1 Boring Old Man

In 1969, a couple of things happened. I became a father, and I started a fellowship in Immunology as part of an Internal Medicine residency. Both were pretty big deals. Immunology wasn’t/isn’t a specialty, so my clinical assignment was in Rheumatology. It wasn’t my main interest, but it was plenty interesting enough. The older Rheumatologists were allied with the Physical Medicine doctors who had spent their careers dealing with polio victims. By my era, their version was going away as a specialty along with the disappearance of polio. The younger Rheumatologists were all about Immunology and "auto-immune" diseases. In conferences, we heard about wonderful new research in Immunology, but when we saw patients – we were dealing with some pretty dire illnesses of unknown cause, and treatments were mostly empirical. The Rheumatologists saw every intervention as a therapeutic trial. Sometimes this worked. Sometimes that worked. So you started this, and watched carefully. If it failed, you started over with that. It doesn’t sound very scientific, but I came to see it as the essence of science. Every prescription was an experiment – a therapeutic trial. So in Rheumatoid Arthritis clinic, the old guys were putting casts on particularly inflamed joints to prevent deformity. The young guys were starting the anti-inflammatory treatment du jour – anti-malarials, gold injections, occasional brief cortisone, non-steroidals – trying to "cool off" the active disease. There were no cures, but a lot of good medicine got practiced by careful trial and error. Nowadays, Rheumatology is much further down the road and their immunosuppressants are much more precise. Rheumatoid Arthritis itself remains a mystery, but "crippling" RA just isn’t the show-stopper it used to be. But they’re still doing therapeutic trials…

Obviously, I had some other interests too, and ended up a psychiatrist/psychoanalyst. But I never got over the idea of the therapeutic trial. Psychiatry, psychotherapy, psychoanalysis – they’re all murky too. Once again, sometimes this works. Sometimes that works. So you start this, and watch carefully. If it fails, you start over with that [I guess I’m drawn to matters murky]. Once I left academics, the patients I saw were heavily filtered. They’d tried medication and various psychotherapies, so if I saw them, they were treatment failures of one kind or another and often cynical, but privately hopeful [or hopeful, but privately cynical]. I was surprised at how many of them had been treated well, but the treatment failed because of a missed diagnosis. Examples? Undiagnosed non-hyperactive Attention Deficit Disordered people having as much internal agita sitting in a board room as they had as kids in a classroom. People who had severe visual disturbances corrected in their later youth, but still carrying the burden of an early childhood lived in ‘near-blindness.’ Far and away, the majority of missed diagnoses were unrecognized post-traumatic disorders. And then there were the people I had been trained to treat – neurotic people with personality problems sometimes amenable to [bilateral] hard work. They weren’t all successes, but enough to be worth the climb. A few people with Schizophrenia or Manic-Depressive Illness happened along, but I referred them to people with more up-to-date expertise.

The point here is that I wasn’t so involved in the world of psychiatric medications as many of my colleagues. And when I did prescribe, it was with patients I was seeing frequently, so the therapeutic trial lesson remained part of the mix. That’s why I’m not an anti-medication activist like a lot of people writing in this genre. I saw enough medication successes to have a healthy respect for the anti-depressants, anxiolytics, and the ADD medications. When they’re the right this, they’re a godsend. When they’re not, time to stop and try that. I saw plenty of medication failure too, as with any therapeutic trial. I don’t prescribe neuroleptic anti-psychotics to non-psychotic patients and don’t plan to, so I can’t comment on those drugs except in actively psychotic people. I never augmented an anti-depressant with an antipsychotic, but I did augment psychotherapy of various ilks with an antidepressant.

After I retired, I did nothing medical for five years ["tired"]. I avoided volunteer work because the local charity clinic prescribed pain medication and minor tranquillizers. This is rural America, where drug abuse means either home-grown "meth" or "pills." I had no interest in seeing drug-seeking people. When the clinic finally gave up and decided to no longer stock or prescribe narcotics or "benzos," I gave in and agreed to become a doctor again in several charity clinics on a limited basis. I obviously enjoy doing it, though my role is very different from the one I had practicing in Atlanta. It was going back to work that got me involved in writing this blog. I knew I was going to have to catch up on the psychiatric medications. Instead of catching up, I got caught up by what seems to me the insanity of modern psychiatric and primary care prescribing of psychoactive drugs. And when I started looking at the literature, I became [and remain] appalled. I’m not an anti—medication—activist. I’m an anti—medication-obsessed-doctor—activist. Carefully considered use of medication in a therapeutic trial can be as much a part of approaching a mentally ill person as putting a splint on a hot joint or trying various anti-inflammatory agents in active RA. The notion that one can predict the right thing to do simply based on a disease diagnosis is the fantasy of actuaries trying to digitize a statistically diverse and analog world.