evidence-based medicine [the final installment]: some memories…

Posted on Thursday 3 February 2011

A Memory: My first faculty job after Residency involved running the CIS [Crisis Intervention Service]. That’s what we called the Psychiatric Emergency Room at Grady Hospital in Atlanta. It was the mid 1970s, when the Community Mental Health Movement was running out of juice [and money], but still the paradigm du jour. I was asked to give a few lectures about Community Mental Health to the First Year Residents, so I went to the Library [the musty kind we had before the Internet], and read and read. I read about how the idea of Crisis Intervention arose out of the military’s experience in World War II. And I read about Kennedy’s Mental Health Act and the liberation of mental patients into a system of Mental Health Centers that would maintain them in the Community [What I didn’t read about was Nixon’s defunding of the whole system or about its demise, because that hadn’t been written quite yet]. As I was collating the information for my coming [way over-prepared] lectures, it occurred to me that there was something missing – Thorazine. The thing that closed our gigantic Mental Hospitals was the discovery of Thorazine, not the lofty rhetoric of the Community Mental Health Movement. I added that into the lecture at the end. I moved on to become Residency Training Director after a year, but the fate of the Chronically Mentally Ill stayed on the front burner of my mind.

It was obvious that the resources were evaporating in front of our eyes, and that we were approaching the point where we didn’t have enough hospital beds to treat our client load. So I did a study in my spare time – kind of a hobby. At times when the hospital was not full [so discharge was predicated on the condition of the patient and scheduled aftercare] there were two distinct populations. A fast group who were admitted, rapidly stabilized, and returned to their lives. There was a second slower group, patients with more chronic psychosis who took a while to get in shape to live in the world. I could show these populations mathematically, with p values that were impressive [<0.001]. For periods when the hospital was full, there was only one population – the fast track [p<0.001]. That fit what the Residents said. When the hospital was full, discharge was forced to make room for the throng.

So, I was on a roll. I could show that the racidivism rate for patients discharged during the "full hospital" times was much higher than those discharged in the "available beds" times [p<0.001]. I even got fancy and showed that the nurse/doctor resignations were almost exclusively during the full hospital times. I didn’t work in or for this State Hospital, though that was where our departmental offices were. When I proudly showed my results to the Hospital Superintendent, he politely told me that I hadn’t gotten permission and research could only be done by bona fide State Hospital staff. The guy saying that was something of a friend and I balked. He said something like "We can’t ‘prove’ that the things we’re doing because we have no control over the State Legislature are wrong. You want me to lose my job?" [So ended my career as a Community Mental Health Research guru].

Another Memory: After I resigned from the Psychiatry Department, I stayed on for a year while I figured out what to do with myself. I  had tenure, so that was my prerogative. I say resigned, but I would surely have been asked to leave had I not, though I didn’t quite know that at the time. It was fine. I didn’t fit, nor wanted to fit, with the changes. But that didn’t mean I was at war with our new Chairman. We were very different, but we still talked. I liked him. I think he liked me but saw me as dangerous or something like that. I taught the Medical School Course for a year until he found a replacement for the former Director who also didn’t fit [they were at war].

One day, the Chairman and I were talking, and I said [provocatively] that I saw Psychiatry as the medical specialty that dealt with what was ambiguous in medicine. My example was Brain Syphilis. Those patients Kraeplin studied back in the end of the nineteenth century [Schizophrenia and Manic Depressive Illness] were way in the minority in Mental Hospitals. The main population were people with Tertiary Syphilis. When treatment became available for Syphilis, they disappeared [I’ve seen only one such case in my lifetime]. I claimed that as soon as any mental illness came along that was genuinely treatable, it would disappear from the Psychiatric domain. I was going to go on to say that the antipsychotics were not close to a cure for Schizophrenia, so that illness was with us still [that was actually my point in the first place].

Well he got really nervous, said some things about what was going to later become the evidence-based medicine mệme, and he gave me a book about it that he was sure I would enjoy, then excused himself from the conversation to deal with other matters.

Yet another Memory: After being waved off by the Hospital Superintendent [first memory], I talked to a guy who was occupying the position of Vice Chairman in the Department. He’d been in State Government in Mental Health and either left or was removed, so he was hanging around looking for his next big move – later to be a Chairman then Dean at a smaller school. I [naively] told him about my hobby study. Before I could finish, he tightened up and said, "There’s never been any evidence that long term hospitalization helps Schizophrenia!"

Now I wasn’t saying that long term hospitalization helps Schizophrenia. I didn’t think it did then. I still don’t. I was in the "deinstitutionalization" set too. What I was saying was that if we let the Staff who were good at stabilizing the chronically ill and assuring their community "placement" do their jobs by providing them adequate time and space, things would go a lot better and reduce racidivism. But he froze up like a snowman [with a red face] and kept saying, "There’s never been any evidence that long term hospitalization helps Schizophrenia!" It was a similar contentious encounter later with him that lead to my actual resignation.

Recalling those encounters, I think I come off as being a perverse figure, misanthropic. I don’t recall being that way at the time. But I think I was extremely naive. I knew that my psychoanalytic-ness was a problem, but none of these things above had to do with that credential. They had to do with my perception about what was happening in response to the introduction of antipsychotic medications. I had even created a computer model and gone to some trouble to gather real numbers to plug into it. It took the rate of new patients with Schizophrenia, the relapse rates of Chronic Schizophrenics in the best Mental Health Center we had, and the length of stay curves when the hospital wasn’t stressed, and computed the number of hospital beds that would be required to manage the patients. It was a least-case scenario. We’d already fallen below that number and were still on the way down. I was afraid the patients would be homeless, dead, or in a prison setting [that’s exactly what did happen to a lot of them].

It wasn’t until I started thinking back on those days writing this series that it occurred to me that it wasn’t the fact that I was a candidate in the Psychoanalytic Institute that made me such a pariah all of a sudden. It didn’t help, but it wasn’t the center of it. It was two other things. I was not going to compromise on the outpatient placements of the residents where we taught psychotherapy. But I think the biggest was this hobby study of mine about keeping the hospital beds for the treatment of the chronically ill at a level that would support the Community Mental Health Movement [that I thought we all agreed with]. Ironically, after I left, those outpatient placements survived [the residents  and other faculty insisted]. That Mental Hospital, however, is now a field of weeds and debris where homeless people often sleep – paradoxically, the place that used to care for them.

All of this happened in the early days of the evidence-based medicine movement that I’ve been talking about. I realize that I was naive and only looking at one side of things. The people above me were looking at the fact that it was the Reagan years and the plight of the mentally ill was way on the back burner – some liberal bleeding heart issue. The Fed and the States had gotten over taking care of the chronically afflicted. Likewise, the antipsychotic medication really did change treatment in a substantial way. But the denial about the downside and the limitations of the miracle medications was widespread and set in stone. The medicine worked. It just had to work. So things were just not close to as rosy as the managers of the purse strings had wished. The promise of better medications for Mental Illness was alluring, but any fool could see that they were throwing out the babies with the bath water in hopes of something that just wasn’t going to happen [I guess I was just any fool].

I never saw the intrusion of the Pharmaceutical Industry coming back in those days. That part was a surprise. I saw the folly of the "key opinion leaders" [particularly you know who] but never grasped the extent to which they overwhelmed American Psychiatry. And all of the Speakers Bureaus, the Continuing Medical Education advertising, the "ghostwriting," the Chairmen of Psychiatry Departments founding Pharmaceutical Companies, the rampant Conflicts of Interest – I was oblivious. I guess I’d used up all my crusader juices and limped to the privacy of "private" practice [and the ivied halls of the Psychoanalytic Institute]. All of those unexpected developments were things I couldn’t have done anything about, but I do wish I had become involved in speaking out about the weaknesses of the DSM III/DSM IV criteria and their non-evolution instead of ignoring them. That would have been at least one area where a lot of single voices might have made a difference. But, to be honest, this may just be the way change happens. Things have to bottom out before people take notice. I’ll end with that. Things have really bottomed out. It’s time to change…
  1.  
    Carl
    February 3, 2011 | 11:04 PM
     

    A masterpiece. I bet the New Yorker would run the whole series!

  2.  
    Peggi
    February 4, 2011 | 12:08 PM
     

    I agree with Carl; I think your series needs broader distribution. It is certainly time for change. I love the part about using up all your crusader juices and limping over to private practice. Those of us who attempt to be dragonslayers often end up limping off somewhere.

  3.  
    February 4, 2011 | 2:59 PM
     

    An excellent group of posts!

    My big objection is that what passes for “evidence-based medicine” in much of psychiatry, and much of all of medicine is a cruel parody of what the people who originally came up with EBM meant.

    The quick summary of EBM I use in introductions to talks (during the rare times I am invited to give such talks) is:
    – Medicine based on the systematic search for and systematic, critical review of the best available evidence
    – The integration of best research evidence with clinical expertise and patient values
    – The underlying goal is to maximize the likelihood of benefit and minimize the likelihood of harm for each patient, according to the patient’s values

    Although most of us (true) EBM advocates do believe that all things being equal, a randomized trial is more likely to be valid than an observational research design, we do not worship RCTs, do not believe all or even most RCTs are valid and generalizable, and do not dismiss evidence from various kinds of observation.

    Furthermore, we believe in rigorous, unbiased critical review of all clinical research, including RCTs. Most of the RCTs that commercial vested interests sponsor, run and tout are badly flawed, probably deliberately in order to increase the likelihood that the results will favor the sponsors. If these trials are reported (a big if), and reported honestly (another big if), critical review, a la the old “Users Guides” series, will generally reveal their major flaws. The most important and common one is failure to assess important outcomes, both good and bad that matter to the patient. So a typical study that looks for a small improvement on a cobbled together symptom index might leave out any assessment of the symptoms that matter the most to most patients, symptoms that might reflect adverse effects of the treatment, overall functional status/ well-being/ etc, etc, etc.

    (The relevant Users’ Guides questions are:
    Were all clinically relevant outcomes considered?
    Are the benefits worth the harms and costs?)

    However, what is often touted as “EBM” is really pseudo-evidence based medicine, a melange of manipulated, biased studies done to serve vested interests, while studies that provide inconvenient results are suppressed, hawked by conflicted “key opinion leaders,” compounded by other KOLs into “evidence-based” guidelines that are also meant or promote commercial interests, then promoted by various kinds of stealth marketing, including marketing disguised as various kinds of medical education, etc, etc.

    I still believe in the sort of EBM that Sackett et al pushed for in the 1970s and 1980s. But there is precious little of the true EBM around now, while we drown in pseudo-evidence based medicine.

  4.  
    February 4, 2011 | 4:42 PM
     

    Dr. Poses,

    Thanks for your comment. I’m a fan of Healthcare Renewal, and considered using your term “pseudo-evidence-based medicine,” but decided that they have so perverted the concept that I’d stick with the one they’ve co-opted. At its core, it’s a good term – but they’ve corrupted it to the point that it may be unusable, at least in Psychiatry.

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