Troubling Times

Alice Keys, MD
30
104

These are troubling times for me as a physician and as a psychiatrist. They were even more so before I ran away… excuse me… took this… uh… sabbatical of mine.

None of this enormous mess we are all in together is brand new. We, as a nation, have grown into it rather slowly. Perhaps if this mess of a medical system had happened more suddenly it would have been easier to spot, easier for us all to perform the necessary pruning. Our entire country and all of us are buried to the neck in a quicksand that has been designed, bit by bit, over the decades. It’s deep.

It’s easy to lose energy and focus pointing at one another; pointing and blasting away. The easiest shots to make are at those closest by, the ones that are here, by your side.

It’s easy to lose power and momentum for movement toward meaningful change by imagining that psychiatry, psychiatrists and our patients are the only issues at stake; that we are the special case with special issues and that psychiatry is THE problem.

But I’m afraid we’re not the whole picture. We are important. Very much so. Every single person and their suffering is important. But psychiatry and it’s devolution to a pill model of care is only a ripple in this ocean of pill focused medical care we’re drowning in.

I keep coming back to this question, over and over:

“Can I, as one single individual physician, make any difference in where we, as a nation of about 311 million people, go from here? Can I make any difference with regard to finding ways to provide sensible and equitable healthcare for everyone?”

Although I’ve been gone from the practice of medicine for eight months at this point, I did spend almost a year back at work after I read “Anatomy of an Epidemic”. On the sunny afternoon I finished reading this book, I was certain I could not go back to work as a psychiatrist. Ever. It was a dark night of my soul in the middle of a brilliant sunny day.

I sat on the porch, watched the green trees and blue sky. I thought about many of the people I had treated with psychiatric medicines. I wondered how his life or her life would have been different if I had not given them medicines. I felt I needed to go away till I could get perspective on it all.

But the next morning a friend called and told me they were short handed at the clinic. He asked if I could come in and help out.

I thought, maybe there’s a way I can have a positive and transforming effect by working from inside the system.

I spent much of the next year saying “no” to a lot of requests for pills, saying “no” to dosage increases, explaining my concerns about the medicines to patients, colleagues and co-workers, reviewing and encouraging alternative approaches to managing symptoms.

Over that year I did not meet a single patient that did not come with a request for pills. My “no” and alternatives were met with “I’ll come back when the other doctor’s here” and “I don’t have time to exercise” and “I can’t afford therapy” and “If you don’t give me meds I’ll get kicked out” and “Alcohol’s not a problem for me” and “I haven’t used meth in two weeks and I still feel bad”. There was even one anxious pregnant woman who told me she’d already had a baby that required open heart surgery at birth. She demanded I give her the same medicine again. I did not. Patients did not thank me for protecting them from the effects of the drugs.

I’ve been happy to hear from all the people who do not want to take medicines and who want to taper to the lowest possible doses. You are not the ones I met at work. Not at all.

The system feels massive to me. The weight of the moving freight train of history embedded with clinical staff, funding managers and well marketed-to patients is bigger than me. I felt like I was bailing the ocean with a teaspoon. Galileo was jailed when he said the earth moved around the sun. I was simply overwhelmed by telling the truth every day I went to work.

I am here to use what I hope to be more powerful and wide-reaching tools than seeing patients, one by one; words on Robert Whitaker’s webzine.

I’ve known for a long time that words create the world. I mean this in both a practical sense and a philosophical one. I’ve written medical records and reports and requests for care authorization and disability claims. I understand how words on paper are used to define who and what we are. I also know that the words we speak and write and hear create our realities: angry words create an angry world and kind, loving words create a loving world.

No one who participates in this discussion comes to the table completely alone. And no one, alone, wields power sufficient to remake the practice of medicine into the cooperative two-way relationship and meaningful healing profession it could be.

 

Previous articleFantasy Video Game Zaps Depression in Adolescents
Next articleAmerican Woman 2
Alice Keys, MD
Necessary Phoenix: Can one physician help heal the practice of medicine? After two and a half decades of work as a psychiatrist in private practice, community clinics and inpatient units, Dr. Keys shares her personal perspectives on the devolution of medical care and the needed resurrection.

30 COMMENTS

  1. Alice,

    Thank you for your blog. I’m a psychiatrist and struggle with some of the issues you describe. I especially connected with your comment: “The system feels massive to me. The weight of the moving freight train of history embedded with clinical staff, funding managers and well marketed-to patients is bigger than me. I felt like I was bailing the ocean with a teaspoon.”

    Thank you for your words. Let’s hope they do indeed have an effect.

    Warmly,
    Bill

  2. On paper things always look easy but not so in real life. I know people always look for an easy sollution and I actually know a few people who were helped by pills to overcome a crisis. My son was one of them: the psychiatrists should have helped him off those pills when we asked them though. All the psychiatrists we dealt with were well meaning people and thought they were doing the right thing to start with. They were hampered by governement “guidlines” though and the local mental health trust policies. And then there is the modern compensation culture: I wouldn’t like to be a doctor in this modern day and age.

    • Despite how negative I am about the medication, even I would say that it came in handy for my son when he was in a crisis and was frightening everybody around him. The medications act like a tranquillizer dart and they do come in handy. The problem, like you say, is that doctors don’t see that medications are better only in an emergency. They see them as life long necessities. In an ideal world, instead of being tranquillized in an emergency, the person would be given time out in a facility that knew how to manage the situation without drugs. A few years ago I delayed too long putting my son in hospital because I knew that once admitted, he would be kept on medications far too long. After much battling on my part, he’s finally off them.

  3. I don’t think it is as simple as just say no to meds. If someone has been on medication for years, and suddenly a new doctor is refusing to give them a refill- that is quite terrifying, and a loss of power, and potentially not the best thing for them. Maybe their brain has adapted to the drugs, maybe they need them. Maybe they are one of the few who benefit. And yes, some people don’t have time to exercise- or are simple too depressed. I treat hand injuries. I have patients who come in with an overuse injury- one that I know would quiet down if they would just rest it. But some people can’t, or won’t, do this. (often new mothers or the self employed). For these people, I start talking surgery sooner rather than later, because their life just doesn’t allow them to do what they need to heal without it.

  4. Indeed, it is not a one person at a time kind of struggle. It is not about persuading one service user at a time to come off drugs (as service users who like their drugs sometimes accuse me of). It is not about converting one Dr at a time to prefer no or low drug treatments.

    It is about dismantling the whole drug company/psychiatry/regulatory complex which has influenced the whole of society and the way mental distress is thought about and treated. Drug company mult-million PR and advertising is a powerful force and a few well intentions physicians are but a drop in the ocean.

    It is about creating a political/social movement and this blog on this website is an important part of that.

  5. Dr. Keys,

    Yes,we are in troubling times.
    And we must all work together to come up with a model –
    one with a solid foundation.

    IMO, we need to have dialogue.
    But we also must begin to act.
    We must first stop the bleeding.
    And begin to think big, to set our goals high, with what we want to accomplish.

    Maria Mangicaro was kind enough to place a vision on the ISEPP website, for anyone interested. Comments are welcome –

    http://isepp.wordpress.com/2011/07/25/mental-health-freedom-and-recovery-act/

    Duane Sherry, M.S.
    discoverandrecover.wordpress.com

  6. Two great posts Dr! You probably know Dr. Mark Foster who posts here as well. He writes powerfully of many of the challenges you describe. I’m very encouraged that we now have several physicians blogging, reading and responding on the site.

    I appreciate your observations that many of the folks you worked with wanted the meds and felt they needed them. This is a multi-faceted issue and one person can’t focus on everything at the same time. Let me suggest, as others have done, that your postings are far more influential than you might think. Changing a culture takes time, but if it’s to change at all people need to start doing/thinking/saying things differently. You’re doing all the above! So thanks for helping to make a difference. I look forward to your next post.

  7. If you look at the entire system pushing doctors and patients into a pattern that’s not good for either, it is massive, and that’s discouraging.

    Even large professional organizations with millions in lobbying dollars have to work constantly and patiently at bending the system to their interests.

    But if you look at your immediate surroundings, at your community, you can see things you can do to change things. Maybe small things, but every mite adds to the tipping point.

    I think mutual support is important, we all feel so isolated in this. I hope eventually doctors will band together in a formal organization to change their profession. In the meantime, each one, teach one is a worthy pursuit!

    Dr. Keys, how about speaking to local medical societies and community health programs about the appropriate use of psychiatric medications? And how to recognize adverse effects? This is truly grassroots work doctors can do to affect change. And you’ll find friends among those receptive to your ideas.

  8. I empathize with your struggle. Having worked for 12 years as a psychiatric nurse in a community mental health practice, with two very competent and caring docs, I have felt many of the emotions you describe above. My biggest ethical problem with working in that setting was the concept and practice of informed consent. We stretch the limits of credibility by convincing ourselves (and the regulators) that it occurs in the psychiatric arena. In my own experience, it was most often a formality, with either subtle or not so subtle efforts to minimize the information regarding side-effects, always in the spirit of obtaining med compliance. Combine this with the mental haze (a nice way of describing it) which accompanies the array of meds which many patients are newly prescibed when discharged from an inpatient ward, and we are truly stretching the limits of not only credibility, but the actual laws in place to insure appropriate treatment. The straw that broke this camel’s back, over time, was the prescribing to children, where the consent was given by (most often) ill-advised and maladjusted parents, seeking to make up for poor family/social dynamics by scapegoating the compensatory behaviors of a vulnerable child. Just too much to observe on an ongoing basis. I teach college nursing now, Pharm in the fall and Psych Mental Health in the spring, and comfort myself with the belief I am educating a new generation of nurses who will have at least a small appreciation of the dynamics of our health care system’s pill centered approach. Credit to you for speaking your mind.

LEAVE A REPLY