June 17, 2011

Mark Foster, DO
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Bob–

Here is a letter that I wrote several months ago in response to an early reader of my blog here. She expressed concern about the way I described my reaction to a patient who, in very poor mental and physical health, expressed to me her desire to become pregnant by another man while her husband was in jail. You can read that initial encounter here: September 21, 2010

The reader felt that I was passing a value judgment on this woman’s fitness for reproduction, and likened my remarks to the sentiments that prompted the forced sterilizations of the eugenics era. In going back and rereading this entry now, I agree that some of my language sounds harsh, perhaps even snide, and I regret that. But in as much as I am on a journey of my own, I think it is interesting to see how my own sensitivities have developed, hopefully for the better.

I am including this response now because within it I think I am approaching an important point: the illusion of scientific objectivity. This is especially true for physicians engaging in the realm on mental health. We inescapably bring our own biases to every patient encounter, acknowledged or not. This is why we call them medical opinions. Biopsychiatry’s impossible pretensions to empirical objectivity has been in part what has spurred on the abuses of the system that we see today.

My hope is that my response here can create some discussion, helping physicians to recognize the subjectivity of their opinions, and helping consumers recognize the shared humanity and manifest imperfections of their providers.

Sept 28, 2010

Dear R*******,

Thank you writing and expressing your concerns. It is enlightening and humbling to hear how my descriptions sound from a patient’s point of view. I apologize if I offended you or anyone else. Please be aware that I have taken great care to insulate from identification the actual patients in question. In the event that I have not obtained express permission from the patient in regards to utilizing their situation, then I have obscured any identifying characteristics to make them unrecognizable to perhaps even themselves. Yet the larger context of the situations remains unchanged. In this way, I believe that I can share a physician’s-eye view of our nations’ addiction to psychotropics, which I consider to be a matter of utmost importance, through the lens of specific patient encounters, and yet still respect patient privacy and confidentiality.

That being said, I realize that it may be jarring to hear a doctor, whom you assume is the objective observer in these encounters, to describe patients, sometimes using emotional language, or what may seem to be derogatory remarks. I admit that I cannot maintain perfect objectivity when interacting with patients, though I try my best to do so. Obviously, what you are reading here is much different that what I place in the patients’ medical chart. In my mind, nothing of what I have said in the letters is judgmental, derogatory or hurtful–it is simply my reaction to patients who have found themselves in manifestly awful situations. But perhaps to a reader it appears judgmental. For me, words such as “blond” or having a “low level of intelligence” are simply accurate descriptors of the patients in question, as I would consider all of the physical and mental characteristics of patients to be pertinent in describing these real, living, breathing human beings and their perceived need for (or reaction to) psychoactive medications.

As to the woman in question, who has severely impaired insight and judgment, who has lost legal custody of her other two children, who expressed a desire to become pregnant by another man while her husband is in jail, while she is on two category C or D medications (considered unsafe or dangerous in pregnancy), smoking two packs a day, episodically using multiple illicit drugs, and has hepatitis C: I don’t think any physician could, or should, react with complete objectivity and a lack of emotion in this context. Pregnancy is dangerous to her health, and especially to a potential fetus, not to mention the adverse social consequences. I believe it would be very poor form for me to try to maintain some sort of impassive approach as I counsel her here. Inasmuch as patients come to me seeking an opinion, then I must tell them my honest opinion as to the short term and long term consequences of their actions. The (gulp!) comment may have appeared snide, and for that I apologize. But that honest, human reaction is a far cry from advocating forced sterilization for unfit or “imbecilic” parents. I would never condone such a thing. But I would be willing to tell this woman, as I did, that she has no business trying to get pregnant until she can at least stop smoking and get off of her teratogenic psychiatric medications.

Personally, I don’t believe the ideal of the completely objective physician exists. We are humans, too, not robots, and so, social expectations to the contrary, we can never react with complete, unemotional disengagement from our patients or their situations. I think that false façade of objectivity creates more problems than it solves, because our personal prejudices and repressed biases will eventually rise through our interactions and recommendations, anyways. Better to strive for objectivity, but to be honest with patients when those irrepressible human sentiments may be surfacing and coloring our impartiality. In that way, I don’t believe a physician should aspire to the blind justice we expect from the judicial system. A doctor’s visit is, after all, just two people, sitting in a room, trying to carve out a path forward through the tangled jungles of science, society, and personal responsibility. Patients always have a choice to seek different opinion.

In this case of this woman, she knows me well through our repeated visits, and she comes to me out of choice, not coercion. I believe she keeps coming to see me because she knows I will be honest with her. I actually have recommended that she see a psychiatrist, but she refuses, saying, “They don’t listen to me like you do. They’re just going to put me back on those zombie meds.” I agree that doesn’t quite square with her requests that I prescribe her sleeping pills, but there again is her lack of insight and judgment. Frankly, I am willing to continue to try to compassionately counsel her, occasionally compromise with her, and manage her meds, because I believe she will not get any additional benefit from seeing a psychiatrist, only worsening polypharmacy. To be clear, I don’t believe that I will ever “fix” her, but at least I can spare her from the harmful effects of the antipsychotics that she would probably otherwise be prescribed, which Robert Whitaker’s book so clearly describes. I wish there was a better way, a more robust, non-pharmaceutical mental health system for patients like this. But at present, such a system doesn’t exist, at least to my knowledge, and so I just do the best I can.

Perhaps part of the issue here is that my patient descriptions all began as personal letters to Robert. In that context, I let my guard down as a scientific observer and expressed to Robert my own emotional struggles in managing these patients. He felt that posting these letters would help give valuable insight into a physician’s mindset as he struggles to care for real patients amidst the competing interests, inefficiencies, and ironies of our fragmented health care system.

In the end, I believe that my letters to Robert are, if nothing else, honest. Perhaps too honest. You have helped me realize that I need to be cautious in the language I use to describe patients so as to avoid stereotyping. I will take that message to heart, and I hope you will find my future letters illuminating, authentic, paradigm-challenging, and yet inoffensive.

Sincerely,

Mark