What Clinicians Can Learn from their Patients
I arrived back home in rural southern California late Wednesday night. Two days before, on the opposite coast, I gave a grand rounds lecture to about 60 clinicians at Princeton House, a psychiatric facility associated with the Princeton Healthcare System in Princeton, NJ.
Therapists and social workers made up the bulk of my audience, but a smattering of psychiatrists also turned up. The year before, I had given about 15 or 16 talks to fellow patients and loved ones. This was new to me.
As a journalist, my role is to listen to the experts, not tell them how to do their jobs. The week before, I had attended the American Psychiatric Association's annual meeting. Mainly, I breathed through my nose. I only opened my mouth to ask questions. Until I can figure out in which hemisphere of the brain the left prefrontal cortex is located, that's the way it should be.
The title of my talk was "Controversies in Psychiatry: A Patient/Reporter Discusses Compliance."
I was only going to tell my audience that sending a patient out the door with just a prescription is not treatment, that when patients complain about feeling like fat stupid zombie eunuchs on the meds they prescribe that we are not doing this to ruin their day, that new generation antipsychotics are basically Thorazine with the tires rotated, and that maybe psychiatrists need to pay as much attention to their patients as the Heidi Klum/Russell Crowe-look-alikes that the drug companies send to their offices.
Nope, nothing too controversial.
I had 69 PowerPoint slides to back up everything I had to say - citations from mainstream psychiatric journals, quotes from leading experts, research studies ad infinitum.
I started out my talk with "The Problem Patient." Marilyn Monroe was Exhibit A. Marilyn walks into your office, I began. Everything points to bipolar. How do you treat her?
"Do I hear mood stabilizer?" I asked.
Sixty heads nodded. (Hmm, maybe these guys need mood DEstabilizers.)
Fine, we have a consensus, I said instead. But how does the most important person in the equation feel about this? Namely the patient.
This is Marilyn, after all. Over-the-top is her baseline. For someone else to act like Marilyn, well maybe that's hypomanic. For Marilyn to act like Marilyn - that's normal. So we want to reel her in a bit without over-medicating her. After all, how long do you think Marilyn is going to stay on her meds if she feels her wings are being clipped?
Then we have to consider Marilyn's various personality issues, such as clear suggestions of borderline personality disorder and assorted behavioral quirks. You are not just treating the illness, I explained. You are treating anything that gets in the way of treatment.
Finally, there is the illness itself. Marilyn's moods and emotions are bound to affect her judgment, including her ability to make a rational decision to stay on her meds.
So Marilyn has three strikes against her before she even leaves the office.
Every head in the room was nodding in agreement with me when I posed the proposition that Marilyn would never stay on her meds. Unless something more was done for Marilyn, she was doomed. That sending Marilyn out the door with nothing more than a prescription was a fatally-flawed principle.
I should have stopped my talk right there. I had made my point in the first 10 minutes. But this was a 45-minute presentation and I had another 35-minutes (plus Q and A time) to fill up. Everything that followed was anticlimax.
If I had to do it over again, I would have thrown away the script after one particular remark of mine. This is when I explained that a lot of us see the world through the eyes of artists and poets and mystics and visionaries, not to mention highly-successful professionals and entrepreneurs.
Basically, give us respect for who we are. Honor it.
"We don't want to be like you," I explained.
Sixty startled faces. Uneasy silence.
"From my point of view," I adlibbed, "all the rest of the world has flat affect" (clinical terminology for I find all of you as exciting as Ben Stein in Ferris Bueller's Day Off).
Doubly-startled faces. Tension you could cut with a cliche.
"Including Robin Williams," I joked.
Laughter, sighs of relief. Then I moved ahead with the next point in my script.
Hey, wait, I should have said instead. I'm finding this interesting. Let's talk about this. Seriously, we don't want to be like you. Why should you find this so surprising?
I had missed a golden opportunity to get a dialogue going. Clearly, these clinicians needed to learn where we were coming from. Clearly, I needed to learn where they were coming from. I'll probably never get another chance to speak to clinicians again, so I may never find out.
I finished my talk, and the room emptied out at once. Unlike talking to patients and families, no one was interested in hanging around, in talking to me one on one. I couldn't help but think of the F Scott Fitzgerald quote:
"Let me tell you about the very rich. They are different from you and me."
Except that we are the ones who are very rich. Who, after all, wants to be Ben Stein?