Tuesday, September 1, 2009

No One Owns Us, No Matter Who Has Sold Us

Thank you Dr. Frances for making explicit what has been an implicit, sad trend in our profession. I also believe we have slowly sold out to the pharmaceuticals. Perhaps, first, it was to legitimize ourselves as part of "real" medicine. I could have lived with the psychiatry of twenty or even ten years ago. The pens, dinners, and drug samples did not pose any heart-wrenching ethical dilemmas for me or any colleague I knew. But these past ten years, there's been a creeping toxic alliance between big business (insurance, big pharm) and our professional elite. And this sell-out has nothing to do with plastic perks. We have invited the drug companies to dictate our theories and diseases and support our research for answers that sell their products. The only folks who don't recognize this as self-serving and transparent are us.

The overselling of pharmaceuticals by psychiatric "spokes-professionals" has saddled the hard-working private Docs with the credibility gap of a used-car salesman. That's why people are running to alternative medicine. Given the recent news, why shouldn't someone wonder if we’re hyping meds to "guarantee" repeat business?

And what about the quality of our own professional life? We're left with a field that chokes on creativity and once embraced innovations. Now, anyone who does not march to the drum-beat of evidence-based medicine risks censure, although the limitations of this model have been extensively exposed.

I agree with Dr. Frances that classifications used by practitioners should be created or at least informed by them. We are the professionals who have a grasp of those who get ill. Those who conceptualize patients in terms of significant deviations and benign to severe symptoms will not know them, nor see obvious truths. Right now, one obvious truth is people are angry with us and it's not a part of their diagnosis. They need to trust the integrity of professional they see. How can they, given the above? Would we?

What Dr. Frances describes is a nightmare - new diseases to pathologize more of "normal" life that will need more medication. Throw in electronic medical records and no one will dare go to us, for fear of being branded with a four digit code. (Yes, I mean that allusion. How many readers remember our protests to Soviet psychiatry?)

I agree with Dr. Frances that the DSM, our "Bible" implies more than metaphorical weight. We need to think carefully now. What we define as illness also implies what's healthy. This "Bible" will imply that those who do “adapt" to our stressed-filled, detached, and achingly competitive lifestyle are adjusted. Since many of us share that life, we may not want to look at it too closely.

Do we agree? If you are over 40, you have witnessed a rocket acceleration of changes in how we live. During this time, our profession has adopted a complaint posture, one that accedes to conformity, going with a flow and being on top of it. We don't think to buck it, anymore. And the flow now is materialism which dictates that cost-effective is a synonym for "right" and "best." We have been instrumental in promoting that equation so we should ponder the truth of this, at least a little.

And unless we get totally discredited by our more ambitious colleagues, like it or not, we psychiatrists are still the "Priests of Normality. If we take our role with any gravity, we might ask ourselves whether the lifestyle we endorse as "normal” really nurtures healthy.

Whether or not you believe we have sold out to big pharm, whether or not you think medications are the answer for all ills are no longer important. As Dr. Frances implies, there are bigger "fish frying" and more than our professional integrity or power at stake.

The past ten years, our profession has joined hands with big business and politicians and marched an increasingly materialistic road, from the medicine we practice (in which personality is reduced to DNA and neurotransmitter concentrations) to the values that guide us (bottom line bucks.) Meanwhile, we are bleeding soul and courage, words that will never be found in any DSM, ever. But we know them and feel a gnawing void when they are not present.

Maybe we got so entrenched in materialism for the same reasons our culture did. That doesn't mean we have to remain so. As "Priests of Normality," we could concern ourselves with making "normal" more humane, rather than "making" a DSM that makes mental illness more pervasive. We could use the credibility we have left to make businesses more family-friendly. We might have more healthy children. We could focus on people empowering themselves to take charge of their out-of-control lives. Why should we push pills to "help" people adapt to what's making them sick? We could change the focus of who we are. We could stop being prescribers.

No one owns us, no matter who has sold us.

Peggy Finston MD
Prescott, Arizona

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