“Brain disease”: the anti-psychiatrists respond

I don’t avoid reading opinions strongly critical of psychiatry. They help sharpen my reasoning skills. It’s always possible they might alter my views in some way.  And like most everyone, I consider myself openminded and receptive to criticism. However, after years of reading Thomas Szasz, Robert Whitaker, and the screeds of the less articulate, after perusing the leaflets and poster displays of the protesters at APA conferences, I’ve heard most of the arguments by now. I rarely engage with such harsh critics. As I’ve written elsewhere, there has to be a shared foundation, some agreed-upon axioms, for a dialog to take place. Otherwise it’s just a shouting match.

My own views are pretty stable at this point. I’m critical of many aspects of psychiatry: I blog about sloppy thinking in the field, the limitations of DSM nosology, the overuse of pharmaceuticals. I teach psychiatry residents to think psychologically and how to practice ethically. But unlike anti-psychiatrists, I don’t consider psychiatry a hoax or an evil injustice. If I did, I’d find another career. And while it isn’t hard to cite cases of psychiatric mismanagement, it’s a good deal easier to cite cases of psychiatric benefit. We help people far more than we harm them. Truth be told, I’m proud to be a psychiatrist.  If I wasn’t, I’d do something else.

Philip Hickey PhD is a retired psychologist who blogs on behaviorism and mental health. His articles are reposted on Mad in America, a popular website created by Whitaker that is highly critical of psychiatry. Dr. Hickey wrote a lengthy critique of my December 12 post on whether psychiatric disorders are brain diseases. I considered replying in the comments section on MIA, but the anti-psychiatric echo chamber there assures it would fall on deaf ears. So instead I’ll follow up here.

In composing my last post I was more concerned about slamming luminaries in my field than worrying about how anti-psychiatrists might react. The piece, after all, is critical of language by prominent psychiatrists. Consequently, I granted that schizophrenia and several other named disorders look primarily biological in nature, even though this hasn’t been proven. Dr. Hickey agrees with me on first impressions, which was all I was claiming. However, he then goes to great lengths to refute this rather trivial bone I threw to the biological psychiatrists.  I could now respond to each objection point by point — schizophrenia does affect a diverse array of mental functions, not merely the few in the DSM criteria; neuroanatomical changes go well beyond mere “brain shrinkage”.  But why bother?  I’m not here to argue for the biological foundations of schizophrenia.  Indeed, doing so too well weakens the main point of my prior post.  Note the insidious dynamic: confronted by someone so “anti” I’m called upon to be more “pro,” even though this serves neither of us.

I also predicted, without offering much in the way of argument, that a few severe psychiatric conditions will eventually be shown to have biological causes. Dr. Hickey vehemently disagrees, and holds that behaviorism and learning theory account for these conditions. That’s wildly implausible, but no matter. The truth is, no one really knows.

Dr. Hickey wanders into the weeds of DSM diagnosis and labeling, a topic I didn’t address at all, other than to use the common terms for psychiatric maladies.  I don’t object to cautious circumlocutions like “feelings and behaviors currently lumped under the controversial label ‘schizophrenia’.” It just takes longer to write. Whether schizophrenia is one disease or many (or not a disease at all), whether the DSM criteria are valid or way off-base, whether some of the features called schizophrenia are actually iatrogenic — none of this matters for my argument. The point remains that the clinical presentation we call schizophrenia looks like biological dysfunction even though its etiology remains unknown.

Dr. Hickey took pains to explain in great detail the limitations of reductionist thinking, how new properties emerge at higher levels of organization, and how it is a category error to refer, say, to psychology at a molecular level.  This is because I misspoke in trying to convey the reductionist viewpoint. I wrote that, in theory, “all psychopathology can be reduced to aberrant electrochemical events, i.e. brain disease.”  That’s not true; a learned phobia is a ready counterexample.  It’s particularly unfortunate that I made this mistake, as it confirms the worst fears of those who believe we psychiatrists are mired in primitive reductionism.  Actually, Dr. Hickey and I agree here.

Now having said that, although some psychopathology arises solely psychologically, it’s also common for genetics or biochemistry to underlie aberrant psychological functioning.  This is the case for the many known diseases such as brain tumors, neurosyphilis, and lead poisoning that were once wrongly thought to be purely psychological (or demonic).  There is no reason to assume that all such discoveries are behind us.  Rather than digging one’s heels into radical behaviorism, radical neurobiology, or radical something-else, isn’t it more honest simply to say we don’t know what the future will reveal?

I’ll end by noting that anti-psychiatrists object to any pathologizing of behavior as stigmatizing and dehumanizing.  Unfortunately, it’s inevitable, and not just by psychiatrists. Paranoid psychosis — a behavioral description, not a diagnosis — may result from drugs, sleep deprivation, brain tumors, or extreme stress. Whatever the cause it’s still an unpleasant, dysfunctional state that differs markedly from the usual way human minds work. We can choose new, less stigmatizing names for such states, but we will never give up describing ourselves and others in value-laden terms. The conditions we call mental illnesses — and it’s interesting to ponder what exactly counts — are usually miserable for the sufferers, and arouse pity and fear in observers. It’s not realistic to imagine we’ll ever carefully tiptoe past naming such states.

I thank Dr. Hickey for his close reading of my article, and for calling it interesting and thought-provoking, probably the highest praise a psychiatrist can ever expect from such a critic.  I note that he calls me a typical psychiatrist when he disagrees with me, atypical and rare when we agree.  I would respectfully suggest that I’m not that rare.  Most of the psychiatrists I know have no rigid orthodoxy, no ideological axe to grind.  Most see only voluntary patients who come for relief of distress — and end up feeling relieved.  All value psychotherapy whether or not they provide it themselves, and all add a healthy dose of common sense to their specialized training. Psychiatry has much to improve, but that will only happen when supporters and critics engage in dialog, not a shouting match.

Are psychiatric disorders brain diseases?

brainSome maladies that attract psychiatric attention are unequivocally brain diseases.  Huntington’s disease.  Brain tumors.  Lead poisoning.  However, these are not psychiatric diseases.  Huntington’s is a genetic abnormality diagnosed and treated by neurologists.  Brain tumors are managed by neurosurgeons and oncologists.  Lead toxicity is treated by internal medicine.  Indeed, a long list of medical and surgical diseases include psychiatric features: stroke, anoxic brain injury, meningitis, lupus, diabetic ketoacidosis, and febrile delirium to name a few.  One important job of the psychiatrist is to recognize such problems, treat the psychiatric manifestations when appropriate, and refer the case to one’s colleague — neurologist, internist, surgeon — for treatment of the underlying problem.

Of the conditions deemed inherently psychiatric, some seem rooted in biological brain dysfunction.  Schizophrenia, autism, bipolar disorder, and severe forms of obsessive compulsive disorder and melancholic depression are often cited.  It’s important to note that their apparently biological nature derives from natural history and clinical presentation, not from diagnostic tests, and not because we know their root causes.  Schizophrenia, for example, runs in families, usually appears at a characteristic age, severely affects a diverse array of mental functions, looks very similar across cultures, and brings with it reliable if non-specific neuroanatomical changes.  Even though schizophrenia cannot be diagnosed under the microscope or on brain imaging, it is plausible that a biological mechanism eventually will be found.  (The same type of reasoning applied to AIDS before the discovery of HIV, and to many other medical diseases.)  A similar argument can be made for other putatively biological psychiatric disorders.

Lately, however, some big names in psychiatry have taken a more ideological stance, declaring that psychiatric disorders in general are brain diseases — right now, no further proof needed.  Dr. Charles Nemeroff, widely published professor and chairman of psychiatry at the University of Miami Miller School of Medicine, writes:

In the past two decades, we have learned much about the causes of depression. We now know from brain imaging studies that depression, like Parkinson’s disease and stroke, is a brain disease.

Dr. Thomas Insel, recent director of the National Institute of Mental Health (NIMH) wrote:

Mental disorders are biological disorders involving brain circuits…

Psychiatrist and Nobel laureate Dr. Eric Kandel says:

All mental processes are brain processes, and therefore all disorders of mental functioning are biological diseases.

These claims by prominent psychiatrists agitate critics.  No biomarker for any psychiatric disorder has yet been identified. Genetic vulnerabilities have been discovered, but nothing resembling a smoking gun.  Functional brain imaging reveals biological correlates of mental impairment, not etiology, and no such imaging can diagnose a specific psychiatric condition.  Our best account for most mental disorders remains a complex interaction of innate vulnerability and environmental stress, the “diathesis-stress model”.  These psychiatric leaders know the research as well as anyone. How can they call psychiatric disorders brain diseases without scientific proof?

The brain mediates all mental activity, normal or not.  Consequently, any psychiatric intervention — or influential life experience — acts upon the brain.  This is not a new discovery.  A century ago, Sigmund Freud wrote “Project for a Scientific Psychology,” in which he proposed that ultimately the mind would be understood biologically.  No modern studies of brain tissue, no genetic testing, no advanced brain imaging were needed for the father of psychoanalysis to posit that mental activity arises from biology.  It is a philosophical position, monism as opposed to Cartesian dualism, not a scientific finding.  Note that Freud could then have made it a point to declare, as Drs. Insel and Kandel do now, that all mental disorders are biological diseases.  No additional science was required even a century ago.

He didn’t because there was nothing to gain.  The best treatments at the time were psychological, not biological.  There was no grant money at stake, no research agenda to support.  The status and livelihood of early psychoanalysts did not depend on their treatment being biological.

Psychiatric “brain disease” is neither an exaggeration nor a lie.  It does not require scientific proof — and brain imaging has neither strengthened nor weakened the case.  For as long as one is not a philosophical dualist, it is surely true.  In theory, all psychology can be reduced to electrochemical events in brain cells. All psychopathology can be reduced to aberrant electrochemical events, i.e., brain disease.

Without elucidating the causative mechanisms, however, this reductionism amounts to little more than political rhetoric.  Calling psychiatric disorders brain diseases serves no clinical or research purpose, it only serves political ends: bringing psychiatry into the fold as a “real” medical specialty, impressing Congress and other funding sources, perhaps allaying stigma.  As a tactic it smacks of insecurity and self-aggrandizement, wholly unbefitting a serious medical specialty.

Freud’s psychoanalysis acts on brain cells, and ultimately alters chemical bonds in those brain cells.  We could rename psychoanalysis and psychotherapy “verbal neuromodulation.”  But to what end?  A reductionistic account of this sort, festooned with pseudoscientific verbiage, has no practical significance.

Brain research is a young field.  It should be vigorously pursued for what will surely be learned.  If history is any guide, many conditions currently considered psychiatric will eventually be explained biologically — and ironically, they will no longer be psychiatric conditions, as was the case with Huntington’s disease, brain tumors, lead poisoning, and many other diseases that now belong to other medical specialties.

Stumping for psychiatry as clinical neurobiology will be justified when basic research in this area affects clinical practice. Until then, “brain disease” is only a philosophical technicality, a spin, to give our clinical work and the institution of psychiatry an air of scientific credibility.  Particularly in light of how diseases leave psychiatry once they are well understood, the field should embrace uncertainty, not preempt it with the premature use of brain disease language.

Image courtesy of dream designs at FreeDigitalPhotos.net


therapyAs we grow into adulthood, each of us develops a personal comfort zone located on the continuum between paranoia and gullibility.  A few of us are highly suspicious by nature, a few are unwitting dupes; most of us are in between.  Mental health professionals are no exception, and it shows in our work.  Is a request for tranquilizers or stimulants legitimate, or are we abetting a substance abuser? When told of horrific past abuse, do we believe every word, or do we allow for possible exaggeration or distortion?  Credulity and skepticism exist in dynamic balance: too much of either impairs clinical work.

Our pride animates these assessments.  On the one hand, we see ourselves as sensitive and caring.  Empathy seems to require believing people’s stories, to be “on their side.”  On the other hand, we feel vulnerable and ashamed when fooled (as we sometimes are), and safer and proud of ourselves when we don’t fall for it.  Fueled by pride, proponents defend various points on the credulity continuum.  Some psychiatrists declare that they never prescribe tranquilizers because doing so invites manipulation by drug-seeking patients.  Conversely, some equally proud therapists never question the meaning of their clients’ cancellations, because doing so “lacks empathy.”

Like most doctors, I’m a critical thinker by nature.  This is a nice way of saying my comfort zone lies slightly closer to paranoid than gullible.  The perverse logic of the Freudian unconscious thus comes naturally to me.  Patients who claim complete marital satisfaction may be in denial, or at least recalling selectively.  Impassioned pronouncements of adoration may be “reaction formation,” telegraphing the exact opposite.  Dramatic hatred or disgust may hide a fascination, even an attraction.  The trick here, lest we treat our prejudice and not the real person in front of us, is to entertain such possibilities without becoming too attached to them.  It’s also important to distinguish empathy from blind agreement, belief, or endorsement.  I can empathize with a delusional person’s fear and panic without endorsing the delusions themselves.

A funny thing happened to me the other day.  A mental health professional in a remote land emailed me, seeking online psychotherapy for himself.  I was flattered that this colleague searched the world over and chose me.  He sought exactly the type of psychotherapy I like to conduct.  If not for distance — which would ultimately be a deal-breaker in any case, as I consider online therapy a poor substitute for the in-person kind — it seemed almost too good to be true.  Thus, wary of falling prey to my own pride and narcissism, I immediately suspected a scam.   After all, if something looks too good to be true, it probably is.  I imagined this email went to many therapists, and that it was a con, like those Nigerian emails that promise great riches and are now an internet cliche.  This is precisely what con artists do so well: appeal to one’s greed or pride.  They hook you, then reel you in.  I wasn’t going to let that happen.

As a savvy internet user, I knew just what to do.  I found the person online, and wrote him directly via his website.  I included the bogus email I received, to let this far-flung colleague know I wasn’t about to be taken in, and also that his identity was likely stolen for nefarious purposes.  I was rather proud of myself.

It turned out the original email was legitimate.  Adding injury to insult, I also violated the privacy of my correspondent, who doesn’t read his own website email.  I had unwittingly turned an earnest request into an awkward encounter by being too incredulous and self-protective.  In rushing to defend my pride against an imaginary threat, that very pride distanced me from someone who sought my help, and even hurt him.  It was an important and humbling lesson.

I sometimes share with patients that there is no disproving paranoia; it’s the safer stance at any moment.  Why ever let your guard down? Unfortunately this safety, which is sometimes only illusory in the end, comes at significant cost: isolation, viewing others as threats, constant fight-or-flight tension.  Sometimes this is the best self-protection we can muster in the aftermath of emotional abuse or betrayal.  However, it’s not the best we can do as human beings.  A degree of credulity, in contrast, brings vulnerability.  We can be hurt, humiliated, and diminished.  But it also allows relatedness, connection, and love.

In order for dynamic therapy to lead to change, psychotherapists must get caught up in our patients’ dynamics.  Not too much, such that we lose perspective and act like everyone else in the patient’s life.  Nor too little, such that no genuine connection or relatedness occurs.  Both parties ideally permit themselves enough credulity to be drawn into emotional engagement, while maintaining enough skepticism (or “observing ego”) to note what is happening.  Ideally, that is, for we therapists are the more obliged to maintain a watchful eye, and must balance credulity and critical thinking more carefully.

Logical argument is unlikely to convince the paranoid to be more credulous, nor the gullible to be more skeptical.  Our comfort zones are established early and unconsciously, based on emotion not logic.  The emotional power of dynamic psychotherapy and psychoanalysis, as well as close, healthy relationships in everyday life, can nudge our comfort zone in a direction that serves us better — and serves our patients better, if we happen to be psychotherapists ourselves.  Meanwhile, reflecting on prideful attachment to a particular stance on this continuum may offer us perspective and more flexibility.

Image courtesy of Ambro at FreeDigitalPhotos.net

Hiring the one-armed surgeon

surgical_gloveTwo of the most commented posts on my blog are about charging patients for missed sessions and how psychotherapies end.  As there is no single correct approach to either of these, there’s plenty of room for practices legitimately to vary, and plenty of room for patients, i.e., most of my commenters, to express their likes and dislikes.  By my reading, many commenters assume that cancellation and termination policies mainly feed their therapists’ wallets; they tend to dismiss clinical rationales that are not obvious common sense.  I’m often drawn to defend the field and their therapists, and to point out that insight doesn’t always come painlessly.

Other times, though, I’m just dumbfounded (or the more hip term, gobsmacked).  One therapist reportedly starts sessions ten minutes late on a regular basis, and repeatedly cancels with less than a day’s notice for home furniture deliveries and the like.  Another conducted a therapy session “lying half dead on the couch. Her eyes were literally half closed – she was sick but didn’t call ahead of time to reschedule.” Yet another disappeared in mid-treatment and was later found to be practicing without a valid license.  Another psychotherapist left a voicemail at 6 pm to cancel a 7 pm appointment because her 6 pm cancelled and she wanted to go home.  And most recently, a patient wrote that her therapist revealed her own diagnosis of borderline personality disorder “with narcissistic overlay,” then went on to cancel the writer’s regular weekly therapy appointment, without advance discussion or notice, following an apparent misunderstanding.

It’s important to consider that these reports may be distorted.  That is the nature of transference.  For example, patients have accused me of “yelling” at them when I clearly had not; some are certain that I want them to end treatment when that isn’t true.  It’s possible that these therapeutic missteps are fantasies or exaggerations of the truth.  But I have no reason to think so.  The reported behavior sounds all too human.

Why do therapists — my colleagues — act like this?   We all have momentary lapses due to fatigue or personal crises.  These are unfortunate but usually rare and short-term.  A good therapist gets back on track quickly, acknowledges (and apologizes for) any hurt feelings, and repairs the damage done.  Sometimes a particular patient really “pushes our buttons,” i.e., stirs up strong countertransference, and we lose our composure as we are swept up in the patient’s narrative.  Ideally, these enactments are also brief, lasting only until we step back and gain perspective.  According to some schools of psychotherapy, they may even be helpful.  However, since countertransference can be partially or wholly unconscious, they may unfortunately go on much longer than ideal.  The therapist’s own therapy may mitigate, if not eliminate, these reactions.

Beyond this, however, some therapists seem impaired.  A psychotherapist who has little tolerance for strong emotion, who routinely engages in power struggles, who can’t stand rejection, who is excessively self-interested (or self-sacrificing!), or who has outsized needs for adoration or deference — well, that’s like hiring a one-armed surgeon.  (Not to denigrate any actual one-armed surgeons out there, but you have to admit it’s a disadvantage.)  Certainly in traditional dynamic psychotherapy, and to some extent in any professional helping relationship, our own personalities and social skills are part of what we offer.  We need to be healthy enough to “be there” for patients, and not add to their problems.  Surely it’s possible to pursue a career as a psychotherapist even if one suffers “borderline personality disorder with narcissistic overlay.” But it’s a significant handicap, much like the challenges facing a surgeon who is missing an arm.

Don’t get me wrong.  Overcoming such challenges is courageous and noble.  I’d have great respect for a one-armed surgeon if I ever met one.  I have similar respect for those who overcome debilitating psychiatric conditions to pursue their dreams.  But from the patient’s point of view, the idea is not to give the underdog a chance.  The idea is to get help.  Given the choice, most patients would not opt for a one-armed surgeon.  Most would not opt for a psychotherapist who acts in erratic or traumatizing ways.  The difference is that the surgeon’s impairment is obvious and the therapist’s is not.

There’s a cliche that mental health professionals (MHPs) enter the field to figure ourselves out, or to deal with our own inner demons.  Like most stereotypes, it contains a kernel of truth.  What’s important is the degree to which we’ve succeeded in gaining that insight and conquering those demons.  What’s even more important is how our personality affects our patients — however far we’ve traveled and whatever we’ve overcome.

We are all fallible experts

Jean-Piaget-1970It’s a blessing and a curse that we humans are such adept conceptualizers and heuristic thinkers.  We continually compare our perceptions about the world to paradigms in our head, performing quick, unconscious goodness-of-fit assessments. We instantly sense danger when a large furry beast rapidly advances.  We don’t waste time discerning whether it’s a lion or a tiger. (If it ends up being a friendly dog we breathe a sigh of relief, but better safe than sorry.)  Immediately categorizing a new situation as dangerous versus safe is an indispensable survival skill.  It many cases arriving at a decision right away is more important than perfect accuracy; some “false positives” are acceptable.

We’re not the only animal to react this way.  Lab experiments with mice, rats, and other creatures demonstrate their ability to abstract categories and react rapidly in order to stay safe or further their interests.  However, when it comes to assessing our fellow human beings, we elevate this skill to an art form. We instantly judge whether a person approaching us is dangerous, whether a negotiator is honest, whether to give weight to what another person says.  These intuitions are woven into everyday life, yet are hard to account for in detail.  Observing even one or two qualities we associate with dishonesty, e.g., a shifty gaze or inconsistent narrative, may be enough for us to withhold trust.  The stakes involved, and our past experience in similar situations, color our judgments in complex ways.

Expertise in any area of life is the gradual replacement of conscious, cognitive assessment by more fluid, less conscious impression.  A beginning surfer decides which wave to ride; an experienced surfer rides a wave that looks and feels right.  A new driver tensely scans and analyzes the scene; a long-time driver takes in the scene as a whole, anticipating traffic problems in advance.  A medical student concludes that a patient has a serious disease; an experienced physician walks into the patient’s room and immediately surmises this.  Experience leads to intuition, a sense about the situation.  It’s implicit pattern recognition: “yes, I’ve seen one of these before.”

In this way we are all experts about other people.  We get a gut feeling, a sense, a vibe.  When it comes to getting along with one another, we’re like the experienced surfer, long-time driver, and seasoned doctor.  We don’t consciously analyze, conclude, or decide; the calculus happens unconsciously.  And although some of us are better judges of character than others, most of us are right most of the time.

Stereotypes and prejudice are the price we pay for this expertise. The Swiss psychologist Jean Piaget explained how children fit (“assimilate”) their observations about the world into their pre-existing assumptions, and only more reluctantly change (“accommodate”) their assumptions to fit new observations. This is a good description of how adults operate too. Pattern recognition fails when valid new observations don’t fit the old pattern.  We call it prejudice when past experience with criminals of a certain appearance leads police officers to assume that others who look like them are criminals too.  We call it stereotyping when female health professionals trigger “nurse” before “doctor,” even though there are plenty of male nurses and female physicians.

Mental paradigms change slowly. “Consciousness raising” can help, but fundamentally it takes repeated exposure to countervailing examples to change assumptions. After all, those assumptions and paradigms have saved us more often than not.  Our common, repeated exposure to friendly dogs tempers our inherent reaction to large furry beasts, and repeated exposure to different kinds of people refines our expertise in this area as well.

Medical professionalism vs commercialism

fast-cheap-goodThe history of American medicine is the story of the rise and fall of a professional guild.  In the 19th and early 20th Centuries, physicians distinguished themselves from other healers by banding together to form professional associations dedicated to science-based practice.  Even more important, medical ethics put the patient first, above considerations of personal gain or even collective social goods.  The medical guild may have been insular, self-protectively territorial and paternalistic, but it was also self-sacrificing and altruistic.  Doctors earned the public’s trust one patient, or family, at a time.

The last quarter of the 20th Century saw this guild wither under waves of commercialism and populism.  Third party payers started “managing” care, trumping medical decisions with budgetary ones.  Large medical corporations leveraged economies of scale to provide services at lower cost.  Meanwhile, government oversight gradually replaced the guild’s self-policing.  Since the days of Vietnam and Watergate, no authority in America, even medicine, gets a free pass.  With oversight comes infrastructure, formalized quality control, reporting requirements.  Unfortunately, sensible-sounding social policy may be unworkable on the ground.  Private medical practices are gradually disappearing.

The weakening grip of physicians over the practice of medicine re-opened the door for commercial innovation — or pandering, depending on one’s perspective.  Generations ago, patients were drawn to inexpensive folk remedies, expensive patent medicines, and traveling road shows.  The modern parallels are free information on the internet, ads for expensive prescription drugs on television, and slick smartphone apps.  Patients now see a doctor for a one-time encounter online, at an urgent care clinic, or in a “Minute Clinic” behind a chain drugstore.  Enhanced access and convenience, often at lower cost, is the upside.  The downside is fragmentation of medical care rendering it an impersonal commodity, where doctors are interchangeable and patients are widgets on an assembly line.

The hard lesson of the marketplace is caveat emptor.  Little wonder that patients only reluctantly divulge personal matters to strangers in white coats, and increasingly prefer to do their own online research.  A trusting doctor-patient relationship, once the soul of medicine, begins to sound as quaint and precious as “old world craftsmanship” — nice if you can afford a concierge doctor who still offers it.

A number of battles are being waged in this larger war between professionalism and commercialism.  On one side are physicians rallying under the traditional banner of uncompromising standards, and prizing the individual patient over cost and social considerations.  Detractors, however, paint this stance as paternalistic, and say doctors are clinging to the last scraps of guild status and privilege.  On the other side are entrepreneurs happy to “disrupt” the status quo and give the public what it wants, namely lower cost, faster service, and transparency.  Detractors, however, say these entrepreneurs pander to a fast-food mindset that cuts corners and increases medical risk.

The Texas Medical Board ruled earlier this year that doctors must examine patients in person (or “face to face”) before treating them online, essentially declaring telemedicine an adjunct to in-person care, not a replacement.  Teladoc, the largest U.S. telemedicine provider, filed an antitrust lawsuit in U.S. District Court, which suspended the Board’s ruling.  The court’s decision suggests it is not up to doctors to set a standard of medical care.  It’s a marketplace decision.  If people want to be diagnosed without the benefit of a physical examination, and companies choose to provide that service, that’s their right.  It will be interesting to see whether medical malpractice will be harder to prove once the marketplace lowers the standard of care.

Likewise, doctors favor follow-up visits to discuss certain test results, particularly those with life or death implications.   This is motivated by benign paternalism: putting the results in context, softening the blow of bad news, helping the patient not jump to conclusions, framing the next steps.  Many service professionals, from caterers to auto mechanics, offer at least a little of this contextualization.  But it’s a value-added service that costs real money in medical practice.  Many patients prefer to get their results online or directly from the lab instead: it’s faster, less expensive, and feels more transparent.  Interpreting the results with the help of Dr. Google is a risk that saves time and money.

The tension between traditional medical values and expanding commercialism, amplified in this age of instant online information and services, puts the squeeze on physicians. We need to explain our rationales carefully and stand up for high quality in the face of expediency.  Yet we also need to choose our battles. We may be forced to accept a role for medical fast food as well as fine dining.  And this is not only for the sake of affordability, although that’s one very real consideration.  Americans crave speed and convenience, as distasteful as that may be to old-world craftspeople, Cordon Bleu chefs, and principled physicians.  Speed, cost, quality — pick any two.

Parenting medical disruptors

rebel-without-a-cause-2Popularized telemedicine — that is, teleconferencing with a physician over one’s smartphone — worries many critics because it assumes patients can be evaluated without a physical exam.  The critics are right that those with a financial interest in “disrupting” health care typically minimize the trade-offs.  Convenience and lower cost are trumpeted, while risks of misdiagnosis and mismanagement are waved off.  The concerns of practicing physicians are dismissed as self-serving and illegitimate.  Common sense supplants expertise; repudiation of experts, or perhaps a rebellion against them, lies just under the surface. Startup culture celebrates and sometimes handsomely rewards brash Big Thinkers who don’t let a few practical matters, like the fact that diagnosis isn’t always a slam dunk, impede progress.  Steven Jobs wasn’t the only one with a reality distortion field.

The tension between professionalism and commercialism isn’t new or limited to medicine.  Misgivings by medical personnel about “Dr. Google” and smartphone telemedicine parallel misgivings by attorneys about do-it-yourself wills and divorces, and by CPAs about at-home tax return software.  In each domain professionals lament the erosion of quality, and their inability to provide it, while business disruptors revel in expanded markets.

It’s also well accepted that providing high quality products or services, and wide availability at the same time, is an elusive challenge.  Usually it’s one or the other.  Although the marketplace accommodates fine dining and fast food, the fiduciary role of doctors, attorneys, accountants, and banks separates these fields from the restaurant business.  Banking is a prime example: no amount of convenience or access make up for uncertainty about the safety of one’s money.  And while profit, or making a living, motivates professionals as much as it does the businesspeople who aim to unseat them, only the former maintain longstanding traditions and ethical codes to put their patients or clients before profit.  The stale charge that heel-dragging professionals are financially self-serving applies far more to the gung-ho disruptors themselves.  Medical care has always been about high quality and wide availability, which is why health care reform is genuinely hard.  Trading away quality for availability or expediency is simply cutting corners.  We could have done that all along.

Smartphone telemedicine doesn’t currently allow physical examination.  There are a range of scenarios (“use cases”) where this makes little difference, and many others where it matters a lot.  But technology is a moving target.  It’s a safe bet that remote examination technology will improve, gradually putting this concern to rest.  Criticism of telemedicine is not about what it someday may become — “Star Trek” style holodecks with virtual physicians? — but about today’s enthusiasts getting ahead of themselves.  That is, selling science fiction, not science.  This creates a peculiar dynamic: innovators speak in vague but urgent tones of our shiny future and the need for traditionalists to step aside for progress, while critics walk a tightrope between condoning exploration and improvement, and at the same time keeping everyone safe.  This resembles nothing so much as parental oversight over a teenager.  Like good parents, professionals must step aside to allow entrepreneurs to try new things, learn from their mistakes, and yes, ultimately make the world better than they found it.  But we can’t be negligent either.  Some cool new toys are risky, some daring adventures bring unanticipated danger.  It’s no coincidence that the language of “disruption” sounds adolescent, and that pushback from the disruptors sounds like a teenager complaining that his or her parents are old-fashioned, uncool, and self-interested.

There’s a direct parallel in my specialty.  For over 35 years, advocates of a neurobiological approach to psychiatry have oversold what we actually know.  From now-discredited “chemical imbalances” to current talk of circuitopathies, neurobiology enthusiasts dismiss humility (and occasionally honesty) as old-fashioned and uncool.  This began with an Oedipal victory over Papa Freud in the 1970s, was codified into DSM-III in 1980, celebrated as the Decade of the Brain in the 1990s, and has shaped the NIMH and psychiatric research ever since.  Neurobiology has become the dominant paradigm, a matter of faith.  But aside from a limited range of scenarios (“use cases”) involving addiction and bonafide brain injury, it’s vaporware so far.  We psychiatrists are told to think neurobiologically, and to educate our patients using the language of brain circuitry — even though it’s often an educated guess, and even though it doesn’t actually change our treatment.

Surely time is on the side of the innovators.  It’s a safe bet we’ll learn much more about the brain, gradually discovering the causes of at least some disorders we currently call psychiatric.  Thoughtful criticism of neurobiological psychiatry is not about what it someday may become.  It’s about today’s advocates getting ahead of themselves, selling wishes and half-truths as established science.  Neurobiology disruptors speak in vague but urgent tones of our imminent bright future and a need for the older generation to step aside for progress.  Meanwhile, critics play the parental role, walking a tightrope between encouraging exploration and improvement, while keeping everyone safe with care for the brain and the mind.

It’s not easy parenting adolescents.  Sophomoric self-righteousness, know-it-all smugness, and knee-jerk rebellion can be irritating as hell.  Suddenly, adults are idiots and “just don’t understand.”  The young resist all guidance and veer toward obvious trouble.  It’s nerve-wracking to hang back and watch this happen; to refrain, except in extreme circumstances, from wagging a parental finger and chiding, “you have a LOT to learn!”  And all these challenges grow in complexity when the “adolescents” are actually adults, sometimes even colleagues, and when professional expertise and decades of hands-on experience invite only suspicion, not authority or respect.  Even if our concerns are dismissed as the bloviation of myopic dinosaurs, we still hope our colleagues, business counterparts, and larger society grow up fast enough to see past the seduction of disruption and rebellion.  We need to weigh the real trade-offs we face.