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Rush to Judgment

[Note: This article is 12 years old, but remains as relevant today as it was when it was written.]
“A quiet slip of a 10 year old” boy.  Taking eight psychoactive medications simultaneously.  That can’t be right, can it?  Dr. Laurel Williams in her heartfelt op-ed piece, “Too Many Inadequate Diagnoses of Child Bipolar Disorder” (Salt Lake Tribune, 12/17/08) would have us believe of course not.  She would have us believe that this is a travesty fostered by greedy drug companies, parents who believe “as seen on TV” must be the absolute truth, and doctors, who because of lack of time or interest, and their own weak-minded enslavement to the drug companies, just push pill after pill on the patient without spending a moment to find out who the patient is.  Is Doctor Williams right?  Perhaps.  But perhaps not.  The answer to the question is actually quite complex, and illuminates some of the difficulties inherent in Medical Science, in Medical Health delivery systems and in access to care.  It deserves a thoughtful response.

Dr. Williams makes some excellent points.  These include overconfidence in a pill being a simple solution, the national shortage of Child Psychiatrists, pressure by managed care to push psychiatrists into the role of medication prescribers, rather than functioning as the complete physicians for which they were trained, and the lack of a health policy that will allow affordable access to care.  She also mentions the need for physicians to critically review well-defined studies.  This is extremely important because it takes a physician with years of training and experience to be able to critically review a study that might look great on the surface, but be so flawed in its methodology as to be valueless.

Science is always evolving, always questioning.  Today’s study leads to tomorrow’s in a never-ending quest to deepen our understanding, to increase what we know and decrease confusion about what we don’t know.  Psychiatry is the branch of medicine dealing with the mind.  The mind is a theoretical construct that connects the brain and the soul.  The brain runs on chemicals and electricity.  The soul runs on – whatever one’s beliefs are - but in Psychiatry we believe that a biopsychosocialspiritual model is involved.

Clearly, Dr. Williams knows all this and planned a comprehensive multi-disciplinary approach to understand who this 10-year-old boy was and what his needs were.  But she failed.  What went wrong?

Two things.  First, while Dr. Williams was right to question the diagnosis of Bipolar Disorder, she was wrong to assume that it wasn’t correct.  We should wonder what might have happened if she had telephoned the other physician, found out his or her thinking on the patient’s situation, learned the history of what was tried first, what had failed to work at all, what had worked a little bit, but not enough.  Dr. Williams noted that in her hour with the boy, he displayed no signs or symptoms of Bipolar Disorder.  Was that because he didn’t have it, or was it because the medications were working?  If a patient came to Dr. Williams saying he was taking insulin prescribed by another doctor who had diagnosed Diabetes, would she take him off his insulin if she found he had a normal blood sugar?

Secondly, despite Dr. Williams’ “lengthy conversation” with the boy’s mother, the mother did not trust Dr. Williams.  She thought Dr. Williams was discriminating against her.  Dr. Williams had failed to establish a therapeutic alliance with the mother.  Without a therapeutic alliance, the best plan in the world comes to naught.  The patient has to feel that she is being listened to, respected and taken seriously.  

As clinicians, we know that “it takes two to tango.”  Establishment of a therapeutic alliance is something that both the physician and the patient contribute to, or it doesn’t happen.  Sometimes it is not established because the two people simply do not “click” and it is not the fault of either one.  From Dr. Williams’ point of view, her clinic’s two-hour assessment and the one hour that she spent with the boy and his mother should have been ample time to establish an alliance.  All busy clinicians hope that the time they have available will be enough.  Sometimes it is.  Sometimes it’s not.  The shortage of Child Psychiatrists doesn’t help.  We are fortunate that here in Utah, we Psychiatrists have outreach programs to liaison with family practitioners and educators statewide, including rural areas.

Dr. Williams believes rightly that we need to win our patients back.  But rather than trying to dampen their alleged faith in TV advertising, perhaps to win them back we need to look inside at exactly what we are doing and how we are doing it.
Michael A. Kalm, M.D.
Past President, Utah Psychiatric Association
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