My thoughts on your thoughts:
(some points are skipped)
1. I agree completely. Usually less is definately more. I as a psychiatrist are there to evaluate. That means I'll ask the questions that I feel with further my assessment, or clarify issues that will further my assessment. This should ideally have an impact on treatment.
This is not to say that healthy curiousity has no place in the interview. It's one of our innate qualities as humans, and can often lead to the root of motivations and behaviors - which are then treated.
2. Take too much history. This is one of my pet peeves. There seems to be a direct inverse relationship between the strength of the resident/attending, and the amount of copious detail obtained. I'm not interested in where my 62 year old decompensated schizophrenic attended high school, and you're right - I don't trust other peoples' diagnoses when it comes to family history. Attendings, nearly invariably, will push for deeper and deeper histories in hopes that more thorough presentations and history taking (of course not done by them) will somehow get them off the hook, allowing them to return to their faculty practice earlier.
3. Blame lawyers/insurance companies/big pharma.
Lawyers are a problem. I'm not sure how anyone can think they are not. WHile your belief in the American Justice system is stout and utopian, it's also somewhat naive and appears unrealistic. Not all malpractice cases have merit, as you point out, but some do make it to trial that should not have. Even one is too much. Defensive medicine costs the country billions/year. This is a direct product of medical litigation. 10 million dollar settlements from average IQ juries DO happen to mothers whose children are born with MR and CP. It's not right, and it is our reality. It is an adversarial system by definition, and doctors have nothing to gain...they can only lose. Of course, the opposite is true of lawyers, as they incur their own immunity and have mostly to only benefit from outrageous awards.
They have no means of self-regulation, unlike physicians, and they know that easy money can be made in the med-mal business. It's a visciously competitive world for attornies, and this is one way they can maintain their perceived lifestyle. It should not come on the backs of doctors. "Laws" such as "get rid of bad doctors" statutes in Florida are a disgusting example of this.
4. Become social policy analysts. Another pet peeve of mine. We have no business shaping fringe issues such as gay marriage, use of psychiatric techinques in interrogation, etc. YOUR view on morals or the APA's view may not be my view, or even the majority. No one wants to appear cold hearted, and the groupthink mentality is rarely useful.
5. Therapy is important. However, not all patients want, nor do I think they need, in-depth analysis or "rehashing" as one of my patients says of their old issues and hurts. OCD is nearly 100% biological. Some of my patients with OCD function perfectly in the outside world with the benefit of medication. They don't want therapy, and frankly, they don't need it.
The same can hold true for other disorders such as schizophrenia and even bipolar disorder.
6. Sometimes people don't need to know.
Exactly. Another phrase I also use that makes my attending cringe. They feel the need to disclose the 95th possible side effect that occured in on in a sample of 3000 patients due to #3 above.
7. Polypharmacy. This a difficult one.
I'll be honest. Sometimes it's indicated. It's not just me that thinks that. Some great pharmacologists (Stahl, etc), advocate this. Unfortunately, it's not as simple as "all antipsychotics block dopamine receptors, so why are you adding another one." We're only beginning to see now that there are neurochemical pathways that are not unique to humans as a whole, and that different same class medications have different effect on receptor subtypes, etc. This is why one antipsychotic may cause orthostatic hypotension, while another will rarely do so.
Let me be clear. I in no way advocate someone being on 3 antipsychotics, 2 antidepressants, and a benzo. That is unreasonable. However, I have seen on dozens of occasions, stabilization that occured only after a second agent was added, with concomitant decompensation when the second agent (or the first) was discontinued some time later.
Thankfully, there is a push to not blindly follow scientific outcome and evidence based medicine. While a core in evidence base is important, there is an important axiom that must be remembered: What works for all "those" patients may not work for
my patient. In no branch of medicine is this more true than psychiatry. My job is to get the patient feeling better and to remain stable. If two medications accomplishes that goal while one does not, I'm keeping them on two.
Of course, monotherapy is the strived-for goal if at all possible.
8. His axial diagnosis is "Nothing!"
Again I couldn't agree more. It seems to me that it is the more immature and unsophisticated psychiatrist that feels the need to label anything and everything (including behaviors) that walk into the door. No one is more of a fan of classic descriptive psychiatry than me, but there is an important difference between "diagnosis" and "description." The former is often useless.
Great thoughts.
Keep them up!
--but the tiny white on black type gives me a headache!!!!
