Monday, March 31, 2014

Losing the White Coat Part 2: Residency

This is part 2 of a series on the evolution of my approach to psychiatry. Part 1 was about my medical school experience, and A Most Influential Professor described a key experience I had in college.

I went into psychiatry because I was fascinated by the variety of human emotions, behavior, and psychopathology, and I wanted to explore the plethora of influences (cultural, social, psychological, and biological) on those aspects of humanity. My medical school emphasized the biological approach, so I decided to continue my training elsewhere for residency.

At my residency program, while there was more of an emphasis on psychotherapy compared to my medical school, the biological psychiatrists still reigned supreme. The university had some well known psychotherapists, but they tended to have titles such as "emeritus professor" or "clinical professor," meaning that they were not around very much. And I doubt they would have felt welcome, with the residents' main jobs being completing paperwork and adjusting medications during the majority of their rotations, rather than running groups or conducting therapy.

It was easy to see who the big money-makers of the department were: the researchers who focused on the neural basis of mental disorders while providing biological treatments in their clinical practice. There was a bipolar disorder expert, who once had a patient on 10 different medications, to the point that it was impossible to tell what was the patient's "disease" and what were the side effects. There was the schizophrenia expert who headed the locked inpatient unit, who frequently gave talks to psychiatrists in the community advertising the newest antipsychotic medications. She claimed that because she was on the speaker bureau for all the big pharma companies, she was unbiased in her assessment of the medications. And then there was the renowned depression expert, who once told us, "Even if the medications are no more effective than placebo, it doesn't mean that you shouldn't treat the patients." Make of that what you will.

However, the experience that opened my eyes most to the flaws of a purely biological approach to psychiatry was what I saw happening with Dr. Z, one of the psychiatrists on the electroconvulsive therapy (ECT) service. He gave great lectures, drawing up pretty diagrams of the circuits in the brain believed to underly mood and depression. Unlike most psychiatrists, he often walked around in scrubs, and he had a confident charm to go along with a cheerful disposition. Perhaps appropriately so, since he offered a treatment unparalleled in its effectiveness for patients with severe psychotic depression and bipolar disorder.

The problem, though, was that the bipolar disorder diagnosis (and its attendant "treatment resistant depression") became so loosely applied that practically anyone with mood swings was being diagnosed with "bipolar II," and Dr. Z fully embraced this trend. His evaluations for whether a patient was a good candidate for ECT were thorough, to a point. There was meticulous documentation of the medications that the patient has tried and the inadequate response to them. Mostly ignored, however, were details about what the patient's life was actually like and what factors may have been influencing their symptoms. Thus, plenty of patients who clearly had borderline personality disorder (BPD) were deemed "excellent candidates" for ECT; none of the depression medications that they had tried ever did lasting good, since their moods would turn depressed or irritable in response to interpersonal stress, regardless of what meds they were taking.

I remember hearing two stories in particular about his patients (details altered to protect anonymity). One day, a patient of Dr. Z's arrived in clinic holding a knife to her chest after her boyfriend broke up with her. She told the astounded clinic receptionist that she would stab herself if she did not see Dr. Z right away. Dr. Z was not in, and the patient ended up walking into the office of another psychiatrist, who managed to calmly talk her down while security was notified. Another time, a patient was dragged kicking and screaming into the ER after swallowing a handful of pills during an argument with her husband. She was heard yelling, "I'll only talk to Dr. Z! Where is he? I know he's coming because he loves me!" Dr. Z clearly had a profound effect on his BPD patients, even if the benefits of ECT for those patients was very temporary.

Recently, I read Dr. David Allen's post on the difference between the symptoms of major depression and the depression often seen in BPD. But even back then something felt off to me about doing ECT on patients who had "treatment resistant depression" because of a personality disorder, which brings me back to the title of this post. At the institutions where I trained, the psychiatrists who wore the white physician's coats, not surprisingly, tended to be the more biologically-oriented ones. Thus, in my mind the white coat became associated with their view of psychiatry, one that I did not share.

Thankfully, my mind was already set on being a child psychiatrist. At least in the world of child psychiatry, despite the influence of biological psychiatrists like Harvard's Biederman, many (I don't dare to claim "most," given the direction things seem to be heading) child psychiatrists still consider the influence of things like family, parenting, and developmental trauma on behavior, rather than just focusing on figuring out the black box of the brain.