We will have many medications in the future, he prophesied; that will not be a problem. Our challenge will be in teaching doctors how to use them, “otherwise it would be like giving a driver’s license to someone who can’t drive.”
Groundbreaking scientific studies get published, and I rarely hear from colleagues. But any article emanating from the Manhattan media sets e-mails abuzz; PDFs are forwarded and tut-tutting is heard.
This is no way to learn.
We don’t follow William Osler’s advice: “Read the old books and the journals,” he said.1 But we don’t read the journals, and we don’t even know about the old books. Instead, we all read The New York Times.
Gardiner Harris’ recent look at psychiatry in The New York Times2 is not entirely disinterested. The journalist-author has a well-deserved, and in some ways admirable, muckraking reputation, criticizing the barons of Capitalism-whether they produce coal or Zyprexa. He now interviews for the Times a 68-year-old psychiatrist who used to do pure psychotherapy in the 1970s and 1980s and today provides pure medication treatment in 15-minute med checks. Much dissatisfaction is described.
The psychiatrist interviewed calls himself a good Volkswagen mechanic, apparently unaware that our patients’ brains are Porsches. VW knowledge is not good enough.
The metaphor dovetails with the final testament of a founder of psychopharmacology, the great Frank Ayd, a man whose wife brought the first haloperidol pills to the United States in her purse on a flight from Europe. In the era when Freudian talk was the rage, Frank realized that these medications actually did something helpful. Frank passed away in his late 80s a few years ago, and in his last public interview (with Psychiatric Times), he bequeathed us a warning. We will have many medications in the future, he prophesied; that will not be a problem. Our challenge will be in teaching doctors how to use them, “otherwise it would be like giving a driver’s license to someone who can’t drive.”3
The problem with psychopharmacology today is precisely the notion that it is easy, that it doesn’t take much thought, that it can be handled in 15 minutes, and that (as the Times article states) a trained ape could do it. Most psychiatry residency programs boast many, many hours of psychotherapy training and much less time for psychopharmacology didactics. Some even explicitly proclaim that psychopharmacology can simply be learned from a book. I suppose we should just close all medical schools: all of medicine can be learned from books.
Osler is gyrating underground; I can hear him moaning.
Nature is the great teacher, Osler always taught; each patient is a book, teaching new lessons. But we still need books too, so it matters which books. It is not enough to read books, we have to have good books to read. Some popular texts of psychopharmacology, rather than relying on clinical knowledge, teach biological speculation. This drug affects that receptor; this neurotransmitter needs to be increased in this condition, that one decreased in that condition. It’s simple: imagine the synapse, memorize some facts about a couple dozen drugs, and you’re finished.
And what about the teaching, from Hippocrates via Osler, that we shouldn’t treat symptoms, but that we should primarily treat diseases? And what are the mental diseases? Schizophrenia and manic depression, I’d say; but you’ll have this objection or that. All the ideas can be found in the old books. Let’s discuss them.
We don’t carefully identify diseases of the mind. We throw pills at the symptoms: penny-in-the-slot practice, Osler called it, guaranteed to produce a harmful polypharmacy. We don’t carefully follow the clinical research science supporting which drugs to use, and more importantly not to use, for which diseases.
Listen to an old book, the 1806 text of Philippe Pinel4: “In diseases of the mind . . . it is an art of no little importance to administer medicines properly; but, it is an art of much greater importance and more difficult acquisition to know when to suspend or altogether omit them.”
All drugs are toxic; only their indication and dosage make them therapeutic. (You won’t find that in the morning paper. It’s in Osler’s Aequanimitas.) Maybe that’s why we went to medical school.
Enough. My morning coffee’s still hot. Pass the newspaper.
1. Osler W. Aequanimitas. 3rd ed. New York: McGraw-Hill; 1932.
2. Harris G. Talk doesn’t pay, so psychiatry turns instead to drug therapy. New York Times. March 5, 2011.
3. Kaplan A. Through the Times with Frank J. Ayd, Jr, MD. Psychiatr Times. 2005;22(1):17-24.
4. Pinel P. A Treatise on Insanity. Birmingham, AL: The Classics of Medicine Library; 1806.