evidence-based medicine IV: the symptoms sermon…

Posted on Sunday 30 January 2011

Somewhere along the way in medical training, I realized that I was being taught a coherent system that had evolved over centuries, and was awed by its clarity. When I saw a patient, I was to use a time honored algorithm to approach the problem of their complaints. I was to gather a complete narrative  [Present Illness] of the Chief Complaint, then check out the Past Medical History and do a Review of Systems to assess their overall health and body functioning, followed by a thorough Physical Examination. While going through this procedure and/or shortly thereafter, I was to sort the database of medical conditions for Signs and Symptoms and create a list of the conditions that fit this patient – called the Differential Diagnosis. I then resorted that database for things [tests, consultations, etc.] that would help me narrow that list as far as possible in order to arrive at a Diagnosis. Having hopefully arrived at the right place, another sorting – this time looking for Etiology, what was the underlying cause of this Disease [or diseases], and what was the Treatment for the cause [if it could be treated]. Symptomatic Treatment came after, never before, I knew what I was treating – or was close enough to be sure that treating symptoms wouldn’t get in the way of finding the cause. That’s a real Algorithm – an almost holy algorithm. It’s an indelible part of my mind and I’m grateful to have been taught it so thoroughly. There are many variations on the theme [in an emergency, do a focused version very fast], but the principle is invariant. As a medical student, I wondered why old experienced doctors seemed to skip a lot of what they made us go through so obsessively. Then I got to be an old experienced doctor and realized that they were only asking the things they didn’t already know intuitively [from having done it a blue jillion times].

When I came into Psychiatry, I was personally drawn to something else [see evidence-based medicine II - my conflict of interest]. I wasn’t drawn to Schizophrenia, or Manic-Depressive Illness, or Psychopharmacology. As a practicing Internist after my training, I realized that most of the patients I saw were referred because some other doctor thought they might have a physical illness of note, but in most, their problem was elsewhere – in their mind or their life situation. I actually kept score for a year [something like 70% mind or life, 20% physical disorders I could treat, 10% physical disorders I couldn't treat]. That [and a million other things] sent me down an alternative path. But that holy Algorithm up there has never gone away. For one thing, there are just too many medical conditions that look psychiatric. A supervisor once said it quite well. He said that we have a hierarchy of roles that come in order on importance – person, doctor, psychiatrist, psychotherapist, psychoanalyst. "Never skip a step," he said.

Even though many of our Mental Illnesses are of unknown etiology, I still think with my Internist/Doctor mind. So the idea that what one would focus on in classifying and treating disease would be symptoms seems inherently "non-medical" to me rather than the opposite. And I’m not referring to my psychoanalytic identity right now [psychoanalysis or psychodynamic psychotherapy being very causal medical models]. I’m talking about Psychiatry proper. When I see a Schizophrenic person, I really don’t see myself treating symptoms. To me, it feels more like treating something like Lupus when I was a Rheumatologist. Lupus is a disease of unknown etiology that can be devastating, not always, but plenty often enough. Treating the usual presenting symptoms is kind of easy, but the patient has a whole life left to live, and so there are many things to think about – things to avoid, medications not to take, the dangers of the medications that are taken, the consequences of being untreated, the consequences of being treated, further problems down the road, things to be monitored along the way. Most of Internal Medicine was that way – long term management of treatable but not curable afflictions. Symptoms are just one field in a very large database and just because the entry in the field under etiology is "unknown" doesn’t mean that "treatment" equals "symptomatic treatment."

There is always a conflict between Physicians and their Patients. What patients want is:
  • To be taken seriously
  • Symptom relief
  • For their symptoms do not mean that there’s something bad wrong inside
What doctors do when they’re doing it right is to probe to find those bad things inside. What patient wants the doctor to find them? But they let us look, hoping it’ll come up blank. An example of the conflict: Once years ago, after days of fear and procrastination, I went to my old wizened Dermatologist, whom I had known because he referred me patients [the patients he referred never had what he thought they had, but 100% of the time had a really good reason to see a Psychiatrist]. He looked at the thing I’d found on my leg and said, "You think you Psychiatrists are the only people who can treat anxiety. Watch this!" He then said, "It ain’t cancer." I took his point.

As I’ve mentioned endlessly, I came into Psychiatry to learn about all those patients I saw as an Internist with mind and life problems. Back then, I gave the symptomatic remedies out the gazooh, at least the ones available  at the time. I even ordered a book that was some late 60′s version of Schatzberg and Nemeroff’s Recognition and Treatment of Psychiatric Disorders: A Psychopharmacology Handbook for Primary Care. It wasn’t enough for either me or my patients, so I went on a hegira that I found very rewarding. I’m not sure our symptomatic therapies have come as far as many of my colleagues seem to think since I first arrived. If I thought that a symptom list keyed to medications was the solution, I’d have never left Internal Medicine in the first place. It was a lot of fun.

I am aware that this post is a sermon – an opinionated sermon from an n=1. I’m old now, and am allowed to preach if I want to. I think I know science when I see it, and Psychiatry seems off course. I’m not preaching the gospel of a psychoanalytic orientation. I’m looking for a balanced approach to mental illness that sounds more like the science of practicing medicine [and I'll admit that some of the psychopharmacology talk and the commercials on t.v. remind me of a scene from the movie, Pulp Fiction]…

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