Sunday, September 09, 2007

Are You My Patient?






I'm actually blogging (or starting to blog) from our hotel room at the beach, waiting for the kid to wake up so we can check out and catch some final rays and junk food.
It's our traditional weekend-after-Labor-Day away with the Camel Family, a final sweet kiss goodbye to summer. With many thanks to ClinkShrink for moving in with Max and the teenager who couldn't miss practice.

So Fa
t Doctor has up a great (aren't they all?) post about patients who check in to the hospital with abdominal pain and then refuse either the work up or the necessary intervention. There's the guy with acute appendicitis who won't allow surgery ....and if that hot appendix ruptures, the mortality rates are quite high, even I remember that. I read it and wondered, just like Fat Doctor, if you don't want treatment, why go to a hospital? Okay, okay, I'm being harsh, maybe AppyGuy is only refusing surgery and had hoped there was another option for treatment-- maybe he's taking antibiotics and this will help and maybe he won't rupture and will get better. But to refuse a non-invasive work-up? Or to die rather than have a routine procedure?

So here's another good thing about being a psychiatrist: patients rarely die (and even more rarely from their psychiatric disorders) and we Never send patients out thinking there's is the Probability they will die from their psychiatric symptoms. I'm not saying we always get it right...sometimes patients hide their symptoms, sometimes they talk about being suicidal so often that we lose the ability to distinguish when it becomes imminent, but if we think the patient is in danger from their symptoms, we hospitalize them, either voluntarily or involuntarily.

I work in a private practice and in two clinics; I haven't set foot in an Emergency Room for years. It's been a really long time since I've hospitalized anyone involuntarily and I'm happy about this. While in psychiatry, there are moments when it's absolutely necessary, for the most part, I don't like making decisions for other people.

In outpatient practice, people often have very strong opinions about what kind of treatment they want when they walk through the door. It's not uncommon for me to tell people on the phone before I see them that I don't provide the treatment they're looking for and they'd be better served by someone else (--there are lots of psychiatrists in Baltimore, if someone is looking for a doc to prescribe high-dose Xanax, I'm just not it). Other people are pretty set on what kind of treatment they don't want.

Mostly, I try to work with people, I try to give them what they want or help them understand why what they want isn't the right thing to want. So Prozac helped your friend and you'd like to try that? I might think Lexapro is a better choice, and I'll tell them why, and if they still want Prozac, well, perhaps I let that choice be theirs. So Prozac helped your friend and you'd like to try that? Oh, but you have Bipolar Disorder, something totally different than your friend has, and Prozac may well destabilize you, throw you into a dangerous manic episode, shorten your cycle length, and worsen your overall prognosis: I think we should try a mood stabilizer first and only after that's on board should we even think about adding Prozac or any other antidepressant. You get the idea. And yes, I'll tell you why I asked what your favorite SSRI is soon, but in the meantime, if you haven't voted on our sidebar poll, please do.

Sometimes a patient tells me they won't take Drug X. Ever. And if I think Drug X offers the best chance of relief or recovery, I persist in telling them this. My kids can assure you that I'm very good at repeating myself to the point of nagging. Mostly, I convince people to at least try what I think might work best, but I have never, ever, said to a patient, "If you won't take Drug X, I won't treat you." That's just not what this is about.

Thinking about the Fat Doctor dilemma, there is a psychiatric correlate. Mostly I'm either able to talk patients into trying it my way, or I'm able to achieve some level of comfort while they do it their way. Every now and then I have a patient who is really suffering (or is behaving in a way that causes others to suffer) and who repeatedly foils any shot at recovery. They're miserable, and yet they refuse any treatment suggestions--either they argue with every suggestion I make, or they simply don't do it. The don't get blood levels, they won't try another medication, they won't raise the dose of the old medication or even take the old medication that worked for them the last 14 times, they won't try any behavioral changes (regular sleep hours, exercise, stop the substances, give up the boyfriend who beats you), they won't allow me to communicate with crucial significant others in their lives, they call all the shots, leave me standing there feeling helpless. And before you click on the comment button to tell us about the one or two times you didn't do what your doc suggested, that's not what I'm talking about-- I'm talking about the person who comes, pays, says they want help, but doesn't follow ANY recommendations. I'm sometimes left to point out this dynamic and say "Are you my patient?"