Ambiguity and Asking Questions

[Psyxh1]

So, I'm going to begin as a new intern this July. Something that has perturbed me over the years is that if you ask 5 different psychiatrists to evaluate a patient, each of them might come up with a different diagnosis and different treatment methods. How do you know who is the one who appropriately and correctly evaluated the patient? On my last clerkship I found myself disagreeing with some of the diagnoses given to patients and when I would discuss this with the other students sometimes they would agree with me and other times they wouldn't. It was also common for them to have a 3rd opinion(distinct from either mine or the residents'/attendings').

I would also discuss my questions with the attending and he would explain his thinking. I am wondering if I continue to ask questions about diagnoses or treatment plans during residency will I be inadvertently irritating the attending by appearing as if I am in disagreement with his thought processes? Mind you, I don't consider myself an argumentative person in these situations and I always respectfully ask questions. I think my worry is that since there can be a lot of ambiguity at times how do I know whether what I am learning is correct and what do I do in these situations where I feel that the patient is incorrectly diagnosed and given the wrong treatment? How can I, myself be certain that I correctly evaluated the patient?

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[notdeadyet]

This is a great post and you've already spotted some of the things that can be both fascinating and frustrating about psychiatry. And you're asking the right questions, too.

I'd love to give a blanket answer, but unfortunately "it depends on the attending" is going to be the most true. You will meet some real narcissists (in medicine, go figure!) that will view any questions that may imply disagreement as a form of challenge. Your approach to not being argumentative is right on. I think a good technique is to ask the attending to walk you through his or her thought process, rather than focus on why you disagree with the conclusion/diagnosis. If you are walked through the thinking, you should learn why the attending came up with diagnosis A and not B. It also gives you the opportunity to ask about alternatives as you're going through the evidence in front of you. When you approach it this way (as a learning exercise), if you do it with the appropriate affect, it shouldn't offend any but the real bastard attendings. And at most decent programs, they are thankfully rare in psych.

 

[smalltownpsych]

Conceptualization is more important than diagnosis and diagnosis is just one part of the conceptualization. Arriving at the correct dx is just the first step but since there is a high degree of symptom overlap and comorbidity, keep in mid that there can also be more than one correct dx. Is it GAD, Borderline PD, PTSD, Social Anxiety Disorder, MDD, Substance Use Disorder, or All of the Above? A significant % of my patients fit this description. What is more important is why is the patient is thinking, feeling, and behaving the way they are and how do we best address that through our interventions. Finding non-concrete thinkers to discuss cases with from the various angles can be helpful to expand your conceptual skills.

 

[nancysinatra]

... "it depends on the attending" is going to be the most true. You will meet some real narcissists (in medicine, go figure!) that will view any questions that may imply disagreement as a form of challenge. Your approach to not being argumentative is right on. I think a good technique is to ask the attending to walk you through his or her thought process, rather than focus on why you disagree with the conclusion/diagnosis. If you are walked through the thinking, you should learn why the attending came up with diagnosis A and not B. It also gives you the opportunity to ask about alternatives as you're going through the evidence in front of you.

I agree with this approach for 1st and 2nd year trainees. But at a certain level of training, residents should expect attendings to be able to not only explain but also defend their reasoning. The best format for this would be weekly M&M rounds. Attendings should be forced to justify to their own colleagues and supervisors (with residents in the audience) why they used the reasoning they did, especially in cases where there is treatment failure. Otherwise the DSM is just a big cafeteria where you can pick and choose and all outcomes are "equal."

Beyond that, I find it sad that this soon-t0-be-intern even has to ask this question. Residents should not be the ones asking most of the questions - the attendings should be asking the residents. Residency is the time when you are supposed to slave away over textbooks and journal articles and come to wards prepared. If even the ATTENDING can't explain their reasoning, what does that say about the knowledge base behind the field???

Imagine if surgery interns had to go online and say "Do you think my attending will be offended if I ask why they are doing an open appy vs a laparoscopic one?" Of COURSE the attending will be offended - because the resident should have read up in advance. But here is another failing of psychiatry - that we don't read that much. It is possible to pass the psych boards without even studying much. Even our literature base is suspect. So it shouldn't be a great surprise to anyone that if you take the same patient to 5 attendings, you'll get 5 different diagnoses.

But - if all you want to do is succeed in your residency, then you should probably be careful about asking questions. I found that being very indirect and peppering my questions with mild flattery was one good way to get attendings to do their jobs - i.e. explain their reasoning. If you choose positive euphemisms like "ambiguity" or "multiple good options" you will win over people more than if you use phrases like "contradictory" or "lacking evidence."

On the other hand, if unresolved contradictions really bother you, you might want to reconsider your specialty choice.

 

[nancysinatra]

Arriving at the correct dx is just the first step but since there is a high degree of symptom overlap and comorbidity, keep in mid that there can also be more than one correct dx. Is it GAD, Borderline PD, PTSD, Social Anxiety Disorder, MDD, Substance Use Disorder, or All of the Above? A significant % of my patients fit this description. What is more important is why is the patient is thinking, feeling, and behaving the way they are and how do we best address that through our interventions. Finding non-concrete thinkers to discuss cases with from the various angles can be helpful to expand your conceptual skills.

I know you come from a different background, but to me, coming from a medical background, all this tells me is that the DSM is a joke. If it's full of overlap that is a sign of its failure. A diagnosis should be a diagnosis. It is either right or wrong, and verified with testing and pathology. I'm not saying that people's mental states are not complicated; and maybe the "diagnostic" approach doesn't work for mental problems, but then why call them "diagnoses" if they can't even be separated out correctly? How is that different from "diagnosing" "imbalances of the four humors," exactly?

 

[nitemagi]

I know you come from a different background, but to me, coming from a medical background, all this tells me is that the DSM is a joke. If it's full of overlap that is a sign of its failure. A diagnosis should be a diagnosis. It is either right or wrong, and verified with testing and pathology. I'm not saying that people's mental states are not complicated; and maybe the "diagnostic" approach doesn't work for mental problems, but then why call them "diagnoses" if they can't even be separated out correctly? How is that different from "diagnosing" "imbalances of the four humors," exactly?

I would agree with this, with the exception that really we make provisional diagnoses most of the time, based on available data. The problems happen when you have better/worse interviewers that don't end up gathering good data, the interviewer has their own biases to filter out data, and the patient gives an incomplete history.

 

[hamstergang]

But here is another failing of psychiatry - that we don't read that much.

I don't know where you get stuff like this from. Maybe you don't read much, and maybe your attendings didn't read much (though I don't know how you'd know how much they were reading). But on what are you basing your assessment that psychiatrists as a whole don't read as much as other medical specialties?

If it's full of overlap that is a sign of its failure. A diagnosis should be a diagnosis. It is either right or wrong, and verified with testing and pathology. I'm not saying that people's mental states are not complicated; and maybe the "diagnostic" approach doesn't work for mental problems, but then why call them "diagnoses" if they can't even be separated out correctly? How is that different from "diagnosing" "imbalances of the four humors," exactly?

At this point in time, we can't make psychiatric diagnoses that are verifiable with lab/imaging/pathology testing. And yet we have psychiatric patients that come to us and need treatment. So what do you propose we do?

The DSM fills this hole. It doesn't pretend to be perfect or to represent actual diseases. What it does is allow us to communicate (with each other, with insurance companies, with patients). I think when you recognize the DSM for what it really is, it serves that role rather well.

 

[Bartelby]

I am wondering if I continue to ask questions about diagnoses or treatment plans during residency will I be inadvertently irritating the attending by appearing as if I am in disagreement with his thought processes?

Please don't carry this idea into training. You should be asking questions, learning how attendings approach diagnosis and formulation, wondering what makes an attending choose one versus another intervention. This is standard for trainees, including for non-psychiatrist physicians! If asked in a non confrontational manner and with genuine interest then I doubt you will ruffle many feathers. If you do upset a few narcissists, so what? That sounds better than making it through your training without really understanding why you did the things you did.

 

[nancysinatra]

I don't know where you get stuff like this from. Maybe you don't read much, and maybe your attendings didn't read much (though I don't know how you'd know how much they were reading). But on what are you basing your assessment that psychiatrists as a whole don't read as much as other medical specialties?

Of course I know there are psychiatrists that read, but I based my comment on the fact that in order to pass the psych boards, you don't have to know as many facts or as much basic science as you would to pass, say, the derm, or pathology, or even the neuro boards. I found the psych boards to be much easier than any of the USMLEs, too. There was very little on the molecular level. The psychosocial topics were not exactly delved into in a way that was intellectually deep. (It was Freud-lite, at most.) I also didn't have to study much for the PRITES, or to pass my residency rotations, and I don't know anyone who did, really. Almost all my learning was experiential. At no point was there a seminal textbook or article whose content would have been essential for me to know in order to graduate or pass the boards.

I also noticed that I had to do a lot more reading on my medicine months than on my psych rotations. During residency I did an ICU rotation, where the attending brought in an article every Monday, and then on Wednesday, he would randomly ask one of us present the methodology and relate the findings to specific patients we were seeing. By examining the methodology I learned a lot about the pathophysiology, diagnosis and treatment of medical illnesses. Of course, when you have diagnostic tools and measurable markers, and when you have some basic existing known pathophysiology, you can design a much greater variety of research studies than when you don't. When you can discuss the findings in relation to your own patients, it makes the lessons of the article stick. What was great was that this level of research was being presented to us, mere residents.

By contract, I never once had a psych attending on a rotation dissect an article's methodology. We read articles, and we discussed them generally and might gain a clinical pearl or two, but it was never analytical and never changed patient care. We had a journal club that was more analytical, but the residents chose the articles they wanted to present, and were never forced to present something new or difficult. We discussed the methodologies of some RTCs in didactics. But unless you're at the cutting edge of research in psychiatry yourself, you really don't need to know very much at the molecular level, or be able to discuss research design beyond RTCs, even during the hardest residency rotations. There was never a formal standard for how to choose or analyze what we were reading. So my standard was, is, and always will be what I learned on my ICU rotation.

Now that I am out of residency, it is up to me to read on my own. I don't read as much as I should, but I have an excuse, which is that I'm leaving the field. There are some interesting articles in the AJP, but when was the last time an article - or even a concept - came along that every psychiatrist HAS to know in order to stay up to date in practice?

At this point in time, we can't make psychiatric diagnoses that are verifiable with lab/imaging/pathology testing. And yet we have psychiatric patients that come to us and need treatment. So what do you propose we do?

The DSM fills this hole. It doesn't pretend to be perfect or to represent actual diseases. What it does is allow us to communicate (with each other, with insurance companies, with patients). I think when you recognize the DSM for what it really is, it serves that role rather well.

So would you think it was ok if every other medical field got rid of their textbooks, and used the ICD-10 to actually make their diagnoses? If you needed eye surgery, is it ok with you that your ophthalmologist only knows a listing of eye diseases and has a checklist of their symptoms, but has no clue how what causes them or whether your diagnosis is actually correct? If they threw out their instruments, would you still trust them?

I propose that we stop lying to patients, and to the public, by telling people that they have "disorders" which are mere constructs of a guidebook that is designed by psychometricians and promoted by committees of our guild organization. Why not use Kaplan & Saddock, or some other textbook instead, or create a new one? One that doesn't "change over" every few years, but rather incorporates historical knowledge and theories with more modern perspectives from the sciences and psychology, where both "biological" and "psychodynamic" psychiatry can both have a voice? Where medicine and neurology are incorporated as well?

I would also propose that we devote far, far more resources to research. A two-year research stint could be mandatory at all but a few residency programs, for example. ENT has something like that - they have 5 and 7 year programs. Entry into psychiatry could be made much harder, with the goal of recruiting people who will lead the field forward. If the field has to shrink down for awhile to achieve this, I think it's worth it.

As far as what I'd say to patients who need treatment? If only I COULD! I'd tell them they're out of luck! They're alive in an era where we have no great tools, and almost no knowledge, only a tiny bit more than we had even 50 years ago. I'd encourage therapy, and tell them that based on their "symptoms" we can try a few medications, but I can't make any promises.

 

[birchswing]

As far as what I'd say to patients who need treatment? If only I COULD! I'd tell them they're out of luck! They're alive in an era where we have no great tools, and almost no knowledge, only a tiny bit more than we had even 50 years ago. I'd encourage therapy, and tell them that based on their "symptoms" we can try a few medications, but I can't make any promises.

Sounds like a perfect doctor to me.

It's far better than the doctor who tells their patient they have a chemical imbalance and needs X drug to correct it and goes into a BS spiel about how it's just like a diabetic taking insulin. And when they get worse the doctor tells them that by treating the first chemical imbalance, another one that was "hidden" under the first has manifested itself and now needs to be treated with drug Y, as if these symptoms are caused by tangible entities with anthropomorphized qualities, such as the ability to hide.

That patient is now down a path that doesn't lead to anything good.

If your first interaction as a patient is with a doctor who is very humanistic, connects with you, focuses on how well you've been doing with the adversities you've had, and presents the limited options you mention, that patient is headed down a far better path. If I've found anything that works well when listening to people complain about life's problems, it's to tell them what great insight they have and that they're already doing a great job handling their problem. Very few doctors come to problems from that perspective.

But I can see how it would be discouraging on the other side of things to feel limited in your options.

 

[smalltownpsych]

I know you come from a different background, but to me, coming from a medical background, all this tells me is that the DSM is a joke. If it's full of overlap that is a sign of its failure. A diagnosis should be a diagnosis. It is either right or wrong, and verified with testing and pathology. I'm not saying that people's mental states are not complicated; and maybe the "diagnostic" approach doesn't work for mental problems, but then why call them "diagnoses" if they can't even be separated out correctly? How is that different from "diagnosing" "imbalances of the four humors," exactly?

I concur. Many of our disorders are based on ubiquitous symptoms. Could you imagine going to a primary care doc with a fever and he or she diagnoses you with Major Fever Disorder with headache and no vomiting? I have had numerous patients who don't really get better until they start leaving the labels and the medications behind. I agree that we need to tell the truth about this and be wary of the initial relief that some patients express when receiving a dx. I can and do talk to my patients about the limitations of the their diagnoses and I talk about depression and anxiety as normal and adaptive human experiences that cannot be eliminated. I also explain trauma response to them as opposed to dx criteria for PTSD. Some patients get it and can heal and improve tremendously, others just want a medicine to feel better. I wish that more in our field and society would make that message clearer. Are you still going into psychiatry? We always need skeptics and docs who are dissatisfied with the current state challenging the field. It will be less helpful to criticize from another aspect of medicine and you might get even more frustrated in another field since half of what you will deal with will still be psych unless you are in a field where patients aren't awake.

 

[Shikima]

I concur. Many of our disorders are based on ubiquitous symptoms. Could you imagine going to a primary care doc with a fever and he or she diagnoses you with Major Fever Disorder with headache and no vomiting? I have had numerous patients who don't really get better until they start leaving the labels and the medications behind. I agree that we need to tell the truth about this and be wary of the initial relief that some patients express when receiving a dx. I can and do talk to my patients about the limitations of the their diagnoses and I talk about depression and anxiety as normal and adaptive human experiences that cannot be eliminated. I also explain trauma response to them as opposed to dx criteria for PTSD. Some patients get it and can heal and improve tremendously, others just want a medicine to feel better. I wish that more in our field and society would make that message clearer. Are you still going into psychiatry? We always need skeptics and docs who are dissatisfied with the current state challenging the field. It will be less helpful to criticize from another aspect of medicine and you might get even more frustrated in another field since half of what you will deal with will still be psych unless you are in a field where patients aren't awake.

Unfortunately, those who create the diagnoses in committee which comes from the DSM over to ICD are the ones dictating the rules.

 

[smalltownpsych]

Unfortunately, those who create the diagnoses in committee which comes from the DSM over to ICD are the ones dictating the rules.

Diagnosis by committee:

 

[hamstergang]

I never once had a psych attending on a rotation dissect an article's methodology.

There's too much to respond to, and it all basically comes down to this anyway -- this quote speaks to your poor residency experience, not an issue with psychiatry as a whole. I certainly had a great deal of learning how to critically evaluate the literature in my training. We've been over this a few times on this forum already, so I don't know why you keep thinking that your experience is more universal:

I'm not going to give lots of specifics about my residency experience because I don't want to identify the place. Hence I make snide but vague comments as a way of venting my misery from that period which I am still recovering from. Anyway the place had financial issues. It affected the training. The attitudes in that part of the country were depressing to me.

As far as what I'd say to patients who need treatment? If only I COULD! I'd tell them they're out of luck! They're alive in an era where we have no great tools, and almost no knowledge, only a tiny bit more than we had even 50 years ago. I'd encourage therapy, and tell them that based on their "symptoms" we can try a few medications, but I can't make any promises.

As for the second half of your post, there's again too many small points to respond to that are basically summed up here. Of course you can be honest with your patients, and it's rather ridiculous that you would think otherwise. The current state of psychiatry isn't where you want it to be, but that's where we're at. Of course we should continue to do more research but that doesn't help us practice psychiatry today. We have to work with what we have in front of us and advocate for funds to be allocated in ways that can help us in the future.

 

[notdeadyet]

Now that I am out of residency, it is up to me to read on my own. I don't read as much as I should, but I have an excuse, which is that I'm leaving the field.

It sounds like it's time. Are you comfortable saying where your next phase of life is taking you? If not (or if you already have and I've missed it), no worries and best of luck to you in your next adventure. Life is way too short to work in a career you don't find meaningful.

 

[nancysinatra]

There's too much to respond to, and it all basically comes down to this anyway -- this quote speaks to your poor residency experience, not an issue with psychiatry as a whole. I certainly had a great deal of learning how to critically evaluate the literature in my training. We've been over this a few times on this forum already, so I don't know why you keep thinking that your experience is more universal:



As for the second half of your post, there's again too many small points to respond to that are basically summed up here. Of course you can be honest with your patients, and it's rather ridiculous that you would think otherwise. The current state of psychiatry isn't where you want it to be, but that's where we're at. Of course we should continue to do more research but that doesn't help us practice psychiatry today. We have to work with what we have in front of us and advocate for funds to be allocated in ways that can help us in the future.

Fair enough, but the reason I keep saying the same things on this forum is not necessarily because I believe them so strongly, but because the forum has a pro-psychiatry bent that makes me feel like I have entered the cheerleading squad's headquarters every time I come on here. I conceded your points, and if I talked to you in person we'd probably agree on a lot.

 

[nancysinatra]

It sounds like it's time. Are you comfortable saying where your next phase of life is taking you? If not (or if you already have and I've missed it), no worries and best of luck to you in your next adventure. Life is way too short to work in a career you don't find meaningful.

Thanks! I'd love to say what I'm doing next, but it's an odd move and I'm worried about my anonymity. I don't want my new supervisors to come on here and find all my angry posts! ;-) In time I might feel more open talking about it. It's another field of medicine where I'll bring my psych background and yet learn a lot more. It's structured as a fellowship and it draws from all of medicine. I haven't been this excited about a new job or training since I was a premed!

I don't hate psychiatry. I certainly like many of the people I've met in this field, and I learned a lot from many attendings in residency, and because of that I know there are fabulous things being done in this field. I always find it meaningful when a patient makes a turnaround in their life. I went into psychiatry because I thought it would be awesome to help people who are struggling turn their lives in positive directions - and in doing so, reduce some of the problems in our society. But that never happens! My patients only rarely get better in any objective sense, and when they do, it's on a microscopic scale, and meanwhile, there's another patient somewhere else, getting worse. Those of you who can see past these frustrations, who enjoy working with patients who are slowly making emotional changes - you have my admiration.

But whenever someone posts on this forum about how they are struggling with the contradictory nature of so many aspects of psychiatry, I feel sorry for them. And a little worried...

 

[notdeadyet]

Thanks! I'd love to say what I'm doing next, but it's an odd move and I'm worried about my anonymity. I don't want my new supervisors to come on here and find all my angry posts! ;-) In time I might feel more open talking about it. It's another field of medicine where I'll bring my psych background and yet learn a lot more. It's structured as a fellowship and it draws from all of medicine. I haven't been this excited about a new job or training since I was a premed!

Congratulations to you. I'm glad you found your niche.


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[Armadillos]

Nancysinatra does have a point in that it may not feel as urgent to be hitting the books hard in psych compared to other fields of medicine because so many of our treatments treat different diagnoses and it's generally not urgent to immediately nail a diagnosis. Schizophrenia vs Mania is obviously an important distinction, but you could hypothetically blindly prescribe seroquel and you would be practicing within FDA indications.

I imagine if hypothetically ordering a manic patient an antipsychotic instead of a mood stabilizer at 4am in the ER was going to kill the patient then psychiatry residents would be doing a lot more reading.

 

[nancysinatra]

There's too much to respond to, and it all basically comes down to this anyway -- this quote speaks to your poor residency experience, not an issue with psychiatry as a whole. I certainly had a great deal of learning how to critically evaluate the literature in my training. We've been over this a few times on this forum already, so I don't know why you keep thinking that your experience is more universal

I want to respond to this again because I think you are being a bit unfair in your response to me. You asked my why I thought we don't have to "read" as much in psychiatry, and I gave a long answer, and then rather than responding, you dismissed my answer by saying that the entirety of my response speaks to my bad experience as a resident. Actually, my residency experience had very little to do with my response. I used details from my residency only to answer your question more completely. I still think it must be harder to pass the derm boards than the psych boards, and I still think that psychiatrists can get board certified with relatively little time spent hitting the books. If you're going to criticize my post, at least address this point. It has nothing to do with individual residency programs.

Besides which, even if I was making a universal conclusion based on my individual residency experience -- so what? The vast majority of people who attend a psych residency will attend only one residency program. I have no obligation to "try to understand" what other people's residencies were like. Because it doesn't matter. It's a zero sum game. You choose your specialty, and you match at a program, and there's no way out - not with today's student debt. It's win or lose. It's not my job to "realize" that other programs were "different" (if they actually were). Rather, it's the job of people who want to lead this field and see it succeed, to make sure the training is adequate everywhere.

 

[nancysinatra]

Nancysinatra does have a point in that it may not feel as urgent to be hitting the books hard in psych compared to other fields of medicine because so many of our treatments treat different diagnoses and it's generally not urgent to immediately nail a diagnosis. Schizophrenia vs Mania is obviously an important distinction, but you could hypothetically blindly prescribe seroquel and you would be practicing within FDA indications.

I imagine if hypothetically ordering a manic patient an antipsychotic instead of a mood stabilizer at 4am in the ER was going to kill the patient then psychiatry residents would be doing a lot more reading.

Exactly. It's not even a judgment; it's just a statement.

 

[doctorpilgrim]

Thanks! I'd love to say what I'm doing next, but it's an odd move and I'm worried about my anonymity. I don't want my new supervisors to come on here and find all my angry posts! ;-) In time I might feel more open talking about it. It's another field of medicine where I'll bring my psych background and yet learn a lot more. It's structured as a fellowship and it draws from all of medicine. I haven't been this excited about a new job or training since I was a premed!

I don't hate psychiatry. I certainly like many of the people I've met in this field, and I learned a lot from many attendings in residency, and because of that I know there are fabulous things being done in this field. I always find it meaningful when a patient makes a turnaround in their life. I went into psychiatry because I thought it would be awesome to help people who are struggling turn their lives in positive directions - and in doing so, reduce some of the problems in our society. But that never happens! My patients only rarely get better in any objective sense, and when they do, it's on a microscopic scale, and meanwhile, there's another patient somewhere else, getting worse. Those of you who can see past these frustrations, who enjoy working with patients who are slowly making emotional changes - you have my admiration.

But whenever someone posts on this forum about how they are struggling with the contradictory nature of so many aspects of psychiatry, I feel sorry for them. And a little worried...

You make some good points but you are over generalizing based on your experience. Every field in medicine has its shortcomings.
I am not trying to disparage your experience and you make some valid points. But if you read your posts you may realize the strong language you are using.Alleviating human suffering through psychotherapy is as noble a goal as algorithm based oncology.

We do the best we can in psychiatry with the tools we have.


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[HarryMTieboutMD]

Well, this has turned into an interesting discussion, but to address the original poster, welcome to clinical medicine. Do you think this is any different than in any other diagnostic specialty? As physicians, we are ultimately paid for how we think and reason through cases, and this thinking is developed through an extensive basic science foundation in undergrad and med school followed by rigorous clinical training in residency. This is what sets us apart from midlevels. This is why in medical school one of the most emphasized points during third year is "differential diagnosis".

In psychiatry we still have operational diagnoses without biomarkers, so the discrepancies and ambiguities might seem more blatant, but they really aren't. And you can have every lab and every image available on your computer screen, yet still reason through a given case and come up with a completely different answer than your colleague. Again, this is why you keep a broad differential diagnosis in mind. As you will see in intern year, in internal medicine diagnoses and treatment plans will FREQUENTLY change based on input from different, though equally competent physicians who have thoroughly reasoned through a case. The important point is that you can explain your reasoning, and when you make mistakes, learn from them.

And yes strictly speaking our purely psychiatric diagnoses are limited in number (the DSM continued proliferation of BS diagnoses notwithstanding), but you will need to understand, especially on a consult or ED service psychiatric manifestations of medical illnesses and substance/medication, some of which are quite characteristic and some are not because the ED resident and consulting teams will generally not have a clue (if they need to consult you).

Oh, and about reading. From personal experience reading basic science, clinical/translation, and population based research from top psych jounrnals (AJP, Jama Psych, Molecular Psychiatry, and Biological Psychiatry- not has high impact factor as the others but still has great articles) as well as occasional publications in Nature and Science has without questioned enhanced my clinical skills and is absolutely indispensable to how I practice medicine. As a physician, you should be reading consistently.

 

[thoffen]

HarryMTieboutMD makes a good point. This isn't inherently different from other fields of medicine with clinical diagnoses, however other fields often have known pathologic mechanisms and some biologic evidence contributing to diagnosis, so it feels different even if it inherently isn't.

There are patients who will not neatly fit into diagnostic criteria, and there will be significant disagreement from committees, etc., on this. Much of this is because our descriptors of illness/symptoms are very subjective and culturally informed, and patients are often motivated in some fashion for how their mental health is diagnosed/treated in ways they are not with their medical health.

Nonetheless, this isn't inherently bad. It's a fact in medicine, and you can take some solace in that psychiatry is the place where there lies opportunity for people recognize it, talk about it, and help you manage your feelings on this problem. Additionally, it's helpful to disenfranchise yourself from the idea that, in any field of medicine, your usual role is to diagnose accurately and cure patients. Often, the best we can do is build a connection to our patients that is personal but within the boundaries of our profession, and to enable them to work on their own lives in ways that are oriented with reality. The payoff of that is sometimes 20 years down the road, but there could be a lot of power in something like "it seems a lot of people have been having a hard time figuring out what's going on with you, honestly I'm having trouble to. What is it that we're missing?" and then exploring how it's affecting the person.

 

[smalltownpsych]

Also, just wanted to add that the more you understand neurological and endocrinological function and how that relates to behavior, the stronger the conceptualizations and the more people will see that we really do know what we are talking about much of the time. For example, just throwing out a diagnostic label like PTSD is not nearly as useful as stating how the higher cortical functions can be inhibited as part of a trauma response and connecting that to an observed behavior.

 

[Guyton]

I believe the discussion hinges around medical uncertainty. Medicine is filled with decisions made in the absence of well-established information. Evidence based guidelines are just that- guidelines. They provide the general framework within which physicians operate; they help us differentiate the “horses from the zebras.” Many physicians struggle with the reconciliation of population based evidence with case based practice. In fact, emphasis of physicians’ education in the sciences may contribute to a perception of threat in ambiguous clinical situations. Such intolerance to uncertainty is likely correlated with discomfort in treating equivocal medical conditions.

Thus, physicians will likely gravitate toward medical specialties that play into their personal diagnostic comfort zone. The more unambiguous specialties tend to draw like-minded physicians. As an internist, I approach problems in a different fashion than I do as a psychiatrist. Although both specialties share a basic premise of medical knowledge- internal medicine is much more amenable to an algorithmic approach. Psychiatry lends itself to a more empiric method. This is not to say the two disciplines are incompatible, but the approach to expertise in each is nuanced.

As a discipline, internal medicine is blessed with a plethora of high quality data. Indeed, the information is such that one must use algorithm and rigorous method to apply it in a meaningful fashion. There is general consensus in the field on the pathophysiology, natural history, and prognosis of many diseases. The fund of knowledge is such that it lends itself to diligent reading. Whereas, the study of psychiatry is obfuscated by lower quality data, less certain etiology, and more interrater variability regarding diagnosis.

I find these challenges in psychiatry engaging. Sure, I still enjoy satisfaction bringing someone out of a hyperosmolar nonketotic coma. There is an encouraging mathematical symmetry with metabolic derangement. However, I find helping that patient engage in the management their diabetes more effectively equally rewarding. This often requires the application psychiatric expertise to complicated psychological factors or disorders. Of the two clinical problems, I am much more confident in my prognosis on the former than the later. I don’t think reading more would change that.

 

[thoffen]

I find these challenges in psychiatry engaging. Sure, I still enjoy satisfaction bringing someone out of a hyperosmolar nonketotic coma. There is an encouraging mathematical symmetry with metabolic derangement. However, I find helping that patient engage in the management their diabetes more effectively equally rewarding.

I think this is essential to highlight. In fact, I would challenge you to consider that you might find helping the patient engage in their management of diabetes inherently more rewarding, and in fact that even non-psychiatrists and the most algorithmic doctors of all feel the same.

However, choice A is something in which you are an expert, that only you since you are the doctor can act to intervene, and it is 100% up to you whether you fix it or not, and it is something that you can absolutely 100% feel certain that you did the right thing and fixed it (or not, but there would have been nothing you could have done). The reality is not 100%, but given the degree of evidence and precision of guidelines, you can trick yourself into believing there is an objective 100% right thing to do.

Whereas the latter may be more rewarding but requires that you place yourself in a very different position. One as ally to patient in them solving their own problems, and one where you cannot be sure of your contribution, and you have to face the uncertainty that it might not get done right without you doing it, but even still it won't get done at all if you take it upon yourself. And this is the one where the failure is dire, chronic, and unknown. Where identity as an individual lies, instead of saying "I can treat DKA", it's "I can treat John. But maybe I can't". In short, admitting you are vulnerable.

Nonetheless, I still think it is more rewarding for the latter, and it is our own discomfort for vulnerability that we are palliating with so much evidence -- so often missing the target. Psychiatry is heading in the same direction as the rest of medicine, but at least there are vestiges of a different understanding floating around.

 

[hamstergang]

You asked my why I thought we don't have to "read" as much in psychiatry, and I gave a long answer, and then rather than responding, you dismissed my answer by saying that the entirety of my response speaks to my bad experience as a resident. Actually, my residency experience had very little to do with my response. I used details from my residency only to answer your question more completely. I still think it must be harder to pass the derm boards than the psych boards, and I still think that psychiatrists can get board certified with relatively little time spent hitting the books.

I'm not asking for the reason psychiatrists read less, I'm asking where you get the idea that psychiatrists actually read less. Even if I accept that the psychiatry board is easier (I have no idea), that doesn't mean that psychiatrists read less. It would be a possible explanation if psychiatrists did in fact read less, but it is not evidence that less reading is actually done.

Besides which, even if I was making a universal conclusion based on my individual residency experience -- so what? The vast majority of people who attend a psych residency will attend only one residency program. I have no obligation to "try to understand" what other people's residencies were like. Because it doesn't matter. It's a zero sum game. You choose your specialty, and you match at a program, and there's no way out - not with today's student debt. It's win or lose. It's not my job to "realize" that other programs were "different" (if they actually were). Rather, it's the job of people who want to lead this field and see it succeed, to make sure the training is adequate everywhere.

Now you just seem to be ranting about I don't know what for some reason. Residency is not a zero-sum game -- we can improve things everywhere without sacrificing training at other places. And I'm not asking you to understand what others' experiences have been like, but you can still recognize that one person's experience does not define a field. Sure, it's not your job to think about what residency has been like for me, but then don't get upset when I call you out for painting the whole field by your experience even when it runs counter to mine.

The point is, your program had problems and your education there was sub-optimal (by your description). Most programs didn't have such problems. If you're going to base your assumptions of the whole field on your experience, you're likely going to be inaccurate. If you care about being inaccurate is up to you, but that decision will influence the responses you get from others.

 

[nancysinatra]

You make some good points but you are over generalizing based on your experience. Every field in medicine has its shortcomings.
I am not trying to disparage your experience and you make some valid points. But if you read your posts you may realize the strong language you are using.Alleviating human suffering through psychotherapy is as noble a goal as algorithm based oncology.

We do the best we can in psychiatry with the tools we have.


Sent from my iPhone using SDN mobile

I'm not over generalizing at all. I'm just saying what I think. If others have opinions that differ, they are equally free to present them. The more the merrier!

Now I respect good psychotherapy, but I don't necessarily agree that "alleviating human suffering through psychotherapy is as noble a goal as an algorithm based on oncology." Here's why - it's really simple: Cancer, which is also a form of human suffering, kills people in huge numbers, high enough that I bet we all know someone who has died from it. Most of us probably even know someone who died from a relatively "rare" form of cancer, such as Waldenstrom's macroglobulinemia, which my uncle died from. Chemotherapy, radiation and surgery (and prevention) save a lot of people, enough to make dents in the population numbers, I am guessing. I think saving lives matters. And cancer is a worthy adversary. I'm so glad there are algorithms for treating cancer! Otherwise I have a couple friends who probably wouldn't be here!

Is the same thing true in psychiatry? Well, let me see... The single most deadly condition in psychiatry is anorexia nervosa, correct? Yet it's almost never discussed on this forum, and no one sheds tears over it, and very few psychotherapies are specially devoted to it - and none very successful. So where is the noble effort to save lives? I mean, this is our deadliest condition, shouldn't we have huge numbers of our specialists focused on it? Oh, guess what? No.

The only other thing remotely deadly in psychiatry, aside from anorexia nervosa, is suicide. A lot of psychiatrists do devote themselves to preventing this outcome. But suicide rates are also low, which means, no matter how many suicides we prevent, it won't affect the rates. Does psychotherapy in particular put a dent in the population statistics for depression? As far as I know it does not. A huge amount of our professional attention is focused on this one thing, and yet, is it helping society? It's like if all the oncologists in American decided to focus only upon one single, random, rare, mostly non-lethal form of cancer... and then were satisfied even when results showed no changes in mortality rates.

Now, it does seem that improvements in oncology have led to declining deaths from a number of forms of cancer, such as childhood leukemia. Meanwhile other cancers may be on the rise. But I have no doubt that people in oncology labs in America's best universities are at least working on these rising forms of cancer. I have no such confidence in the laboratories of American psychiatry. I don't even know where they are.

Mortality isn't the only measure - there's also morbidity. But I don't think we address that enough in psychiatry. At least, we don't seem to measure our results. I have all these patients I see for med management who are stable - I'm not worried they'll kill themselves - but their lives are a mess. They're on SSDI, and they take 7 meds for example (they came this way). To me, that alone is "morbidity." And psychiatry makes it worse. We fill out the disability forms and we prescribe the medications. That is hardly noble.

I still think it's great to relieve suffering through psychotherapy. Maaaaybe, if you're really good, it's noble. But it's easy to say we're doing a noble job when actually we're not. Everyone in medicine works hard, and means well. I think we should be judged not by our intentions, but by how much we accomplish.

 

[Bartelby]

I still think it's great to relieve suffering through psychotherapy. Maaaaybe, if you're really good, it's noble. But it's easy to say we're doing a noble job when actually we're not. Everyone in medicine works hard, and means well. I think we should be judged not by our intentions, but by how much we accomplish.

And it surprises me that (by your own telling) you accomplish so little. You mention that we don't have any useful tools:

"As far as what I'd say to patients who need treatment? If only I COULD! I'd tell them they're out of luck! They're alive in an era where we have no great tools, and almost no knowledge, only a tiny bit more than we had even 50 years ago. I'd encourage therapy, and tell them that based on their "symptoms" we can try a few medications, but I can't make any promises."

I am still finishing out PGY-IV and yet have taken house-bound panic patients and gotten them back to working and enjoying life after years of misery. I've taken manic patients who were completely out of touch with reality and stabilized them back to near their pre-episode baseline. I've taken depressed patients who felt everything was a fog and watched as the fog lifted and they re-engaged with their families and lives. I've helped multiple people go from drinking eight drinks a night to only drinking now and then. I've helped a personality disordered patient who regularly screamed at and intimidated their spouse in front of their children regain enough composure to stop doing that and begin rebuilding a quality of life. I've helped people go from daily self-mutilation to only rare self-injury. I've also done plenty of other useful work, and this is as a trainee with a relatively small patient panel.

I have also had patients with schizophrenia, personality, disorders, persistent MDD, etc. that I have not been able to do that much for. I hope that by being there for them, listening to them, and trying to connect them with whatever might help (including social services and programs) that I have at least made some improvement in their quality of life but I can't say that for sure.

But in short your doom and gloom representation of psychiatry is very one sided. You make it sound like we would be better served by pretty much abolishing the field and just training researchers. I get that you are bitter about psychiatry, but I think we do a lot of good.

You also make an odd criticism of our current approach, saying that the DSM is similar to the "four humors" approach and that we should use a textbook to explain the pathophysiology of all disorders. As many others have said we don't know the pathophys of disorders, so to create such a textbook would actually take us back to the "four humors" days of providing a pathophysiologically-based diagnostic system that is just incorrect. Right now we see that a lot of people present with certain clusters of symptoms and define things by syndromes, I too hope that we can do better in the future but if we don't know the etiology then it's not useful to write books pretending that we do.

 

[smalltownpsych]

I'm not over generalizing at all. I'm just saying what I think. If others have opinions that differ, they are equally free to present them. The more the merrier!

Now I respect good psychotherapy, but I don't necessarily agree that "alleviating human suffering through psychotherapy is as noble a goal as an algorithm based on oncology." Here's why - it's really simple: Cancer, which is also a form of human suffering, kills people in huge numbers, high enough that I bet we all know someone who has died from it. Most of us probably even know someone who died from a relatively "rare" form of cancer, such as Waldenstrom's macroglobulinemia, which my uncle died from. Chemotherapy, radiation and surgery (and prevention) save a lot of people, enough to make dents in the population numbers, I am guessing. I think saving lives matters. And cancer is a worthy adversary. I'm so glad there are algorithms for treating cancer! Otherwise I have a couple friends who probably wouldn't be here!

Is the same thing true in psychiatry? Well, let me see... The single most deadly condition in psychiatry is anorexia nervosa, correct? Yet it's almost never discussed on this forum, and no one sheds tears over it, and very few psychotherapies are specially devoted to it - and none very successful. So where is the noble effort to save lives? I mean, this is our deadliest condition, shouldn't we have huge numbers of our specialists focused on it? Oh, guess what? No.

The only other thing remotely deadly in psychiatry, aside from anorexia nervosa, is suicide. A lot of psychiatrists do devote themselves to preventing this outcome. But suicide rates are also low, which means, no matter how many suicides we prevent, it won't affect the rates. Does psychotherapy in particular put a dent in the population statistics for depression? As far as I know it does not. A huge amount of our professional attention is focused on this one thing, and yet, is it helping society? It's like if all the oncologists in American decided to focus only upon one single, random, rare, mostly non-lethal form of cancer... and then were satisfied even when results showed no changes in mortality rates.

Now, it does seem that improvements in oncology have led to declining deaths from a number of forms of cancer, such as childhood leukemia. Meanwhile other cancers may be on the rise. But I have no doubt that people in oncology labs in America's best universities are at least working on these rising forms of cancer. I have no such confidence in the laboratories of American psychiatry. I don't even know where they are.

Mortality isn't the only measure - there's also morbidity. But I don't think we address that enough in psychiatry. At least, we don't seem to measure our results. I have all these patients I see for med management who are stable - I'm not worried they'll kill themselves - but their lives are a mess. They're on SSDI, and they take 7 meds for example (they came this way). To me, that alone is "morbidity." And psychiatry makes it worse. We fill out the disability forms and we prescribe the medications. That is hardly noble.

I still think it's great to relieve suffering through psychotherapy. Maaaaybe, if you're really good, it's noble. But it's easy to say we're doing a noble job when actually we're not. Everyone in medicine works hard, and means well. I think we should be judged not by our intentions, but by how much we accomplish.

Ouch! There is a lot of truth in what you wrote and I think it is important for us as a field to acknowledge the problems you laid out. On the other hand, I watched a local play of To Kill a Mockingbird last night and was in tears at the end as I thought about Boo Radley and schizophrenia and how far we have come. A couple of my patients have schizophrenia and it is a pleasure to be part of their support system and watch medications and psychotherapy help them to function in a fairly normal fashion. It also saddens me to see how poorly run the CMHC is run and also how disincentifying and demeaning the disability and and housing system is. We have a long long way to go and I am equally dissatisfied with where we are at as a field and as a society.

 

[Bartelby]

The only other thing remotely deadly in psychiatry, aside from anorexia nervosa, is suicide.

It's also worth pointing out that some of what you are claiming is just factually incorrect. You claim that the only things in psychiatry that can kill are anorexia and suicide. You ignore:

-psychotic disorganization that leads to death by exposure, wandering into traffic, etc
-substance abusers who accidentally overdose
-impaired individuals (from various causes) who cause traffic accidents
-homicidal behavior (like the psychosis-inspired behavior in the Tarasoff case)
-catatonia
-delirious mania
-mismanaging general medical emergencies as psychiatric (after misdiagnosis)
-somatizing or Munchausen's patients who die as as a result of unnecessary procedures
-rare deaths from self-mutilation or swallowing objects

And those are just off the top of my head.

 

[clausewitz2]

It's also worth pointing out that some of what you are claiming is just factually incorrect. You claim that the only things in psychiatry that can kill are anorexia and suicide. You ignore:

-psychotic disorganization that leads to death by exposure, wandering into traffic, etc
-substance abusers who accidentally overdose
-impaired individuals (from various causes) who cause traffic accidents
-homicidal behavior (like the psychosis-inspired behavior in the Tarasoff case)
-catatonia
-delirious mania
-mismanaging general medical emergencies as psychiatric (after misdiagnosis)
-somatizing or Munchausen's patients who die as as a result of unnecessary procedures
-rare deaths from self-mutilation or swallowing objects

And those are just off the top of my head.

Let's not forget encounters with law enforcement that go terribly wrong.

 

[NickNaylor]

I skipped a good majority of the posts but thought this was an interesting subject.

I've had some of this conflict throughout intern year on my psych rotations. The "it depends on the attending" approach is definitely valid. As you work with different attendings, you will start to get a sense of how rigorously - or not - they approach history-taking and diagnosis. However, I also agree that you shouldn't be reserved about asking questions (note: this is different than being confrontational). By asking questions of attendings when I don't understand the diagnosis, one of two things happens: I learn that the attending can't justify the diagnosis and I add that to my running impression of attendings, or I learn something. Sometimes the attending focuses on something that I disregarded and we come to different conclusions as a result. I think that is an incredibly educational task - even if you don't necessarily agree with an attending's interpretation of or emphasis on a particular piece of information, it opens your eyes to the kinds of things you should at least pay some attention to.

The truth is that we often make diagnoses on incomplete, biased information and fairly snap judgments based on, in the big scheme of things, a relatively brief interview. As others said, this may not be a perfect system, but it in many cases it is adequate enough to perform our key function, which is helping the patient. This is part of the challenge of psychiatry. Ambiguity and grey areas are centerstage in our specialty.

Ultimately you can still learn even in the face of this ambiguity. It would be great if we had perfectly validated and reproducible diagnosis, but sadly we do not. I don't think that means the endeavor is useless or that you can't learn something from trying to sort out the problem.

 

[doctorpilgrim]

I believe the discussion hinges around medical uncertainty. Medicine is filled with decisions made in the absence of well-established information. Evidence based guidelines are just that- guidelines. They provide the general framework within which physicians operate; they help us differentiate the “horses from the zebras.” Many physicians struggle with the reconciliation of population based evidence with case based practice. In fact, emphasis of physicians’ education in the sciences may contribute to a perception of threat in ambiguous clinical situations. Such intolerance to uncertainty is likely correlated with discomfort in treating equivocal medical conditions.

Thus, physicians will likely gravitate toward medical specialties that play into their personal diagnostic comfort zone. The more unambiguous specialties tend to draw like-minded physicians. As an internist, I approach problems in a different fashion than I do as a psychiatrist. Although both specialties share a basic premise of medical knowledge- internal medicine is much more amenable to an algorithmic approach. Psychiatry lends itself to a more empiric method. This is not to say the two disciplines are incompatible, but the approach to expertise in each is nuanced.

As a discipline, internal medicine is blessed with a plethora of high quality data. Indeed, the information is such that one must use algorithm and rigorous method to apply it in a meaningful fashion. There is general consensus in the field on the pathophysiology, natural history, and prognosis of many diseases. The fund of knowledge is such that it lends itself to diligent reading. Whereas, the study of psychiatry is obfuscated by lower quality data, less certain etiology, and more interrater variability regarding diagnosis.

I find these challenges in psychiatry engaging. Sure, I still enjoy satisfaction bringing someone out of a hyperosmolar nonketotic coma. There is an encouraging mathematical symmetry with metabolic derangement. However, I find helping that patient engage in the management their diabetes more effectively equally rewarding. This often requires the application psychiatric expertise to complicated psychological factors or disorders. Of the two clinical problems, I am much more confident in my prognosis on the former than the later. I don’t think reading more would change that.

So if you are comfortable with ambiguity and take it as a challenge then psychiatry is rewarding.
Trying to blame bad care on ambiguity in psychiatry when we know, is what it is. We help patients in their struggles with humility and accepting that we know what we know. I don't think there is certainty in any field although I may be wrong.


Sent from my iPhone using SDN mobile

 

[Ceke2002]

The single most deadly condition in psychiatry is anorexia nervosa, correct? Yet it's almost never discussed on this forum, and no one sheds tears over it, and very few psychotherapies are specially devoted to it - and none very successful. So where is the noble effort to save lives? I mean, this is our deadliest condition, shouldn't we have huge numbers of our specialists focused on it? Oh, guess what? No.

It's also worth pointing out that some of what you are claiming is just factually incorrect. You claim that the only things in psychiatry that can kill are anorexia and suicide. You ignore:

-psychotic disorganization that leads to death by exposure, wandering into traffic, etc
-substance abusers who accidentally overdose
-impaired individuals (from various causes) who cause traffic accidents
-homicidal behavior (like the psychosis-inspired behavior in the Tarasoff case)
-catatonia
-delirious mania
-mismanaging general medical emergencies as psychiatric (after misdiagnosis)
-somatizing or Munchausen's patients who die as as a result of unnecessary procedures
-rare deaths from self-mutilation or swallowing objects

And those are just off the top of my head.

I'll add to this list. In terms of deaths directly caused by Anorexia Nervosa alone, here's a list of the friends from my eating disorder support group that have passed away since 2004, with their diagnoses and cause of death (I'm listing them by the first two letters of their name only).

Em - Diagnoses: Bipolar Disorder (not responsive to medication), Bulimia, Binge Eating Disorder, Self Harm ~ Cause of Death: Suicidal Hanging
Am - Diagnoses: Bulimia, Depression ~ Cause of Death: Suicidal Overdose
Ju - Diagnoses: Borderline Personality Disorder, Depression, Bulimia, Self Harm ~ Cause of Death: Suicidal Gunshot
Ka - Diagnoses: Anorexia Nervosa (purging subtype), Depression, Self Harm ~ Cause of Death: Suicidal Overdose
Al - Diagnoses: Anorexia Nervosa (purging subtype), Depression ~ Cause of Death: Pulmonary Embolism from an unrelated condition (after achieving full recovery/remission from psych presentation)
Li - Diagnoses: Bulimia, Binge Eating Disorder, Depression, Self Harm, Alcohol Addiction ~ Cause of Death: Paracetamol Overdose (death by misadventure unable to determine suicidal intent)
Ti - Diagnoses: Anorexia Nervosa (purging subtype in partial remission), Depression, Borderline Personality Disorder ~ Cause of Death: Suicidal Overdose
Ja - Diagnoses: Anorexia Nervosa (predominantly restricting subtype) ~ Cause of Death: Sudden Heart Failure
Ha - Diagnoses: Bulimia, Depression, Alcohol Addiction ~ Cause of Death: Gastric Rupture

So if you count diagnoses besides Anorexia Nervosa alone, that's still only two people I've known personally who died as a direct result of their eating disorder (heart failure and gastric rupture) and not indirectly through suicide or death by misadventure. If you're going to look at reducing the morbidity of something like Anorexia Nervosa, in my opinion at least, then you need to look at the actual causes of death in the longer term so that research/preventative measures can be better focused. And if you think that the diagnosis and treatment of Anorexia Nervosa hasn't improved at all in the past 30 or so years, then you're wrong -- having developed Anorexia Nervosa myself back in 1980, I've seen a lot of the changes first hand (better recognition with earlier treatment intervention for one) much of it in the last 10-15 years alone.

As for lack of research, research into Anorexia Nervosa has increased enormously in the last 10 years at least. Look at the brain imaging and twin studies conducted by Walter Kaye, or the world wide ANGI study currently being conducted to name just a few. Heck even one of the last frontiers of research into Anorexia Nervosa is finally being breached albeit gradually ~ just what to do, exactly, with the chronic (SE-AN) patients. Granted things could be better, things could always be better, and there are advocacy groups pushing for things like better research funding, but name any other Psychiatric illness that wouldn't benefit from more research or where research is already adequate enough.

Just on a final note, of course there is nobility in saving lives, but there is also nobility in improving the quality of someone's life.