imagery.html

2:  Haberman M, Swan J.  Inside the Worst Three Weeks of Donald Trump’s 2024 Campaign.  New York Times.  August 10, 2024.  https://www.nytimes.com/2024/08/10/us/politics/trump-campaign-election.html

3:  BBC News Hour November 6, 2024:  Interview of Ukrainian PM Kira Rudik (starts at 19 min 27 second mark): https://www.bbc.co.uk/sounds/play/w172zb96nbcppzq

4:  Lu C.  Trump Wields Sexist Insults at Final Campaign Rally. The Republican nominee has a long history of misogynistic rhetoric.  Foreign Policy November 5, 2024.  https://foreignpolicy.com/2024/11/05/trump-sexist-insults-remarks-pelosi-harris-gender/

And all of the post-election spin claims Trump is not a misogynist.

Graphics Credit:  Thanks to Tyler Black @tylerblack32 for allowing me the use of one of his election graphics from X(formerly Twitter).   See the entire sequence for his statistical commentary on the election dynamics. 

Current Political Violence In The USA

 

One last political post before the election.  I have been working on a graphic on the political violence scenario and how it has drastically changed in the past 8 years. Part of the issue with aggression and violence is that it is generally very difficult for most people to talk about. They lack the vocabulary and for a long time there was the suggestion that it may have been the fault of the victim.  It took far too long to recognize that this was a dynamic in domestic violence situations and modernize those laws to set limits on the violence and ultimately prevent homicides. Another factor that recently came to light was the issue of firearm access by perpetrators of domestic violence. A recent court case challenged the ban on firearms possession by these men and contrary to the general trend of increasing gun extremism that ban was upheld (United States v. Rahimi).

I do not intend to elaborate on what is contained in the table. I encourage any reader to do your own research on what I have posted.  I have extensive references, but with these political posts – most people do not seem to be interested, especially when they run counter to the conventional wisdom or prevailing political rhetoric. Instead I will make some general comments on aggression, violence, and its effects.

As an acute care psychiatrist, I was faced with the problem on a daily basis.  Aggressive and violent people brought to my care generally by the police or paramedics.  The people I saw were involved in fights, shootouts, violent confrontations with the police, homicides (real and attempted), vandalism, threatening behavior, and suicide attempts.  The behaviors were extreme enough to precipitate 911 calls and for emergency responders to bring them to my hospital.  Not all hospitals take these calls because not all hospitals are set up to deal with violence and aggression.  The staff and the physicians need to approach it as a treatable problem.  That is the first lesson. Violence and aggression – even when it is caused by psychiatric illness is not considered a medical problem.  It is considered a moral problem.  In other words – the person intended to commit violent acts because they are either morally deficient or simply have no moral code. The vast majority of people I treated in this situation had a severe psychiatric disorder and did not know what they were doing. They could not appreciate the wrongfulness of their act.

In order for the person with aggression to be admitted to my unit – they had to have a psychiatric diagnosis rather than just criminal behavior.  That is an imperfect triage criterion and in a few cases, people were admitted with either criminal behavior or aggressive behavior that was goal directed to get what they want. Common examples include intimidating people for money or sex or just disagreeing with them. The associated excuses would be: “Well he/she had it coming.”, “They were just there when I went off.”, or "They did not give me what I wanted.”  These are all attitudes that people use who see others as strictly a means to an end. Other people are just there to be manipulated to get what they want. They are not seen as people just struggling along like everyone else with important goals and relationships. Resentment is a common theme and many of the perpetrators see themselves as getting a bad deal in life, not getting what other people have, and that may include loyalty in relationships.

All of that is a backdrop to the actual aggression or violence.  No matter how egregious that violence and aggression is – it is very common to see it minimized after the fact. That minimization can take the form of complete denial “I wasn’t there” to partial denial “I did not mean to kill him.”

On the less obvious end – aggression can include threatening behavior that involves appearing to be very angry and using profanity in someone’s presence for no clear reason, throwing objects, destroying property, right up to specific threats to kill or injure a person.  There is some confusion over how well these behaviors predict actual violent acts that result in injury but there are two considerations.  The argument has been made that psychiatrists really can not predict violence very well and that may be true for routine evaluations of relatively stable people in outpatient setting.  The prevalence of violence in that population is so low that I would not anticipate being able to predict it.  That changes in an acute care setting where the transition from verbal aggression or aggression toward property to physical violence against people happens very quickly.  The goal is always to stop it before the physical phase.

 At the societal level, the laws have slowly been changing to catch up.  Domestic violence laws lagged for decades until many states adopted the law that if a call occurred, an arrest had to be made. The law about domestic violence convictions leading to no gun possession was a similar development.  Finally, terroristic threat laws made it illegal to threaten people before any physical violence occurred. These terroristic threats laws have developed over the past 30 years and are really a major development compared with the idea that the person making the threats hasn’t done anything yet and we can’t do anything unless they do something.  It is hard to imagine how many people were directly threatened and heard that response from law enforcement.

The driving force behind these legal changes was recognition of what the victims were going through. In some cases, years of harassment, needing to take extraordinary measures to assure their safety, and suffering the effects of this extreme stress in the form of chronic insomnia, anxiety, panic attacks, post-traumatic stress disorder, depression, and physical symptoms.  In many cases jobs and families were disrupted.

The groups I named in the above graphic have been through all of that and more.  In the Insurrection there were estimates of 140-170 officers injured and 5 dead – one from injuries sustained at the scene and 4 subsequently by suicide.  I have not seen any specific reports of the number of police affected by mental health symptoms but expect it is significant. Various efforts have been made to minimize the event and the media seems to go along with them. Even though the popular press does say that one party and one candidate has been lying continuously that the 2020 election had been “stolen” – very little is done on a day-by-day basis to confront this lie.   Nobody is saying that we have a Presidential candidate who attempted to overthrow the elected government of the United States and currently has operatives in place to disrupt the current election. That may be why 1 out of 3 election workers report being harassed often to the point that they quit volunteer jobs that they have been in for decades. 

The remaining groups in the table are self-evident.  We have all seen people screaming and threatening in school board town hall meetings.  There are substantiated reports of severe threats to public health officials and disaster workers. This is all politically motivated aggression and violence that is precipitated by misinformation and political rhetoric. A good recent example was the attempt to connect anti-immigrant rhetoric to hurricane relief and suggest that funds were being diverted to undocumented immigrants. Gun extremism and abortion clinic violence predates the most recent cycle but are good examples of the process. Make emotional inaccurate claims, blame somebody for the problem even if they are law abiding, and let the chips fall where they may.  This process just keeps repeating itself with a party that always doubles down, never acknowledges they are wrong, and never acknowledges what they are really doing – dividing people and turning them against one another.   This line of rhetoric also distracts from the fact that the party in question really has no acceptable policy.  When their self-proclaimed genius economic policy was vetted by Nobel laureates in economics it was found to be seriously deficient.

When I posted this graphic on another site I was immediately confronted with the question about violence and crime created by undocumented immigrants.  I responded with a study done by the Department of Justice based on the arrest records of the most right wing state in the US – Texas. That study shows that these people are much less likely to be arrested for violent or property crimes than citizens born in the US.  Even without knowing about it – it makes sense. The people at the southern border are fleeing corrupt governments and criminals in South and Central America.  The last thing they want to see happen is to be deported back to their country of origin. Because they are undocumented, they need to maintain as low a profile as possible. That would include no encounters with law enforcement.

The idea that political violence could be compared to violence by undocumented immigrants is a feature of the rhetoric used to obscure the real problem. That real problem is that there should be no political violence at all in the United States.  Politics in this country is supposed to operate on the peaceful transfer of power and no party using its power to intimidate either the voters or the election process. We are way past that at this point and it is all on one party.  The political violence is a direct effect of dishonesty and manipulation.  There has not been an adequate effort by the opposition to push back in many of these areas and that leads me to have grave concerns about the upcoming election.

I am hoping that the vote rejects political violence and all that involves so that people can feel safe and we can start to focus on real problems instead of contrived political problems.  You can get rid of political violence by voting it out - at least in this election.  It will be a worse problem to get rid of if it becomes institutionalized.

 

George Dawson, MD, DFAPA

Supplementary 1:  Unfortunately I have to keep adding boxes.  The latest is a direct comment form former President Trump.  Before anyone suggests he was just "joking" or "nobody takes him seriously" or tires to explain it in any other way consider this.  This is unprecedented discourse in an American election.  It follows Trump threatening to use the military against his perceived "enemies form within."  It should be fairly clear that he considers political opponents or in many cases people who just disagree with him as enemies.  Violent rhetoric aside - this is not an attitude any reasonable politician can have when they are supposed to represent all of the American people.

Why A Diagnosis Is Not Stigmatizing and What Is...

 

 

The topic came up last week and it happens on a recurrent basis – diagnoses especially psychiatric diagnoses are not good because they are stigmatizing.  I addressed this fairly comprehensively in a post on this blog 10 years ago, but the persistent antipsychiatry rhetoric out there keeps repeating inaccuracies.  Since then there has been a comprehensive academic definition of stigma that makes things clearer.

Before that academic definition the standard dictionary definition was “a stain or reproach, as on one’s reputation” (1).  There is also a medical definition that is used to designate obvious pathognomonic findings: “visible evidence of disease” (2) and a long list of signs that apply.  There are additional definitions that do not apply to the specific situation of how mental illness is stigmatizing. The American Psychiatric Association has a web page on stigma and the adverse effects.  The web page does a good job of breaking it down to the public, personal, and structural levels.  Specific evidence-based interventions are suggested. They typically involve first-hand experience of persons with mental illnesses.

More sophisticated definitions of stigma are available today.  For the purpose of this post I am using one by Andersen, et al (3) that modifies previous work done by Link and Phelan (4).  According to the authors, stigma is a social process that involves “labelling, negative stereotyping, separation, and power asymmetry.” (p. 852).  They state further that stigma is not present unless all these criteria are met – specifically stigma exists “if and only if” all these criteria are present. 

Labelling in this case is defined as “social selection of human differences”.  The authors give an example of associating alcohol use with homelessness and whether it is a matter of “cognitive efficiency” based on personal experience and probabilities. The labelling that occurs is a result of these socially observed differences. Although these labelled associations can be positive, for the definition of stigma only negative associations are relevant for stigma.  That results in the negative stereotyping.

Separation creates a false barrier between the negatively stereotyped and everyone else.   It suggests that there cannot possibly be any overlap between the characteristics of the stereotyped and everyone else.  Earlier in their paper, the authors use the example of obesity, where it is obvious that there are several almost universal stereotypical qualities and overt discrimination. The same thing is true of ageism, where it is often assumed that elderly people are universally frail, cognitively impaired, and have negative personality traits. It is an us versus them mentality that is currently popular in right wing politics in the US.

Power asymmetry is attributed to the fact that is takes social, economic, and political power to label and negatively stereotype. This is inconsistent with the idea that it happens at an individual level and those individuals together can form a power structure. 

The authors cite an example from Link and Phelan: “They notice that mentally ill patients might label clinicians as e.g. “pill pushers” and link them to the stereotypes of being cold, paternalistic, and arrogant. But the clinicians will not, therefore, be a stigmatized group, because this group of patients simply do not possess the sufficient power to “(…) imbue their cognitions about staff with serious discriminatory consequences.”   

The social and pollical dimensions of the pill pusher characterization ignores history and the prevalence factor.  On a historical basis, Osler suggested that medications being used over a century ago were either worthless or cause more harm than good.  At the turn of the century "dope doctors" ran large practices by keeping people addicted to opiates. On the prevalence side, does the number of people with that characterization equal or exceed the number of people with other common important stigmatizing biases like obesity or ageism?  I doubt it. We do see an excessive amount of rhetoric directed at psychiatrists that is largely inaccurate and contrived and it is not without professional, social, and pollical fallout (5,6).  Very few reasonable people seem willing to discuss that.  The other reality that is rarely discussed is the fact that doctors are not powerful and certainly are not trained to use or exert power.  Today they are ordered around by middle level managers with no training in medicine exerting whatever form of administrative power that they choose.

There are much better examples of stigmatizing processes that are obvious but never discussed in today’s world.  I come back to the entertainment industry at the top of the list.  Apart from movie reviews psychiatrists have been curiously silent about this process that has gone on unabated for decades.  To cite a recent obvious example, I would refer anyone to the most recent episode of The Penguin an HBO series.  In season 1 Episode 4, we see one of the protagonists falsely diagnosed with mental illness to keep her from disclosing several homicides committed by her father.  She is placed in a medieval Arkham asylum where the patients are shackled by the neck and treated inhumanely.  She is eventually baited into committing a very violent homicide against another patient who is trying to befriend her.  The psychiatrists there are portrayed as indifferent at best and of course using electroconvulsive therapy as a punishment (there has not been any progress on that issue since One Flew Over the Cuckoo’s nest in 1975).  There may be people who argue these problems may have existed in 18^th and 19^th century asylums – but the problem is this is set in modern times.  The Penguin is driving a 2013 Maserati Quattroporte VI.  This episode plays the familiar stigma as the mentally ill being excessively violent and psychiatrists as agents of the state conspiring against people, using psychiatric treatments as punishments, and not caring at all about individual patients.

Right wing politics is a second source of stigmatization on almost a daily basis.  Trump and affiliated MAGA politicians routinely suggest that mass shooting and gun violence are attributable to mental illness – even though it clearly correlates with firearm availability and density.  In the case of undocumented immigrants, they are triply stigmatized as criminals, mentally ill, and invaders of the country when there is no evidence for it.

A final source is a carry over from my previous post.  Businesses and healthcare companies actively discriminate against mental illness despite parity legislation.  That should be obvious by the lack of resources that people face when trying to find treatment for a severe mental illness. It is easy to find state-of-the-art care and subspeciality care for any other bodily symptom – but not psychiatric care.  Getting an appointment to see a psychiatrist even in large metropolitan areas is often impossible.  Inpatient bed capacity in the United States is somewhere below the bed capacity of developing countries in the world. The majority of people with mental illnesses are not treated.

That is my update on stigma.  The only thing that has changed in the last 10 years is the current spin that a psychiatric diagnosis or treatment is stigma or stigmatizing and of course it is not at all.  As a reminder, a diagnosis is for the information of the patient and other treating professionals, it is confidential, and it is used by people who are professionally obligated to act in the best interest of the patient and incorporate that person's preferences.       

 

George Dawson, MD, DFAPA

 

1:  Random House.  Webster’s College Dictionary.  Random House, New York, 1996: p. 1314.

2:   Steadman’s Medical Dictionary.  The Williams and Wilkins Company, Baltimore1976: p.1338

3:  Andersen MM, Varga S, Folker AP. On the definition of stigma. J Eval Clin Pract. 2022 Oct;28(5):847-853. doi: 10.1111/jep.13684. Epub 2022 Apr 23. PMID: 35462457; PMCID: PMC9790447.

4:  Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001; 27(1):363‐385.

5:  Perlis RH, Jones DS. High-Impact Medical Journals Reflect Negative Sentiment Toward Psychiatry. NEJM AI. 2023 Dec 11;1(1):AIcs2300066.

6:  Bithell C. Why psychiatry should engage with the media. Advances in psychiatric treatment. 2011 Mar;17(2):82-4.

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