This article is a re-post from the first month this blog existed (11/09). Since there are many more readers now than there were then, I’m guessing that most of you haven’t seen this post. It was originally titled, “Doctor, Do Something!”
As the saying goes, when you’ve got a hammer, everything looks like a nail. Send a patient to a surgeon, and he very well might get surgery. Send a patient to a psychiatrist, and he very well may end up on psychotropic medication.
As physicians, we need to take responsibility for our own actions. We should not prescribe or perform procedures unnecessarily. However, even if we are responsible for our own actions, not looking at our culture as part of the problem here would be a mistake.
America is an action-oriented, “do something” society. As members of this society, we tend to believe that we not only have the right to pursue happiness, but the right to happiness and good outcomes. When something isn’t right, we often turn to others to fix our life problems for us. The general assumption is that the answers lie outside of ourselves and that the remedy to life’s woes is available. The is very much a Western view and quite opposite the typical Eastern view of life.
Although well-intended, we doctors often give in to the pressure from patients, families, and nurses to “do something” even when offering emotional support and reassurance may be the best option.
Sometimes this has involved life issues where temporary emotional distress is not inappropriate: “My boyfriend broke up with me 2 days ago, and my meds aren’t working any more! Can you increase my ______?”
Other times patients have not waited long enough for results: “This antidepressant is doing nothing! I can’t tell any difference at all. I’ve been taking it every day for the past two weeks. I want something that’s going to help!” It’s not uncommon to hear comments like this even though it was explained clearly that the medication will take several weeks to work.
A parent may request a med change for their child with ADHD: “He’s still rude, manipulating everybody, and running the house. Can you increase his Adderall?”
In the correctional environment, some inmates frequently experience sadness about being away from family and being incarcerated yet are not clinically depressed. I spend time talking with them and find that in that environment a little support can go a long way. But, if they are requesting antidepressant medication I explain to them that there is no pill for emotional pain.
I want to be clear that I am not at all intending to discount or minimize the real-life concerns that our patients bring to us. However, just because our patients or families of patients are in real distress does not automatically mean that we have a solution for them.
So, how have I handled these situations? Probably like most other doctors. Sometimes I’ve felt like I’ve done the right thing, and other times I’ve given in and regretted it. I think that this is an important fine-tuning of practice skills that develops over a career. I believe we need to consciously think about it more and try to resist the easy way out: placating our patients when it’s not the right thing to do. We may be well-intended, but we’re not helping them when we do this.
A few months ago I read an interesting article from Psychiatric Times entitled, “The Value of Nothing.”
It offers an interesting perspective on this topic and is worth reading. Here is an excerpt that illustrates my point:
“When I first started as an attending, I inherited the patients of a respected psychiatrist who had moved on to another institution. I meticulously reviewed information on every patient in the Veterans Affairs computerized medical record before my initial visit with each person. After several weeks, I noticed that at each session my predecessor had either increased a drug dosage or, more often, changed medications in response to variegated symptoms from financial difficulties to somatic complaints. Bewildered, I finally asked my supervisor if there was a reason for all the switching that I was unable to grasp. His reply was instructive: “Dr X couldn’t stand not to do something when someone was distressed, and so he changed the medications.” This hyperreactive prescribing taught me some valuable early lessons in patient care:
• Carefully assess the obvious and hidden circumstances that underlie changes in symptoms.
• Be quick to offer psychological support and be slower to change the course of therapy.
• Time, observation, and watchful waiting are your allies in clarifying the situation and in determining whether a response is needed.”
What do you think about this topic? Please share your comments.
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http://jamesbakermd.com/2010/08/08/elsewhere-15/ Elsewhere | Mental Notes
