Our Own Worst Enemies

May 19, 2010

My medical school clinical preceptor asked me, during my first year, what specialties (at The University of Chicago, the attitude toward general practice was well represented by the dismissive references to ‘LMDs’-local medical doctors) I was considering.

My medical school clinical preceptor asked me, during my first year, what specialties (at The University of Chicago, the attitude toward general practice was well represented by the dismissive references to ‘LMDs’-local medical doctors) I was considering. When I told him that I intended to become a psychiatrist, he told me that I must have a ‘mushy, unscientific mind’. (I report this with trepidation; some readers may find that characterization of me all too apt). In fact, during the course of my medical education, I had some very scientific questions about accepted wisdom -- how do we know that some early cancers don’t resolve by themselves? Is it really necessary, not to mention optimal, for women in normal labor to be confined to bed, be denied oral nourishment, and to be shaved from the navel downwards?--that were not well received by the faculty at the time but garnered research attention decades later.

At the time, I was only the slightest bit uncomfortable about accepting and proudly sporting the personalized leather ‘doctor bag’ and stethoscope a pharmaceutical company provided to each first-year student.

I believe that the unexamined life is not worth living (though there are people who seem to have pretty good lives without examining them). In medicine, self-examination is absolutely vital, but sorely neglected until very recently. What is the evidence for our diagnoses and treatments? Do the treatment results we offer outweigh the treatment pains we inflict? Do we even consider the pains? Are the benefits worth the costs? Are we even aware of the costs? How does the source of payment affect us? Concerns about the relationships between medicine and the pharmaceutical industry were a low background rumble for decades and then erupted onto the front pages and into Congressional hearings. The suggestion that our patient care recommendations and research directions are influenced by the source of payment inflicted a narcissistic injury, struck at a core part of our identity--and has thus been resentfully resisted by many of us. What had we been thinking---that for-profit companies would expend hundreds of millions of dollars without expecting some financial return? 

At the same time, industry is an easy target-rich and self-interested. We have forgotten, or it is easier to forget, that we are influenced by the sources of our incomes--and our prestige--whatever those sources may be. Disclosure is not the answer.  Disclosure may be necessary, but it is a band-aid; it doesn’t appear to change the behaviors of the disclosers or the disclosees appreciably. On the positive side, disclosure will give those willing and able to comb through the information the data they need to question published research findings. On the down side, it will make us complaisant.

Freud pioneered and championed a mostly very useful form of self-examination. Like so many radical concepts, it became an orthodoxy, but that is another story. I am proud to be a member of the most thoughtful, most philosophical, medical specialty. Not for a moment do I accept the accusation that psychiatrists are greedier than other doctors. But that is the accusation we are living with and that some of us are fostering.

I can’t watch Civil War scenes of limb amputations without anesthesia. But no one associates those brutal procedures with the high-tech and much-admired surgery of today. Oncology manages to cloak the most primitive possible treatments--poison and burning--with elaborate protocols. Yet the mention of psychiatry conjures ECT, and ECT conjures images of the snake pit.  Most of us recognize the value of ECT, and of our other somatic treatments, but we focus, instead, on bewailing the death of psychotherapy--and at our own hands, it seems. 

Knowledge of psychodynamics is invaluable, not only for the care of troubled individuals, but for the management of faculties, boards, group practices, and our own families. It is a great shame that that managed behavioral care enterprises have successfully squeezed so many of us into 15-minute patient encounters. On the other hand, I would like to apologize to the psychoanalytic training patient whom I denied antidepressants, decades ago, while he suffered through hours of free association and months of misery. Instead of beating our breasts about the eclipse of psychotherapy by psychopharmacology, we should be creating balance and synergy between them. That is perfectly possible.

Self-examination is a virtue; self-deprecation is a pleasant social convention; self-denigration is, at best, an affectation, and, at worst, an offense against ourselves, our students, and our patients. We are the only specialty with our own dedicated hate group. We shouldn’t be our own worst enemies.