Why Psychiatrists Are Physicians First

Jun 20, 2013

For now, it is encouraging to know that psychiatrists remember that they, too, are physicians first who can tap into their medical training to provide comprehensive patient care.

“You must change her meds immediately,” barked the voice on the phone message. The voice did not state its name, but the caller ID indicated that it was a hospital social worker. The voice message continued, “This is Maria’s therapist. She’s vomiting. She needs a different antidepressant.”

What an odd message, I thought to myself. The therapist’s tone suited a military base, where commanding officers issue orders. I found it curious that so many people (therapists included) automatically assume that all physical symptoms are adverse effects of psychotropic medications, and nothing but-even when a multitude of other medications are prescribed by other doctors.

When I returned her call, the therapist was more insistent than ever. She again demanded that I call in a different antidepressant for Maria, who was sitting in her office at the time. I assured the therapist that I would do what was right for the patient, but reminded her that treatment decisions are not based on second-hand information. I asked to speak to Maria.

“What’s happening, Maria?” I queried. Maria explained that she’d been vomiting since early morning. She reported that she felt worse than she ever had in her life. “Anything else? Pain? Diarrhea? Where did the pain start? Does it move? Did you check your temperature?” I inquired about a possible pregnancy, even though her inability to conceive had triggered her depression in the first place.

As if by instinct, I reverted to the medical model, rattling off questions that residents ask in emergency departments (EDs). I had asked those questions hundreds of times in the past and could recite them in my sleep-even though decades had passed since my gynecology rotation, when I was on call  in the ED every third night.

According to Maria, the situation started with stomach pains the night before. The pain increased. Then the vomiting began. She also reported that her pain made it hard to stand up straight.

She added more details, but I had heard all that I needed to hear. She was describing an acute abdomen, not a reaction to antidepressant medications. For sure, SSRIs can cause nausea, usually in the first week or two of treatment-but they do not induce pain, and surely not the level of pain that leaves patients doubled over.

Maria balked at my suggestion to go to the ED, but she agreed to see her internist immediately. His office was on hospital grounds and just a quick cab ride away. Over the phone, the internist assured me that he could transfer her promptly if need be. Later that evening, the internist called back, saying that he examined her and then sent her straight to the hospital, where she was being scanned and standing by for surgery.

The next day, I received yet another phone call, this time from the patient herself. Her speech was thick and garbled, as expected of someone in a post-op haze. I could make out some of the slurred words: “bowel obstruction” and “I would have died without surgery.” No mention of adverse effects from her antidepressants. No speculation about what would have happened if I had acquiesced and called in a different antidepressant prescription. There was no reason to mention this now, or maybe ever. It was enough that she knew that she might not have lived to see the dawn of day, had her symptoms not been diagnosed and treated promptly.

I wondered if she had Crohn disease or another undiagnosed GI or gynecologic disorder that contributed to the obstruction. Time would tell. Unfortunately, time did tell. A day later, Maria was summoned back into surgery. The senior pathologist reviewed the slides and saw occult cancer cells. She needed another resection, stat. This time around, the biopsy confirmed their worst fears. Prognosis? Uncertain. Or so they said.

I will not detail everything that followed, except to say that many details followed. Let me summarize by saying that even a pitiful 24 months’ survival rate is still superior to the 24 hours that awaited Maria, had her nausea been written off to the effect of an SSRI

A cautionary tale
This event occurred many, many years ago. At the time, I considered writing up this case because it highlights the hazards of attributing all physical symptoms to psychotropics without getting full histories and fuller workups. Yet I dismissed the idea, thinking that this information would not be news to psychiatrists, who are physicians first, and are trained to perform a “differential diagnosis” before jumping to conclusions and starting treatment prematurely or thoughtlessly.

Much time has passed and times have changed, yet these recollections never left me. Rather, memories of this young woman and her travails percolated beneath the surface, waiting for the right event that would make them boil over and spill out.

That event occurred in April 2013, when the Illinois Senate approved prescriptive “privileges” for psychologists (who are not medically trained). The prerequisites for psychologists to step up to the plate, to prescribe meds for their patients? A 2-year online course in psychopharmacology, recertification at specified intervals, supervision of 100 patients by a psychologist (not a psychiatrist), and collaboration with a physician. There is no clinical medical training, much less medical school rotations.

How could this be? Were it not for my grueling (and often unpleasant) medical training, and rotations through the ED, medical, surgical, and ob-gyn wards, where I palpated hundreds of abdomens of patients in pain, and where I elicited detailed multisystemic histories from every patient, I would never have known how to tease out Maria’s complaints. I would not have known to suspect an acute abdomen, based on the specific but limited symptoms that she volunteered. I would not have known when to ask her to elaborate on the little specks of information provided at the start.

As physicians, we have learned the natural history of illnesses, and then ask “yes” or “no” questions that send us in different diagnostic directions. Those questions are quite different from the open-ended, intentionally vague questions used in dynamic therapy-but they can be lifesaving.

I shudder to think what would have happened to Maria, had she relied upon the non-medical assessment of her situation. At this point, I am happy to know that I saved a life by using my medical skills. However, I’m terribly unhappy to think about future patients who might be treated by practitioners who believe that learning how to prescribe, and nothing more, is sufficient.

This past month, I had extra reason for concern. As one who was born, reared, and educated in the state of Illinois, where I attended the Chicago Jewish Academy, University of Illinois at Chicago for my undergraduate years, and University of Illinois at Chicago College of Medicine (before campuses were built outside of Chicago), I was especially saddened to learn of the actions of the Illinois Senate. I hoped that some learned soul would explain the value of “differential diagnosis” to the powers that be, so that they reconsider.

Fortunately, senate members did reconsider. The bill was squashed. This battle was won-for now-but new fights will flare on other fronts. Someone else’s home state will be affected next. For now, it is encouraging to know that psychiatrists are reading these reflections and remembering that they, too, are physicians first who can tap into their medical training to provide comprehensive patient care.