Elliott B. Martin Jr, MD

Back in July 2015, I wrote an article for 

Managing Ebola: The Archaeology of a Disease

” at the early stages of the burgeoning Ebola outbreak. I quoted Dr Adrian Hill, director of the Jenner Institute on vaccine research at Oxford: “We know there will be more outbreaks . . . Many viruses are lurking, and then there are going to be new viruses.”

 Here we are, only 5 years later, in the face of a pandemic, literally tracing the archaeology of a new disease.

As across the country, COVID-19 has become the primary focus of hospitals in my geographic region (the greater Boston area). At time of this writing, we have not yet been overwhelmed, but cases are growing. The psychological warfare waged by this virus has been overwhelming, both for patients and for health care providers. Patients are afraid of contracting and transmitting the virus. But health care workers, especially those used to a degree of predictability, seem to be susceptible to the stress of uncertainty and loss of control engendered by the COVID-19 pandemic.

Since the declaration of the pandemic, we have had several cases in our emergency department (ED) of what I have referred to as corona psychosis; 3 of which are presented here.

“Dr Smith” is in her 40s; she is a practicing physician and administrator at a medical center. She was brought unwillingly to the ED by her husband. She had no prior documented psychiatric history and no significant medical history. She was almost 2 years out of the postpartum period. She did not drink alcohol or use other psychoactive substances. Her husband learned of staff concerns that she was becoming increasingly irrational and erratic at work, corresponding to the dramatic increase in media coverage of the coronavirus.

Upon psychiatric evaluation, Dr Smith’s speech was pressured and she was paranoid. Despite being asymptomatic, she convinced staff at another hospital to test her for the virus; the test came back negative. Dr Smith then became belligerently mistrustful of “the system,” refusing to believe she did not have the virus. Dr Smith became convinced that not only was she infected, but her family was infected as well. She believed that the Center for Disease Control had specifically targeted her and her family, transmitting the disease surreptitiously by means of drones while they slept.

As a result, Dr Smith had not slept for 3 days. She denied any hallucinations; she maintained good behavioral control throughout the exam, but she clearly was delusional. When asked about her plans, she stated only she “would monitor the situation.” When asked why she returned to work if she believed she was infected, she said, “I have to find the cure.” Although we encouraged her to admit herself to the psychiatric unit, she refused. She responded well to lorazepam in the ED, and her husband, also a medical professional, insisted on taking her home. Dr Smith did not meet criteria for involuntary commitment, and she was discharged.

“Ms Rogers” is a nurse in her mid-40s. Married with teenage children, she had a history of depression and anxiety, as well as some concerns for a possible alcohol use disorder. She had no documented history of psychotic symptoms. She self-presented, complaining of worsening depression since the expanded media coronavirus coverage. Ms Rogers noted she was feeling quite hopeless and suicidal.

Ms Rogers wrote a detailed suicide note to her husband, making it clear that she “was already in the process” of committing suicide. She explained, both in her note and to us, that she had infected herself with coronavirus with the intent of dying. She tested negative for the virus at an outside hospital. When asked how she had infected herself, Ms Rogers explained that she “went 24 hours without washing her hands.” She was not intoxicated, and there was no evidence of withdrawal.

Although she was convinced that she would die within 2 weeks, Ms Rogers agreed to a voluntary admission to the psychiatric unit. She responded well to low-dose lorazepam in the ED. Her symptoms are currently being treated with a combination of an antipsychotic and an antidepressant medication.

“Ms Greene” presented while still working her shift as a hospital custodian. She was in her 40s, and married with grown children. Ms Greene worked on the hospital housekeeping staff for many years without incident. She had a long history of intermittent anxiety treated well by her primary care physician with minimal use of as-needed alprazolam.

Ms Greene was cleaning a patient’s room on the psychiatric unit when a nurse entered the next room, gowned, gloved, and masked, to perform a routine influenza/RSV swab on a different patient. Upon witnessing this, Ms Greene became convinced that she had contracted coronavirus. She became quite agitated, started pulling at her hair and shouting nonsensically in her native language. She could not be calmed down verbally, and she had to be escorted to the ED by hospital security.

Upon examination, there was no indication that Ms Greene was at increased risk of coronavirus; and she was asymptomatic. Due to Department of Public Health guidelines, therefore, she was not tested for coronavirus. She partially responded to lorazepam, but she remained delusional that she was “infected.” Family members took her home. Ms. Greene has been on medical leave since then.

Although this is a small series of patients from a single community hospital, I anticipate as this crisis unfolds-and as people are more socially isolated-there will be an increase in these brief psychotic reactions. Based on these cases, anxiety (and perhaps depression) may be a contributing factor, the more acute symptoms responding (at least temporarily) well to lorazepam.

What is otherwise striking is the commonality of all 3 patients working in hospitals at the frontline of the current crisis. I am concerned about the toll this crisis is taking on those in the trenches. There have been many subtle signs of stress vulnerability in providers, increasingly outward signs of a more generalized helplessness at the loss of control.

The anxiety is growing more palpable-both for patients and health care professionals-and I would urge everyone involved in these efforts to seek and to provide ongoing support for you and your teammates. As psychiatrists, we need to be attuned to colleagues as this drama unfolds. Like all crises, this too will end, and hopefully, these and other “corona psychosis” cases and anxiety will resolve.

The cases discussed here are composites and not meant to identify any one person. 

This article was originally posted on March 25, 2020, and has since been updated.

 is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.

1. Researchers warn G7 leaders on disease preparedness. University of Oxford. June 3, 2015. 

http://www.ox.ac.uk/news/2015-06-03-researchers-warn-g7-leaders-disease-preparedness-0

2. The Authorized G7 Publication. Ebola: global health threats need a global research and development solution. G7: Beyond. 2015.2015:90-91.

Articles

Some health care workers have been particulary vulnerable to the stress of uncertainty and loss of control engendered by the COVID-19 pandemic, illustrated by 3 cases presented here.

Brief Psychotic Disorder Triggered by Fear of Coronavirus?

 the focus of much national debate has once again pivoted toward gun control, and the role of mental illness in creating the mass murderer. The arguments have taken a predictably 

 turn, focusing less on understanding why a human being would do such a thing and more on why such acts are not considered acts of domestic terrorism.

Recognizing these murders as “acts of domestic terrorism” may allow for more resources to be allocated to subsequent investigations but will contribute nothing toward our understanding of the mental processes that drive such a killer.

Identifying mass murderers as “disenfranchised white males” only plays into identitarian politics-that is, post WWII, far right ideology-and keeps the discussion skin deep. Branding these acts as “hate crimes” is also woefully inaccurate, unless the “hate” refers to the almost certain self-loathing of the perpetrator. Most mass murder victims are people wholly unknown to the murderer. Unlike crimes of passion, there is almost certainly no personal animosity between a mass murderer and his victim. These crimes are more analogous to video games. The killing is more metaphorical than fueled by any particular “hatred.” The murderers are racking up points more than anything, as many as possible before their own (expected) demise.

Stepping back a bit, with a critical and historical eye, mass murder was an anomaly until the 1990s, accelerating tremendously through the early 2000s until now. Weaponry has not really improved much during that span. The logical question is what happened during those years to spur such an increase in violence? Did mental illness explode? One may argue so, I suppose, as the rates of suicide have 

in dramatic step with these homicides during this same period, if in fact suicide is also an end result of purported mental illness.

Again, this would depend on one’s definition of hatred. Generally, people who kill in cold blood are not fueled by hatred of their victims, but more perhaps by self-hatred, or hatred of an ideal.

 Planned, well-executed mass murders cannot really be viewed as crimes of passion. If anything, these are more crimes of ambivalence, with the flesh and blood victim providing the same transient “rush” as the virtual-victim, again, in a video game.

I come back to the video game analogy on purpose. The World Wide Web came into existence in 1991. It gained international traction in 1993, erupting in infinite directions with absolutely no restriction or regulation. And although the “smart”-phone was invented in 1992, “social” media-the most massive collection of pornography, hatred, violence, and vitriol the world has ever known-was unleashed without restraint with the development of the “I”-phone in 2007.

No one had any idea what all this might do to the collective human psyche.

In this context, much effort is being made now to demonize the mass murderer as a product of “white supremacist” “ideology,” somehow considered a “logical” extension of several hundred years of eroding “white privilege.” Of course, this contention, dubious as it is, only works for the “white” mass murderer. It does not account for the roughly 

 committed by non-white people over the past 37 years.

 Frankly, these discussions of white nationalism and the like are red herrings, easy media fodder, and distractions from more profound considerations, in my opinion. Throw in a perpetrator’s supposed “mental illness” and “hate,” and the awkwardly proposed picture, though it may then be condensable to 144 characters or less, is utterly nonsensical.

The historical course of “eroding white privilege” is really the logical progression of the then neoliberal ideals come to fruition during the 18th century, the so-called Age of Enlightenment, culminating in the American and French Revolutions. The grievance with monarchy at the time was, at its core, the middle class, the business class, desire for increasingly liberal economic policies, the desire to “spread the wealth” more from the kings, the government, to the people. This was a gradual process at first, co-occurring with social welfare laws designed to keep this burgeoning “capitalism” from spinning out of control.

Predictably, exploitation became the rule, and resistance to this generally dehumanizing process was stiff. The 19th and 20th centuries were obviously riddled with brutal conflicts over this single principle. The word “terrorist” first emerged during this revolutionary age, used to describe both right- and left-wing political extremists.

With the collapse of the Soviet Union and its satellite communist states in the 1980s, neoliberal capitalism won the day. History ended in 1989, according to some,

 coinciding with the birth of virtual culture. And with this incredibly powerful new tool, really an economic doomsday device, capitalist forces in their most brutal, pure, and exploitative forms were suddenly unleashed without an ounce of forethought.

“Globalization” became the new buzzword. 

 is perhaps more apt. And the corporate state was born. Governments have increasingly shrunk before corporate board rooms in the face of a virtual Leviathan beyond anyone’s control. In the virtual marketplace, humans are merely data points, and there is little regard for anyone’s humanity anymore except in the most superficial of ways (ie, race, ethnicity, gender). Demographic points easily crunched into the algorithms.

The human brain has changed accordingly. Desperately trying to process the 24-7 stimulation of the virtual world, is there really much wonder at the stupendous rise in autism rates over this time period, the steep rise in ADHD, the general fragmentation of personality and identity, and the increase in suicide? There is certainly little wonder at the appeal of intoxicating substances and the lure of a virtual existence over a real one. Frankly, there is little wonder at the inability to consider more deeply than the surface, and the disproportionate passion invested in single issues.

The virtual world is tremendously isolating. It is brutal and unforgiving. German-Korean critic Byung-Chul Han

 the fiction of online “community,” or “multitudes,” characterizing the virtual world as a vicious “swarm” of individuals wrapped up in their own self-righteousness and inability to step out of the present moment, with the vast majority of social media content becoming increasingly nasty and self-serving, characterized by vitriolic snark. He in fact refers to the internet as “the s-storm.”

Just prior to the digital age, moral philosopher Philip Hallie

 wrote extensively on the nature of cruelty, distinguishing between episodic and institutional cruelty. Episodic cruelty is the easy kind, where the victim and perpetrator are both aware an act of cruelty is occurring. Institutional cruelty applies more to one’s daily existence. A debt-credit culture, a skewed judicial culture, an unfair contract culture. A bureaucratic culture epitomized early in 

 come to full fruition in the era of Big Data.

The question may well also be inverted as to why such acceleration in suicide? The superficial profile of the suicide and homicide is essentially the same: the “disenfranchised white male.”

The answer probably lies within the tremendous self-loathing at the heart of the otherwise impotent virtual psyche. The “swarm” is a virtual id with no constraining cyber-superego. It needs victims. The easiest, safest, and fully sanctioned target at this point, is the now faceless and colorless, so-called “white male”-by now come to represent everything the swarm hates about itself. And the cyber-realm is the perfect stage for projective identification. The victimizer is victimized to the point that he honors the unconscious fantasy of his perceived tormenters. And he does so at times with the drama the swarm demands.

None of this, of course, allows for any meaningful discussion. Politics, on all sides, has degenerated into such profound immaturity and snark, in embarrassing efforts to appease the swarm, that who would dare offer or entertain contrary opinions? Look at psychiatry’s own historical tendency to blow with the political winds, intensifying as well as in recent years, in the face at times of mountains of contrary evidence that cannot be acknowledged over concerns for digital retaliation.

Disconnecting from the storm, and encouraging our patients to detach from the fray, is the first logical step.

Editor's note: The views expressed in this article are those of the author and do not necessarily reflect the opinions of 

is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.

https://www.gunviolencearchive.org/reports/mass-shooting

2. Center for Disease Control. Suicide rates rising across the U.S. 

https://www.cdc.gov/media/releases/2018/p0607-suicide-prevention.html

The Myth of Martyrdom: What Really Drives Suicide Bombers, Rampage Shooters, and Other Self-Destructive Killers.

4. Follman M, Aronsen G, Pan D. US Mass Shootings, 1982-2019: Data From Mother Jones’ Investigation. 

https://www.motherjones.com/politics/2012/12/mass-shootings-mother-jones-full-data

5. Francis Fukuyama, The End of History and the Last Man, The Free Press, New York, 2006.

7. Hallie P. From cruelty to goodness. In: Sommers C, Sommers F, Editors. Vice and Virtue in Everyday Life. San Diego: Harcourt College Publishers; 1989: 9-24.

8. Reiner S. Death by Data: How Kafka’s The Trial Prefigured the Nightmare of the Modern Surveillance State. 

https://www.newstatesman.com/2014/01/death-data-how-kafkas-trial-prefigured-nightmare-modern-surveillance-state

Recognizing violent incidents as “acts of domestic terrorism” contribute nothing toward our understanding of the mental processes that drive such behavior. More in this commentary.

Mass Murder in the Digital Age

Two cases illustrate the dilemma of the duty to warn. The intricacies of Tarasoff involve so many variables, from state to state, scenario to scenario, case to case. How does one practice good clinical judgment? Following this piece, James L. Knoll IV, MD, provides a forensic analysis, in 

Psychiatric Malpractice Grand Rounds: The Tarasoff Dilemma

I would like to present for consideration and discussion two personal stories in which the so-called Tarasoff Rule, or the “duty to warn” a threatened third party, was invoked. One was arguably appropriate; the other, arguably not. In my experience, invoking Tarasoff remains quite contentious, and even legal specialists are often indecisive. For patient confidentiality, details in the cases presented have been changed.

When I was an intern, we had a young man committed to us for attacking his mother, and for continuing to threaten her. This was especially problematic in that he lived with her, had no intention of living without her, and his mother was firmly set on his continuing to live with her. We held him for weeks, into months. He had several forensic evaluations along the way.

At first resistant, he eventually agreed to take medication. He learned “to say all the right things,” such that the forensic specialist assigned to his case agreed with the judge in the case that there were no longer grounds to hold him against his will. I, and others who had worked closely with him, did not agree, and so the Tarasoff rule was invoked.

I sat down face-to-face with the young man’s mother. I discussed at length with her that the patient would have to be discharged, and the reasons why. I explained as concretely as I could that although he had previously repeatedly made physical and homicidal threats toward her, he recently had been taking medication with superficial improvement such that a judge, as well as a specialist in criminal mental health, had advised us that we could no longer hold him against his will. She acknowledged all this with tears in her eyes and stoic resignation on her face. She absolutely understood what I was telling her, but she made it quite clear that she would welcome him back home regardless.

Two days later, he was arrested for stabbing his mother several times in the face. She survived the attack. He was eventually committed to a state forensics facility.

When I was a fellow at a major pediatric hospital, we had a very disturbed young man who had been sent to us by his outpatient therapist after he had revealed to her several notebooks detailing the many gruesome ways he was planning on eviscerating and alternatively torturing and taking apart piece by piece a particular older boy at his high school. The notebooks were filled, front to back, with minute, bizarre scribblings, macabre poems, as well as several hand-drawn pictures of a mutilated young man in various stages of deconstruction and decomposition. Here and there were very large printed words, “DIE! DIE!” followed by the intended victim’s name.

The victim was a student in the same school, two years older. He reportedly had no idea this younger boy, whose eroto-manic delusions had utterly gotten the best of him, felt this way about him. The patient’s target was captain of the football team, a major player on the debate team, highly ranked in his class, of a well-known and popular local family, and apparently destined for great things, not least of which was having the most popular girls in school hanging off both arms.

This younger boy was not popular. He was homely and overweight, suffered from psoriasis and acne, and was withdrawn and isolative. He had few, if any friends. His parents had put him in therapy for what they saw as depression related to his sexual orientation. It was clear over the weeks we had him in the hospital, however, that his depression was complicated by significant delusional thinking. He believed he in fact had had some sort of relationship with this other boy.

These delusions, in fact, were so intense, that our patient initially believed the older boy impregnated him. More importantly, and frighteningly, he believed he had been most grievously wronged by this boy. We never did learn what this great insult was. But, in lieu of his love/hate-object, he made frequent threats against his perceived unborn baby. He was determined to make “the father” pay for the perceived transgression.

By all accounts otherwise, the older boy had no idea this younger boy even existed. Again, we kept the patient as long as we legally could. He did seem to improve with the combination of medication and “milieu therapy.” Eventually we had no reason to keep him. His parents wanted him home; he wanted to go home. He was different than the young man in the first case, in that no one really believed he would now actually harm anyone. He seemed to have developed some insight, and he eagerly approached therapy. He had been in the hospital nearly three months.

My supervisors, in consultation with the hospital’s legal team, debated long and hard over whether Tarasoff needed to be invoked in this situation. It was illuminating to learn just how gray this area is. The legal team was mostly noncommittal. But eventually, and at the hapless trainee’s (namely, my) expense, my clinical supervisors came to view this opportunity to invoke Tarasoff as a “teaching moment.”

I notified the local police where this boy lived. I notified, with parents’ permission, the school administration. (The parents did not want their son to transfer to another school-our first, most insistent, and best recommendation.) And then I had to call the older boy’s parents.

“Yes, hi. My name is Dr Martin, and I’m calling from the hospital. You don’t know me, but I’m calling about your son.”

“Oh, my goodness, what about him? Is he okay?”

“Oh, yes. And I do apologize. He’s not here. In the hospital, I mean. In fact, I’ve never met him.”

“Mrs Smith, I am required by law to inform you that we have a patient here who will be discharged tomorrow, and this patient has made repeated homicidal threats toward your son.”

“No, no, Mrs Smith. I work on the psychiatric unit here at the hospital, and we have been working with this patient for months now. It is our opinion that this patient is no longer dangerous, but we are required by law to inform you of the threats made earlier to your son.”

“Who is this person?” I could hear the panic.

“What do you mean, you ‘can’t tell me that’?!”

“I apologize, Mrs Smith, and I know this is awkward-”

“No, no, no, no. You call me out of the blue, tell me you’re from a hospital, and then tell me you’re about to release a patient who has made threats to kill our son?! And worse, you tell me you cannot let me know who this person is!”

“You’ve got a lot of nerve, Doctor. Do you know who my husband is?”

“Ma’am, I once again apologize; and believe me, if it were up to me, we wouldn’t be having this conversation, but-”

 you! How dare you call me like this! I’m calling our attorney right now! What did you say your name is?! We are going to find out who this psychopath is, and we are going to be sure this nutcase is not allowed anywhere near the school!”

“I have already notified the local police.”

“So they know the name of this psycho.” (I believe this was a statement).

“I’m going to call Bob right now. And 

, Doctor so-and-so, believe me, you haven’t heard the last of this.”

That, in fact, was the last I heard of her, and honestly, I totally saw her point.

In the emergency department setting, we mostly turf cases in which there is a question of invoking Tarasoff. In other words, we commit patients to the hospital and let the inpatient folks deal with it. We work under a (creative) assumption that by doing so, we absolve ourselves of the duty to warn.

But again, I’ve never gotten a straight answer on that one either.

Dr Martin is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.

The author reports no conflicts of interest concerning the subject matter of this article.

The author presents for consideration and discussion two personal stories in which the so-called Tarasoff Rule, or the “duty to warn” a threatened third party, was invoked. One was arguably appropriate; the other, arguably not.

To Invoke or Not to Invoke: Tarasoff Is the Question

There has been a lot of talk about reforming medical education. Reading through the American Medical Association’s “

” proposals to reform both medical school and graduate medical education, “innovation” certainly remains the buzzword of the day.

 Ironically, this seems to reflect more of an old-fashioned “keeping up with the times” mentality, with a general premise of breaking away from perceived dogma. As to specifically what these “times” are that seem to be passing the rest of us by, and what has become problematically dogmatic in training, I admit I have been unable to locate in any of the proposals other than the broader, “timely” rubric of change for change’s sake.

Granted, the “times” have spun violently out of control over the past 20 years: witness the digitization and corporatization of medicine. The training process itself, for physicians, has remained relatively unchanged. And it is almost certainly the growing disconnect between the end of medical school and the start of residency that is driving the movement to reform training now. The old “medical” world is now the “health care” world, with many different hands in the pot. And whereas physician training remains conservatively geared toward creating “good doctors,” administrative training is often diametrically opposed to this.

Proposals for changing physician training, especially as more corporate entities tinker under the health care hood, rather than suggest administrators broaden their own education more humanistically, focus on aligning physician training more with corporate goals. That is, replacing the time-worn critical-dialectical process with the informatic-algorithm. Less art, more “science”; less wisdom, more analytics.

In these algorithmic times, then, how is it that we can broaden and make medical education more fulfilling? Currently the clinical training-an experiential mix of bedside lecture, bedside quizzing, and bedside suffering-can be demoralizing, dehumanizing, and humiliating. It can also be inspiring and uplifting. It is a training highly dependent on trust and chance, on both teamwork and individual decision-making. “It could always be worse,” is the telling mantra, and mistakes are not tolerated. In other words, clinical training resists what makes the informatic-algorithm work best: standardization.

And this illustrates the critical difference between medical school and post-graduate training. The greater appeal of medical school today, and especially the pre-medical path, is almost certainly that it offers a rigidly disciplined structure against a tide of otherwise increasingly fragmented and unfocused learning options, especially through adolescence and young adulthood. This phase of training does lend itself well to standardization, at a time in training when it is absolutely necessary.

Residency, on the other hand, is all about the art of mastering chaos. Only worse. Doing so while suddenly crushed with soul-numbing debt, while suddenly scaling impossible learning curves and juggling major teaching responsibilities. It is about mastering the pretense of knowing everything while rapidly absorbing new technological and administrative requirements. All the while studying for licensure exams, applying for fellowships, starting families. All the while negotiating the gauntlet of abuse and bullying from seniors, attendings, nurses, administrators, patients, families.

We used to half joke in residency that this generally “miserable way of being” had evolved as a means of helping one learn about suffering through suffering. Many of my previously jovial colleagues, however, soon found themselves subsisting on the increasingly standard pharmacologic stew of stimulants, “benzoes,” and antidepressants. 

 Learned helplessness, PTSD, and the victim mentality are ubiquitous, and one may justly wonder whether “education” is even really the right word.

How then to combine disparate approaches to reform?>

How then to combine disparate approaches to reform?

Possibilities: thinking outside the algorithm

In these politically fraught times, many have urged 

 and advocacy as a means of broadening and providing for more meaningful medical education.

 Indeed, such strategies may help somewhat. But just like meditation can actually induce panic in a fair amount of people, so can activism be stifling to many who are searching for that medical holy grail. “Causes” tend to become their own dogma. Critical thought-the cornerstone of all education-often finds itself quashed in the rhetoric and rage of “social justice.” Physicians especially should never close their minds. Certainly, residents should not be forbidden from this path, but if they choose it, they need to be careful of politicizing patients, of taking sides.

Perhaps a more effective strategy would be simply to encourage residents to ask questions more broadly, more conversationally, of their patients, to understand the issues that are meaningful to them (patients), to get to know the neighborhoods in which they work, to learn the history and geography of their regions. When I was a resident, in efforts to develop relationships in the community, we regularly toured the neighborhoods and frequented the shelters, detox facilities, and shantytowns. As a fellow, we often dropped by and volunteered at the local schools and Head Start programs.

By all means, we should educate residents as to their local insurance market, to grasp what their patients will and will not do, what they will and will not pay for, and what they can and cannot afford. Tangential to this are the many “quality improvement projects” initiated by colleagues and administrators, typically through existing electronic health records. Because they are easy (ie, algorithm- and checklist-friendly), they are also good resume and CV filler. These, then, often have very little thoughtfulness or evidence behind them, and frequently contribute more to administrative burden and burnout for the rest of us than any meaningful improvement in quality.

Outside moonlighting is an overlooked opportunity. Often discussed in hushed tones, this needs to come out into the light as this may in fact be the best way to transition from resident to attending. Different hospitals, different systems, different patients, different colleagues. Different ways of doing things. Especially in areas otherwise dominated by hyper-supervised corporate entities where it becomes very easy, and dangerous, to believe in one’s own infallibility, there may be no better way to learn self-reliance and decision-making, to finally becoming a doctor. (And it is an excellent introduction to another unspoken issue: money management.)

The art vs. the science of medicine: Two personal stories

As a resident, I gathered three faculty advisers, two psychiatrists who had written extensively on philosophy and psychiatry, and one philosophy professor who had written extensively on psychiatry. We coordinated monthly meetings with the departments of philosophy, history of science, psychology, and psychiatry. Together we created the Yale Philosophy and Psychiatry Group. It grew every month.

We met over pizza to discuss assigned papers on philosophical issues in psychiatry, medicine, and/or health care in general. We drew guest speakers from all over the world who volunteered their time. Faculty, residents, fellows, medical students, graduate students, undergraduates, and community professionals from all over the region with an interest in any given topic joined us. We published papers, including one well-known and still frequently cited “pluralogue” on the 

Taking part in this project was easily the most fulfilling and educational part of my time in residency. Not just the academic camaraderie and open-mindedness of the group itself, but that it forced me to read more, forced me to think more. It helped me at least feel more authentic as a doctor, as a thinker, as a human being.

Later, as a fellow at Boston Children’s Hospital, I took active part in organizing educational workshops on training clinicians in the art, and/or lack thereof, of the difficult conversation. Again, these groups were eclectic, the atmosphere designed to allow everyone-regardless of role, training, or experience-to speak freely, to allow everyone to discuss their fears and limits as clinicians. There was extensive role-playing with professional actors, and clinicians universally praised the experience for how it helped them in their practices and daily lives. Many took these seminars over and over. We continue to publish educational articles based on these workshops.

These are the types of educational experiences I believe would be more helpful in creating more authentic physicians, more fulfilled human beings. And perhaps that is the answer: not to avoid dogmatic pitfalls, but to be better able to recognize them for what they are.

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1. American Medical Association. Accelerating Change in Medical Education. 

https://www.ama-assn.org/education/accelerating-change-medical-education

2. Dyrbye LN, Burke SE, Hardeman RR, et al. 

Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians

https://medtechboston.medstro.com/blog/2014/08/13/the-activist-generation

4. Palma M. Training for Activism, Action and the Future of Medicine. in-Training. May 26, 2016. 

http://in-training.org/training-activism-action-future-medicine-11054

5. Phillips J, Frances A, Cerullo MA, et al. 

The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis

Our ability to speak freely regardless of role, training, or experience is one element that allows psychiatrists to discuss their fears and limits as clinicians.

Can We Free Ourselves of the Dogma of Medical Education?

There is no document of civilization which is not at the same time a document of barbarism.

When I first read this quote, my initial impression was that it came from Freud. If pressed, I would have guessed from his late-life despairing opus, 

 But I was wrong. These were among the last words written by Walter Benjamin, months before his suicide in 1940. In fact, these words are engraved on his tombstone. Even more oddly, and perhaps profoundly befitting his somewhat scattered career, this German-Jewish atheist who died by suicide was allowed burial in consecrated Catholic soil in Spain.

Walter Benjamin was one of the founding fathers of the so-called Frankfurt School of Philosophy in the 1920s and 1930s, which included Theodor Adorno, Max Horkheimer, Erich Fromm, Hannah Arendt, and Herbert Marcuse. The members were German neo-Marxists and psychoanalytically influenced scholars who were openly critical of the German people who allowed the National Socialists to come into power. The group introduced the concept of applying multidisciplinary study and dialectical methods to the bigger questions of history, psychology, economics, philosophy, and art-even to medicine, long before there was any discussion of a “bio-psycho-social” approach. For better or for worse, they developed the increasingly ill-defined “critical theory” that has so pervasively, even fetishistically, enthralled the academic towers in America since the 1960s.

Of all the group, Benjamin, primarily an historian and art critic, struggled most with mood lability. He wrote several suicide notes throughout the course of his brief lifetime, typically addressed to his current female partner, before finally composing his last one-addressed to no one in particular, on the night of September 26th, 1940. He gave the note to one of his fellow German-Jewish refugees, Henny Garland, who took it and did nothing to stop him from overdosing on morphine. She destroyed the note and convinced the authorities that Benjamin’s death was the result of heart failure, concerned that if the authorities discovered Benjamin’s death was a suicide it would weaken the entire group’s chances of obtaining exit visas.

The standard historical interpretation of Benjamin’s death is one of tragic pseudo-irony. Benjamin, with the help of his expatriated colleagues, Adorno and Horkheimer, had undertaken a desperate flight from Marseilles to Port Bou in Spain with several other refugees. Benjamin carried a single attachÃ© case reportedly containing an unknown manuscript, and “enough morphine to kill a horse.” He had already abandoned his brother and sister to their own devices (as German-Jewish exiles with no citizenship; as did Gurland, who abandoned her prisoner-of-war second husband, only to marry Fromm 4 years later, and to commit suicide herself in 1952). Once in Port Bou, the group was told that Spain was no longer issuing exit visas to undocumented French refugees, and this was the pretext for Benjamin’s suicide. The next day, this decision was reversed, and the group was allowed to leave for neutral Portugal, and eventually for New York.

Walter Benjamin’s suicide is especially interesting as a bridge from the Freudian psychosocial era of hysteria-neuroses to the current era of the borderline-narcissist. Psychoanalysis was foundational to the Frankfurt School, and philosophically they were really a marriage of Marx and Freud. All the founding members were sons of wealthy Jewish businessmen who turned their backs on the capitalism of their fathers (often able to do so, ironically, with the financial support of their fathers), but who frequently, especially Benjamin, wrote nostalgically, almost longingly, of their childhoods.

Benjamin especially refused to grow up. His entire historical worldview in fact was that we all march through history backward, that we all greet the imminent future with our backs turned. In other words, the future is a constant reappraisal of the past, a constant atonement, a series of ruminations and regrets, a wistful clinging to prior accomplishments.

The biggest target of Benjamin and his colleagues, and the root of their almost paradoxical nostalgia, was the so-called “culture industry,” the manufacture less of products than of wants and desires by, as they saw it, vast capitalistic machines. They frequently compared Hollywood to the Nazi propaganda machine, and they harbored little doubt that Hitler and his lieutenants’ primary motivation was less ideological than financial. (America was under the sway of “monopoly capitalism”; Germany and the Soviet Union under “totalitarian capitalism.”) They feared less that the Nazis would militarily conquer the world than that the rest of the world would link arms in capitalistic solidarity with the Nazis.

In this context Walter Benjamin became the 20th-century iteration of the “wandering Jew.” While his colleagues settled in Frankfurt, at least until it became too dangerous, he remained restless, taking up residence variously along the Mediterranean and in Germany and Paris, intermittently moving back home with his parents. He was married, but he had frequent affairs, often quite intense relationships that left him temporarily suicidal. He seemed to care little for his only son.

What is especially significant here is Benjamin’s comparison of the what he calls “destructive character,” what we might more euphemistically call the “cluster B personality,” with the “consciousness of historical man.” In his 1931 essay, 

, he sums it up in this way: “The destructive character lives from the feeling not that life is worth living, but that suicide is not worth the trouble.”

This reads like a blithe shrugging off of the slightly later Algerian-French existentialist philosopher Albert Camus’ famous admonition that whether to commit or not commit suicide is the only legitimate philosophical question remaining.

This is where the German critical theorists and French existentialists agreed. Because there is always work to be done.

Arthur Schopenhauer, perhaps the most miserable 19th-century philosopher who ever lived, in his cheerily titled 

 ironically provided what may be the best admonition against suicide, and the one repeatedly resorted to by the critical theorists and existentialists: “The only cogent argument against suicide is that it is opposed to the achievement of the highest moral goal, inasmuch as it substitutes for a true redemption of this world of misery a merely apparent one.”

In other words, suicide is inauthentic. The redemption sought through suicide is illusory. As Benjamin himself put it, “The destructive character sees nothing permanent. But for this very reason he sees ways everywhere. Where others encounter walls or mountains, there, too, he sees a way. . . . Because he sees ways everywhere, he always stands at a crossroads. . . . What exists he reduces to rubble-not for the sake of rubble, but for that of the way leading through it.”

 Jean-Paul Sartre qualified this years later by specifying that suicide is essentially “out of bounds.” It is the one “way” out that, by its very inauthenticity, remains inaccessible.

Benjamin’s essay was 10 to 11 years before Camus’ seminal work, 

 in which he elaborates upon the “absurdity” of existence, the inescapable contradiction between the human faculty of reason and an unreasonable world. He bemoans the inevitable “philosophical suicide” that results from any attempt to provide an overarching metaphysical structure to existence: all conclusions invariably contradict their (absurd) premises. His conclusion? We must continue on. We must find our path. Sisyphus was damned to a hell on a treadmill. But even he eventually acknowledges the truth of his absurd situation, of his own personal tragedy, and there is meaning in that.

That is, even in the midst of hell, there is still, or even especially, work to be done.

Dr Martin is Director of Consultation Emergency Psychiatric Services at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.

https://en.wikipedia.org/wiki/Theses_on_the_Philosophy_of_History

. Seaside, OR: Rough Draft Printing; 1913.

http://www.revistapunkto.com/2011/12/destructive-character-walter-benjamin.html

. Trans. Justin O’Brien. New York: Vintage; 1983.

Walter Benjamin’s suicide is especially interesting as a bridge from the Freudian psychosocial era of hysteria-neuroses to the current era of the borderline-narcissist.

A Historical Perspective on Suicide

famously declared that history ended on November 9, 1989. That was the date the Berlin Wall fell, the final victory of liberal democracy over every other form of government. The rest has been just a sorting through and biding time until all other governments come, in due course, to this realization.

 history ended on September 6, 1522. This was the day Ferdinand Magellan’s surviving crew, all 18 of them, sans Magellan, arrived back in Spain after circumnavigating the globe, thereby ushering in the era of “globalization” or the “post-history era.” Ever since, the rest has been a sorting out of the planet’s wealth by ruling oligarchies.

The nice thing about post-history is the opportunity it presents for a number of firsts. This is the first time there has been a broadly recognized health care crisis; this is the first time that health care has been referred to as an industry; in fact, this is the first time that medicine has been referred to as health care, with the implicit acknowledgment that medicine itself is a mere percentage of some greater enterprise. A medical megaplex-part physical structure, part ether-that by its very large-ness, its very enmeshment within an oligo-capitalist-informatic economy, has ceased to be an academic, philosophic, aesthetic, or noble endeavor.

 Insurers have ruled the day for less than a century, yet post-historically have come to dictate the practice of medicine: “Can you help me, Doc?” “Well, let me call your insurance company and see what we can do.”

So what is the role of the physician in this new post-historical age, this age of science, of neo-Enlightenment? Certainly in this age of cures, of solutions, the physician’s role is vastly different from that of his earlier counterparts. Before the age of cures-that is, when a physician was able to make and fulfill the odds-on promise of cure-he was bound to the patient’s bedside, as confessor and confidante, as a paternal figure of comfort and security. Indeed, the paternalistic model of the physician as authoritarian and dictator of patient care has long since fallen into disrepair-less through ineffectuality than semantic unkindness-in favor of a more insurance-friendly collaborative care model in which patient and physician agree upon a plan.

How might this work? The good post-historical doctor, with the advertising resources of the megalith at his or her disposal, above all must objectify the patient, must reduce him or her to an elemental story of biochemistry and pathology, must create only the slimmest measure of directed subjectivity within the patient. The real power of the post-historical physician is to grant the patient either a cherished or hated subjective experience.

Post-historical medicine of course is based on a legal-economic principle of autonomy, a principle without much historical basis, that views the individual as an isolated objective “unit” whose inner experience, once brought to said unit’s awareness, will allow the unit to make decisions in its own best self-interest. This model clearly only works in the context of a physician-patient relationship governed by the possibility of cure, where the physician actually holds something of value to the patient.

Still, there are many, if not a majority, of patients who wish nothing more than for their physicians to make medical decisions for them. Illness after all is a troubling subjective experience, mental illness near unbearable. It is little wonder the appeal of dissolution via narcotics or other drugs, meditation, death, or exotic religious experiences. Subjectivity is terrifying enough; more so in the face of disease. And subjectivity is certainly not to be equated with autonomy. One can act autonomously with little subjective experience. Similarly, one can maintain subjective experience in the midst of totalitarianism. The point here is that the subjectivity previously rendered by the physician now provides an illusion of autonomy against a perceived evil of paternalism.

The illusion of course is that of choice. Treatment options are presented with the full expectation that the patient will agree, similar to the illusion of choice in contractual agreements for other necessary services. In other words, a subjective experience common to all-if one needs such services, then one has no choice but to accept the proffered terms. Autonomy is after all a business concept, that aspect of an isolated objective unit that is targeted by media and is “open for business.” As a client is free to purchase the suggestions of a financial advisor, so a client purchases the suggestions of a physician. And given one’s inherent freedoms, one may well say “no thanks,” rendering the collaboration over-“see you later, no hard feelings.”

Patients did not generally free their physicians of moral obligations like this in the days before cures. Placebo after all relies on a paternal model. And although a patient with his wits about him was perfectly aware he was nothing more than an object to his physician, he needed this objectification in order to verify his experience, to maintain the awareness of his unconscious, to prepare himself either to pass on, or to generate the resources to recover. Compassion was meted out judiciously, and a good physician was more expert in the course of disease, and the expected signs and symptoms. The role of the hospital was minimal, and the emergency department didn’t exist until well into the 20th century.

In the age of cures, the physician is responsible for creating and maintaining an experience of “illness” among patients. This is reinforced by the pharmaceutical industry that relies on patients wanting drugs. And all is overseen and regulated by the institutional cruelty of the insurance industry: “Did the patient actually have a gun in his mouth?” “Yes.” “Was it loaded?” “I’m not sure.” “Then the best we can do is authorize one day in the hospital.”

Only the psychiatrist with his empty doctor’s bag and his lack of treatment algorithms has the ability to stand outside this system, to throw a wrench into the capital-dependent health care machinery. The non-psychiatric physician wants no part of de-constructing the subjective reality of the patient. The fantasy of illness keeps the machine moving. The psychiatrist on the other hand is charged with challenging the very subjective fantasies of the patient, with uncovering the non-fantastic inner experience that may in fact be closer to the truth of that patient.

Typically what is uncovered is depression, more colorfully described by some as “strange sadness” or “fundamental melancholy.”

 In other words, mortality. In an age where self-absorption is advertised, encouraged, lauded, and at times fantastically rewarded-in an operant conditioning sort of way-the fact that such is a cardinal symptom of depression proper is passed over as non-expedient. This is not to say that depression as an illness is not easily treated pharmacologically, but the fundamental nature of this depression, this melancholy, this hopelessness is not-and cannot be-addressed by a health care machine.

The thoughtful psychiatrist then finds himself living in “history,” more akin to the paternalistic physician, the priest, the witch, the alchemist of yore. Indeed the psychiatrist remains on the fringes of the current medical model, not so much accommodated as tolerated by the health care machinery, allowed to prescribe, but contained to 15 minutes. Like limiting the confessional to 15 minutes, and these are constraints utterly beyond the foresight of earlier philosopher-physicians. How is the future supposed to interpret this? And worse, how will the future interpret the agreed-upon solution? With denial; complete, utter denial.

Cognitive behavioral therapy is covered by insurance precisely because denial is this treatment’s stated goal. That is, it facilitates patients’ denial of their own subjective experience. Good old-fashioned psychoanalysis, on the other hand, is designed to uncover one’s subjectivity from amid the ruins of an unconscious truth. A more complicated process, not easily explained to third-party payers and with less easily shown outcomes, psychoanalysis is not covered. The treatment, as envisioned by Freud in a pre-third party payer era, took root at the end of an epoch that provided a broad, humanistic education to its physicians. This also coincides with Darwin’s destruction of the remnants of Christianity via the dissemination of evolutionist principles. Evolution effectively demolished the preconceived longings, hopes, and prophecies of the past. Faith as a measure unto itself was rendered insignificant, and science took over.

So how will trust-fund scholar-futureniks interpret the health care megalith that was once a simple physician-philosopher construct? Post-historical medicine is an industry, an inquisitorial bureaucracy, legislated by treatment algorithms and standards of care easily interpreted by physicians, patients, insurers, and judges. There is no magic; even placebo has been quantified.

 Insurers, whose decision-makers remain remote and anonymous, dictate the practice of medicine from on high. The government has put a price on human life, and the vast majority of a physician’s day is spent documenting evidence.6 Efficiency is rewarded, and time itself has become the most highly prized commodity.

Memorization is easy, and algorithms make medicine very easy. Advertising makes medicine even easier; and the Internet makes medicine downright facile: “What do you think is wrong with you?” “I looked it up online, and I think I have such and such.” “Okay, I can prescribe you this or that.” “Actually I saw this advertised on television, and I would like to try it.” “No problem. We can do that.” The capability of performing Google searches is misinterpreted as the action of an educated consumer, of a “citizen-scientist.”

Luckily for both patients and physicians, the one thing that has not changed over the centuries is the remarkable ability of the human body to heal itself.

 Unfortunately for both patients and physicians, however, the fractured mind remains mostly resistant to cure. Imagine conquering death, only to live with unrelenting anguish. Depression is the leading cause of disability worldwide, and this may indeed be the most telling legacy of the lost art of healing.

 Perhaps it is true that the more things change, the more they remain the same.

If indeed Ambrose Bierce is correct that learning is the kind of ignorance that distinguishes the studious, then let me offer myself as example.

As a younger man, I remember opening Doctor Louis-Ferdinand Auguste Destouches’s pseudo-autobiographical novel, 

-sometimes the sequel, sometimes the prequel to 

-at a time when I was so down and out as to have started ruminating over military heroics. Dr. Destouches of course is better known by his celebrated pseudonym, CÃ©line. (A modest gentleman, he famously declared Jean Genet the second greatest writer in France.)

This was even before my other, brief life in academia, a time when I lived nobly, purely, as a struggling writer. Like the author, I was over-educated and under-employed. I ate sparingly, and had somehow procured a degree in science along the way. Of all things, the thought of medical school had also intruded here and there.

But I resisted. Like Louis-Ferdinand, I wished to be destined for bigger things. If not to be a great writer, then at least a great pamphleteer, inciter, rabble-rouser, arm in arm with Doctor Thomas Young and Thomas Paine.

Depression is the leading cause of disability worldwide, and this may indeed be the most telling legacy of the lost art of healing.

Author | Elliott B. Martin Jr, MD

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