Podcast #60: On the Verge

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In Podcast Number 60, we discuss the following:

Questions from readers--

• Sarebear asks: What is a Nervous Breakdown?
• Mary and Max, an award-winning claymation movie about an 8-yo girl and a middle-aged man with Asperger's. Very educational about Asperger's, and extremely entertaining.
• Another reader asks: How are psychiatrists prepared to manage psychiatric disorders in patients with autism?

• The New York Time review of a movie, Beautiful Boy, which led us in to a discussion of guilt and blame and our desire as human beings to believe we have control over what happens to us.  Too bad none of us saw the movie.

• Clink talks about an article that appeared in the Archives of General Psychiatry, National Study of Suicide in All People with a Criminal Justice History.

• Finally, we talk (or perhaps "ramble" is a better word) about the psychology of podcasting.

Thank you for joining us!

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This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

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The Patient Who Didn't Like the Doc. On-Line.

KevinMD has a post up today by Tobin Arthur called

Online reputation can have career implications for physicians

Arthur also refers to a post on the AMA's website back in October by Amy Lynn Sorrel,

Negative online reviews leave doctors with little recourse

Good timing because I wanted to post a vignette about a friend who is distraught about the on-line reviews he's gotten from patients. To protect both the innocent and the guilty, I'm confabulating the details & demographics, but the gist of the story is real and I'd like to hear your comments.

Dr. Tom Shrinky (not his real name) is a friend of mine who practices in Sanetown, PA (not a real place). He's an excellent psychiatrist with a great reputation, a packed practice with a long wait for new patient entry, and he's as conscientious as they come: he carries his cell phone everywhere and he returns all calls within the day. Plus, he's a nice guy, though I may be biased because we're friends.

One day, a patient says to Dr. Shrinky, "Doc, you know, I Googled you, and it wasn't pretty." Alarmed, Tom goes to Google himself and discovers that he's got a patient review up on one of these rate-your-doc sites. The comments are strangely personal, they comment on his recent weight loss, and say that he's in bed with the drug companies. There are a couple of other reviews, all 5 star, all saying how he's the best shrink in the world, but his overall rating is 3 star, and you'd wonder if he wasn't dying from the comment.

Okay, you hate a restaurant, you zing it on Yelp and you don't go back.

But Tom believes he knows who put these comments up. He has a patient, a lawyer he sees for weekly psychotherapy sessions. The patient is often hostile towards him, often treats him in a demeaning fashion, and this relationship does not feel good. The patient left treatment once briefly, years ago, but returned because, "You shrinks are all nuts and you're better than Dr. Cashew." Why Tom took him back, I'll never know. Tom tries to get the patient to focus on his hostility as part of the treatment.

So, a drug rep did stop by the office once to drop off samples while the patient was in the waiting room, and the patient had made a comment about this. And Tom had lost a lot of weight recently-- he'd taken up running and before he knew it, he was doing half-marathons. He cut back on carbs, beer and soda, and 60 pounds had dropped off him over 14 months. He looked great, and everyone commented including his patients. This particular patient, however, had said nothing, and one day walked in, looked Tom up and down, and said, "Have you got cancer or AIDS?" So the comment on the review about how he'd lost a lot of weight recently and looked like he had cancer. Tom could think of no one else who was unhappy with him or who would do this.

Unlike the restaurant patron, Tom's patient continues to show up weekly for psychotherapy. Tom feels a bit intimidated by him (this is not new) and is always happy when he cancels. So far, Tom hasn't asked if he wrote the review, but it bothers him. Others have put up counter-reviews, but there is a second bad review, and Tom thinks this is also the same patient. A colleague mentioned that a patient he tried to refer would not see him because of the reviews.

So, my thoughts, and then please do add yours:

--It seems to me that sometimes people have negative feelings in the course of a psychotherapy (ah, we might call this transference, but it would be dismissive to attribute all negative feedback to negative transference). In this case, it's no longer a doctor-patient issue, but one that has potentially included the entire world via the Internet.

--Should Tom ask his patient if he's put up the reviews? What does that get him? The patient may become embarrassed or defensive, or he may say he didn't do it (and maybe he didn't?) and be angry at the accusation.

--How does a psychiatrist (or any doctor) continue to treat someone who publicly struck at their reputation?

--And here's another problem for the doc--- a patient who would do this might also go to the physician licensing board and complain, and so Tom may worry that to terminate this patient's care may incite the patient's anger and result in a complaint and investigation of his practice. The patient is a credible professional and a complaint from him would likely be taken quite seriously. While Tom is certain he's provided responsible care and has not violated any standards of practice, he's well aware that a Board investigation (if a complaint did progress to that) takes years and causes a great deal of expense and agony, and so he may well be worried about fanning any flames.

--And finally, Tom is worried about upsetting the patient. He's been taking care of this patient for years, and he doesn't want this to end badly.

So what should Dr. Tom Shrinky do?

Movie Review: Oasis

I saw this film over the weekend after a recommendation from a friend. It's a Korean film about ostracized misfits who find one another in the midst of a harsh society. The main character, Jong-du Hong, is released from prison after serving time for killing someone in a drunk driving accident. His family are not happy to see him again. They are hard-pressed for money and have had to squeeze into a small apartment with his many siblings. His family does not hesitate to tell him that he is a burden and that they were better off when he was locked up.

He visits the family of the person he killed to make amends, only to find them in the process of moving out of their apartment. They are leaving behind the child of the accident victim, Gong-ju Han, a severely disabled woman with cerebral palsy. Jong-du confronts her brother as they are leaving and demands to know who will take care of her. He is kicked out of the apartment and she is left alone, with physical contortions that horribly distort her limbs. It was painful to watch.

Jong-du returns repeatedly to try to visit Gong-ju, to bring her flowers and to check on her. Finally, one day he is let into the apartment. He tries to rape her then flees when she passes out.

This is the point where the movie becomes inexplicable to me. Following the attempted rape Gong-ju fantasizes about Jong-du and imagines having a lover, and struggles against her cerebral palsy to put on makeup. Jong-du returns and the two become lovers. Their train-wrecked lives come together in a predictable way. One physically damaged, one psychologically damaged, both without psychological or social support. The result is inevitable and predictable.

The Rotten Tomatoes web site gave this film an 89% favorable rating, although I'm not sure why. One of the difficulties of this movie, besides the implication that rape can trigger love, is the fact that Jong-du's facial contortions made it impossible to read her emotions, and I was left wondering if she was in pain, afraid or ecstatic. When it was crucial to directly tell the audience what she was feeling the director cut to a fantasy mode, and the physically-whole actress acted out Gong-ju's feelings. We learn she is entranced by this man, that she fancies herself teasing him and playfully flirting with him, that her days are filled with wonder and fulfillment when he is around.

The most potent part of the film was the portrayal of how this disabled woman was treated by Korean society----she was refused service at a restaurant and rejected at a family gathering---overt discrimination highlighted by Jong-du's naivety. He brings her to his mother's birthday party only to be confronted by his siblings about his inappropriateness. Gong-ju's family can't even imagine that anyone could love her, and they take it for granted that he is abusing her when they finally do make love.

Jong-du ultimately goest to prison after a false rape allegation, but personally I think he should have been there quicker after the first, real, attempt.

Scientific American Mind Reviews My Three Shrinks Podcast

Christopher Intagliata, from the magazine, Scientific American Mind, reviewed our podcast in their June/July 2008 issue.  Click the review below to go to the SciAm Mind website.

   "...a few bottles of wine..."  

LOL... if we did that, there'd be no shrill bickering, just dysarthric, discordant "singing".

Go buy this issue (you can even buy a digital version) so you can also read about oxytocin and trust, psychiatric genetics, anorexia, chronic itching, and unleashing your inner genius.