I was fortunate enough to get great training (SUNY-Upstate for MD and Oregon for residency/child fellowship). After graduating I promised myself I would be true to my psychodynamic roots (Hal Boeverman RIP), do thorough evaluations and provide the finest psychiatric care possible. After leaving Oregon I happened to travel through Montana on the way to visit my family back in NY State. I was smitten.
I am always amazed at the differences between academic and community psychiatrists.
Fortunately a job was available in Billings, and here I have been ever since. I felt like quite the bright young thing arriving in the hinterlands and remember being appalled when the first thing my nurse asked me for was a presigned book of prescriptions, since she did most of the refills. I was horrified at the thought! The signature is sacred! I soon figured out that my nurse knew more about child psychiatry than I ever would, and the scrips were signed.
Now we do everything via computer, and I just sign the controlled substances. I also found out that I had inherited a practice of hundreds upon hundreds of children and adolescents. Our four-man clinic runs the only child unit for hundreds of miles in all directions. It is not uncommon for people to drive ten hours for an appointment. I quickly abandoned my idealistic hope of providing exquisite care for the few, and began my life’s work of providing pretty decent care for many. And obviously, I have become fairly comfortable with the 90-min evaluations and the 25-min med check.
But when I see an article like Dr. Edersheims’s excellent piece on off label prescribing of atypicals, I have this horrible mixture of guilt and despair. Edersheim nicely makes an argument for how to handle the vagaries of off-label prescribing, but if I tried to practice even a fifth of her ideals regarding extra info, collecting articles, more monitoring, increased consultation, I would never make it past my 9:00 appointment.
The reality is I have a 10 year old from Lewistown hallucinating in my office and the next patient is a 14-year-old from Billings who has broken up with a boyfriend and wants to die. The other reality is that I am about it. Therapists are rare in rural Montana. Pediatricians and family practitioners don’t want to go near this stuff. So of course I am going to go off-label.
I am a general child psychiatrist; everything (practically) is off-label. And it seems to me we have gotten so defensive and fixated about medication side effects (which can be horrible!) that we as a profession go into denial about what happens if we don’t treat these conditions. We have just a relative few weapons for a lot of chronic, dangerous illnesses. They need to be prescribed as intelligently as possible, but we also need to understand that those of us in the field need to treat a lot people quickly and efficiently and to not underestimate the morbidity and mortality of ignoring the plight of folks who need “off-label” treatment.
Jim Peak MD
Billings, MT
