Losing the White Coat Part 1: Medical School

This is part 1 of a series on the evolution of my approach to psychiatry. For background, I recommend reading A Most Influential Professor, which is essentially part 0 of this series.

Just about every medical school has a traditional white coat ceremony, during which the incoming class of medical students get their shiny new white coats that they will then wear throughout the rest of medical school during clinical experiences. At my school, the ceremony came with a recitation of a modified Hippocratic oath, adding to the gravitas of the day and helping us reflect on our future roles as healers and doctors.

The psychiatry faculty and residents at my school made it a point to insist that they were “doctors first." As medical students, we were repeatedly told about the contributions our institution made to modern biological psychiatry, and how it was a bastion of biologically-minded psychiatrists even during the era when psychoanalysts dominated psychiatry.

It was not surprising, then, to see psychiatry attendings walking around the hospital and lecture halls wearing their long white coats. Even the lone psychologist that taught some medical student lectures wore a white coat when he was in the hospital.

However, something always felt amiss with this biomedical aura. The psychiatry attendings were very quick – too quick – to defend the medical-ness of their specialty. I was told on multiple occasions that the arbitrary diagnostic criteria used in the DSM-IV are no different than the cutoffs used to define blood pressure in hypertension or glucose levels in diabetes. However, despite the prominent role the school's psychiatry department made in establishing biological psychiatry, physicians in other specialties there did not seem to respect the psychiatrists very much. The psychiatry interns took care of fewer patients on their Internal Medicine rotations than the medical interns, yet the psychiatry program director always insisted that the psychiatry interns performed just as well as the medicine ones.

As a third year medical student, I did my psychiatry rotation in a publicly-funded mental hospital, wearing my white coat just like the residents and attendings. There certainly were cases in which something clearly biochemical was going on in the brain of my patients, such as when a young man came into the ER hearing voices and feeling very paranoid after using a large amount of cocaine. I got to see antipsychotic medications help some patients with schizophrenia, but only so much, and with obvious side effects. There was clearly a vast gulf in understanding between the psychiatrists and patients, with the psychiatric residents spending minimal amounts of time with their patients and going home by 3pm each day. I was not sure how much wearing a white coat contributed to this distance or if it was mostly due to the culture of the place, but it certainly did not help foster empathy.

There were many other cases that left me feeling uneasy. As a fourth year medical student on the consult service, I accompanied a psychiatry resident when he evaluated a patient for suicidal thoughts. Afterwards, he told the primary team, "Don't worry, he's just a boy borderline." The attitude seemed to be that this patient would not actually harm himself because he was just "being manipulative," or that personality disorders somehow were not real, perhaps because there was nothing "biological" that could be done.

I did have a great experience working with the child psychiatrists at my medical school, who because of their specialty necessarily had to take a more holistic view of things. But even so, they tended to focus on the children as individual entities, without deep thought given to how interactions with parents influenced the children's behaviors.

When I asked the program director about learning psychotherapy as a resident there, I was told by that they don't really teach psychotherapy, because that is not going to be part of the job of a psychiatrist going forward. I would learn enough to know what kind of psychotherapy to refer a patient for, if it were necessary. Talking to the psychiatry residents though, some of them clearly wished that they had more psychotherapy training, so they could be more complete and competent clinicians.

I knew as a medical student that this approach to psychiatry was not for me. I would go elsewhere to continue my training.

A Psychiatrist's Favorite Breaking Bad Moments

I came upon Breaking Bad very late in the game. I have only been watching for the past few weeks, and I still have 8 episodes left. But since watching Season 2, I have decided it's my favorite show since The Wire. While I'm obviously not unique in feeling that way, I wanted to share some of the things I've enjoyed most about the show, from my perspective as a psychiatrist and doctor.

What impresses me most about Breaking Bad is how it portrayed the interactions of its characters with the healthcare system. Just as The Wire showed how individuals were entangled with dysfunctional inner-city institutions, Breaking Bad showed the absurd hoops people have to jump through for good health care in America. This has been written about extensively elsewhere, but what I found most fascinating and revealing was how the characters – like most people in real life – had no recourse but to work with the system as is, since the system is too colossal for any individual to fight.

Moreover, every single "medical drama" I have ever seen has made me cringe because they just felt off. The doctors and patients were overly dramatic, acting too angry, or too serious, or too witty. They always brought out the paddles when they were trying to revive someone, even if the patient was in asystole. There were too many aha moments, too many exciting procedures, too little quiet suffering. I could go on forever. Breaking Bad made few of those mistakes and got lots of little details right. In particular, I think that the way the characters reacted to being poked and prodded, the look in their eyes as they had to accept the indignity of using a bedpan or stripping down for a PET/CT, and how the doctors and patients talked to each other, all seemed true to life. After seeing the episode in which Walt and Skyler met his new oncologist Dr. Delcavoli for the first time, I had the unprecedented urge to google the name of the actor who played Dr. Delcavoli to see if he was a doctor in real life.

Other details that I loved about the show:

Walt's Family Dynamics

It was clear to me early on that Walt's father was not around when he was growing up, though the show did not reveal why until late in Season 4. I have witnessed numerous patients who grew up in abusive or neglectful homes, who vow to be better parents to their own children, but then inadvertently create a dysfunctional situation of their own. In Walt's case, his justification for starting a meth lab was so he could provide for his family after his death. He likely grew up poor, so his ideal image of a father was someone who could make sure his family did not have to scrape by. However, in embarking on his quest for money, he deprived Skyler and his son Walter Jr. of his presence, driving him apart from the rest of this family. Thinking that he only had months to live, he never seemed to consider whether his family would prefer to have $700,000 or some meaningful time with him. He tries to make it up to his son later by buying Junior a muscle car, but that's no substitute for being a good parent.

My favorite moment of the entire series came in Season 4, Episode 10, when Walt, after the stress of a huge fight with his partner Jesse, broke down crying in front of Junior, who comforted him and helped him to bed. The next morning, Walt talked about how when he was a child, he saw his own father die from Hungtingon's disease, growing weaker physically and mentally, and how he did not want his son remembering him that way. Junior forcefully told Walt that he had no need to feel ashamed, and that unlike how he had behaved for the past year, at least last night "you were real!"

Hank's Post-Traumatic Stress

After Hank's shootout with Tuco Salamaca and then nearly being killed by a Mexican cartel's IED-planted-in-a-decapitated-head-on-a-tortoise in Season 2, he was clearly suffering from post-traumatic stress. The show did not try to get fancy by showing what was going on inside his head from his point of view, but the viewer can clearly see all the external signs of fear and hyperarousal, whether triggered by intrusive recollections/flashbacks or misinterpreting popping noises at night for gunfire. Then, Hank suffered even more trauma when he survived an attempt by the Salamaca brothers to kill him in Season 3. He grew angry and terse with his wife and nearly withdrew completely from life. Even though his emotional recovery from those traumatic events seemed to happen a bit too smoothly and quickly, it felt true to me that what helped him most was having a purpose in life again when he put his energy into going after Gustavo Fring's meth operation.

Jesse's Misinterpretation of Acceptance

While Jesse was in rehab at the start of Season 3, the show did a good job of illustrating the concept of acceptance when the therapy group leader talked about accidentally killing his own daughter, and how beating himself up for it only led to more drug use. Acceptance, as I understand it, does not mean thinking that something is ok. It's an acknowledgement of fact, that something unpleasant or terrible has happened and that one is imperfect, but also acknowledging that one cannot change the past, but can only control how one acts in the present moment. However, Jesse seemed to interpret acceptance somewhat differently, because after he left rehab, he told Walt that he had learned to accept the fact that "I'm the bad guy." Later in Season 4, after killing a man, Jesse berated the same group leader at a 12-step meeting, asking if he is supposed to accept himself no matter what he does. Given Jesse's emotional turmoil and the extent of his grief and guilt, it is not surprising that this was a difficult concept for him to, well, accept.

Walt's "Fugue State"

In Season 2, Walt went missing from his family because he was stuck in his mobile meth lab out in the desert. Upon hitchhiking back to civilization, he stripped naked in a convenience store and made up a story about being in a fugue state. What I love about this scenario is that it fits my experience (admittedly based on a very small n) that most of the time, when someone is found far from home claiming to have forgotten everything, it's B.S. made up by a somewhat sociopathic person to get out of trouble of some sort. And just like in real life, first Walt was seen by his medical providers, who ordered various tests and called a neurology consult. Then, when no answers were forthcoming, they brought in the shrink. I got a good laugh when Walt told the consulting psychiatrist the truth about how he made up the fugue state after the psychiatrist explained the rules of confidentiality. This, unfortunately, is not something I've had the fortune of seeing yet in real life.

I'm impressed if you've never seen Breaking Bad but managed to read this far. What are you waiting for? In addition to being thrilling entertainment, Breaking Bad is an incisive examination of the follies of our society, with some of the finest acting and thorniest moral questions that I have seen.

A Simple Case of Depression

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

It started off as a seemingly straight-forward case, as it often does. The patient ("Kevin") was a shy, quiet 13 year-old young man, one who had "never caused any trouble," according to his parents. Until earlier this year, he had gotten straight A's, enjoyed reading, and regularly hung out with several friends. Then, during the second semester of the previous school year, he just stopped doing his homework. He also started spending more time on the computer and less time with friends. His grades dropped to C's and D's, and two weeks into this school year, he was still not doing his homework, which is what prompted the evaluation.

Talking with Kevin, his face was a blank mask. He did not feel sad or depressed, but he no longer enjoyed reading or felt motivated to do homework like he used to. He spent all his time on Facebook or playing computer games. He stayed up late and woke up early, felt tired all the time and had trouble concentrating at school. He occasionally had thoughts of not wanting to live, though he has never seriously contemplated suicide or harmed himself. He was also eating less than usual, and often had negative thoughts about himself, that he was a failure.

He clearly met the criteria for a major depressive episode, and if I were using a purely biomedical approach to psychiatry, I might have been satisfied with starting him on a serotonin reuptake inhibitor and hoping that he will be feeling better in about a month. However, his seemingly out-of-the-blue changes in mood and behavior struck me as odd. I was also struck by the fact that he was only now being evaluated, even though his grades started dropping over 6 months ago.

During the initial visits, Kevin's parents had insisted that there was no family history of any mental illness or substance abuse. They had a close relationship with their son, and they frequently went to the movies or baseball games as a family. However, the more I talked to Kevin, the more I learned about the nuances of his family. His parents were widely inconsistent in how they approached his struggles. His mother yelled at him when he got bad grades and told him he could not use the computer, while his father was more lenient, did not set limits, and even bought him an iPad after his grades started slipping. When one parent's approach did not seem to work, the other parent took over for a while, until that approach failed as well.

I spent a good deal of time talking with Kevin's parents about the importance of them both agreeing on their parenting approach, so they can set reasonable limits around electronics use and enforce bedtimes that allow Kevin to get adequate sleep. After a couple of weeks, Kevin's sleep improved, and he felt less tired during the day, but he still was not doing his homework. I continued to talk with Kevin about his family life, having him walk me through what happened in the evenings. The picture that emerged was not that of a close-knit family. Over the last few years, the family had stopped eating together at the dinner table since Kevin's father had been getting home later from work. After work, both parents tended to unwind by drinking. Their jobs have gotten more stressful in the past year, and Kevin told me that they have been drinking more as a result, at least 3 to 4 drinks per parent per night. He was essentially left to his own devices while his parents enjoyed their beverages.

I have no way of proving this, but I thought it was a strong possibility that Kevin's refusal to do homework was an attempt to get his parents to notice him and reengage with him. When I brought up the issue of alcohol with Kevin's parents, they both seemed surprised that he was aware of their drinking habits. They told me that they were doing most of their drinking when Kevin was already asleep, which really made me wonder just how much they were drinking. I did not tell them outright to stop drinking, but I asked them to think about if and how their drinking may be impacting Kevin.

After that, I never heard from them again. Perhaps I came across as judgmental, or perhaps I tried to push for too much change before I had established enough rapport with the family. But it was clear to me that Kevin's "depression" could not really improve without some serious behavior change from his parents. Sometimes I think about the appeal of simply focusing on the identified patient and what brain chemicals may be awry. But then I remind myself that complexity is what drew me to psychiatry in the first place. With a more comprehensive approach, at least I sometimes feel that I get a peek behind the curtain at what's really happening, even if I am often unable to do more to influence the outcome.

Louis C.K., Mindfulness Guru?

Note: The last couple of months have been very busy for me, so I apologize for the infrequency of posts. Now that things have gotten back to normal, I hope to resume posting weekly.

Louis C.K.'s recent appearance on Conan has already been linked to on multiple sites, with most of the headlines reading something like "Louis C.K. on why kids shouldn't have smartphones." Check out the video below if you haven't yet see it:



C.K. is one of my favorite comedians, and this clip shows why. Like many comedians, he often says things that people are thinking but are too afraid to say themselves. Here, he puts a voice to many things that I as a child psychiatrist would love to say to parents, but have a hard time finding a diplomatic way to do so.

To me, what he said is not about "hating cellphones" or "kids shouldn't have cell phones." His riff is much broader than that. He starts out talking about parenting, and how parents give in to their kids and get them phones because "all the other kids have the terrible things." Of course, this happened long before cell phones became common, and gets to the heart of how much trouble parents have in setting appropriate limits because they are afraid of momentarily making their child sad or mad. However, if a parent doesn't teach his or her child how to handle being being disappointed or told "no," then who is? Why not "let your kid go and be a better example to the other [bleeping] kids," as Louis C.K. says?

He then talks about how face-to-face interactions can help build empathy, but when a child engages in cyber-bullying, he or she does not get the feedback of seeing the other child's expression turn to sadness, and instead "when they write 'you're fat', then they just go mmm..that was fun, I like that."

Next, C.K. gets to the heart of what mindfulness is about to me. "You need to build an ability to just be yourself and not be doing something. That’s what the phones are taking away. The ability to just sit there, like this. That’s being a person." I would add that of course, the ability to just sit and tolerate being yourself was already difficult before smartphones became ubiquitous, with a 2006 Kaiser Family Foundation report showing that American youth spent almost 4 hours a day watching TV/videos, over 1.5 hours listening to music, about 1 hour on a computer, and almost another hour playing video games, with many of these activities happening simultaneously. Let's not forget all the other mindless ways of distraction other than smartphones.

C.K. even ventured into existentialism, how "underneath everything in your life, there's that thing, that forever empty…that knowledge that it's all for nothing, and that you're alone." He dares to utter the truth, long known to Buddhists, that "life is tremendously sad, just by being in it." He adds, "That's why we text and drive, pretty much 100% of people who are driving are texting…people are willing to risk taking a life and ruining their own cause they don't want to be alone for a second."

Lastly, Louis shared a story about how he was driving one day, and a Bruce Springsteen song came on that made him feel really sad. Instead of avoiding his sad feelings by texting people, "I pulled over, and I just cried…so much, and it was beautiful…sadness is poetic, you're lucky to live sad moments…I was grateful to feel sad, and then I met it with true, profound happiness." His overall message is one that I try to tell patients all the time. They often tell me that they don't let themselves feel sadness or grief, because they're afraid of feeling overwhelmed. However, attempts to suppress those sad feelings just get in the way of a person truly being content with life. As C.K. said, "Because we don't want the first bit of sad, we push it away...and you never feel completely sad or completely happy, you just feel kinda satisfied with your products, and then you die."

Despite the jokiness of the delivery, Louis C.K.'s message is quite serious and well thought-out. I hope everyone listens.

What Jean Twenge Gets Wrong About Narcissism

Earlier this week, a New York Times article, Seeing Narcissists Everywhere, featured psychologist Jean Twenge, who has documented the rise of narcissism in Millenials in academic papers and two books. She has also made numerous appearances on TV programs such as Good Morning America and Today touting her view that the promotion of self-esteem over the past few decades has led to the current generation's sense of entitlement. She bases much of her views on standardized questionnaires given to college students, especially the Narcissistic Personality Inventory (NPI).

Unfortunately, the article featured only the most superficial criticism of Dr. Twenge's work, including other researchers who "calculated self-esteem scores" over time and did not find a change, or who disagree that the NPI actually measures narcissism, or who analyzed other sets of NPI data and did not see a significant change over time. I would like to offer some more in-depth critiques. To be clear, I absolutely agree that narcissism is prevalent in our society and that it leads to a host of ills.

Endemic, not epidemic

First, I find the title of one of Twenge's books, The Narcissism Epidemic, to be deeply misleading and alarmist. According to the MedlinePlus Medical Dictionary, "epidemic" is defined:

affecting or tending to affect an atypically large number of individuals within a population, community, or region at the same time

What's "atypically large" about the prevalence of narcissism, given our status and wealth-obsessed culture? I think it would be more accurate to call narcissism "endemic" rather than "epidemic." We all have narcissistic tendencies, and to characterize it as an epidemic externalizes and puts the focus on others. It's as misguided as those "how to spot a narcissist" articles. The title also implies that Twenge has somehow discovered something new, which is certainly not the case. In 1979, Christopher Lasch published The Culture of Narcissism: American Life in an Age of Diminishing Expectations, a deeper critique of our culture that obviously predates the "self-esteem movement" of the 1980's.

More than meets the eye

Narcissism presents in more than just one way. There is the stereotypical view of a self-absorbed, overconfident, extroverted, somewhat callous individual, and this is likely the construct that the NPI measures. However, there's also covert narcissism, which is well-recognized in the literature, but which Twenge does not seem to appreciate. For example, suppose there are people who think I'm more altruistic than anyone else or no one else can appreciate the uniqueness of my suffering, or who base their sense of self-worth entirely on what other people think while outwardly appearing anxious or depressed. I would argue that these people also have narcissistic issues, even though their form of narcissism is not well-measured by the NPI or formally a part of the DSM definition of narcissistic personality disorder (NPD). Originally, the DSM-5 draft had proposed changes to NPD that encompassed the covert form as well, but ultimately (and unfortunately) those changes did not make the cut.

Beyond the explicit message

Twenge seems to think that there's a direct path from parents telling their children how special they are to the children becoming narcissistic and entitled adults. That may be true, but people are a bit more complicated than that. I won't talk about any particular person, since it's unethical for me to diagnose someone I'm not treating. But let's say there's a politician who has done little over his career other than appearing on TV and provoking the opposition. And suppose this politician admits in a major interview that when growing up, his parents were distant and far from the self-esteem boosting types. And then suppose that this man's sexually-charged text messages are released to the public and reveal a deep fount of insecurity rather than confidence.

Thus, the implicit message that children and adolescents receive from parents and from society is just as influential or more so than the explicit message. Take for example this passage from the NYT article:

 "I got a onesie as a gift that I gave away on principle," said Dr. Twenge, 41, a professor of psychology at San Diego State University and a mother of three girls under 7, in an interview at a diner on the West Side of Manhattan.

"It said, 'One of a Kind,' " she said, poking at a fruit salad. "That actually isn’t so bad, because it’s true of any baby. But it’s just not something I want to emphasize."

So she's not telling her children they are "unique" or "special." That's all well and good, but what if she's reinforcing society's message that to be successful, one has to publish best-selling books or appear on the Today show? How she handles these issues with her children is far more important than what's on the onesies that they wear. If she truly is not aware of this, then perhaps the article would be better titled: "Seeing Narcissists Everywhere, Except the One in the Mirror."