evidence-based medicine II – my conflict of interest

Posted on Saturday 29 January 2011

Who would want to argue with the concept of evidence-based medicine? What would one be arguing for? non-evidence based medicine? And if the concept were only a way to remind we physicians of our bond with science and the scientific method as opposed to unproven and unprovable treatments found in other "healing arts" there would be nothing to argue about. In my case, besides being a Psychiatrist, I am also a Psychoanalyst and have heard endlessly that our observations and theories are based on single cases and are not amenable to scientific proof. My discussion of evidence-based medicine here has nothing directly to do with my psychoanalytic credentials. It’s actually the other way around – my psychoanalytic credentials have to do with my thoughts about this topic. So I’ll put that part first [if you know me, you’ll already know this story so skip the next post]. Consider this post a self-revelatory introductory statement vis-à-vis my right to weigh in on evidence-based medicine

I was a mathematician without a cause and went to medical school looking for a way to apply that part of my mind to something practical. It was a good fit, and some years later, I was an Internist with a specialty in Rheumatology. I had done a two year NIH Fellowship in Immunology and was looking around for a post-doctoral fellowship, when I got drafted into the Air Force [a surprise]. So, I found myself spending a relaxing three years living in Europe practicing Internal Medicine with a relatively healthy population. I liked it a lot [again, a surprise], and when I thought about why – it was the people and their stories. The majority of people I saw didn’t have much in the way of medical illness. Their problems were in their lives and the way they approached living, often manifested as physical complaints. That was easy to see, but I had only occasional glimpses of how to help them. So, the end of that story was a dramatic change of direction and off to retrain in Psychiatry. It was the psychotherapy that interested me, and that lead to the further training in Psychoanalysis. But I am a card-carrying Psychiatrist who stayed on the faculty full time for ten years directing the Residency Training Program in Psychiatry,  and I have spent more than my share of time dealing with the severely mentally ill. In my later years, I practiced as a psychodynamically-oriented Psychiatrist and almost all my cases were psychotherapy patients [with a minority in "analysis"].

As an internist, what evidence-based medicine means is easy to talk about. For example, I saw lots of people with high blood pressure. It’s one of those things you don’t "feel" most of the time. And like my colleagues, I treated it with medication that often had annoying side effects. That was based on studies that showed that untreated high blood pressure caused problems down the line – evidence-based medicine. When I saw a new patient who was ill, like my colleagues, I collected the signs and symptoms, the laboratory work, the XRays, the EKG, all in order to make the most precise diagnosis possible and I planned treatment based on the best course available from evidence-based medicine. You wouldn’t want me treating your disease shooting from the hip. You’d want me to make sure that your treatment was tried and true, safe, proven, and current. And that’s what I did.

In Psychiatry, it was different. We have conditions that fit the evidence-based medical model fairly well. They are mostly people who are brought to see us rather than just walk in the door. People with Dementia, Schizophrenia, Mania, Depressions, Addictions, Withdrawal States, etc. They have signs and symptoms like medical patients. Although in many cases [Schizophrenia, Mania, Depressive States] we don’t know the cause, we still act like doctors following a protocol of treatment that is reasonably standard. Then there are other people who come with fairly clearly defined syndromes – OCD, Anxiety States, etc. where the evidence-based model kind of works – in other words, we can somewhat use the experience from similar cases to plan treatment, at least early on. And then there are a large number of people who come because of a variety of symptoms or problems in living, and the  strict evidence-based model goes out the window because they’re ‘one of a kind.’ Those were the cases I spent my career with. And they weren’t the least ill either – many were quite ill and in a lot of distress, tortured.

In my mind, they required another kind of evidence-based medicine. In those cases where the tangles were embedded in their own specific lives, the experience from other cases or clinical trials wasn’t very helpful – the illnesses were unique. To me, this was the most evidence-based medicine of all, but the evidence came from their individual experience, not from anyone else’s story. So the guy who would bolt from the relationships he craved had to learn that it had to do with his mother’s subtle controlling way of dealing with her son. At the outset, neither of us knew that. We had to figure it out together based on the evidence from his life and in his relationships, including his relationship with me. That’s a simplistic example, but makes the point. What’s a mathematician/Immunologist doing in that world? To me it’s just clear as a bell. It’s the same part of my mind that studied differential equations and topology – figuring out things. The proof was in the pudding. If he could see the connection and begin to knowingly feel it working in his mind, he could understand why he fled relationships based on mis-perceptions and stop running [which he did]. It felt as much a part of the scientific method as treating Peptic Ulcer Disease to me. I enjoyed it because it was more complex, always something different, just like I enjoy a carefully crafted Mystery Story or good programs on the History or Discovery Channels about things I know nothing about.

The reason that I went into my personal take on evidence-based medicine is because the wave that went through Psychiatry starting in the 1980’s carrying the banner of EVIDENCE-BASED MEDICINE specifically targeted people like me [psychoanalysts, psychodynamic psychiatrists, and a number of others among us] as unscientific [in public], and charlatans [in private]. They had some legitimate complaints. Psychoanalysis did predominate in American Psychiatry beyond its years and offered more than it could deliver.

So my personal take on what constitutes science and evidence is different from those who carry the EVIDENCE-BASED MEDICINE banner these days in Psychiatry. I’m fine with studies where n=1, but that’s my personal take on things, not everyone’s. In the next several posts, I intend to mount several arguments against their use of the term that are not from my biography or my extra discipline, but I thought in the spirit of modern transparency, I should start with my own biases. There are plenty of Psychiatrists who aren’t Psychoanalysts who, I expect, feel the same way. There’s nothing particularly psychoanalytic about my example. There are many roads that would lead one to success with that case. And he was pretty depressed when he showed up. I doubt that an SSRI or an Atypical Antipsychotic would’ve helped, but I don’t know for sure because we didn’t try them…
    January 29, 2011 | 10:18 AM

    Mickey, thanks for such a lucid explanation that helps me understand my very similar reactions to yours — i.e., that “evidence-based” means something different for the kind of patients that we analytic-oriented therapists generally work with. The “evidence” is how the therapeutic experience and the insight change that individual’s life.

    I’m afraid that I lost all patience with the direction of Psychiatry and opted out in favor of my psychoanalyst identity. I came to the point of not reading articles that had statistics in them and hardly ever prescribing medications.

    It narrowed the field to the kind of patients I like to work with, but it also was a cop-out — and maybe too many of us abandoned psychiatry to the number-crunchers and thereby contributed to their take-over of the field.

    Thanks for your broader perspective.

    January 29, 2011 | 4:51 PM

    I am neither a psychiatrist nor particularly psychoanalytic in orientation (I’m a masters level clinician in a humanistic psychotherapeutic tradition) but I am right there with you, brother. I come from a background in computer programming; I have gone from debugging computers and networks to minds and social systems. The deductive process is the same, and it’s astonishing to me that a process that in programming is considered the height of logical rigor is decried as unscientific when applied to human problems. There’s a double standard here, and it seems clear to me it’s based on a neurotic need to keep the self in the Shadow (OK maybe just a little bit psychodynamic), to maintain that the self (one’s own or others’) cannot be known. Approaches to mind-changing which are aggregate and statistical is premise aren’t as threatening as approaches which insist that self-inspection is not only possible but profitable.

    January 30, 2011 | 3:11 PM

    The other big difference is that, when you deal with a statistically derived algorhythm to decide how to treat someone, you don’t have to get “involved” with that person. It can remain superficial, impersonal and arms length.

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