6. Prozac Monologues

Saturday, April 13, 2019

Doctors as Priests, Providers and Protectors - Part 4

In Priests, Providers, and Protectors: The Three Faces of  the PhysicianRon Pies proposes a third way to view physicians, not exalting them to the grandiose position of Priest nor demoting them to mere Provider. In the role I call the Protector, the physician's chief obligation is that of  the safeguarding of the patient's physical, emotional, and spiritual well being.

This is a role that acknowledges the patient's autonomy, while recognizing the physician's expertise and the ethical imperative to use that expertise to express foundational principles of the medical field: beneficence, nonmaleficense, and justice. Do good, don't do harm, and I'm not sure what he means by justice, though I have some ideas. The examples below are mine, not his.

Protector falls on the ear a tad pretentious. Alas, us literary types on occasion choose alliteration over precision. A trip to the thesaurus gave me the word Defender. Either word reminds us that patients need physicians. We need their expertise and their access to the tools of modern medicine, because we don't know what they know, and we cannot write our own prescriptions nor do our own surgeries.

We also need their attention, dedication, and good will. Their knowledge and access give them power over. There is no getting around that. So we need them to exercise that power with beneficence and nonmaleficence. This is a fiduciary responsibility, a trust relationship. In our ever more contractual culture, the notion of an obligation to be trustworthy is a throwback, intentionally so on Pies' part.

Physicians' fiduciary responsibility puts constraints on their power over. It limits the provider role. There are things that physicians are ethically constrained from providing, for example, addictive substances to addicts and, some say, the means to those who want to die.

Fiduciary responsibility also acknowledges the limits of patient autonomy. The role of physician as protector is to step in and take over when the patient's autonomy has been compromised by his/her condition. The middle of a coronary or a mental health crisis is not a good time for the patient to research alternatives or weigh costs and benefits. The role of the physician here, as Pies sees it, is to restore the patient's autonomy.

What about justice, which Pies calls one of the foundational principles of the medical field? Those in power want to be the arbiters of what justice is, though they are poorly positioned to recognize their own violations of it. When medicine for profit came to be (really, profit, not universal health care, is the novel concept), the power of modern day physicians slipped. In this brave new world of health care as an industry, physicians have another role, that of employee, preferably non-unionized, from the industry's perspective.

As the health care industry devolves into a hostage situation, with the mounting deaths of people with type 1 diabetes as just one indicator, many physicians have taken up the cause of single payer health care, particularly psychiatrists whose patients have least access to employment and health insurance, and are least able to advocate for themselves politically.

Physicians find themselves having to weigh in when a law would controvert professional ethics and permit them to refuse care to certain groups for "religious reasons." Another incursion of government into medicine contradicts physicians' ethics by restricting the medical information they can give to patients. These are but two examples where physicians have stepped up in the political arena to protect patients' physical, emotional, and spiritual well-being.

Pies, the ethicist calls his colleagues to their calling with its ancient responsibilities. He represents a movement that I think of as "reweaving the web," a counterrevolution against utilitarianism. Maybe profit isn't the bottom line, after all. Maybe humanity is. Best wishes to my friend who takes up this cause.

Previous posts in this series:

Doctors as Providers
Doctors as Priests
Doctors as Priests - The Look

let docs speak meme from AMA site

Friday, April 5, 2019

Doctors as Priests -- The Look

Several years ago I took Prozac for what was then thought to be Major Depression.  The hypomanic episode it precipitated gave me a book.  But before that, it gave me the runs.  Since my first doctor thought the runs would go away on their own, but I was about to leave for Costa Rica and wanted them to go away faster, I sought a second opinion.  The new patient form asked for my full history, and I told the truth about my depression, as well as the runs.

What follows is an excerpt from Prozac Monologues, the book to be published next year.  It describes that appointment.  I offer it as an example of a doctor functioning as priest.  [See last week's commentary on Ron Pies' article, Priests, Providers, and Protectors: The Three Faces of the Physician.]  Not the Father kind of priest, but the more ancient healer/witch/shaman kind.  It's tricky to handle the power of the priesthood.  But I want doctors to manage that power responsibly, not give it up on account of its ambiguity.  It is the power of relationship.  We need doctors to use every power at their disposal to heal.  Priesthood is one of those powers.

The Look

...When the doctor looked at the piece of paper with all those words circled on it, she didn't smile at my weak attempt at humor.  Oh well.  What she was most concerned about for my trip to Costa Rica was how I would manage my depression as the Prozac was leaving my system -- which I could tell it was, because the dark suffocating cloud was coming back.

And now we had arrived at the heart of the matter.  I knew this part.  I could have conducted it myself.  I have conducted it myself, when sitting across from some other poor soul in my own office.  Did I have a "plan"?  Well yes, I had a "plan" but I didn't "plan" to use my "plan."  She didn't think that was funny either.  In which case, there was no way I was going to describe my bizarre thought about sticking a nail file in somebody's neck.

I told her I felt more in control of my bizarre thoughts, less afraid of them, since I was learning to laugh at them, which was true.  Actually, I had already started working on a comedy routine called "Bizarre" in my head.  But I didn't tell her that, because there was no humor in sight.  And she was working up to it.  I could tell.  Her face was rearranging itself into The Look.

She said, Can you promise me that you will not hurt yourself?

Those are the words, spoken in a soft, low tone, that go with The Look.  The Look is given with the chin down, looking up at you, but straight in your eyes, this puppy dog kind of expression, as if to say, It would hurt my feelings so very badly if you broke your promise to me."  Some people are better at it than others.  But she was fabulous.  It was a sight to behold.

Now I know the lines.  I have said them on occasion to some other poor soul, trying to cover the time between his/her appointment with me and the next appointment with somebody who could offer more expert help.  But I don't know how good I am myself at The Look.  I have never practiced in front of the mirror.  Good enough, I guess.  Because I have never lost anybody.

Wow.  What a concept.  I have never lost anybody.  It really isn't funny, is it, that responsibility.

Because I myself have given, as well as received The Look, I noticed the technique.  That is how I knew she was reaching deep beyond the technician of the best practices procedure, even beyond the healer, right into the heart of the witch doctor.  She was casting a spell.  And even though I noticed the technique, I deeply wanted this spell to work.  This spell was truly in my best interest.  It could save my life.  So I looked into her eyes, took a deep breath, and let myself fall under the spell.  Yes, I promise.  I will not hurt myself.

Of course, behind the puppy dog in The Look is The Steel Trap, with its unspoken words, You will not leave this office unescorted, unless you can make this promise.  And that is the safety net, in case you need to fall.

There is no insurance code for The Look.  It is possible for the doctor to ask the questions and check them on a form and fill out the paperwork and never enter that sacred space that is crossed by means of The Look.

By the way, it isn't the promise that saves lives.  That's just words out of a book.  People lie if they don't care about the person who wants them to promise, or if they think the person asking doesn't care, or if they just think they need to.  Because, well, if they need to.

No, it's the spell.  The spell is cast by the willingness of the doctor to cross into that dark and sacred space.  The person on whom the spell is cast discovers that there is another human being on this planet who is willing to look deep into the pain, to acknowledge the danger there, to refuse to hide from it with intellectualism or humor or anything else, and hand over a piece of his/her will to live.

If somebody gives you The Look, look back.  Look deep.  Allow that transfer of will to take place.

Say "Yes," if you mean it.  Say "No" if you need more help right now.

And live.

Other posts in this series:
photo of Prozac by Tom Varco, used under Creative Commons license
photo of candle by anonymous, used under Creative Commons license

Thursday, March 28, 2019

Doctors as Priests, Providers, and Protectors - Part 2

Ron Pies and I ask similar questions.  Well, I never asked Is Suicide Immoral?  But maybe I should let that one go...  In addition to being Professor of Psychiatry at SUNY and Tufts, Pies is a bioethicist and Editor in Chief Emeritus at Psychiatrictimes.com.  So while he writes books like Clinical Manual of Psychiatric Diagnosis and Treatment: A Biopsychosocial Approach, his philosopher, poet, and novelist vocations are expressed in other works, including The Myeloma Year: And Essays on Mind and Spirit.

The kind of guy I'd love to meet for coffee and conversation, Pies added to my fascination an article reflecting on his role as a doctor, Priests, Providers, and Protectors: The Three Faces of the Physician.  See, my senior thesis reflected on my own future role as priest, the ordained kind, Is the Holy Spirit an Equal Opportunity Employer?  Both of us take on the notion of priest as Father.

"Yes, Father, I've been taking my medicine."  A patient's slip of the tongue led Pies to recall the ancient connection between the roles of healer and holy person.  It's a natural connection, if you consider the divine will to be for healing.  It doesn't matter what faith tradition you examine.  The two roles were originally one.

Alas, early Christian writers introduced the Father metaphor into their reflections about priesthood.  Monasteries used the title for the Abbot.  Then over time, the role of parish priest followed the monastic model.  Quite ironically, I might add, since Father is the one title Jesus told his followers not to use.  But subsequent generations have never been able to relinquish the implied power over, even since the last century when the title became problematic in the face of women clergy and in the Episcopal Church, women priests.  The newly ordained guys this century seem to cling to Father all the more.

And with the title came paternalism, a system based on the concept of women and children as a man's property.

Pies rightly rejects the paternalism of the medical system.  "The priest-like status of doctors historically encouraged paternalism to which patients readily acquiesced... We are not priests, and we should not lay claim to the 'God-given' power or authority of priests -- which, as we well know, may be subject to abuse and exploitation."

Indeed.  And yet...  Healing is not mediated solely through the application of a doctor's medical expertise.  The worst, most harmful thing a psychiatrist ever said to me was, "I don't do relationships.  I use pharmacology to treat psychological illness."

It's the paternalism, not the priesthood itself, that is the problem.  When the roles were originally one role, it was that of witch, witch-doctor, shaman, druid.  These words do not sit easy in our modern minds for good reason -- there was all out assault on these healers by Church and a modern scientific establishment that enforced its own paternalism.

Next week I will publish an excerpt of a book to be published next year, Prozac Monologues: Are You Sure It's Just Depression?  In the excerpt, a doctor who does do relationships used the spiritual power of her role.  She didn't call herself a witch-doctor.  But the priest sitting in her office and in need of that power recognized the spell.

Other posts in this series:

Doctors as Providers
Doctors as Priests - The Look
Doctors as Protectors

book cover from Amazon.com
photo of stained glass St. Luke the Physician by author
photo of various pills used under Creative Commons license
Condemned Witches Burning in St. Peter's Port from the 1800s, in public domain

Sunday, March 17, 2019

Doctors as Priests, Providers, and Protectors - Part 1

The Three Faces of the Physician is the subtitle of a recent article in Psychiatric Times by Ronald L. Pies, MD, Professor in Psychiatry at SUNY and Tufts, Editor in Chief Emeritus at said e-zine, bioethicist, and aspiring mensch.  Dr. Pies and I have been allies on a certain DSM revision.  We once butted heads over the nature of suicide.  And he has provided valuable assistance in the science chapters of my soon to be published book Prozac Monologues: Are You Sure It's Just Depression?  His (typically) thoughtful examination of the shifting role of physician calls for a response from the side of the relationship, the confessant, consumer, and cared for, aka patient.  My (typically) thoughtful response will be in three parts, starting in the middle of this alliterative stew.

Pies has many problems with the title provider.  It blurs the distinctions among the various health care team members, their roles, responsibilities, and contributions.  It obscures the dignity of a highly educated, hard working and dedicated profession.  It compromises the relationship with its counterpart, the consumer who comes to the exchange overvaluing what she has learned from her internet searches and trying to tell the doctor what to prescribe.

Consumer Movement

Pies traces the origins of the provider usage to two things, the consumer movement in medicine and the encouragement of the insurance industry.  There are good things to be said about the consumer movement, he acknowledges.  I will list a couple of them here.

Monday, March 11, 2019

Loony Saints - Margaret of Cortona Edition

Every once in a while, Prozac Monologues reaches into my Roman Catholic childhood's fascination with saints, especially the ones who today might be assigned a diagnostic code in the DSM.  Twice, Lent Madness has introduced me to new ones that I share with you.

Lent Madness 2012

A few years ago it was Christina the Astonishing.

Today it's Margaret of Cortona.  If you're a Lent Madness regular, you'd expect Margaret to be a shoe in for the first round of voting, where her competition is a stuffy old bishop/theologian, because Margaret became a Franciscan and, more significantly, her story features a dog.  Lent Madness voters are suckers for dogs.

Wednesday, October 17, 2018

Bipolar and Wonky Wiring -- The Football Version

The brain is like a football team.  Go Ducks!

There are several parts, each playing its own position and fulfilling a particular function.  Together they run plays that have been rehearsed and repeated over and over, many until nearly automatic.  The behavior of the other team/environment requires adaptation of these plays, often in mid-play.  And communication among the members is essential.

Here is how they line up on the brain field.  Analysis is at the front, near the forehead.  Memory and emotion hang out together.  Coordination is at the back.  Basic life functions are at the base of the skull.  Communication runs through the middle, connecting them all to one another.

Saturday, September 8, 2018

Bipolar and Mitochondria

Misfirings and mis-timings of a number of systems affecting: hormones, neurotransmitters, and immune system cycles that go off-kilter; glitches in communication between brain cells and within brain cells; and wonky wiring among the networks that connect the thinking, feeling, and evaluating parts of the brain -- that's bipolar disorder in a nutshell.  Okay, a very full nutshell.  Last week I explored one example of hormone cycles gone off-kilter, cortisol.

This week, we go inside cells to discuss my favorite little critters, mitochondria.  I first learned about mitochondria from Madeleine L'Engle, from the second of her Wrinkle in Time series, A Wind in the Door.  Charles Wallace is sick, dying, because of a problem inside his cells.  His mitochondria are not doing their job.

Mitochondria are organisms (technically, organelles) that crawled inside the cells of animals back when animals were being formed out of the ooze.  It is a beautiful relationship.  We are their hosts and meal ticket; they are the power plants that convert food into energy.  If they don't work well, neither do we.  Since the brain uses bucket loads of energy, a problem with energy production has serious consequences for anything the brain is supposed to do.

What Do Mitochondria Do?