March 25th, 2009  Here are three recent New York Times articles that caught my eye. On March 13th, Tara Parker-Pope’s health blog “Well” reprinted “The 12 Most Annoying Habits of Therapists.” Actually, the list comes from PsychCentral, a blog written by psychologist John M. Grohol, and in my opinion reads better there. I won’t list all 12 habits — you can look for yourself — but they include starting sessions late, eating in session, falling asleep, and so forth. The voluminous comments on both blogs relate the sad state of so much therapy out there, including professional lapses far worse than the listed 12. I plan to use the blog post itself, and some of the commentary, as a teaching handout when I lead a psychotherapy seminar later this year. Even beginning therapists should not make these mistakes.
Speaking of psychiatry training, on March 16th, psychiatrist Richard A. Friedman M.D. wrote about a growing lack of confidence in psychiatry residents, citing their inability to make clinical decisions in routine cases, e.g., when to hospitalize or medicate patients. He blames faculty over-concern:
The fault, I believe, lies with medical educators like me. In the pursuit of patient safety, we have deliberately prevented residents from acting independently on their own judgment in situations where a patient poses a theoretical risk.
I share his concern to this point. I encounter resident insecurity much more often than overconfidence. I also agree that one reason for this may be a medical culture that increasingly recognizes a single right (or safe) way to proceed; independent judgment is discouraged.
But Friedman then goes on to blame “a series of reforms that began in the 1980s with limits on residents’ work hours.” The current limits set by ACGME include an 80-hour workweek with a maximum shift of 30 hours. Friedman apparently feels such a schedule lacks “ample opportunity to stand on your own — and risk making a mistake.”
I beg to differ. Sleep deprivation is not a teaching tool. There is no evidence it trains anyone to make decisions with more accuracy or confidence, although it is often justified this way post-hoc. Conflating confidence-building with hazing oversimplifies a complex issue. We don’t need to toughen up residents, we need to help them make confident decisions. Two different things.
Besides, psychiatry residents generally worked fewer hours than residents of other specialties even before the ACGME limits. In other words, the recent limits have had less effect in psychiatry than in specialties such as surgery or ob-gyn. Could it be that psychiatry pays a bit more attention to how people think, feel, and learn, and therefore we were ahead of the curve?
And speaking of being ahead of the curve, today the Times reported that the American Psychiatric Association is ending industry-financed medical seminars at its annual meeting. President Nada L. Stotland, M.D. said the APA was not aware of any other organization that had made a similar decision on seminar sponsorship. Perhaps we psychiatrists will start a trend in medicine. (Neither the article nor the APA website says whether this change will occur in time for the annual meeting held here in San Francisco this May. I imagine not.)
I confess that I attended one of these seminars when the huge APA meeting was in San Francisco some years ago. Normally I avoid all industry largesse, but I was curious and justified it as research. Ironically, although it was lavishly catered and slickly presented, it was perhaps the least biased industry-sponsored talk I’ve ever heard. The smaller local ones are much worse in my experience, presumably because the level of scrutiny is so much higher at the annual meeting. There is press coverage, for example.
In any event, this is the right direction for psychiatry and medicine in general. But speaking of press coverage, I am curious about one detail. The Times, as well as Reuters, reported the APA policy change today, yet blogger Daniel Carlat M.D. scooped them by almost a week. Do official news agencies wait for press releases, while bloggers do the real investigative reporting?
March 18th, 2009  I’ve written about this before — the expanded use of antipsychotic medication for indications other than psychosis. These run the gamut from acute mania, where a solid rationale exists, all the way to simple insomnia, for which there is no good rationale. Somewhere in between, but closer to the insomnia end of the scale, is the FDA-approved use of Abilify for unipolar depression.
When I first heard the atypical antipsychotic Abilify (aripiprazole) was being marketed by Bristol-Myers Squibb and Otsuka for depression, I shook my head in disbelief. (You can watch the tv ad on the official Abilify site here.) To its credit, the commercial recites the major, sometimes disabling or even lethal, side-effects, including neuroleptic malignant syndrome, irreversible tardive dyskinesia, dangerously high blood sugar, akathisia, etc, in a nice slow cadence rather than an auctioneer’s rapid-fire staccato. But nowhere is it mentioned that Abilify is an antipsychotic. Nor that antipsychotics are traditionally prescribed by specialists (psychiatrists), not primary-care providers, due to the unique and considerable risks of this class of drugs. The manufacturers paint a picture that looks like this: A depressed-but-functioning patient seeks help from a primary-care doctor, who prescribes an SSRI antidepressant like Prozac or Zoloft. It doesn’t help enough, so the MD adds Abilify and voila, success!
This is a dangerous scenario on several counts. First, in my opinion, primary-care doctors should not prescribe antipsychotics for psychiatric disorders, period. This is not to disparage the skills of internists and family practitioners who see common psychiatric presentations such as depression and anxiety on a regular basis, and know how to treat them. In fact, most antidepressants in the US are prescribed by primary-care MDs, not psychiatrists. But it is one thing to diagnose depression and prescribe a relatively safe antidepressant, and quite another to handle treatment-resistant cases, to distinguish among bipolar disorder, schizophrenia, organic psychotic states, severe personality disorders, etc, or to know the complex risks and benefits of various mood stabilizers and antipsychotics. These are jobs for a specialist. Can a primary-care doctor treat depression with an SSRI antidepressant, and maybe try a second one if the first doesn’t work? Sure. After that, I’d suggest referral to a psychiatrist.
The next danger in the advertised scenario: Even in a psychiatrist’s hands, there are several safer and smarter alternatives than adding Abilify to an unsuccessful antidepressant. Increase the antidepressant dose. Switch to a different antidepressant. Augment the antidepressant with thyroid supplementation, lithium, buspirone, or another antidepressant. (All of these are more or less controversial, and I tend to avoid them, but all are safer than Abilify. See this article on augmentation.) And perhaps the best and safest option, add psychotherapy. While medications help many depressed people, in my experience they most commonly don’t work when the patient’s problem is of a sort better addressed by psychotherapy than chemical intervention. Of course, you’ll never hear about that in a drug ad.
Most concerning are the questions that have been raised about the scientific evidence for using Abilify for depression. This is a very expensive medication with potentially grave side-effects being promoted as treatment for a very common problem. When a patient suffers severe symptoms such as psychosis or acute mania, the benefits of treatment outweigh even considerable risk and expense. But non-psychotic depression? Abilify would have to do a fantastic job to justify the drawbacks. Apparently it doesn’t. These blogs critique the thin, and perhaps biased, evidence base for using Abilify for depression. An 11% improvement on average hardly seems worth it — unless you’re a pharmaceutical company aiming to capture part of a vast market.
March 6th, 2009  When Sigmund Freud originally developed psychoanalysis (the precursor to dynamic psychotherapy), he likened treatment fees to those for music lessons:
“As to time, I follow the principle of payment for a fixed hour exclusively. A given hour is assigned to each patient, and that hour is his and he is responsible for it even if he does not make use of it. This practice, which for the music or language instructor is considered normal in our society, when it involves a physician sometimes appears harsh or unworthy of his role…”
Nowadays, similar missed-appointment penalties exist in dentist offices, hair salons, and many restaurants, hotels, and spas that require reservations. The rationale in all these settings is that another patient, client, or customer cannot immediately fill the place of a no-show. The time and resources of the doctor or business have been wasted.
Freud’s successors have modified and refined this policy in differing ways. At one extreme are analysts who charge for any missed session, planned or unplanned, regardless of reason. The analyst announces his or her vacation dates and holidays well in advance, and patients can choose to plan their own accordingly. A more lenient if less clear-cut approach is to waive the fee if the therapist can fill the hour with another patient. More commonly, therapists waive fees for sessions cancelled with advance notice; the amount of required notice is specified beforehand and varies considerably among clinicians. The APA code of ethics cautiously endorses this approach:
“It is ethical for the psychiatrist to make a charge for a missed appointment when this falls within the terms of the specific contractual agreement with the patient. Charging for a missed appointment or for one not canceled 24 hours in advance need not, in itself, be considered unethical if a patient is fully advised that the physician will make such a charge. The practice, however, should be resorted to infrequently and always with the utmost consideration for the patient and his or her circumstances.”
Under all three of these variations, the reason for the absence has no bearing on whether the fee is charged, although obviously it can be discussed and explored in the therapy itself. Conversely, some therapists are less concerned about advance notice, and will forgive even uncanceled no-shows if a compelling reason is offered. Since many psychiatrists and other therapists have policies that differ from the APA ethical standard and from each other, it is fair to say there is no consensus in the field about these policies. Here are my reflections on this morass.
There is a certain cold logic to the draconian standard of never waiving the fee for any reason. Aside from any selfish motive to maximize the analyst’s income, this policy provides the most consistent “therapeutic frame,” in that subjective judgments of the analyst never enter the picture. When analysands (patients) fall ill or are forced to remain at work during their therapy hour, they may pay the fee with gratitude that the analyst is holding “their” hour, pay with some regret, or pay while bitterly railing against the autocratic, unfeeling analyst. However they react, it’s all transference.
Well, sort of. For analytic theory also recognizes the “real relationship” (coined by analyst Ralph Greenson in 1967, I believe), which takes into account the realism and genuineness of two people engaged in analytic or psychotherapeutic work. Many would argue that never waiving fees, regardless of circumstance or even months of advance notice, is not very realistic for the world we live in. That is my view, too.
The next contender, to waive the fee if the therapist can fill the hour with another patient, is apparently not uncommon among psychoanalysts, although in my experience it rarely forms the policy of non-analysts. From the clinician’s perspective, this policy, too, guarantees that income will not be lost. However, in this case the outcome for the patient hinges on the analyst’s behavior, i.e., whether and to what extent the analyst attempts to fill the hour. Since the reality of these efforts, and therefore the actual likelihood the fee will be waived, are unknown to the patient, this approach also invites a wide variety of transferential fantasies: That the analyst strives tirelessly to fill the hour, or couldn’t care less; has no other patients, or has a long, eager waiting list; is meticulously honest, or charges the fee regardless of actually filling the hour; and so forth. These reactions can usefully shed light on the patient’s dynamics, moving the treatment forward.
The problem with this policy is that it trades away part of the therapeutic frame. Yes, potentially illuminating transference arises. But it would as well if the analyst unilaterally changed other aspects of the frame, such as the length or frequency of the sessions. Psychoanalysts and dynamic therapists know not to do this; consistency provides the container that allows emotional vulnerability (and therapeutic regression) to occur. Likewise, waiving the fee for a canceled session should not depend on how busy, diligent, honest, or popular the analyst is. If it happens at all, it should depend on patient factors, not analyst factors.
The most typical policy in dynamic psychotherapy is for the therapist to announce at the start of treatment how much advance notice is required to avoid being charged for a cancelled appointment. This can range from the 24 hours suggested in the APA code, to two weeks or longer. In my experience, it is most often one or two business days, although some therapists require notice by the previous session, often a week earlier.
This policy enjoys the therapeutic-frame advantages of consistency: The patient knows, based on his or her own behavior, whether a fee will be charged. This is analogous to knowing that therapy starts and stops on time, that if one is X minutes late, there are Y minutes left for therapy that day. The disadvantages are that cancelled sessions may result in lost income for the therapist, and that no distinction is made between frivolous cancellations (where the fee is still waived if announced well in advance), and dire emergencies (where the fee is charged, since such absences are generally unanticipated). Of course, therapists can break their own rules and refuse to waive the fee for a frivolous cancellation, or to waive it for a sudden emergency. The advantages of consistency are lost — traded away, in effect, for the “real relationship.” Nonetheless, this is probably the best approach overall for a problem with no perfect solution.
At the other extreme, a policy of deciding, on a case by case basis, whether to waive the fee depending on the reason for the absence, is fraught with peril. This strategy pits the therapist’s values against the patient’s, establishes a dynamic of judging the patient, and, in effect, metes out punishment when the patient’s rationale is “not good enough.” I can find little to recommend it.
How about having no policy at all? With each canceled or missed session, the therapist and patient could discuss whether the fee will be charged. I find it curious that I have never heard this idea even contemplated. It could mire the treatment in endless discussion about “the shape of the table” (a Vietnam-era reference to talking about the setting instead of the topic at hand). But that is what dynamic therapy is largely about anyway. It might not provide a sufficient therapeutic frame; it might be too anxiety-provoking for both parties. On the other hand, it would underscore the collaborative, co-constructed nature of therapy.
My own policy is to waive fees for sessions canceled at least a day in advance. I rarely if ever break my own policy. It is not particularly onerous, and patients seem to understand that I could not realistically fill a suddenly vacated hour, even if canceled for good cause. When patients cancel sessions only a few days in advance, I sometimes fill the hour and sometimes cannot, but I consider that my problem, not the patient’s. I feel this policy works fairly well for everyone involved. However, it isn’t perfect, as illustrated by this last case:
A patient recently called on the morning of her appointment to report a bad cold. She was willing to come to her appointment that day; however, she wondered if I might prefer to see her later that week when she would be less contagious. It was an interesting twist on the typical same-day cancellation. In truth, I did prefer to delay her visit. I had a suitable free hour later in the week, and didn’t want to catch her cold. By allowing me to decide, and since it worked to our mutual benefit, I obviously would not charge her for missing that day. We met at the rescheduled time, and all was well. Yet I confess to a nagging uncertainty: By solving this problem for both of us, i.e., agreeing to reschedule her at no charge, did I make a decision that really was hers? Assuming she is in insight-oriented dynamic therapy, would it have been better therapeutically for her to decide between (1) attending her hour while ill, and possibly sickening me, or (2) paying for a missed hour? I leave this as an exercise for the reader.
February 16th, 2009  Happy Chinese New Year (Gung Hay Fat Choy!). As you can see from the photo, I attended the New Year’s parade in San Francisco’s Chinatown this year. This disclosure introduces my topic for today, directed toward patients and would-be patients: Why do therapists disclose so little about ourselves? Why all the secrecy?
The standard answer goes as follows. Traditional psychodynamic psychotherapy, the kind that evolved from Freudian psychoanalysis, derives much of its healing power from observing and analyzing the transference. Transference is a complex concept, but for our purpose it can be understood as interpersonal attitudes and expectations learned early in life, that the patient unconsciously applies (“transfers”) to the therapist. These unconscious expectations can be positive, as in assuming the therapist will be loving, selfless, and perhaps superhuman, and/or negative, as in assuming the therapist will be withholding, competitive, or shaming. The nature of a patient’s transference reveals a great deal about how he or she sees others. “Interpreting the transference” — making these unconscious assumptions conscious — frees the patient to treat self and other more realistically.
For this reason, anything in dynamic psychotherapy that promotes transference, and leaves it in its unperturbed natural state for observation, helps move the process along. This is where Freud’s “tabula rasa” or blank slate idea originates. The less known about the therapist, the more the patient fills in the blanks with transference. According to this view, it is more helpful to learn what the patient imagines about the therapist, than to correct the patient’s misperceptions or to share private details reciprocally.
However, there are several caveats that go with this idea. One is that not every patient in psychodynamic therapy handles frustration and delayed (or thwarted) gratification the same way. Some easily tolerate asking a question and not getting an answer, and enjoy exploring what their own minds come up with. At the other extreme are those who find the process insufferably insulting or humiliating, and cannot do this kind of work. In between are the majority who find therapist non-disclosure frustrating, but who can tolerate and work with it. In addition, patients (i.e., all of us) can shift day by day, or moment by moment, in our frustration tolerance and our willingness to “play” with our ideas and feelings in order to learn more about ourselves. A sensitive therapist recognizes this and responds accordingly.
An even more obvious caveat is that no therapist is truly a blank slate. If nothing else, patients know our race, gender, approximate age, and how we like to decorate the office. And let’s not kid ourselves, perceptive patients can soon guess or estimate details like socioeconomic status, regional dialects and accents, formality, conventionality, frustration tolerance, warmth, and a host of other therapist attributes. Moreover, we often reveal just by our look of recognition, or the lack of it, whether we are familiar with the book, movie, restaurant, cultural happening, or bit of street slang the patient just mentioned. And all this before the patient really gets curious and googles us.
The slate is far from blank. Still, therapists play what must seem like a sadistic guessing game to many patients: “You asked if I’m married [or gay, or have children, or watch ‘The Sopranos’]. What do you imagine about my home life?” I believe many times this exchange feels awkward and stilted for both parties, first, because the therapist does not explain the transference-based rationale behind the socially odd rejoinder, and second, because not answering also serves a boundary-setting function for the therapist, which is also not discussed. Often therapists themselves fail to distinguish these two aims.
I have supervised many beginning therapists who treat non-disclosure as a blindly followed rule about maintaining boundaries. Transference and even their own privacy are poorly articulated afterthoughts. (Conversely, I’ve met a few trainees who disclose freely in defiance of orthodoxy, and to make the therapist and patient “equal,” which they are not. Free and open disclosure by the therapist is compatible with perfectly good therapy — just not the psychodynamic variety that examines transference. It’s also not compatible with one’s own privacy, as discussed below.) With more experience, therapists pick and choose what to disclose, and the whole endeavor becomes less stilted and defensive on the part of the therapist, and more comprehensible to the patient. However, even very experienced therapists sometimes fail to explain to patients why they don’t answer personal questions directly. I see no harm, and much to gain, in offering a brief rationale.
The most important point about therapist self-disclosure is that the therapy is for the patient, not the therapist. Therapists who self-disclose because they like to tell stories or talk about themselves detract from the therapy they provide. They need another outlet (friends and family? a blog?). More subtle is disclosure aimed to make the patient like or respect the therapist. As a general guideline I disclose what I judge will benefit my patient, and not what I judge will not.
But there is a final point to be made about privacy. Being a patient in therapy feels — and is — vulnerable and exposing. It takes courage to bare one’s soul to someone who is initially a stranger; trust comes with time and must be earned. Efforts by either party to “even the playing field” through therapist self-disclosure cannot hasten this process or make it easier; the cost of such doomed effort is the therapist’s privacy. Many therapists have been in therapy ourselves, and that was when we were vulnerable. Good therapists owe their patients undivided attention, thoughtful reflection, concern, and empathy — but not an experience of false equality at the cost of their own privacy. I feel comfortable telling you I attended the Chinese New Year’s parade both because it won’t hamper our transference work if you happen to be my patient, and also because it isn’t very private. I consider both of these factors when a patient asks me a personal question.
February 7th, 2009  A recent Rolling Stone article on the over-prescribing of Eli Lilly’s anti-psychotic Zyprexa (olanzapine) started me thinking in a general way about the psychology of choosing what to prescribe. I’ve written before about the effects of pharmaceutical marketing, how billions are spent to influence doctors’ prescribing habits at both rational and non-rational levels. The Zyprexa article offers more on this topic. But it also widened the issue for me as I reflected on my own prescribing. For today I’ll let Big Pharma off the hook and look at other influences that affect prescribing.
Most doctors have “favorite” medications within a particular class that we prefer to prescribe. Besides marketing influences, this can result from anecdotal experience: If my last patient had a wonderful result on this drug, maybe my next will too. Conversely, if my last patient had a terrible reaction, how can I risk giving the same drug to my next patient? Such reasoning is unscientific yet very compelling. First-hand outcomes are psychologically hard to discount, even when careful studies of large numbers of subjects provide far better evidence for the risks and benefits of a given treatment than anyone’s limited personal experience. Likewise, the opinion of a trusted colleague (or attending physician, if one is a trainee) tends to make an impact regardless of the popularity of, or evidence base for, that opinion.
These are the sorts of biases that the evidence-based medicine (EBM) movement tries to stamp out. According to EBM, we should base clinical decisions on the best available evidence, ideally large randomized controlled trials. On the one hand, the need for Western medicine to declare itself “evidence-based” is almost an embarrassment; it should go without saying. The scientific method is the bedrock of allopathic Western medicine. It separates physicians from faith healers and snake-oil salesmen.
On the other hand, many areas of medicine lack the EBM gold-standard of randomized controlled trials (or the trials are inconclusive, conflict with each other, etc). Studies of certain treatments, like dynamic psychotherapy, present severe methodological challenges. Randomized studies of invasive surgical procedures can be unethical. Some studies are funded and others are not, for reasons having nothing to do with science. Moreover, the results of randomized controlled trials are population averages, and individual patients do not always react the way the “average” patient does. Fully evidence-based practice is an ideal, not possible in real life.
More important, both the prescribing physician and the patient are people, and we humans have feelings and preferences that affect our choices. Doctors often prescribe particular drugs within a class purely out of habit. The familiarity is comforting; dosing is easier, potential side-effects and interactions with other drugs are no surprise and are handled in stride. Experience prescribing one drug increases at the expense of familiarity with equally good alternatives. Conversely, some physicians are “early adopters” who like to prescribe the newest product out. While this is not my style, I assume the motivation is to be on the cutting-edge of the field. The effect of the prescriber’s personality on treatment decisions sounds like a ripe area for research. A brief PubMed search reveals a few interesting abstracts: 1, 2, 3, 4.
Patients, too, have preferences, not only for heavily advertised products, but also for medications taken by relatives and friends. And doctors, knowing that a patient’s belief in a treatment can aid its success, are inclined to prescribe what the patient asks for — if it is in the right ballpark. Patients also weigh risks and benefits in personal ways. One patient may disregard potential weight gain as a trivial concern, while another flatly refuses any treatment that can add pounds. EBM can never account for such personal preferences. (Some PubMed abstracts on patient attitudes and preferences: 1, 2, 3, 4.)
The prescribing of psychiatric medications is a combination of evidence-based medicine and the art of medicine. The latter includes unfortunate biases — at times leading to overprescribing of medications such as Zyprexa — as well as essential sensitivity to psychological issues and patient preferences. Until doctors are replaced by computers, and patients accept treatment without regard to individual preference, medicine will always reflect this combination.
January 28th, 2009  The following is my article originally published in Ethical Times (No. 16, Fall 2008), the bulletin of the Program in Medicine and Human Values at California Pacific Medical Center. Since this piece appeared, PhRMA has voluntarily suspended the distribution of branded items and certain food gifts to doctors (see my post). The ethical argument still holds and is, I believe, still widely overlooked. Reprinted by permission.
Pharmaceutical promotion is big business. In the US alone, the industry spends billions each year (about $16 billion in 2000) to market its products. Most of this budget pays for extensive, multifaceted marketing to doctors, much of it delivered in person by salespeople called “pharmaceutical representatives.” A smaller but still sizable portion of funds produce direct-to-consumer “ask your doctor” ads on television and elsewhere. Pundits debate whether such lavish promotion drives up the cost of health care or helps to contain it, whether it enhances or detracts from patient care. Most of this focus has been on the industry side of the equation. Yet medical ethics demands that we physicians assess the other side of the equation: our own participation in these promotional efforts.
Advertising and product promotion are everywhere in our society, exerting their influence in largely non-rational ways. We imagine that we rationally weigh the features and benefits of competing products and make logical choices. Yet advertisers “sell the sizzle, not the steak.” Catchy jingles, the look of a product and its packaging, celebrity endorsements, associations with attractive people or lifestyles — these appeal to our emotions, often bypassing intellect and logic. In everyday life we sense no ethical impropriety in allowing ourselves to be influenced this way. Who knows, or cares, why we prefer one brand of soap over another? If we choose a household product for its captivating name or fancy packaging we may be misguided or superficial, but we are certainly not evil. We face no ethical dilemma in accepting a free food sample at the supermarket, even if it evokes pleasant associations in us about being fed or induces a subtle wish to reciprocate the generosity. Marketing works at both surface and subterranean levels. As a society we accept that.
Likewise, it is not ethically problematic for patients to respond to television ads by “asking their doctors” about prescription medicines, even though these ads employ the same non-rational enticements used by other industries, such as memorable product names, evocative catch phrases, and scenes of active, happy people. (Some argue it is unethical for the companies to advertise this way, but that is not our focus.) A patient may inquire about a particular medicine for countless reasons, ranging from careful research, e.g., on the Internet, to an offhand comment by a friend. There is no requirement or expectation that a patient’s interest be rationally based. From the patient’s perspective, there is nothing wrong in hearing about a medicine, even from an ad, and asking one’s doctor about it.
The physician, however, is in a very different position. There is an expectation that a doctor’s interest in a particular treatment be rationally based. Moreover, medical ethics requires it.
The doctor-patient relationship is fiduciary. It is founded on the patient’s trust that the doctor always practices medicine in the patient’s best interest. Like other fiduciary relationships (e.g., bank-customer, corporation-shareholder, and attorneys and accountants with their clients), the doctor-patient relationship is vulnerable to conflicts of interest that can undermine trust. In all of these fields, professional ethics dictate that the trustee take reasonable steps to avoid conflicts of interest and divided loyalties.
Physicians in particular must strive to practice medicine in an unbiased, scientific fashion. This is more difficult than it sounds, since influences that are widely accepted and considered benign in everyday life can represent trust-threatening conflicts of interest here. The non-rational influences of product promotion — the gratifying visits by friendly, attractive salespeople bearing personal gifts and free food — directly threaten the fiduciary doctor-patient relationship. By participating in these encounters, physicians actively invite non-rational bias into treatment decisions, in direct violation of the trust patients place in us. It follows that medical ethics should condemn active involvement in this process by physicians, and that reasonable steps should be taken by ethical physicians to avoid participation in promotional activities.
Many physicians defend current practice by claiming that they are immune to non-rational promotional efforts. The pharmaceutical industry does its best, they say, but smart doctors see through the attempted influence and “ignore” it. This rebuttal is not new.
A historical review (1) in a recent issue of JAMA quotes the same view from apologists 50 years ago. However, then as now, there is no evidence that doctors enjoy any special resistance to non-rational product promotion. On the contrary, several empirical studies document the effectiveness of such promotion in swaying the prescribing patterns of doctors. It is tortured logic to assume that a sophisticated industry wastes billions every year on harmlessly ineffective promotional efforts — especially when the very same strategies work well in other industries. Wishful thinking and hubris alone cannot stand up to this evidence.
Increased public scrutiny has prompted modest reforms over the past few years. A growing number of medical centers and teaching institutions now restrict promotional activities on campus. The pharmaceutical industry itself has voluntarily dropped or limited some types of product promotion. Congress is working on legislation requiring public reporting of industry largesse to doctors. These actions recognize the seriousness of the problem. But, beyond all efforts to prevent undue compensation or to make it transparent, the ethics of the physician are the strongest bulwark against improper influence on prescribing practices. Unfortunately, at this time only a small percentage of individual doctors decline sales calls and similar contact with industry. Surveys show that patients express more concern than physicians over this issue.
Being a physician bestows many rewards and gratifications. These are balanced by the restrictions on our actions that are part of ethical practice. We must act professionally and always in our patients’ best interest. We must be competent and skillful, stay current in our field, and use evidence-based approaches when possible. And we must strive to avoid making clinical decisions based on non-rational factors. While this ethical restriction may deprive us of branded coffee mugs and pens, free lunches, and opulent sponsored “educational” dinners, it is a small price to pay for earning our patients’ trust.
—
(1) Podolsky SH, Greene JA, “A Historical Perspective of Pharmaceutical Promotion and Physician Education,” Journal of the American Medical Association 300(7), 20 August 2008, p 831-833.
January 18th, 2009 
Since psychiatric disability is often invisible and unquantifiable, considering oneself psychiatrically disabled can take on many meanings. Certainly there are those who assess their limitations, whether imposed by thought disorder, anxiety, or mood extremes, and accurately gauge themselves disabled. It is a strength to accept reality for what it is, to live one’s life accordingly, and to claim the assistance society offers. However, self-labeled psychiatric disability is not always accurate. Clinically depressed patients sometimes underestimate their abilities and call themselves disabled the same way they call themselves failures, or bad or stupid — as self-denigration. Others who yearn for nurturing or attention use disability as way to obtain these from caregivers. And there are those who feel entitled to special privileges and treatment, and make undue claims on others using disability as a tool.
When I see a clinically depressed patient who is temporarily unable to work, I fill out disability paperwork, usually the California SDI form. Such forms always ask me to estimate when the patient will be able to resume working. With proper treatment, most depressive episodes significantly improve in less than three months, so that is what I usually estimate. I consider this a little on the generous side, as I want my patient to have the disability benefit he or she deserves. However, unlike recovery from pneumonia or a broken leg, recovery from depression varies widely. Some patients are back to baseline in less than a month, others take much longer than three. I have long been fascinated by the dynamics of predicting recovery. Depression, almost by definition, leads to pessimism. For this reason, my three-month estimate often strikes the depressed patient as too soon — too soon to hope to be well, perhaps too soon for me to expect much improvement of them. Yet part of helping someone overcome depression is to lend optimism and hope. I’d rather err on the side of quick recovery than to pessimistically assume long-term disability. Indeed, when I’ve sometimes overestimated the recovery time, and the patient feels well in three weeks instead of three months, I feel I’ve made the more serious error.
A small subset of patients I see are, for want of a better term, “professional patients.” It is their identity to be ill and disabled. It is their defining characteristic, the first way they introduce themselves. Saying it this way risks “blaming the victim,” as these people did not choose to be sick. They are not malingering (intentionally faking illness). However, even unwanted illness can assume a purpose for itself. Disability becomes a calling card to see a variety of doctors, to call the crisis line and talk, to try a shopping bag full of medications. It becomes a ready answer to that very difficult question: Who am I? Some patients remain psychiatrically disabled because it is a way to be in the world, the only way they find comfortable or familiar. It can be challenging to explore the meaning of such disability in therapy. Patients sometimes complain that I don’t “believe” them, that I should take their disability on face value. I prefer to help them find more options in life, as sometimes disability itself is a state of mind.
From the psychiatric perspective, there is a fine line between assertiveness and undue personal entitlement. On the one hand, it is healthy and strong to assert one’s needs, to make a place for oneself in the world. On the other, diagnostic terms like “narcissism” apply to people who feel, without reason, they are so special they need not obey the same rules as everyone else. As described in my last post, some claims to keep pets in “no pets” housing, or to bring them to work or shopping for “emotional support,” seem to cross over this line. Since narcissism is ego-syntonic (not seen as a problem by the patient himself), it is frequently difficult to address in psychotherapy, or to interest the patient in therapy at all.
I have given three examples of dynamics that may prolong self-rated psychiatric disability: depressive pessimism, dependency and identity needs, and narcissism. I could equally and conversely write about denial and counter-dependency as factors that might prevent a truly disabled person from acknowledging it. However, the legal entitlements granted on the basis of disability make the former a more interesting social conundrum. On the one hand, our sense of charity calls for helping the distressed and disadvantaged. On the other, we recoil at self-declared victimization as a means to special treatment. When disability is subjective and difficult to quantify, as it is in many psychiatric conditions, society does not know whether to embrace or reject it. A culture of innate entitlement only makes this approach-avoidance conflict more acute.
|
|
