Key Deficiency in Medical Education System Costs Us All

A friend of mine recently finally got from their doctor something they had been seeking for almost 8 years with little results: an actual diagnosis.

This person began having symptoms of tingling in their fingers and pain in their shoulder almost a decade ago.  During this time they worked as a nurse which is a labor intensive job that requires frequent use of arms and hands and regular heavy lifting.  As time passed her symptoms got worse and worse and she experienced little relief.

Over those 8 years this person visited their primary care physician for this problem about a dozen times, got 3 MRI studies, 2 Electromyograms (a test where doctors test nerve functioning by running electrical currents down nerves), saw 2 neurologists, 3 occupational medicine doctors and 3 orthopedic doctors.  She had several work related shoulder injuries and missed several weeks of work for shoulder related problems during the decade.  The cost of all this, which we all contribute to paying, is exorbitant.

This process continued with little relief until recently she saw a shoulder specialist who at long last diagnosed her with a disease of her shoulder called “Thoracic Outlet Syndrome.”  Thoracic outlet syndrome occurs when nerves and blood vessels exiting the shoulder are compressed causing symptoms of pain, tingling and occasionally vascular insufficiency in the shoulder, neck and arm.

The good news is that almost all patients respond to the specific kind of physical therapy appropriate for this problem and experience an improvement in functioning and symptoms.  For those that don’t respond effective surgical and non surgical treatments (like botox or steroid shots) exist that can lead to improvement.

The bad news for my friend and all of us is that it took the health care system 8 years, dozens of office visits, a half dozen expensive tests (MRI tests cost approximately $2000 a scan and EMG’s $1000-$1500), numerous specialist referrals and several weeks of work disability to reach the diagnosis.  The cost of the system’s failure to diagnosis this injury could easily be estimated to be several tens of thousands of dollars.  The cost for mistakes like this are absorbed by us all.

When one individual fails we can look to that responsible person and chalk the mistake up to deficiency or chance, but when several extremely competent and well trained individuals all fail I believe we need to look at the system that they function in to explain the shortcomings.

In this the failure to me is simple: None of of the half dozen or so physicians she saw before this final one had the necessary expertise to diagnose her problem in spite of a collective decades of training.   No test or study should have been needed to make this diagnosis. To me this is reflective of a larger problem in medical education.  Medical education biases towards training doctors at treating really, really sick people which is a good thing, but there is little emphasis on taking care of the problems that commonly occur in healthy adults.

Shoulder injuries are among the most common complaints that people visit doctors for.  Studies estimate that 1 in 20 visits to primary care providers are for shoulder problems.  As someone who is going through medical education I can state definitively how little I have been educated in shoulder injuries now in my 7th year of medical education.  I know about rare enzyme deficiencies and strange infectious diseases I will never likely encounter, but for something that composes 5% of all doctors visits I know little about.

The same could be said for many of the other problems that healthy adults commonly experience.  Doctors know shockingly little about how to properly manage many things that are relevant to healthy adults like back pain, musculoskeletal problems, pain syndromes, anxiety/depression, nutrition, vitamins and minerals, physical fitness, common skin and eye problems and psychosomatic problems (which one study by Kaiser Permanente estimated to be responsible for 70% of visits to primary care clinics!).  Taken together these problems routinely come up but medical education simply does not emphasize them.

I think Doctors generally feel more comfortable taking care of really, really sick people than they do taking care of people who are mostly healthy.   The kicker is that by the time people are really sick our expertise in stabilizing them is often times not going to make much a difference in the quality and quantity of their lives and will cost a lot a money.  Clinically effective care of the problems that arise in healthy adults, on the other hand, can make lives better, prevent disease, minimize suffering and, as evidenced by the case of my friend, reduce unneeded or harmful treatments, prevent prolonged suffering and save tons of money.

 

Taking care of healthy adults is an important part of medicine that is underemphasized.   Doctors lack expertise to do this even though it has the ability to reduce cost and improve lives.  Integrating expertise in this is an important part of medical care with major public health implications that should be emphasized.

The Dangers of A Widely Used Drug

Imagine that I invented a medicine for a common, widespread chronic medical problem.  I could mass produce and spread this imaginary pill to the entire American population as needed and the medicine was reasonably inexpensive and effective in the short term but it came with some major caveats.

The first caveat is that the medicine was only helpful and effective for short amounts of time.  In fact if this medicine is used for longer than a few weeks based on the body’s adaption to the medicine it loses its effectiveness outright.  This would lead to increased dosage requirements.

The Second caveat is that the medicine comes with a side effect of severely altering level of consciousness in users and also causes depression.  The medicine leads to powerful sedation and has been shown to ultimately hinder people’s ability to function normally or do things like work jobs, care for children, drive vehicles or operate machinery. 

The third caveat is that because the medicine causes a short lived sense of euphoria the medicine is highly addictive.   In fact this medicine is actually one of the most addictive substances known to exist and has been known to ruin millions of lives. 

A shocking fourth caveat is that in a substantial amount of patients who take this medicine continued use will actually make the underlying condition worse.  Many users from taking this pill will become “super” sensitized to the medical condition by this medicine and will experience horrible symptoms which require even more potent and massive doses of the medicine and it’s side effects.

A fifth caveat is that the medicine can powerfully alter human respiratory physiology and routinely cause death in cases of overdose.  In fact this imaginary medicine ends up being one of the leading causes of medically caused death worldwide. 

A sixth caveat is that if patients take the medicine for a few weeks and then stop abruptly they will go through a several week period of physically and psychologically painful withdrawal.  

Clearly I have invented a medicine that has a long and dangerous list of cons to accompany it’s usefulness in the short term. Further imagine that you are a patient being asked to take my medicine.  Would you do it?   What about if you were a policy maker for our government.  Would you allow this medicine to be widely used?  If you were a physician, would you routinely prescribe it?

The frightening reality is that my medicine and all these caveats is not at all an imaginary pill.  It is indeed terrifying that the above scenario actually describes the single most widely used classes of drugs in our country at present time.   The above “imaginary” medicine is opiate drugs.   And the millions of Americans who suffer from chronic non cancer pain and take high doses of these medicines are living with the above caveats whether they realize it or not.   

Opiate drugs are powerful pain medicines that have a well established role in the management of acute pain and trauma and in chronic cancer pain.  However studies show that the outcomes of using opiates for chronic non cancer pain are not as good. 

Despite their widespread use in this area many investigations have shown that these drugs do not have great long term efficacy.   For example one large meta-analysis ( a type of study that pools that results of several smaller studies together) showed that the use of opiods in patients with chronic back pain, compared to placebo or non-opiod analgesia, did not result in significant long term improvement in pain scores or functioning.  

The side effects and consequences are well established however.  People who take high dose opiates for long periods of time have lower functioning and more disability than others.  Because the body quickly adapts to opiates they gradually lose their therapeutic effect and require higher and higher doses to produce the same amount of pain control.   This phenomenon is known as tolerance.   With higher doses of opiates come more and more side effects, sedation and risks of addiction.

Another issue is that for reasons not entirely understood chronic high dose opiate use often makes the body much more sensitive to pain thereby ultimately worsening the underlying problem for which the drug was started. This leads to horrible discomfort and even sometimes can make normal sensations horribly painful a phenomenon known as allodynia.  Imagine taking a treatment for a medical condition that may help in the short term but ultimately could make the underlying problem much worse is the long term.   Who would make such a trade off?

Addiction remains a major problem for prescription opiods.  Recent epidemiologic studies have shown that overdose with prescription opiods is now more common than overdose with street heroin.   It is estimated that almost 5 million Americans engage in non medical use of prescription pain relievers each year.      Opiate dependence can happen rather quickly and Withdrawal symptoms occurs after only 1-2 weeks of daily use and can take several weeks to stop.  

Besides it’s negative impact on functioning and disability, another danger is that opiates are a powerful respiratory depressant and overdose of cause thousands and thousands of deaths every year.  

Opiates are an important and needed component of managing acute pain and cancer pain.    However on a population level opiates have grown from a way of alleviating pain and suffering in acute situations to a widely used panacea for all types of chronic discomfort, aches and pains.  Prescriptions of opiates have increased exponentially over the past few decades.   This happens in spite of medical evidence that these medicines may not be very effective for long term use and come with debilitating side effects, impairments to overall functioning, risks of overdose and addiction and the potential to actually make the underlying pain syndrome worse.

The imaginary drug I described painted a complicated scenario that happens in the real world routinely.  When we use opiates to manage chronic non cancer pain we are making a dangerous trade.   The benefit is short term comfort but the price is the above mentioned caveats and it is a large price to pay.  

To me the bottom line is that the cons of using opiates for widespread management of chronic non cancer pain out weight the pros.  Opiates may have a role in select cases of  severe chronic, refractory non cancer pain (especially in people who have little hope of functioning normally anyways) but the pervasive way that they are currently being used is a dangerous and ineffective way to treat a challenging medical problem. 

 Who could feel comfortable knowing that such a medicine is the most widely used drug in America right now?   

Widespread use of opiates has created nothing less than a public health emergency for our country.   Millions are dying or being harmed every year because of the short sighted way that opiates are presently being used in the management of chronic non cancer pain.   If a virus or bacteria came along that  killed as many people every year as misuse of opiates did it would be in every newspaper and television show and would be considered one of the sentinel events in the history of the human race. 

Misrepresentation of Mental Illness Is Major Problem for Mainstream Media

The headline on the Associated Press Business story published today in media outlets across the globe and undoubtedly read by millions reads "Schizophrenic Markets Shrug off Greek Deal."

The headline attempts to convey the volatile nature of the markets as described in the story.  Financial matters aside, this headline provides yet another example of the gross miscategorization of the mentally ill in popular media.  I cringe when I see words like "schizophrenia" or "bipolar" used in news stories about politics, finance or sports teams.  They do nothing but contribute to misunderstanding of mental disease and stigmatization of the mentally ill.

In clinical terms Schizophrenia is a poorly defined disease without any clearly identified causal pathophysiology or basis. The truth is that mental illness takes it roots in some murky combination of physical, mental, environmental and existential/ psycho-spiritual factors.    The disease schizophrenia in actuality can be given to any number of clinical syndromes and different clinicians will label different individuals with wide disparity of labels.

The nebulous nature of mental illness adds to the confusion in the mainstream about it.  The debate about what if anything exactly  is schizophrenia will rage on for decades, but as a matter of communication and convenience for medical billing the disease is  definined in the DSM-IV as a disease of disordered thought with both positive and negative symptoms.

Positive symptoms include hallucinations (almost always auditory), delusions, paranoia and negative symptoms are things like poor communication, blunted emotional affect, inabiltity to express pleasure and poor interpersonal relationships.  Not all schizophrenics have all these symptoms.  In fact every one is unique in how their disease manifests itself.

In the article Carol Pepper, CEO and founder of Pepper International, a money management firm in New York is quoted saying "The market is going to continue to feel very schizophrenic. Some days it’s depressed, some days it’s excited, some days it’s terrified"

Headlines and quotes like this miscategorize and oversimplify schizophrenia.   They make schizophrenia sound like a disease of raging lunacy, when in fact the diagnosis encompasses a broad range of functionality and symptomology.  Emotional lability can be seen in some schizophrenics, but it is hardly the hallmark of the disease.  In fact emotional apathy or bluntedness is a much more accurate depiction of its effects.

The sufferers of mental illness face tremendous adversity throughout life.  They live shorter, sicker, less happy and less functional lives.   They are stigmatized and misunderstood in a way that few others can understand early in life and this contributes to their suffering and illness.  The last thing they need is to be further ostracized from the rest of society.  The mainstream media should be more responsible about how they categorize mental illness in the headlines and quotations they publish.




Authors Challenge:  please feel free to post further examples of the misrepresentation of mental illness in the mainstream media of you come across them.  Here is the original link:   


http://bostonherald.com/business/general/view/20120312us_edge_higher_as_europe_nears_final_greece_deal/srvc=business&position=also

Medicine's Silent Threat

A silent, hidden threat continues to gain power in our nations medical apparatus. It is

threat which makes no sound, is completely invisible to the eye and stimulates no

senses. Yet it’s power to impact human health in a profound and powerful way is clear

and undisputed. The name of this threat is Ionizing Radiation.

There are several types of radiation found in nature, but ionizing radiation remains

notable for it’s ability to damage human genetic material and exert physiologic effects in

the body. In an era when medical imaging is routine and as accessible to this

generation of physicians as stethoscopes and reflex hammers were to previous ones,

the problem of medical radiation remains an unseen but deadly manifestation of modern

medicine.

The story is one which plays out thousands of times a day in every hospital, clinic and

emergency room in the developed world. A patient presents with a nebulous medical

complaint and the physician taking care for them must answer a critical question:

Should this person undergo medical imaging or not. This decision might not be so

vexing were it not for the long list of harms and benefits that accompany it. It is

estimated that ionizing radiation from medical imagining now accounts for half the

overall radiation exposure in the US each year.

While some medical imaging studies offer harmless non ionizing radiation (like MRI) or

small doses of harmful ionizing radiation (X-ray) among the most widely used imaging

studies is the CT scan which gives a massive dose of ionizing radiation. A single CT

scan provides more ionizing radiation than 200 Chest X-Rays. Despite the radiation exposure, CT scanning remains increasingly among popular among physicians with use of the CT scanner growing exponentially over the past several decades. It is estimated that use of CT scanning in the United States has tripled since 1993.

The effects of all this radiation on the population is far from miniscule. Studies

estimate that the lifetime radiation dose of a few CT scans (how many depends on

which part of the body is being scanned) is comparable amount of ionizing radiation to

being in Hiroshima on the day the atomic bomb went off. One particularly controversial

study estimated that 1.5-2% of all future cancers in the United States will be because of

medical radiation. Another study estimated that CT scanning increase any one

individuals risk of cancer by .35% and while this may not sound like much on a

population level that would translate into tens of thousands of cases of cancer per year.

In fact another study estimated 29000 cases of cancer caused by CT scans done in

2007 alone.

And yet The CAT scan has changed the way medicine is practiced. It was not long ago

when physicians had to rely on history and physical exam to make the diagnosis. CAT

scans gave physicians an accurate, objective way of seeing exactly what was

happening inside our patients that exceeded the power of our own senses.

.

Anyone who has ever practiced medicine understands that the idea behind any medical

intervention is that the therapeutic benefits of doing something that could cause harm

outweigh the risks. The same rules should apply to CT scanning. There are many

indications where the relatively small individual increased risk of cancer from giving a

CT scan is outweighed by the benefit of making a diagnosis, confirming suspicions and

governing treatment.

The problem is that the CT scanner is being used too much and it is contributing to a public

health crisis. Studies estimate that 30% percent of CT scans are not needed and I

believe that is an underestimate. All those unneeded scans are creating exposure to a harmful, but invisible, toxin. If a newly discovered environmental toxin in our food or water was noted to cause almost enough cases of cancer to fill a baseball stadium every year it would be all over our televisions, newspapers and webpages. Should we not hold modern medicine to the same standard?

A few months ago my 6 year old nephew George fell about 12 feet and landed on the ground head first at a family party on rock hard pavement. He was rushed to the emergency room and

even though he was conscious and appeared well he was given a CT scan. The reason

for this was that George’s mechanism of injury was deemed “high risk” and therefore

the CT scan was indicated. His scan was normal and all the adults left the Emergency

Room feeling better that day, reassured that Georgie did not have bleeding inside his

brain. Georgie and his family will have to live with the increased risk of cancer but

overwhelming odds are he will not get cancer from his CT scan.

But George’s situation was black and white. George needed the scan because his fall

was high risk and the good outweighed the bad. When the situations are black and

white decisions are easy to make. When situations are grey things gets tricky. What

if instead of falling from 12 feet he fell from only 4 feet? And what if instead of

absorbing the blow only in his head Georgie had a second injury on his arm indicating

that it had absorbed some of the force of the fall? Georgie would have been in a grey

area under those circumstances. Physicians today who find themselves in those “grey

areas” are relying on CAT scanning to help them figure things out. It

reassures physicians and patients but the costs are tremendous: we are creating tens of

thousands of cancer patients per year. This is the definition of a public health

emergency.

Studies have been done and there are clear evidence based rules that tell doctors when

to use CAT scans to image heads, necks, abdomen and chests. Physicians should be

conscious of the harms of CT scan and the price of getting definite answers and try to

stick to these rules in the context of their own judgement.

The risk is one physicians must take at times, but unnecessary CAT scans are causing disease and we all took an oath to do no harm. When physicians minimize patient harm and rely on evidence based rules to form the backbone of their decision making and help them decide when to use the CT scan then they will  be making decisions that benefit patients and truly doing no harm.

The Chest Cracker Diet and Why the Heart Disease and High Cholesterol Epidemic Makes Perfect Sense to Me

Heart disease is one of the leading killers of Americans and I can see why.

  

Much attention has been placed on prevention of cardiovascular disease in this country and on identifying and controlling risk factors for it. Among the many known cardiovascular risk factors cholesterol is important both for it’s powerful impact on the development of heart disease and in it’s capacity to be modified by medical and lifestyle interventions.   Based on the American diet the cholesterol and heart disease epidemic we are experiencing makes perfect sense.

 

 

About one million Americans die each year from heart disease.  A persons cholesterol level is important to the development of heart disease because of cholesterol's ability to strongly contribute to the process of developing plaques in blood vessels. The presence of these plaques increases the chance that someone will experience heart disease.  A major culprit in this process lies in something that is probably in the kitchen and on the plate every day of almost every person who is reading this: Meat.  

Scientists search for the solution to heart disease and high cholesterol in laboratories with pills and physicians crack open about 250,000 chests each year to try to fix the hearts of Americans who have developed severe heart disease. All the while the cholesterol epidemic rages on as currently it is estimated that over 50 million Americans have high cholesterol.

But the cholesterol epidemic we are experiencing now is no mystery and the most powerful solution is not pills or surgery. A close look at what and how most Americans eat reveals that the cholesterol epidemic is a logical consequence of our cultural beliefs around nutrition and especially eating meat.

 

 

The bottom line is that Americans eat far too much meat per year and it is literally killing us. Every year the typical American eats an artery clogging 260 lbs. of meat per year (that breaks down to about 12 ounces of meat per day) which is the world's highest rate. According to the United Nations that is about 1.5 times the industrial world average, three times the East Asian average, and 40 times the average in Bangladesh .

 

Meat is a problem because ALL meat is high in cholesterol, including white meats like chicken and turkey. I want to repeat that because it is a MAJOR misconception among most Americans: White meats like Chicken, turkey, pork and even fish are all loaded with artery clogging cholesterol and have a comparable amount of cholesterol to red meat. White meats usually (but not always) have less dietary fat and that is why they are considered healthier than red meats but it has nothing to do with cholesterol.

 

How meat contributes to our cholesterol problem is two fold. It is part of our culture to eat meat with every meal. Most Americans don’t feel like they are having a “real” meal if it doesn’t involve meat. Therefore most Americans eat meat several times a day with every meal. Secondly the typical American portion of meat is insanely large. Even a pro-meat nutritionist would advise only a 3.5 ounce portion of meat with a meal (about the size of a deck of cards), but the typical American portion of meat at home or in a restaurant in usually around 12 ounces per meal or 3-4 times what is recomended in a serving.

 

It is important to note that some cholesterol is an essential part of a healthy diet. The ADA advises most Americans to have between 200-300 mg of cholesterol per day to maintain normal bodily function. But the typical American diet dwarfs that amount.

 

Just do the math. A 3 ounce serving of any meat has around 70mg of cholesterol depending on the cut. If, as the U.N reported, the average American person eats 12 ounces of meat per day than that person will have nearly met their daily requirement for cholesterol just from meat alone in a typical day. Now add on all the other cholesterol from other non meat foods comprising a full diet of 3 or 4 meals and 3 snacks each and every day over the course of decades of life and it is quite logical why over 50 million Americans have high cholesterol and our nation is suffering a cholesterol epidemic.

 

Doctors have good medicines that can help combat high cholesterol, but this is like using a band aid to cover a major wound. The real problem is in the dietary traditions of Americans. Americans choose to eat too much too often and that is why we struggle to control cholesterol levels.   American need to change the way they think about food.    

The typical American meat heavy diet should be called “The Chest Cracker’s Diet” because it leads to hundreds of thousands of chests getting cracked open every year among unfortunate, genetically predisposed individuals who develop severe heart disease. Meat eating is often categorized as being manly in the popular media but trust me there is nothing strong or masculine about heart disease or Coronary Artery Bypass Grafting.  Occasionally eating meat is probably alright (I would say one small 4 ounce portion every2-3 days) but as long as Americans insist on following the myth that massive slabs of any kind of meat must be a part of every meal than we will continue to suffer from a cholesterol epidemic and experience alarming death rates from premature heart disease.

Is It Right For Physicians To Take A Parental Role With Patients?

A pair of recent studies looked at different modalities for following patients on weight loss programs. One study compared patients who received  in person follow up from primary care providers versus those who received telephone and web based follow up to those who got nothing at all.  Patients in either follow up group experienced twice as much weight loss after one year than those who had no follow up at all (there was no difference between either follow up intervention).  The other study looked at the effectiveness of in-person “life coaching” on weight loss results and also found it to be significant. 

While the impact of this in terms of weight loss indeed could be huge I also believe this study raises an interesting question about doctor patient relationships and boundaries that is worth exploring.

The overall message of the studies was that patients in both groups who had any kind of follow up with their primary care providers (be it in person, on the phone or web based) experienced better results in losing and maintaining weight than those who did not.  With 2/3’s of Americans overweight or obese, any intervention that can help patients maintain weight loss has the ability to improve millions of lives and should therefore be utilized. The authors hailed the study as a breakthrough in helping patients battle obesity.

“It could be considered something of a breakthrough in weight loss,” said Dr. Frank Sacks, a professor of Cardiovascular Epidemiology at the Harvard School of Public Health who participated in the second study.

While this intervention may be effective in the laboratory the question remains about how this impacts doctor patient relationships in the clinic and if this impact is ethical or fair?  If adult patients are reporting their weight loss to physicians does this not place the physician in a paternalistic or parental role to the patient and if so is it appropriate for doctors to take advantage of this role in clinical practice?   

The hidden dynamic among all human relationships, and especially those between doctors and patients, is a phenomenon called transference.  Transference is the process whereby one individuals unconscious emotional perceptions influences their participation and behavior in a relationship.  The perceptions are usually very powerfully influenced by early childhood influences.

For example a person who had a poor relationship with little verbal communication with a male caretaker early in life may have a difficult time communicating with other male authority figures later in adulthood.  

Transference is classically thought of as a part of psychiatry and psychotherapy, but all doctor patient relationships (and all human relationships) are deeply influenced by the unconscious subjective perceptions of the participants. 

In my coursework with the New England Society of Clinical Hypnosis I will never forget the words of the brilliant hypnotist  and former NESCH president Dr. Max Shapiro who surprised me in a seminar many years ago when he said: “If a patient comes to you with a deific or mystical transference  about hypnosis don’t be afraid to use that in your work with them.”  

Shapiro felt that using the patients unconscious feelings of awe or mysticism around hypnosis (which is often held in such mystical esteem) to their  advantage could be a useful intervention towards reducing symptoms and improving their lives.  Could the same be argued in this situation regarding a patients parental transference to the physician? 

The doctor patient relationship already intrinsically has a parent child tinge to it by it’s inherent nature.  Consider the things that physicians typically provide to patients.  Empathy.  Nurturing.  Moral, emotional and physical guidance.  The very essence of the relationship evokes a parent-child dynamic between the doctor and provider that is unavoidable.

When patients report their progress in weight loss to the doctors does this not place the physician even more in a parental role with the patient?   The physician becomes the source of praise and approval or of disappointment and disapproval like a parent around a critical issue in the patient’s life.  This takes advantage of the parental transference-countertransference between the doctor and the patient and may produce results but is it appropriate?.  Consider that patients with serious behavioral health problems often lack psychological maturity in some way.

There are no right or wrong answers to this question but it is worth thinking about: Should physicians be placing themselves in a position where they can take advantage of the parental transference countertransference dynamic that exists between them and their patients?    It could produce results but is it ethical and fair to adult patients who ultimately would be best served by empowering themselves to ensure their own wellness without reliance on a professional’s praise or approval?  Could taking on a parental role with a patient eventually provoke feelings of rebellion and disobedience (often a part of parent-child relationships) that may undermine the purpose of the intervention eventually?   Should doctors dare to take advantage of this mechanism in patients who lack psychological maturity?

It is likely that right or wrong these interventions will become more widely used because of the results they showed in these studies but I believe these are important questions to ask.  

A Fundamental Flaw In Modern Psychiatry?

There is no question that as modern psychiatry has evolved it has become a powerful force in the United States.

The field underwent a major shift in paradigm the past 30 years.  Psychiatrists used to work mainly with behavioral modalities like different kinds of therapy to encourage self exploration and change, but modern psychiatry has focused on the use of powerful psychoactive drugs to alter behavior.  Psychiatrists previously spent hours in therapy with their patients but today most psychiatrists get less training in therapy in residency and in clinical practice usually only do 15 minute medication visits with patients.  In these visits they prescribe powerful medicines and inquire about side effects from drugs and leave the therapy to psychologists and social workers.  

Psychiatrists have left the therapy couch behind and transitioned mostly to drug based therapies based on the idea of biological psychiatry.  This is the basic concept that a "chemical imbalance in the brain" can be treated with a "precisely tailored" medicine.  While this concept sounds great in advertisements and commercials a closer look shows that the science is behind these "chemical imbalances" is not well defined and the drugs used are hardly precise and often have bad side effects.

The true causes of psychiatric illness goes beyond a simplified chemical imbalance and remains a nebulous combination of psychological, environmental and biological factors that probably varies tremendously among individuals.   The danger is that in actual clinical practice the treatment option most individuals get now from doctors is a drug that alters brain chemistry in a very imprecise way, but mental problems happen on many different levels.

These underlying chemical imbalances may not be well defined in mental illness, but psychiatric drugs have a place in medicine and if a doctor prescribes one a patient should NEVER stop taking it until they have an in depth conversation with the prescriber.   

As this paradigm shift has happened physicians are confronted with the danger of not considering the depth and complexity of most behavioral problems for the individual.  Advertisements and commercials make these drugs sound simple and many doctors place patients on these drugs without much thought, but be advised: Psychiatric drugs are complicated and have serious pros and cons that must be carefully considered.  The decision to start one should never be taken lightly or glanced over.

There is no doubt that part of mental illness is biology.  There are clearly functional, physiological and anatomical changes in the biology of the brain that are associated with different acute and chronic mental and emotional states.  Yet there is murky evidence that any of the biological mechanisms altered by psychoactive drugs actually cause  the "diseases" these drugs treat.  Altering these mechanisms may help change symptoms much like tylenol helps a back ache but that doesn't mean deficiency or disorder in these areas cause clinical disease.  After all, no one would argue that a lack of Tylenol causes backache. 

As Modern Psychiatry has become overly reliant and focused on drug therapy it has lost sight of the human side of behavior. It has stopped seeing the "forest for the trees" and forgotten that every illness occurs in the context of social, cultural, behavioral and psycho-spiritual factors, not simply biology.    Medicine and Psychiatry often try to drug people to meet our arbitrary cultural standards of normal and abnormal (and disease and health), when often the emotional and behavioral states of individuals are natural to that individual, appropriate based on circumstances and have potential for positive change through non-pharmacologial, human centered modalities.   

In a perfect world much thought would be given to the decision to start high functioning adults on any psychoactive medicine.  These drugs would not be routinely handed out with minimal consideration of the whole person's body, mind and spirit.   And the paradigms that doctors use to view behavioral problems would address the existential roots of human problems.


 Over the next few weeks we will present a series of topics in modern psychiatry where we look specifically at the pro and cons of drugs, investigate the science behind behavior and hopefully provide useful information to help people understand modern psychiatry better. The first topic is going to be on antidepressant use so stay tuned!