Lately I’ve been pondering one of my professional roles, that of gatekeeper. Among my other duties, I help patients access things they already know they want, but cannot get without my help. Often this boils down to writing a “doctor’s note”: documentation to excuse a work or school absence, qualify for a discount transit pass, receive state disability payments, and so forth. The government or employer relies on me to verify the patient’s entitlement claim. Metaphorically I stand at the gate, deciding whether to grant my patient passage.
This role seems slightly odd if I think about it too long. After all, I do not work for the government or my patient’s employer, and do not really owe them this service. I act on behalf of my patient. Yet professional ethics compel me at times to write reports exactly contrary to a patient’s reason for seeing me in the first place. For instance, sometimes I must say that, in my view, a patient no longer qualifies for state disability. Although I work for my patient, I can end up opposing his or her wishes (which may be different than his or her ultimate interest).
Perhaps the starkest example of this is applying an involuntary legal hold when a patient is acutely suicidal or otherwise dangerous. Psychiatrists tend to think of this as acting in the patient’s best interest — reassuring ourselves that most patients would thank us later when in a calmer and more rational state of mind. In fact, many do. However, some critics of psychiatry point this out as evidence that we are “working for the state,” not our patients.
A related awkward twist on the gatekeeper idea is my growing role as a medication gatekeeper. By this I mean being asked to write a “doctor’s note,” in the form of a prescription, for a medication the patient has already decided he or she wants. A number of potential patients call nowadays having researched their symptoms online, or in some other way having concluded they need a specific medication. They are not seeking my professional opinion or advice, just the prescription.
This is another situation that seems slightly odd if I think about it too long. For one thing, prescription drugs are available from other countries online and without a prescription, although ordering them this way is illegal in the U.S. and potentially dangerous. Thus, in calling me, patients who could otherwise order directly online are taking extra time and expense to get medications the legal and safe way. Yet they are doing so in a manner that attempts to sidestep the safety features built into the process.
Government oversight and regulation of drugs in the U.S. extends back to the late 1800s and saw a turning point in the 1938 Food, Drugs, and Cosmetics Act. Soon after its passage, the FDA began to identify drugs considered unsafe for direct use by patients; they would require a physician’s prescription. However, all legal medications were available over-the-counter until the Durham-Humphrey Amendment of 1951, which revised the 1938 Act to formally distinguish between prescription and over-the-counter medications. This was when physicians became medication gatekeepers. The idea was to protect the public from itself, to impose controls on the use of substances that are addictive, easily misused, laden with common and/or dangerous side-effects, or carry other possibly hidden risks.
However, Americans have decidedly mixed feeling about the state’s role in “protecting the public from itself.” Traditionally, liberals have favored it and conservatives have opposed it when an issue (e.g., gun control) is framed as one of safety. Conversely, when an issue (e.g., recreational drug use) is framed as a threat to the moral fiber of a community, conservatives favor state control while liberals oppose it.
Prescription medications carry both safety and “moral fiber” implications, and often I feel caught in the middle of these swirling political eddies. Not only am I compelled by professional ethics to be a medication gatekeeper if someone sees me for a prescription, it frequently strikes me as the only sensible arrangement. I know about diseases, drug interactions, and other important, relevant facts that the average person does not. In some cases self-prescribing would be like walking through a minefield blindfolded. But other times I find myself wishing the patient had left me out of the equation entirely and simply ordered online. Adult Americans make many, many decisions for ourselves that may be ill-advised and shortsighted, but we are free to make them anyway. In those cases I feel I am part of an interaction that neither party really wants.
Being a gatekeeper is not why I became a psychiatrist. For most of us, it is an awkward, ill-fitting role for a profession that ideally reflects empathy, collaboration, and cooperation. I much prefer being a medication advisor than a rubber-stamper (or roadblock); fortunately, psychotherapy is by nature collaborative and rarely feels like gatekeeping. I am sure I will continue to ponder all of this, and I welcome your thoughts as well.