“We’re Doctors. We Prescribe Drugs. That’s What We Do.”

One of my most vivid memories of medical school was during my internal medicine rotation, when it had become apparent to me that, despite spending my pre-clinical years studying complex pathophysiology and pharmacology, and the fine art of history-taking and the physical exam, the actual clinical work seemed to be more like a numbers game.  I felt like I was always responding to a data point:  a blood pressure reading, a glucose level, a WBC count.  And the response always seemed to be the same:  I prescribed a drug.

To my immature medical mind, it seemed almost too simple.  I thought a computer could do it just as well.  When I commented to my attending physician that we seemed to be emphasizing medications over lifestyle changes, alternative therapies or preventive measures a patient might take, he responded, “We’re doctors.  We prescribe drugs.  That’s what we do.

Fast forward about 10 years.  I now work part-time in teaching hospital.  One of my responsibilities is the supervision and training of psychiatric residents and medical students.  Recently, one of the students asked whether her final exam for the psych rotation would include questions about psychotherapy, to which my colleague responded (and yes, this is a direct quote), “No.  We’re doctors.  We prescribe drugs.  That’s what we do.”

The echoes of medical school resounded loudly.  But the words from med school professor had had a very different impact on me a decade ago than those spoken by colleague just last week.  While I accepted my professor’s words as the insight of a seasoned expert about what really matters in medicine, my psychiatrist colleague’s comments rubbed me the wrong way.

It made me wonder, has medicine changed?  Or have I?

I (and numerous others) have written extensively about how psychiatric drugs don’t work nearly as well, or as frequently, as advertised.  Others have written eloquently about the inherent dangers of psychiatric medication—a viewpoint which has been, at times, exaggerated, but to which I have become more sympathetic over the years.  These are two reasons to shudder at the fact that psychiatrists-in-training are being taught to emphasize the pharmacological approach.

But more important to me is the fact that, with comments like these, we psychiatrists are actively positioning ourselves to rely on a treatment philosophy that may well have run its course at some point in the not-too-distant future.  (Will today’s psychopharmacologists face a fate like those of the psychoanalysts of the 1950s and 60s?)  If students and residents increasingly see psychiatry as a pharmacology-oriented specialty, they will be less likely to explore other interventions that may ultimately prove to be more helpful to their patients.

Psychiatry is already ceding territory to other professionals.  Psychotherapy is taught in most psychiatric training programs, but few psychiatrists are paid (or choose) to do therapy.  Understanding how to provide systems-based care, or integrate psychiatric care into a patient-centered medical home (PCMH) model, is not something psychiatrists are trained to do, despite the obvious drift of American medicine in this direction.  Even some areas that could arguably be considered areas of unique psychiatric expertise— developmental disorders, addiction treatment, child development, geriatric neuropsychology, psychosomatic medicine, integrated pain management, trauma recovery, to name a few—aren’t a major part of the psychiatric curriculum.  Why not?  There are no drugs that we can prescribe (and, similarly, no drugs approved by the FDA) to treat these conditions.

This gradual erosion of psychiatric training has two consequences.  First, it opens the playing field to other mental health professionals who can generally provide their services more cheaply than psychiatrists do.  While most of these specialists perform their jobs quite admirably (making the psychiatrist irrelevant, by the way), the prioritization of cost over quality may result in patients getting worse care over the long run, especially if rigorous standards are not upheld.  Secondly, because meds are still where the money is, more non-psychiatrists are getting into the psychopharmacology game.  Psychiatric nurse practitioners (who have prescribing privileges), physician assistants, family practice docs, Suboxone jockeys, psychologists (in some states), and many others see psychopharmacology as a way to keep their customers patients satisfied and to keep their offices full.  When, in the end, the data show that these patients fare no worse (or, sadly, no better) than those seen by psychiatrists, then the writing will really be on the wall for most of us.

Some readers, particularly those working in a private practice setting, might respond, OK, I see your point, but some psychiatrists really do provide comprehensive, thoughtful care to their patients.  To which I would say, yes, but they are truly in the minority.  My own career trajectory (as well as my personal life) has taken some unexpected turns, and these turns have taught me how psychiatry is practiced among the masses in “the real world,” not in the Ivory Towers of Cornell, Stanford, or UCLA.  For the majority of patients and providers, psychiatric treatment is a numbers game, and the numbers are easy to follow:  More patients + More appointments per day + More medications prescribed = Everyone wins.

I believe that not only can psychiatrists provide better care than the medication-laden treatments we dole out today, but we have a responsibility to do so.  Four years of medical school and four years of residency provide plenty of time to learn about human behavior, emotions, the roots of motivation, child development, family systems, learning theories, interpersonal skills, coping strategies, evolutionary psychiatry, ego psychology, personality theory, human sexuality, spirituality, existentialism, psychodynamic principles, and basically everything else that makes a person tick, in addition to the basic biology of the disorders we diagnose and treat.  To dismiss this in favor of a medication-oriented curriculum that could be obtained in a weekend seminar or in an industry-funded CME course, is an insult to our intelligence, and, potentially, the downfall of our profession.

When the prescription pad becomes a hammer, then every symptom starts to look like the proverbial nail.  Perhaps it’s time for psychiatrists to dust off some other tools before it’s too late.

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27 Responses to “We’re Doctors. We Prescribe Drugs. That’s What We Do.”

  1. Lizzy says:

    i have seen some great psychiatrists and some terrible psychiatrists during my crazy history. the best have been at the university hospital near where i live– young doctors who KNOW about my illness and CARE enough to help/refer/treat.

    here’s my most recent horror story. i was released from the psych hospital in july, but was informed it would take months to see the psychiatrist at my local community mental health center (it took until november). i was out of lithium and feeling rather out of control by september. despite my nearly TOTAL lack of funds, i went to see a private psychiatrist in the mean time. she accepted my $150, talked to me for 45 minutes, informed me that i was “a fascinating liability,” that she couldn’t treat, and sent me out the door, no treatment, no prescription, and no suggestions for where i could go that WOULD help.

    she could have done a prescreening on the phone and let me keep my money and dignity, AND saved me the time and effort of sharing my entire history, only to get turned away.

  2. observer says:

    Well, you could always have become a psychologist and make even less money than you do now. It is much like saying a surgeon shouldn’t operate or a urologist doesn’t need a patient to disrobe. It is easy to reject what you already have.

  3. Carol Levy says:

    A main issue is insurance reimbursement. Teach the insurance companies that there is a profitability in paying for psychotherapy (reducing inpatient stays and days maybe (?) and there might be more willingness to not see psychiatry as “We prescribe drugs, that is what we do.” But yes, there is also the equation, prescription pad, quick in and out of patient =s a lot more pt visits per day. That is, for sure, to the benefit of the doc’s, and pharmas advantage.

  4. catsrgreat says:

    Lizzy, I had a family doctor prescribe lithium when I was between psychiatrists and he was happy to do it, but this was maybe 10 years ago and maybe they are less willing.

    One suggestion that suprised me was when an elderly psychiatrist saw me at the state hospital (I had a bizarre reaction to yet another medication, and was having zero luck with meds) and he said he recommended that I take vacations in the southern states in the winter. He said he had a patient who went golfing in Florida twice a year in the winter, and it helped a lot. It is difficult to afford, but I think my husband and I may try it this year, because my new doc has recommended the same thing. Anyway, over the years, the docs have pushed meds so very hard, and it is a great surprise to me when some other kind of intervention is suggested.

    And btw, I didn’t get any better care at fancy universities. It was still all pills, pills, pills, and they don’t work for me (except lithium, which does nothing for depression). The support staff were, on average, a lot nicer and better trained at the fancy hospitals, though. The state hospital was abusive beyond belief. The very nice doctor rotated in for a few weeks, I think.

    • Lizzy says:

      i was in a conundrum– while i was hospitalized, it just so happened that my long time psychiatrist retired. i resigned from my job and lost my insurance, so i no longer had a family doctor at all when i got out.

      i wonder at the vacation suggestion– i think that might help. i love young psychiatrists and old psychiatrists… i haven’t had so much luck with middle agers, lol. i would like to travel to a sunny area once our financial situation improves. god knows my husband, who is african, would love it.

      i hated the private hospital in my area– nice nurses, but the doctor was evil personified. at the state hospital, my psychiatrist was all about the meds, for sure… but the psychologist was great, and that is who is recommended that i do dbt, which has made a world of difference in my life.

      i’m not taking any meds now– once i saw the psychiatrist a couple of weeks ago, i was feeling somewhat better already and have decided (probably unwisely) to see how long i can keep my shit together without medication… i was stressing so much about how to get a doctor/get a script/pay for the meds that it just seemed better to just do without. but i’m sure i’ll eventually pay for that decision.

  5. Iatrogenia says:

    i just wrote a bit about Neuroscience, a company that provides various kinds of neurotransmitter testing (via urine sample). https://www.neurorelief.com/index.php?p=testing

    The tests produce what Neuroscience claims is a neurotransmitter profile, showing excesses or deficiencies in neurotransmitters. The results printouts include recommendations for the company’s proprietary supplements matched to the individual’s neurotransmitter profile.

    The tests and supplements are quite expensive. The program, often prescribed by naturopaths, is not covered by insurance. Neuroscience is, as near as I can tell, an expanding business.

    Okay, so here we have a (bogus) diagnosis followed by a (bogus) prescription. How is this different from psychiatry, including psychiatry practiced by GPs or, gasp, psychologists?

    In its pursuit of commercial success, psychiatry has permitted easy replication of a profitable model. It will not have what you call a wide moat unless the fundamental model is changed.

    The good news for psychiatrists is that there’s tremendous demand for specialists who can unravel the psychiatric polypharmacy other doctors get their patients into, i.e. doctors who can safely taper people off drugs and deal with whatever iatrogenic damage emerges.

    In other words, the cleanup team. This should provide plenty of work for interested psychiatrists for decades, until the field differentiates itself from pharmaceutical sales and distribution.

    • Iatrogenia,

      I know some people who were helped by Neuroscience labs… In fact, they have what some say are the best Lyme panel tests… Lyme can mimic the symptoms of “mental illness” (as can many other underlying physical conditions, not the least of which are nutritional deficiencies).

      There is a former child psychologist in the Dallas area who used to provide therapy for kids with emotional problems, until he became quite proficient in testing for amino acid imbalances, and began using amino acids with his patients… He no longer does “talk therapy”… The kids get well, and stay well when their brains are being properly nourished… He has all the business he can handle… Go figure.

      It seems to me that you are quick to call Neuroscience “bogus.” You’re entitled to your opinion… however, I’ve read many of your comments, on this blog and others, where you come across as almost a self-appointed spokesperson for those of us who would like to see a paradigm shift take place, away from the status quo and toward more healing arts and sciences.

      You have on many occasions edited my comments, for instance… insisting I used language that you deem appropriate, etc. I would only ask that if you are intent on editing comments from others, and acting like a self-appointed spokesperson that you will at least let us all know who you are… rather than using a pseudo-name…unless, of course your real name is Iatrogenia…. In other words, who are you? I somehow visualize a guy in a basement in Idaho… Am I right?

      Duane

      • compsports says:

        Duane,

        The issue isn’t psychiatry vs. antipsychiatry or mainstream medicine vs. alternative medicine. It is that many practitioners (mainstream and alternative) practice one size fits all philsophies come heck or high water.

        Steve pointed out how many physicians do this with drugs and Iatrogernia was giving the opposite side of the coin with neurotransmistter testing. By the way, according to medical professionals I have corresponded with who aren’t anti alternative health, true neurotransmitter testing can only take place when you are dead. Anyway, in my opinion, this is no more legitmate than psychiatrists claiming that people with depression are suffering a chemical imbalance.
        By the way Duane, I am not anti alternative health. But to quote Corinna West, who has spoken eloquently about her great improvement after getting off of psych meds, I am anti bullshit and will cry foul when I sense it whether it is coming from mainstream (which includes psychiatry) or alternative folks.

        Anyway, many of us with complicated medical conditions are desperate for professionals who don’t have mainstream or alternative biases and will suggest treatments on what the evidence says. They will also treat me as an individual. Sadly, for now, this is mostly a pipe dream.

      • Iatrogenia says:

        Duane, read my post. It refers to Neuroscience’s neurotransmitter testing, which is bogus. Besides which, “balancing neurotransmitters” is as nonsensical in alternative medicine as it ever was in mainstream medicine.

        Neuroscience should be ashamed of peddling this snake oil, as should any medical practitioner.

      • Iatrongenia,

        Post your own comments, and let others post their comments.
        You’re not a spokesperson for any group, organization or cause… Hell, nobody knows your freakin’ name!

        Duane

      • Compsports,

        It’s become the hip thing to do, the politically-correct thing to do… to preface any/all statements with “I’m not anti-psychiatry”…

        This statement has been around for quite some time. It’s very popular… It really means nothing to me when I hear it, other than it makes me question if the injury from conventional psychiatry will end any time soon… It seems more important to be seen as politically correct than to make the changes that are needed.

        Duane

    • You just described the majority of what I do with my time. So many folks come in from a para-professional with a diagnosis of “bipolar II” and a weird and expensive regimen of seroquel, abilify, and lamictal. It almost always turns out they have a bit of a character disorder, some anxiety, and maybe some ADHD thrown in on top of the depressive symptoms. Sometimes there is an actual bipolar disorder!

      When the APA sends me the latest alarm bell about psychologists prescribing, I think, well, more clean-up for me.

      Steve – thanks or the shout-out. Didn’t know you read my blog 🙂

      • Iatrogenia says:

        All the best psychiatrists seem to be doing clean-up. Thanks for taking care of your patients’ nervous systems, Dr. Dean.

        Too bad they get battered by all those drugs in the first place, like those kids in foster care who are on multiple psychiatric drugs. Tip of the iceberg.

    • Hi there good people, I’m both a PhD scientist and a representative of NeuroScience, Inc. Always happy to jump in and clear up misinformation in what is otherwise a healthy debate. First off, it’s not true that insurance doesn’t cover NeuroScience’s neurotransmitter testing. It does, for most people most of the time. We’ve also been lauded by customers as a company that does its utmost to make the reimbursement procedure as effortless as possible – we submit on the patients’ behalf!

      Second, is neurotransmitter testing bogus? I don’t think so. Peripheral (that is, urinary) neurotransmitters have been documented over 5 decades to be biomarkers of nervous system function – look up this comprehensive review by D.T. Marc and colleagues (http://www.sciencedirect.com/science/article/pii/S0149763410001296) if you dispute this. Peripheral neurotransmitters at a minimum are indicators (biomarkers) of our autonomic nervous system health, just like CRP and cholesterol and HbA1c are markers that healthcare practitioners use to assess our cardiovascular, immune, and metabolic health. Are they be-all end-all diagnostic markers? No more so than some of those other, more well-established markers I just listed. But they can provide pointers as to what may be going on with the patient, more so than the, dare I say it, medieval approach to merely assessing patients’ symptoms and prescribing accordingly.

      Do you know why so many people don’t respond to SSRI (antidepressant medications)? It may be because we (the clinical research community) now know that depression can be due to a wide variety of biochemical imbalances, not just insufficient serotonin signaling. And neurotransmitter testing can help you figure out what other biomarkers are out of whack, and how to correct the imbalances. That’s where the products come in. You don’t need to buy NeuroScience products, by the way, to have the test results be useful. You don’t need to be a CAM or integrative healthcare practitioner. But you do need to appreciate a biochemistry-based, personalized approach to patient care and join the thousands who have seen the benefits to their patients.

      • Iatrogenia says:

        QED.

        Psychiatry, somebody is swimming in your moat.

      • Iatrogenia.

        Vitamin B-12, Vitamin D-3, amino acids…
        These nutrients have no role in healthy brain function?

        I suppose the work of the late Abram Hoffer, M.D., Ph.D. with niacin (B-3).. and others with him in orthomolecular medicine…
        The work of Bonnie Kaplan, Ph.D. at the University of Galgary…

        These folks are all wrong?
        Is that what you’re saying?

        It looks like many of their patients never got the memo.
        In the case of Dr. Hoffer, he achieved a 90 percent full-recovery rate from “schizophrenia” early onset of symptoms… 5,000 patients over the span of 6 decades…. Dr. Kaplan is doing some great research, and seeing results – wellness and recovery from severe “mental illness” with proper nutrients.

        More here –
        http://discoverandrecover.wordpress.com/wellness

        Duane

  6. Tom says:

    You would have to be really insane to seek quality psychotherapy from a psychiatrist unless the doctor was in his or her 60’s or 70’s. Your contention that most psychiatry residency programs teach psychotherapy is a joke. Yeah sure they all put a bit of group therapy in the curriculum, and maybe bring some analysts in from the local psychoanalytic institute to teach a course, but really, let’s face it: psychiatrists are not trained, in most programs, to practice therapy. Your worry that “rigorous standards might not be upheld” if PhD’s and LCSW’s do therapy is utter nonsense. I worry more about “rigorous standards” being upheld if non-trained M.D.’s claim to practice therapy!

  7. Dr. Balt,

    “Dust off some tools before it’s too late?”

    It already is too late… Far too late!

    Psychiatry cannot even come up with a coherent rebuttal…
    Robert Whitaker vs William Glazer, M.D. (open the links in the post) –

    http://www.psychologytoday.com/blog/mad-in-america/201111/can-unethical-research-ever-lead-best-evidence

    Duane

  8. Carol Levy says:

    Duane, I can only spoeak for myself but I feel you are out of line with your comments to Iatrogenia. Honest debate and argument does not require name calling or meanness.

  9. doctorz says:

    Some of these folks either need to be on a psychotropic to calm down or go to anger management classes or try exercise or yoga. How’s that for multidisciplinary therapy?

  10. compsports says:

    Duane,

    Please reread what I wrote as I definitely didn’t preface my remark by stating that I wasn’t antipsychiatry. I also don’t understand how you can say I am concerned with being politically correct when I said I would call bullshit any type of provider that I felt was providing bogus services.

    By the way, Gianna Kalli, might beg to differ with your opinion that all psychiatrists are evil

    http://beyondmeds.com/2011/10/17/drugsensitivity/

    After consulting several providers (mainstream and alternative) about her severe withdrawal symptoms from psych meds who were not helpful, she finally found a psychiatrist/sleep specialist who gets it.

    Next time you want to rant that all psychiatrists are evil, you might want to reread this blog entry.

    • Duane Sherry says:

      compsports,

      I read what you had to say.
      My intent is two-fold:

      1) To point out the dangers of psychiatry
      2) To point out safer and more effective options

      That’s it.

      And doing so over the past few years has caused a great deal of pain… The only reason I continue to do these things is because I feel it’s the right thing to do (on both counts).

      You may disagree with what I have to say…. That’s fine.

      Duane

  11. […] But there’s another, less obvious reason, one which affects all doctors.  Medical training is all about science.  There’s a reason why pre-meds have to take a year of calculus, organic chemistry, and physics to get into medical school.  It’s not because doctors solve differential equations and perform redox reactions all day.  It’s because medicine is a science (or so we tell ourselves), and, as such, we demand a scientific, mechanistic explanation for everything from a broken toe to a myocardial infarction to a manic episode.  We do “med checks,” as much as we might not want to, because that’s what we’ve been trained to do.  And the same holds true for other medical specialties, too.  Little emphasis is placed on talking and listening.  Instead, it’s all about data, numbers, mechanisms, outcomes, and the right drugs for the job. […]

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