{"id":39076,"date":"2013-08-11T19:16:07","date_gmt":"2013-08-11T23:16:07","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=39076"},"modified":"2013-08-11T22:32:45","modified_gmt":"2013-08-12T02:32:45","slug":"a-patch-of-blue","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/08\/11\/a-patch-of-blue\/","title":{"rendered":"a patch of blue&#8230;"},"content":{"rendered":"<div align=\"justify\">The best thing about a weekend away at a meeting seeing okd friends is getting home, no matter how much fun I had. The worst thing about getting home and turning on my <em>modern<\/em> computer is how long it takes to boot while loading all the stuff it takes to make it <em>modern<\/em>. A friend sent a very thoughtful article while I was gone [<a href=\"http:\/\/jama.jamanetwork.com\/article.aspx?articleid=1713595\" target=\"_blank\">Interpreters or Teachers?<\/a>]. It&#8217;s a two pager with only the first page available on-line. I&#8217;ve pasted in a piece of that second page below:<\/div>\n<blockquote>\n<div align=\"justify\">The problem with medicine is not just thatweare distracted by our technologies, but that medicine has too much authority to interpret the meaning of our bodies. Until very recently, medicine was only one among many interpreters of the body. Over the last two centuries, the authority of medicine to interpret the bod has steadily increased. It is now hard to imagine how regular events of human existence like birth, puberty, sex, sadness, menopause, aging, and death can be understood as anything other than medical incidents. Whether we examine patients directly or not,we physicians can renew medicine only if we allow the body to be interpreted as something more than a pathology text.<\/div>\n<ul>\n<li>\n<div align=\"justify\">What does this look like? First, I think it means humility about the limits of our knowledge. There are still more unknowns than knowns in clinical medicine; our maps and territories remain provisional. When&nbsp; you look deeply at the evidence base foremost of what we physicians do, it becomes clear that we have limited, qualified, or compromised evidence to guide our decisions with any particular person.We ought to be clearer with patients about these limits&#8230;<\/div>\n<\/li>\n<li>\n<div align=\"justify\">Second, we could return not to direct examinations that reinforce our interpretative authority, but to a version of the patient&middot;physician relationship informed by our awareness of the limits of medical knowledge. At its core, the patient-physician relationship involves a mutual commitment between a patient and her physician to her own well-being. We psychiatrists call this the therapeutic alliance and have plenty of evidence that it is the source of healing. While the therapeutic alliance is an imbalanced relationship, in that a physician is the designated healer, it is also a relationship in which a patient can show her physician that her illness is only one aspect of her life. Instead of diagnosing depression in consultation or 15-minute office visits, we ought to evaluate depressive symptoms within the context of a therapeutic alliance. By design, the DSM-5 field trials assessed the ability to diagnose disorders like depression outside the therapeutic alliance.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">Third, renewing therapeutic relationships would make the work of being a physician less burdensome. Physician burnout is on the rise, especially for physicians who work as interpreters. I suspect it is because our role as the interpreters of the body gives us too much responsibility over other people. When I interview people with &ldquo;depression,&rdquo; they often say tome something like, &ldquo;My life is a disaster. I know you can fix it.&rdquo; Patients now expect us to be the interpreters of their bodies and lives, and this responsibility over another person can alienate us from our patients.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">Fourth, physicians ought to encourage people to participate in interpretative communities outside medicine. I tell people with depression that now is the time for them to recommit themselves to the friends, family members, and faith communities that helped them pursue their well-being.<\/div>\n<\/li>\n<\/ul>\n<div align=\"justify\">So as I review DSM-5 with my students and residents, I am training them to say to our patients:<\/div>\n<div align=\"justify\">\n<ul>\n<div>We looked for answers in the medical literature.We will apply them to your situation, but none of those answers perfectly fits your situation, so we will sit with you. Not as interpreters who will take responsibility for your troubles, but as teachers, as physicians who are more aware of the limits of our discipline, and more willing to help you return to the communities outside of medicine that support your well-being.<\/div>\n<\/ul><\/div>\n<\/blockquote>\n<div align=\"justify\">The author, Dr. Abraham Nussbaum, is both a psychiatrist and a theologian &#8211; a background apparent in his writing. When he speaks of <em>the communities outside of medicine that support your well-being<\/em>, I suspect he&#8217;s referring to religious communities. From his University of Chicago blurb:<\/div>\n<div align=\"justify\">\n<blockquote>\n<div><em>Dr. Nussbaum completed his undergraduate degree at Swarthmore College,  where he studied religion and English literature.  He completed medical  school and psychiatry training at the University of North Carolina,  along with a master&rsquo;s of theological studies at Duke Divinity School.   His research interests include the history of psychiatry, medical  professionalism, psychiatric diagnosis, and the treatment of people with  schizophrenia.  He is currently co-organizing a conference on the care  of persons with mental illness by Christian communities.<\/em><\/div>\n<\/blockquote><\/div>\n<div align=\"justify\">While I have no objection to his last sentence, I would replace &quot;<em>the communities outside of medicine that support your well-being<\/em>&quot; with simply &quot;<em>your life.<\/em>&quot; Somewhere along my travels, I heard someone say, &quot;<em>physicians are advisers<\/em>.&quot; At the time I heard it, it was an awakening for me. I was a young Internist feeling the weight of the suffering I was around every day and the responsibility of the profession I had chosen as a way to spend my life. If you can&#8217;t learn humility as a doctor, you have a real learning problem. No matter the specialty, the things that can go wrong in the body an mind will bring the most arrogant among us to our knees. So as an adviser, my job was to bring the most to the table that I could muster and present it in the most useful way I could find. That&#8217;s what teachers do and it&#8217;s what Dr. Nussbaum is talking about. The best teacher is the one willing to say &quot;<em>I don&#8217;t know<\/em>&quot; when it&#8217;s the truth and make sure to point to someone else who does know, or be willing to say, &quot;<em>That&#8217;s not known<\/em>&quot; when it&#8217;s also the truth. An adviser&#8217;s responsibility is to offer the best advice, not to present oneself as a &quot;<em>fixer,<\/em>&quot; even if that&#8217;s what the patient wants [or demands]. <\/div>\n<p align=\"justify\">A lot of psychatrists and other mental health types feel really defensive in the face of the criticism that we don&#8217;t know enough. I don&#8217;t feel that. I guess I worked my way through that as an Internist. I don&#8217;t know enough then either. I had been taught that the most important task was knowing-when-you-don&#8217;t-know and hitting the books, looking for help, or knowing that no-one knows and doing my best with the not-yet-known. Psychiatry was no different. We know a lot, but the field of the unknown just happens to be really as big as being human. That&#8217;s just the way it is, speaking of humility. A lot of my personal complaints about psychiatry today are the lack of appropriate humility, and the seeming abandonment of the attitudes expressed here by Dr. Nussbaum.&nbsp;<\/p>\n<p align=\"justify\">What I needed as a patient was to find a place outside my life and a mind outside my mind to help me figure out the things that plagued me that I couldn&#8217;t see myself. They were too automatic or too embedded in conflict to yield to personal reflection. When my helpers slipped up and told me how to live, I reminded them that that&#8217;s not what I came for. I have slipped up in that way more times than I&#8217;d like to admit myself, and received those same reminders. So the kind of advice I&#8217;m talking about is something different. It&#8217;s in the form, &quot;<em>I notice you&#8217;re doing this particular thing over and over and it&#8217;s getting you in trouble over and over. Let&#8217;s take a look and see why.<\/em>&quot; Seeing how people trip themselves up is actually the easiest part. The much harder part is everything else. With so many people criticizing that approach, how can I justify my criticism of the DSM and the over-medication of patients?<\/p>\n<p align=\"justify\">It&#8217;s easy. First, I only saw patients who came looking for a <em>me<\/em>. I only saw patients I thought had a chance of using that approach to their advantage. And finally, I made it clear it was a <em>we <\/em>proposition, that I was no fixer and there were no guarantees. I take and took the same approach prescribing medications. I don&#8217;t do it unless I think it might help, and I&#8217;m obnoxious about discussing the down-side. This blog has helped me a lot with that. I&#8217;ve learned more than I could&#8217;ve imagined about the down-side. It&#8217;s just another part of being an adviser, or a teacher. It was a rewarding career and I&#8217;m glad I found it. And like Dr. Nussbaum, I lament the past &#8211; the days of thorough physical exams, long histories, humility, therapeutic alliances, and most of all, honesty. Growing up, I swore I wouldn&#8217;t be an old man that talked about the good old days. Well, so much for childhood resolutions.<\/p>\n<div align=\"justify\"><img decoding=\"async\" width=\"68\" hspace=\"4\" border=\"0\" align=\"right\" src=\"http:\/\/1boringoldman.com\/images\/pendulum.gif\" \/>I&#8217;m encouraged by seeing more articles such as this, like the one recently by the <a href=\"http:\/\/www.criticalpsychiatry.co.uk\/\" target=\"_blank\">Critical Psychiatry Network<\/a> [see <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/06\/24\/a-long-and-lonely-wait\/\">a long and lonely wait&hellip; <\/a>]. When psychiatry changed so dramatically in 1980, I expected a more reasonable balance after a time. But it has been a third of a century and I&#8217;m still waiting for that pendulum to budge some. Maybe it is finally happening&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>The best thing about a weekend away at a meeting seeing okd friends is getting home, no matter how much fun I had. The worst thing about getting home and turning on my modern computer is how long it takes to boot while loading all the stuff it takes to make it modern. A friend [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-39076","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39076","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=39076"}],"version-history":[{"count":29,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39076\/revisions"}],"predecessor-version":[{"id":42014,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39076\/revisions\/42014"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=39076"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=39076"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=39076"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}