Sunday, October 11, 2009

You May Go Now.

I've learned something important from....reading the comments posted to our blog, listening to people talk, being a person who talks....No one likes to feel their concerns are being dismissed (myself included).

It's a recurrent theme in the comments that are sent to us, especially with regard to medications: a reader has a concern about a medication, feels it isn't working or that the side effects are too severe, and either their doctor does not address their concerns in a way that feels validating or the reader perceives that the doctor does not understand....since I'm not there, I can't say which is happening, but the feeling on the part of our readers is clear.

And just so you know, I've been on both ends of the discussion. I once lowered the dose of a medication, found it to be just as effective at a very low dose, and was told this was a "homeopathic dose." I didn't really know what that meant. In my terms, I had a headache that felt very real to me, and after taking a very low dose of a painkiller, my headache was gone. I wanted the least possible medication, so I stuck with the low dose. I'm not sure what was meant by the comment, but I heard it as the dose I was taking was so low it couldn't really be helping and I must have been imagining it's efficacy. This was my interpretation; the doctor may well have said it was simply to comment on how low the dose of medication was and not as a statement related to either the realness of my symptom or the realness of my response. I suppose I would have preferred to have heard that I must be rather sensitive to the effects of the medication, the "homeopathic dose" comment rubbed me the wrong way.

I've learned there a patients who have unpredictable and unexpected responses to medications. Some people tolerate huge doses of medications, others don't tolerate even small doses. Sometimes people have weird responses, and we don't really know what to make of it. My favorite example of this happened many years ago-- a patient told me he saw "trails" of light when he turned his head which he attributed to the Serzone I prescribed. Okay, that's weird, I'd never heard of that type of side effect from ANY medication. I didn't know what to make of it. The next week, I saw a case report in a journal of three cases of "visual trails" induced by Serzone. Go figure.

So why don't doctors just take patients' word when they say they are having a specific symptom: be it from an illness or from a medication? Why don't doctors hear when patients say they are very sensitive or not and need very high or very low doses of medications? More and more, I think we do.

Why not always?
Here are some reasons:
--Sometimes doctors are dumb.
--Sometimes doctors are egotistical.
--Sometimes doctors are frustrated. Especially if a medication helps an illness but causes awful side effects. And it's not just doctors. Family members will want patients to stay on their medications because they are less irritable, more functional, easier to get along with...even though the medicines cause side effects.
--Sometimes patients lie. This is especially true when controlled substances are involved: So a patient says that he's anxious and absolutely the only thing that helps is 6 mg a day of Xanax and he feels slighted that the doctor doesn't just take it at face value and prescribe it. Or believe that he's dropped the pills down the sink? Or never gotten them from his 90 day mail order company
--Some people are very suggestible and develop many side effects that they've read about. I really do wish there was a way of saying this without the word "suggestible" having a pejorative feel. Can't it just be? In medical school, I once heard someone say you can tell if a patient is simply saying "yes" to everything if they said their hair hurts when they pee (hair can't feel).
--Sometimes patients complain of things we've just never heard of .happening before. I don't think these problems should be dismissed, and I've taken to telling patients that I'm not in their body/head and they really need to be the one to determine if the benefit from the medication outweighs the side effects. This can be a difficult decision in the time while they are waiting to see if the medication is going to be effective.
--Sometimes patients misinterpret their doctor's comments. I'm often told I think such-and-such when in fact I don't think that at all. My doc might be surprised to hear I took the "homeopathic" comment to mean any thing other than 'my, what a low dose you responded to."

Finally, I've learned that patients can have very high expectations of their doctors. People often write in angry that their docs didn't warn them about specific side effects, and they'll mention a side effect to a medication I've never even heard of. It doesn't mean I don't think it happened, it just means it's not the usual for a psychiatrist to warn a patient, hey MedX could make your nose turn green and swell.

I think in psychiatry, we're all still just finding ourselves. So many of these medications are so new, and they efficacy and side effects varies so very much from person to person. Why does one patient get better with no side effects at all from the very first medication, while someone else is on maximum doses of 5 medicines at once, and still another patient has intolerable side effects to a tiny dose of anything?


Rach said...

I think in psychiatry, we're all still just finding ourselves.

I haven't been replying to your posts lately, Dinah, but I have been reading.
I do agree that unlike other areas of clinical medicine that use lab tests to discern exact levels of medication, vitamins, chemicals in the blood stream, psychiatry is as much about having a gut instinct as it is having the knowledge to prescribe appropriately.

Furthermore, I think the statement I just made applies not only to the docs, but to the patients too.
In my own experience, I'm moving towards a model of "informed consumer" and away from "taking the word of God (or my shrink) as is", though sometimes being ignorant is just so much easier!

Jackie said...

I like the "suggestible paragraph" and asking patients if their hair hurts when they pee. It makes me think of right now with my just-barely two year-old. He knows his body parts, he knows what boo-boos are... and so we are starting to ask him if something hurts when he isn't acting right. It often ends up, of course, that he just says "yes" to EVERYTHING... so we are now asking questions about hair hurting and other impossibilities to weed out if he just feels like saying "yes" at the moment.

Unknown said...

Been there w
hen a patient and I are working with a medication that works great for the prescribed purpose but may be producing an unusual but untoward side effect. I really wish and hope that the potential side effect is not from the medication I prescribe.

Anonymous said...

I’ve been fortunate as far as medications/side effects go. The first meds my pdoc prescribed have worked out well and I’ve been on them for a little over a year now w/o any side effects. My problem is that she dismisses my true feelings. When I answer her questions, such as when she had a cancel an appointment a while back for personal reasons, she asked me if I felt that she was rejecting me. I told her that I didn’t and that she was just taking care of personal business like we all need to do sometimes. She has a life outside of the office just like I have a life outside of my job. Her response was, “That is a logical explanation but is that how you really feel?” YES!!! She does this all the time and it frustrates me so much. I completely understand her asking the question but I can’t comprehend why she won’t accept my answer. She’s going on vacation in a few weeks and she keeps asking me how I feel about it and if I think she’s abandoning me. Every time she brings it up, I say, “I hope you have a good time. You’ll be gone for 1 week. So, no, I don’t feel that you’re abandoning me. You’re simply taking a vacation like everybody else does. It has nothing to do with me.” She has the same response about explanation vs. feelings. I feel like maybe I should just lie to her and say, “Please don’t leave me!!!” I won’t do that but I’m curious if that would make those questions stop. Also, almost everything I talk about, she asks how it applies to our relationship or if I am doing something because of how I feel about her. NO!! Which, of course, she doesn’t buy. This is my foray into therapy but all my issues; I’ve had for a long time (WAY before I ever met her). I’m seeing her to work out those issues. She has absolutely nothing to do with them and I can’t seem to convince her of that. Don’t get me wrong, she has helped me a lot but sometimes I feel that we’re just running in circles because she keeps dismissing my answers because it seem they aren’t what she wants to hear even thought they are my true feelings

moviedoc said...

Homeopathic: My understanding is that you start with the stuff that causes the problem, then you dilute it maybe 10:1 with water, shake it (succussion) and repeat the process until what you have left is pretty much pure water. If it does anything other than quench your thirst or reverse dehydration, I suspect it's the placebo effect.

Another reason we should never assume any phenomenon is caused by the medication is because it might signify something serious that demands diagnosis and treatment rather than reassurance.

Anonymous said...

Dinah, I think you took the easy way out, though, as a psychiatrist, you have little choice but to defend your....species. ;)

I think you missed something though, something that maybe you aren't even fully aware of - the fact that psychiatrists all too often have a bit (or more) of a sense of the patient being mentally ill, and therefore, perhaps not as smart/intelligent/thinking/understanding/aware.

Granted, there are thousands of psych patients who fit that bill. But. There are also thousands of us who don't....and we are aware enough to know we're being humored, patronized, or condescended to -- even when hidden behind the clearest facial expressions and kindest words.

Dinah said...

JJ, Rach, and Tigermom, thanks for stopping by.

Anon with the therapist focused on transference issues: this may be my next post.

Moviedoc: I still don't get it. Maybe if you could use the word in a few sentences>?

Anon2: Hmmm...I've said some shrinks are dumb and egotistical. I'm not sure how that defends the "species." Maybe some psychiatrists are condescending. I don't believe that all shrinks necessarily are.

WritingMom said...

I've had doctors dismiss my side effects a couple of times. Once was a combination of doctor frustration and email communication; she wanted me to stay on the drug longer to see if it worked, and I refused because I just couldn't tolerate the side effects any longer. Another instance was when I had a very unusual reaction to a sub-therapeutic dose of Paxil. Looking back, I don't think the doctor was really as dismissive as it felt; probably a bigger part of the problem was that I was severely depressed, so my perceptions were more than a little skewed.

And then there's the situation I'm in now; everybody (psychiatrist, therapist, husband) agrees that my side effects suck, but everybody's also in agreement that I need to stay on the meds. Most of the time I agree with them, but periodically I get so tired and frustrated with the side effects that I JUST WANT OFF RIGHT NOW!

Anonymous said...


I look forward to reading your post re: transference. I just came back from my appointment and we went through the same old song and dance this morning. I feel like it's deja vu!! We've had the exact same conversation 50x. I think she's asking valid questions but I just don't understand the repetitiveness or why she dismisses my responses.