Tuesday, March 17, 2009

Here Ye! Here Ye!!

In medicine we're generally careful not to judge our colleagues harshly on paper. We may report what the patient or another doctor tells us, but we usually hold off on condemning people in a chart-- it makes for messy liability issues, and it's really just poor form to write "Can you believe that idiot prescribed this combo of meds" or "the last doctor never even listened to the patient's complaints."

In real life, I don't believe we're quite so generous. It's not at all unusual for docs to condemn-- in an off-the-cuff manner in casual conversation with friends-- their disdain for the practices of others. Can you believe his former doc prescribed 10 mg/hour of Xanax? Or what about the doc who demands every patient come for weekly therapy sessions even if they don't think they need therapy? Or the doc who only sees patients for 10 minute med checks and never really listens to the patients? How 'bout that doc who gave his suicidal patient a 90 supply of Hemlock? Or how could he start a patient with bipolar disorder on an antidepressant-- of course it de-stabilized him!

I think we're quick with our Can You Believe stories. More in psychiatry than in other branches of medicine? Maybe. Why? Perhaps because less of what we do is clearly defined and even amongst ourselves, we have no full consensus on exactly what it is we do, and in what units. We're certainly getting closer with our use of medications, but still, the guidelines don't take into account what to do if a patient fails many trials of many medications and still has a myriad of symptoms. Sometimes our patients are very sick and we get very desperate. And then too, our label says little about what exactly we do-- one shrink only does med checks, another only does therapy, and we amongst ourselves have not come to a consensus about what is the absolute 'right' thing to do, for whom, in what settings, with what staffing and reimbursement issues, how frequently, and when.

What do you think: are we gentle with each other or not?


The Shrink said...

I think on the whole we're a pretty affable bunch.

We've ready access to second opinions and, invariably, in my corner folks independently say the same thing.

We moan about managers, we seldom moan about colleagues.

On reflection it's vanishingly rare I'll chide a colleague's practice and don't often hear of negative comments 'bout mine. Conversely, we're much more scathing of general physicians in Primary Care than some disciplines.

"He's been seeing this patient with depression for 6 years and never started any effective treatment?!"

"He's been seeing this patient with memory problems for 3 years and never referred for acetylcholinesterase inhibitors?"

"He's been seeing this patient with acute onset of visual hallucinations that have gone on for 2 years and he's never scanned their brain?"

I find myself having cautious conversations with such patients, along the lines of, "Well, although I can understand why Dr X has done this, in truth I'd have been inclined to do blah blah blah. What're your thoughts on this, now?"

Fat Doctor said...

I don't think it is just psychiatry. I think it is all of medicine. Not a day goes by that I don't at least think "can you believe" about a colleague. I know they all think it about me.

I try to remember that we are all mere mortals, doing the best we can with a mountain of literature, no time to digest it, sicker and sicker patients and external limitations on our time.

To quote Rodney King, "Can't we all just get along?"

Anonymous said...

I'm a patient, but I do the "can you believe it" routine about doctors. For example, one of my friends goes to a Primary Care physician who is a personal friend of hers from her days as a drug rep. This is a guy who apparently does not believe in (gets paid more to not believe in??) referrals to specialists. This doc put her on thyroid meds, then ramped up her dose to 250mcg Levoxyl. My friend showed signs of anxiety (too much Levoxyl???) so he then put her on an anti-anxiety med plus she was depressed, so an anti-depressant too. In 10 years of continuous meds she has not been to either a psychiatrist or an endocrinologist. She LOVES her doctor and "all he's done for her" and doesn't think she needs specialists when she has such a great primary care doc. Wow!

BTC said...

Great (and interesting!) post.

Following on from what the previous "patient" said it seems there are a lot of "can you believes" on both sides of the treatment scale. Possibly it is because the professional practitioners as you say do not have a tried and tested accepted process to follow (though as you say this is improving somewhat with meds) especially as every patient and every brain responds differently to treatment and at the other end, the patients do not really know what to expect or what "normal" treatment processes are and what are the outcomes that can be expected?

Also the relationship can be very enclosed - one patient, one doc and the patient never knowing there are any alternatives and not in a position to question.

If the other practitioners who see the treatment plans are not questioning then who will stand up for the patient?

A lack of clarity combined with some smoke and mirrors can lead to a whole load of confusion.

Not that I don't think that everyone is doing the best they can.. just that there could be something of a communication breakdown.