September 27, 2010

Mark Foster, DO
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Bob–

I would guess that as I am typing this, you are in the midst of a spirited defense of your book at the conference. I hope that it goes well for you, and that your audience is receptive. I find myself wishing I could be there to observe and participate, as your book and our exchanges have gotten me fired up.

I have had an awful few days at work, lots of non-patient and corporate issues arising, and I’ve been struggling to find some reserves of energy and compassion . . .

Today, I had a mother bring in three of her children, a 5 year old girl, and 8 and 11 year old boys, who each twiddled away at their own hand-held electronic gaming devices during the course of the visit. Mom is quite overweight, as are the kids except for the 8 year old, who is quite thin. They were all brought in for sore throats, and it turned out to be a viral infection not requiring treatment. As an “oh by the way” at the end of a chaotic visit, she asked if I could refill her 8-year-old’s ADHD med, Concerta, which he needs for school when it starts next week, because she said “His teachers will kill me if he’s not on his meds.” I was running way behind, and my urge was to get out of the room quickly. I could scarcely remember my last visit with this boy, but a quick look at his chart and I discovered that we had taken a drug holiday during the whole summer. He seemed relatively well-behaved during the visit, so I considered how to handle this issue in as efficient a manner as possible. I said, “Well, yes, I can refill that. But do you still think he needs it?” She replied, “He’s done pretty well this summer at home, but he’s a terror in the classroom.” I gave the 10 second synopsis of the idea of your book: “I worry about he long term effects of these meds. Sometimes they make things worse, and kids will outgrow ADHD.” I expected more resistance, so I was surprised when she offered, “Maybe we could see how he does the first two weeks of school before we start them back up?” Great idea, I said. I provided a script, but we scheduled an appointment for 3 weeks from now to follow up, and the goal was not to start the medicine until then if at all possible.

A couple observations from this encounter:

  1. The management of psychotropics as an afterthought occurs so frequently in primary care. In similar situations, such as refilling an SSRI, how often would I have just refilled it and we all go on our merry way? That just ain’t right . . .
  2. I overestimated her degree of resistance, and that almost led me to miss this opportunity. One welcome surprise from these last few weeks is that I’ve learned that most patients are willing to consider this new idea, because they trust me. I think most of them, somewhere deep inside, have an innate resistance to this medical model of psych care, but that never expresses itself because they have been conditioned to believe that meds are the acceptable, socially responsible, definitive solution, expressed in this case as the mother’s belief that “the teachers will kill me if he’s not on his meds,” manifesting the tension between her desire to do what’s right for her son, and to do what is acceptable to society. Correct ideas are powerful things to effect change, and hearing her doctor even briefly express a countervailing opinion allowed her to express a different, and hopefully healthier, frame of reference.

This has led me down a pathway of thought, to how another iatrogenic, drug-induced epidemic appears to have been partially curbed through the development of evidence based guidelines and concerted public education: antibiotic resistance. When I was a child, I think I was on antibiotics every other month for something or another. That patient expectation for the necessity of antibiotics to cure self-limiting or viral infections persists to some degree, but I would venture that it is markedly less than it used to be. I have my one-minute “antibiotics are not indicated” spiel down to perfection, and I find probably 75% of patients respond favorably to this. The other 25% get upset, or beg, and sometimes I cave in and sometimes I don’t. But the point is that, over the past thirty years, scientific evidence and the potential for dire consequences has induced a dramatic reversal in physicians’ habits of what was once accepted as standard medical practice, and that change is slowly percolating down into the public mind. This problem is still very significant, and a lot of the damage with creating resistant super bugs has already been done, but the momentum is now towards a more healthy, natural, medication-free paradigm for treating minor infectious disease. Maybe thirty years from now, we’ll be able to say the same thing about psychotropics.

Final thought: last night, I was awakened at 3 a.m. by my 6 year old when he came into our room sleepwalking. He was mumbling something or another, lost in a dream. As I shepherded him back to his bedroom, he remained asleep, but was able to find his bunk-bed, climb up the ladder, and crawl under the covers. Bleary-eyed myself, I paused briefly to marvel at his little brain in action: on a consciousness level, he was asleep, unaware, on autopilot, but yet his eyes, senses, coordination, and memory allowed him to follow instructions, to walk, climb, and perform rote activities. Once he hit the pillow, he was back in his blissful sleep, his brain continuing unimpeded to regulate his breathing and other basic bodily functions, while his mind escaped to some far away place. (Who knows where? I like to ponder what my kids might be dreaming about. My guess last night was he was at Hogwarts, as we’ve been reading Harry Potter together.) My point in sharing this is that these brains of ours, these minds and personas and emotions and aspirations and free-wills and spirits, are scary beautiful things. And watching my son last night, I found it outrageous to think that the psychiatry/pharmaceutical collusion has succeeded in convincing the public and the medical profession that these beautiful minds of ours can be reduced to simplistic diagrams and discrete biochemical reactions, and when not working right, can be fixed with snake oils and magic bullets. Really, it’s a cynical, debasing paradigm of the human condition. Who put these guys in charge?

Hope the talks and conferences go well.

Mark

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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