What’s the Proper Place of Science in Psychiatry and Medicine?

April 29, 2012

On the pages of this blog I have frequently written about the “scientific” aspects of psychiatry and questioned how truly scientific they are.   And I’m certainly not alone.  With the growing outcry against psychiatry for its medicalization of human behavior and the use of powerful drugs to treat what’s essentially normal variability in our everyday existence, it seems as if everyone is challenging the evidence base behind what we do—except most of us who do it on a daily basis.

Psychiatrists are unique among medical professionals, because we need to play two roles at once.  On the one hand, we must be scientists—determining whether there’s a biological basis for a patient’s symptoms.  On the other hand, we must identify environmental or psychological precursors to a patient’s complaints and help to “fix” those, too.  However, today’s psychiatrists often eschew the latter approach, brushing off their patients’ internal or interpersonal dynamics and ignoring environmental and social influences, rushing instead to play the “doctor” card:  labeling, diagnosing, and prescribing.

Why do we do this?  We all know the obvious reasons:  shrinking appointment lengths, the influence of drug companies, psychiatrists’ increasing desire to see themselves as “clinical neuroscientists,” and so on.

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.

Perhaps it’s time to rethink the whole “medical science” enterprise.  In much of medicine, paying more and more attention to biological measures—and the scientific evidence—hasn’t really improved outcomes.  “Evidence-based medicine,” in fact, is really just a way for payers and the government to create guidelines to reduce costs, not a way to improve individual patients’ care. Moreover, we see examples all the time—in all medical disciplines—of the corruption of scientific data (often fueled by drug company greed) and very little improvement in patient outcomes.  Statins, for instance, are effective drugs for high cholesterol, but their widespread use in people with no other risk factors seems to confer no additional benefit.  Decades of research into understanding appetite and metabolism hasn’t eradicated obesity in our society.  A full-scale effort to elucidate the brain’s “reward pathways” hasn’t made a dent in the prevalence of drug and alcohol addiction.

Psychiatry suffers under the same scientific determinism.  Everything we call a “disease” in psychiatry could just as easily be called something else.  I’ve seen lots of depressed people in my office, but I can’t say for sure whether I’ve ever seen one with a biological illness called “Major Depressive Disorder.”  But that’s what I write in the chart.  If a patient in my med-management clinic tells me he feels better after six weeks on an antidepressant, I have no way of knowing whether it was due to the drug.  But that’s what I tell myself—and that’s usually what he believes, too.  My training encourages me to see my patients as objects, as collections of symptoms, and to interpret my “biological” interventions as having a far greater impact on my patients’ health than the hundreds or thousands of other phenomena my patient experiences in between appointments with me.  Is this fair?

(This may explain some of the extreme animosity from the anti-psychiatry crowd—and others—against some very well-meaning psychiatrists.  With few exceptions, the psychiatrists I know are thoughtful, compassionate people who entered this field with a true desire to alleviate suffering.  Unfortunately, by virtue of their training, many have become uncritical supporters the scientific model, making them easy targets for those who have been hurt by that very same model.)

My colleague Daniel Carlat, in his book Unhinged, asks the question: “Why do [psychiatrists] go to medical school? How do months of intensive training in surgery, internal medicine, radiology, etc., help psychiatrists treat mental illness?”  He lays out several alternatives for the future of psychiatric training.  One option is a hybrid approach that combines a few years of biomedical training with a few years of rigorous exposure to psychological techniques and theories.  Whether this would be acceptable to psychiatrists—many of whom wear their MD degrees as scientific badges of honor—or to psychologists—who might feel that their turf is being threatened—is anyone’s guess.

I see yet another alternative.  Rather than taking future psychiatrists out of medical school and teaching them an abbreviated version of medicine, let’s change medical school itself.  Let’s take some of the science out of medicine and replace it with what really matters: learning how to think critically and communicate with patients (and each other), and to think about our patients in a greater societal context.  Soon the Medical College Admissions Test (MCAT) will include more questions about cultural studies and ethics.  Medical education should go one step further and offer more exposure to economics, politics, management, health-care policy, decision-making skills, communication techniques, multicultural issues, patient advocacy, and, of course, how to interpret and critique the science that does exist.

We doctors will need a scientific background to interpret the data we see on a regular basis, but we must also acknowledge that our day-to-day clinical work requires very little science at all.  (In fact, all the biochemistry, physiology, pharmacology, and anatomy we learned in medical school is either (a) irrelevant, or (b) readily available on our iPhones or by a quick search of Wikipedia.)  We need to be cautious not to bring science into a clinical scenario simply because it’s easy or “it’s what we know,” particularly—especially—when it provides no benefit to the patient.

So we don’t need to take psychiatry out of medicine.  Instead, we should bring a more enlightened, patient-centered approach to all of medicine, starting with formal medical training itself.  This would help all medical professionals to offer care that focuses on the person, rather than an MRI or CT scan, receptor profile or genetic polymorphism, or lab value or score on a checklist.  It would help us to be more accepting of our patients’ diversity and less likely to rush to a diagnosis.  It might even restore some respect for the psychiatric profession, both within and outside of medicine.  Sure, it might mean that fewer patients are labeled with “mental illnesses” (translating into less of a need for psychiatrists), but for the good of our patients—and for the future of our profession—it’s a sacrifice that we ought to be willing to make.


Do I Want A Philosopher As My Surgeon?

February 20, 2012

I recently stumbled upon an article describing upcoming changes to the Medical College Admissions Test.  Also known as the MCAT, this is the exam that strikes fear into the hearts of pre-med students nationwide, due to its rigorous assessment of all the hard sciences that we despised in college.  The MCAT can make or break someone’s application to a prestigious medical school, and in a very real way, it can be the deciding factor as to whether someone even becomes a doctor at all.

According to the article, the AAMC—the organization which administers the MCAT—will “stop focusing solely on biology, physics, statistics, and chemistry, and also will begin asking questions on psychology, ethics, cultural studies, and philosophy.”  The article goes on to say that questions will ask about such topics as “behavior and behavior change, cultural and social differences that influence well-being, and socioeconomic factors, such as access to resources.”

Response has been understandably mixed.  On at least two online physician discussion groups, doctors are denouncing the change.  Medicine is based in science, they argue, and the proposed changes simply encourage mediocrity and “beat the drum for socialized medicine.”  Others express frustration that this shift rewards not those who can practice good medicine, but rather those who can increase “patient satisfaction” scores.  Still others believe the new MCAT is just a way to recruit a new generation of liberal-minded, government-employed docs (or, excuse me, “providers”) just in time for the roll-out of Obamacare.

I must admit that I can understand the resistance from the older generation of physicians.  In the interest of full disclosure, I was trained under the traditional medical model.  I learned anatomy, biochemistry, pathology, microbiology, etc., independently, and then had to synthesize the material myself, rather than through the “problem-based learning” format of today’s medical schools.  I also have an advanced degree in neuroscience, so I’m inclined to think mechanistically, to be critical of experimental designs, and always to search for alternate explanations of what I observe.

In spite of my own training, however, I think I might actually support the new MCAT format.  Medicine is different today.  Driven by factors that are beyond the control of the average physician, diagnostic tools are becoming more automated and treatment protocols more streamlined, even incorporated into our EMRs.  In today’s medicine, the doctor is no longer an independent, objective authority, but rather someone hired to follow a set of rules or guidelines.  We’re rapidly losing sight of (1) who the patient is, (2) what the patient wants, and (3) what unique skills we can provide to that patient.

Some examples:  The scientifically minded physician sees the middle-aged obese male with diabetes and hypertension as a guy with three separate diseases, each requiring its own treatment, often driven by guidelines that result in disorganized, fractured care.  He sees the 90 year-old woman with kidney failure, brittle osteoporosis, and congestive heart failure as a candidate for nephrology, orthopedics, and cardiology consults, exacerbating cost and the likelihood of iatrogenic injury.  In reality, the best care might come from, in the first example, a family doc with an emphasis on lifestyle change, and in the second example, a geriatrician who understands the woman’s resources, needs, and support system.

Psychiatry presents its own unique challenges.  Personally, I believe we psychiatrists have been overzealous in our redefinition of the wide range of abnormal human behaviors as “illnesses” requiring treatment.  It would be refreshing to have an economist work in a community mental health clinic, helping to redirect scarce resources away from expensive antipsychotics or wasteful “disability” programs and towards job-training or housing services instead.  Maybe a sociologist would be less likely to see an HMO patient as “depressed” and needing meds, but enduring complicated relationship problems amenable to therapy and to a reassessment of what she aspires to achieve in her life.

This may sound “touchy-feely” to some.  Trust me, ten years ago—at the peak of my enthusiasm for biological psychiatry—I would have said the same thing, and not in a kind way.  But I’ve since learned that psychiatry is touchy-feely.  And in their own unique ways, all specialties of medicine require a sophisticated understanding of human behavior, psychology, and the socioeconomic realities of the world in which we live and practice.  What medicine truly needs is that rare combination of someone who can not only describe Friedel-Crafts alkylation and define Hardy Weinberg equilibrium, but who can also understand human learning and motivation or describe—even in a very rough way—what the heck “Obamacare” is all about anyway.

If I needed cardiac bypass surgery, would I want a philosophy major as my surgeon?  I honestly don’t care, as long as he or she has the requisite technical skill to put me under the knife.  But perhaps a philosopher would be just as well—or better—prepared to judge whether I needed the operation in the first place, how to evaluate my other options (if any), and—if I undergo the surgery—how to change my behavior so that I won’t need another one.  Better yet, maybe that philosopher would also want to change conditions so that fewer people suffer from coronary artery disease, or to determine a more equitable way to ensure that anyone who needs such a procedure can get it.

If we doctors continue to see ourselves as scientists first and foremost, we’ll be ordering tests and prescribing meds until we’re bankrupt.  At the other extreme, if we’re too people-friendly, patients will certainly like us, but we may have no impact on their long-term health.  Maybe the new MCAT is a way to encourage docs to bridge this gap, to make decisions based on everything that matters, even those factors that today’s medicine tends to ignore.  It’s not clear whether this will succeed, but it’s worth a try.

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