June 27, 2011

Mark Foster, DO
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Dear Bob–

I have been working again, taking temporary assignments filling in for other physicians and working in urgent cares while I get my practice re-established. It has been great to re-engage with real patients in the throes of life, who are struggling with various health and wellness issues. I love the direct interaction, the infinite variety of people and personalities.

Being away from it for a few months has helped me appreciate the true privilege it is to be trusted to be somebody’s doctor, the intimate glimpses of people’s lives that doctors have, and the unique insights into the human condition that those glimpses afford. After all, when I am talking to a patient, there it is: life unfiltered, unrefined. Nobody is reading from a text-book or considering the deep moral and philosophical implications of their predicament. We are all just in the thick of it, patients feeling distressed in some way, usually physically, often mentally, and me simply wanting to help.

Here’s a quote I came across recently from C. Everett Koop, former US Surgeon General: “The intimate reactions between the physician and the patient are, and should be, a mystical experience. Probably no one can fully wrap his mind around the compassion and the outrage, the courage and the despair, the affluence and the poverty, the success and the failure, and the harmony and the discord these relationships explore.”

I like the shared humanity implicit in this statement: a doctor’s visit as a dialogue between two equal humans just trying navigate the tangled jungles of life and health care as best as they can. It’s too bad that all too often these days, doctors treat their patients like cattle to be herded through the office as efficiently as possible. There is simply so much financial incentive to see more and more patients in less and less time. This cattle-herding approach lends itself nicely to cookie-cutter diagnoses and mass-producible therapies like drugs.

It’s a shame when the patients themselves are lost to the system, getting caught in the gears of this machine-like approach to health care, where decisions that should demand cooperative, honest, individualized communication and nuanced thinking are instead made perfunctorily, based on volume, revenue and generic (and ill-fitting) standards of care.

This is particularly true when dealing with mental health, where the diagnoses generated by the DSM-IV–beheld with bible-like reverence by most physicians–are so ethically compromised, so malleable, so reductive and dehumanizing, yet so seductive in their seeming authority, empiricism and standardization.

For example, I saw a young woman at an urgent care recently, age twenty-one, a single mother of two who had just had her second child by C-section only six weeks previously. She was coming to see me about a digestive issue that had started after the delivery. She was on only one medication, Paxil, and since stomach issues are a common side effect of SSRIs, I asked her how long she had been on it.

She told me that when she had gone to her obstetrician to have her staples removed six days after the surgery, she had been tearful and the doctor asked her what was wrong. She said she was feeling overwhelmed and sad. It was supposed to be a quick visit, but he went ahead and asked her if she had ever been diagnosed with depression. She said that she had been on antidepressants for a few months in high school. He asked if she was suicidal, and she said no.

Then, without any further questions, he told that he was worried she was developing Post-Partum Depression and recommended that she start Paxil, which she did the next day. She told me she was scared of this diagnosis, having read about psychotic mothers killing their children, and she was horrified to think that could be her and her children’s fate. No other lifestyle or counseling recommendations were made. She was handed the prescription and scheduled to see him again in six weeks.

She had been taking Paxil for five weeks by the time she came to the urgent care for her stomach issues. Her nausea, cramping and diarrhea had began within days of starting the medicine, but she didn’t see any connection. She assumed that these symptoms were related to recovering from the surgery, which was probably partially true. However, the symptoms got worse the longer she was on the medication and the further she got from the surgery, and now had reached the point that she had no appetite and daily diarrhea. She had developed severe cramping over the weekend and that was what had finally brought her into the urgent care.

We ran a few tests that reassured me there were no infectious or surgical concerns. I told her that, based on the nature and timing of the symptoms, the most obvious culprit here was Paxil. I did not divulge to her my bias against unwarranted psychiatric drugs, just gave her the same facts she could have been found on the drug info sheet. She was surprised and said her doctor had told her not to worry about any potential negative effects. I asked her if she thought the medicine was helping and if it was worth continuing in light of these effects. She said she wasn’t crying as much, but that she was so tired all the time that sometimes she was just ignoring her crying baby. Then she said something that many people say when on SSRIs: “I feel like I’m walking around in a fog all the time.”

Since this would be the only time I would see her, there were limits on what I could recommend. It was important that she have a physician whom she could trust and with who she could follow up with regularly. I told her that it was possible that she didn’t have Post-Partum Depression at all, but rather some common baby blues that were related to hormonal changes, physical fatigue from pregnancy, lack of sleep, and a variety of social and financial stresses. I said that lots of women feel similarly after having a baby, and it usually resolves with time, perspective and patience, although sometimes it can become more severe and warrant more intensive intervention. She said she didn’t really think she was that depressed in the first place, mostly scared of what could happen if she wasn’t on the medicine. She had not been on the Paxil long, so I told her to consider tapering over four weeks, but to make sure to follow up with her regular doctor and discuss this plan with him. Then I gave her a list of lifestyle interventions, and the name of a counseling service.

And then she walked out of the urgent care, baby carrier in tow, back into this big scary world of ours where smart authority figures seem capable of giving such contradictory information. One doctor tells her she has a disease called Post-Partum Depression and gives her a pill that he says has no side effects. Then another doctor tells her she may not have a disease at all and that she is having moderately severe side effects from that same medicine.

Whom to believe? Hopefully, she can take this contradictory information, research it for herself, weigh it with her own values and goals, and then make the decision that is right for her. Unfortunately, I think this rarely happens. Patients tend to just accept what their doctor says, whatever seems to be the quickest and easiest solution.

While patients need to become better and more active advocates for themselves, the implicit authority they invest in their doctor’s opinion is tremendous, and that trust should weigh heavily on every physician. What would be interesting is to see what data the culturally accepted truth (meaning the validity of the PPD criteria and the necessity of drugs) could present to defend itself, and then compare that with the all of the information from contradictory views. (I think Anatomy of an Epidemic would be a good place to start.) Then we all could fairly evaluate the stories these opposing sides told, and decide for ourselves which one was true.

As you have said many times, these are storytelling battles. At times, they can seem high-minded, esoteric, political—choose however you want to spin the data, then believe whatever you want to believe. But I can’t see it that way when I’m dealing with a patient like this. She is suffering, needy, trusting . . . what story are we—meaning me specifically, and the medical profession generally–going to tell her about herself, about her brain, about the safety, effectiveness and necessity of our drugs?

I hope the story she comes to accept is based on scientific truth, human empathy, and optimism, and that her doctor engages with her in that same way, as an exquisitely unique soul experiencing an understandable human reaction to a pivotal life moment, suffering symptoms that could rightly be expected to resolve with patience, support, hope and compassion.

I think she would benefit more from that approach than from the cattle call of psychiatric labels and drug therapy.

Mark