a. The subspecialties of medicine each have their own slightly different personalities and subcultures, and although this is a gross overgeneralization I have long thought of surgeons--that is, general surgeons and their ilk, not orthopods or, say, urologists--as the Baddest Motherfuckers in the business. These guys & gals are the toughest & most reliable hombres: they work the longest hours and rightly take enormous pride in their work. When I was in medical school and a patient was admitted to surgery, the culture of the team was that nothing, absolutely nothing, would get in the way of caring for the patient--not sleep, not food, not any kind of distraction. Although I wandered down the internal medicine pathway, I have always admired the attitude with which surgeons owned their patients.
The word "ownership" is a term we use in medicine and while it sounds rather paternalistic, I have a fondness for it, as it signifies a kind of special level of responsibility. When you "own" a patient, it means that you consider yourself to be the most important of a team of doctors & nurses, that the buck stops with you. And as I've said, during my training I never saw a group that took ownership more seriously than general surgeons and their subspecialties such as cardiothoracic, colorectal, & vascular. At the risk of redundancy, these folks are tough.
Only I've seen some weird things happening at my academic medical center as well as at my little community hospital over the past year or two, and this week while attending as a consultant I witnessed something that I found quite surprising, and I'm wondering if that cast-iron sense of ownership is eroding amongst that hardcore group. I was asked to see a patient about a pre-operative infectious issue before the patient was due to get a mitral valve--should the patient be on antibiotics & if so how long, does the surgery have to go on hold, that sort of question. When I finished the consult I had my team get on the phone to talk to the intern, whom they dutifully paged. Only the intern who answered wasn't the surgical intern, it was the medicine intern.
"Wait, this lady's on the medicine team?" I said in frank astonishment. The patient had been admitted to the hospital specifically to get a valve replacement; that's purely a surgical issue. She didn't have a lot of medical problems that required an internist to be her primary doc in the hospital. And yet, somehow, she was sitting there on a medicine team with the cardiothoracic docs serving as consultants.
For laypeople out there this may be hard to grasp why this is a bad idea, but suffice it to say that you manage patients differently based on the kind of training you've had, as well as the kind of patients you care for. Surgeons are better taking care of patients undergoing surgery because, well, they do surgeries! And the surgical patient has a host of problems that internists don't encounter in the same way: fluid shift issues, mostly, which doesn't sound like much, but can be the difference between life and death if you misread the signals. This lady really did not belong on an internal medicine service, and search me as to why she was.
This isn't isolated, as I've seen pancreatitis patients, diverticulitis patients, cholecystitis patients all get turfed to medicine in the recent past. Some of these are borderline calls and could be taken care of adequately either way; some of these are what I would consider clear-cut surgical patients and I scratch my head when they are refused by the surgeon and sent to medicine (where I work, internal medicine does not have the luxury of refusing patients except in extreme circumstances).
Anyway, I'm happy to "own" such patients although I'm not sure that it's always in the patient's best interests for internal medicine doctors to be managing surgical cases. I'm also wondering if something's changed in the ethic of those surgeons whom I have held in such high esteem for so long.
b. Many months back I took my best shot at discussing a book before I had read it. The link, which can be found here, is a discussion about a book that had made a bit of a flap in the psychiatry community called Anatomy of An Epidemic by Robert Whitaker. Since I hadn't read the book, I did not venture to offer an opinion about it, but wondered about how the reviews framed what appeared to be a startling hypothesis: namely, that psychiatric drugs have, for at least a generation, made patients who suffer from psychiatric disease worse on the whole. Was the book worth reading? was my simple question, and I concluded it was and that I'd get around to it as soon as I could.
Well, I did, and my initial reaction is wow. Whitaker's book goes to the core of psychiatry and takes a sledgehammer to it, and he makes one hell of a powerful case that there's nothing behind the curtain. This is not the work of a pseudoscientific idiot who is raging against the machine; Whitaker supports his thesis by citing reputable scientific sources, and does so quite thoroughly. Unlike Celia Farber, an AIDS denialist who is short on facts and long on paranoia, Whitaker lays out his argument with the kind of precision and scientific grounding medical schools hope & pray they can impart to their students.
Whether Whitaker's contentions are completely right I cannot say; I just don't know the literature of psychiatry well enough. (A small quibble: I think he didn't portray Peter Kramer's excellent book Listenting to Prozac fairly, but it's been a long time since I read that book.) But he's without doubt persuasive, and has written a book that anyone who is seriously interested in the broad sweep of modern psychiatry should read. Next up on my reading list is Dr. Dan Carlat's Unhinged; the utterly awesome Dr. Marcia Angell, the former Editor In Chief of The New England Journal of Medicine and author of The Truth About Drug Companies, has a review about both books (as well as Irving Kirsch's The Emperor's New Drugs) in a recent New York Review of Books which can be found here.
Anyway, the point is simple: read this book.
c. Prior to her death, my only knowledge of Amy Winehouse was that she was a singer, and that her escapades with drug addiction were tabloid fodder. I had never listened to her music, but the comparison of her to Janis Joplin in the NYT obit, as well as the description of her as a jazz singer, caught my interest. I downloaded Frank and over the span of the next several days I heard her voice while driving to and from work, and suddenly shared in the collective frustration over a life that held such promise and exhibited such talent. I have not yet gotten around to listening to her signature album Back to Black, but I have become a fan.
Her place in music history is of course an open question, but even if I am blown away by Back to Black I think her troubles with addiction, which led to her decline and untimely death, will place her in that rank of singers whose talents we'll never really know. Joplin was the Times's point of comparison but I've spent some time thinking about Billie Holliday as I listen to her. Holliday gave more of her music to the world, surviving to 44 instead of Winehouse's 27, but she too represents the kind of talent that ventures too close to the flame. Match that against perhaps the greatest singer ever, Ella Fitzgerald, who kept care of herself her entire life (she died from diabetic complications, not drugs or alcohol), devoted it mostly to singing, and it's hard to listen to Holliday without some twinge of regret. Holliday in some way played the Charlie Parker to Fitzgerald's Dizzie Gillespie, the former dancing with demons on a nightly basis, the latter plugging away like a tortoise racing against a hare.
But Holliday, and Winehouse too, may have made the Faustian bargain of communing with the dark side in order to create their art, and it may not make sense at some level to shake our heads at their self-destructive recklessness. I love this clip of Holliday singing "My Man Don't Love Me" from a series that CBS television did called The Story of Jazz in 1957, two years before her death. (There's many things to love about this, actually: that one of the three major networks had a primetime series showcasing America's greatest and most serious artists; that Holliday is hardly the only important face in this ensemble, with a kind of Fania All Stars version of American jazz surrounding her like Coleman Hawkins, Lester Young, Gerry Mulligan and others; and that it's the last time Young & Holliday had a musical tete-a-tete before they both succumbed to their addictions.) The song is beautiful, but it's dark, jagged, and bloody; in short, it is the perfect song for Holliday at her peak. Would Winehouse have been able to step into that mix and take over for Lady Day? I think so. Would the First Lady of Song? I think not.
All of which is to say that Winehouse may have paid a price for her short-lived brilliance, but to judge that bargain as inherently wrong (or indeed, to understand it as anything other than a bargain) may be to fundamentally misunderstand her talents. I tell my med students when confonted with the peculiar vices of their patients: don't judge, just understand. Should we not do the same for Winehouse as her audience?
--br
Showing posts with label Robert Whitaker. Show all posts
Showing posts with label Robert Whitaker. Show all posts
Saturday, August 6, 2011
Sunday, January 30, 2011
Is Robert Whitaker's book Anatomy of an Epidemic acceptable heresy, or dangerous nonsense?
Over the past year in the world of psychiatry there has been a small hubbub about a book that was released last April entitled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Its author is Robert Whitaker, a science journalist who has an expertise in issues involving psychiatry, having written a previous book entitled Mad In America: Bad Science, Bad Medicine, and The Enduring Mistreatment of the Mentally Ill. The gist of Whitaker's book is that the very treatments used for psychiatric illness (that is, drugs) for the past generation may, in fact, be driving the epidemic in the first place, prolonging and worsening psychiatric symptoms.
Needless to say it is a provocative hypothesis, but for the most part it has not yet taken hold in the collective consciousness in the manner of Rachel Carson's Silent Spring, to which vague comparisons could be made. As of now it ranks only 19th in the amazon.com category for "Mental Illness," being edged out by such books as Will I Ever Be Good Enough? Healing the Daughters of Narcissistic Mothers as well as The Sociopath Next Door (which particularly sounds like a remarkably silly book). Part of its modest showing has to do with the media coverage, mostly limited to smaller outlets such as Salon and New Scientist; a local NPR station in Boston covered Whitaker's address to the department of psychiatry at Harvard earlier this month. Time had a brief dispatch, and The Boston Globe published a review, somewhat oddly, by a pediatrician specializing in lung and sleep disorders. Without the media flap, the book's sales appear to have faltered.
This last review by Dr. Daniel Rosen is particularly interesting because he finishes his review, which roundly criticizes Whitaker's contentions, by making a dark allusion to the dangers of agreeing with Whitaker's thinking. "Thabo Mbeki [the president of South Africa at the turn of the century] refused to accept that AIDS was caused by the HIV virus, believing instead that it was a side effect of malnutrition and the medications used to treat AIDS itself," Rosen noted. "Those who would seize the opportunity to cast psychiatry as a discipline into the rubbish heap without consideration for the benefits it has brought to so many would do well to remember how Mbeki’s inability to distinguish between theory and fact exacted such an enormous toll in human life and suffering."
It's an interesting little maneuver because, without explicitly saying so, Rosen essentially proclaimed that Whitaker's book belongs to a completely different class of book than the kind a reader would naturally assume he was discussing, which is to say that Rosen was accusing Whitaker of writing dangerous nonsense rather than acceptable heresy. And the two categories are as different as they could be in the world of science and medicine.
The typical mechanism of scientific progress relies on the establishment of heresies. Let's say we have some model about how stomach ulcers come into being: people think that it's related to stress, and doctors who read the literature prescribe a bland diet and tell people to chill out. Then along comes someone who's been doing biopsies of patients with ulcers and reports a new bacteria that's pretty much impossible to grow, but is clearly there, and thinks that it's this weird new bacteria, and not a stressful lifestyle, that is the cause of ulcers. This someone--after doing further research on his little bacterium--writes papers, gives talks at various conferences, and essentially argues with the scientific establishment that he's right and the old way of thinking about ulcers is wrong. Eventually, enough people are convinced by his data and adopt the new model. What I've just described actually happened and involves the discovery of the bug Helicobacter pylori by Dr. Barry Marshall in Australia in the early 1980's; by the late 1990's the H. pylori model was universally accepted. It's what you'd call standard, acceptable heresy, and science thrives on such a process.
The problem that very simple-minded people frequently are unable to appreciate, however, is that just because science works by overturning conventional beliefs, it doesn't mean that anything goes, or that just because some theory isn't shared by mainstream scientists, it must by definition have some merit. So a lot of writers and thinkers of science distinguish this form of thinking from "acceptable heresy" by regarding it as "dangerous nonsense." In the world of science, the two most dangerous forms of nonsense is that a) evolution isn't really true, and b) man-made global warming doesn't exist. In the world of medicine, the two would be a) vaccines cause autism, and b) HIV is not the cause of AIDS.
Which brings us back to Dr. Rosen's comparison of Robert Whitaker and AIDS denialists: it's Rosen's way of telling people that they shouldn't even bother, that Whitaker's work is not acceptable heresy, but rather dangerous nonsense. And Whitaker got the point of that right away: he posted a same-day reply in his blog at Psychology Today decrying that particular rhetorical trick, calling it "a bit over the top" in what wins points for remarkable restraint.
The question is: who is right? Should we agree with Dr. Rosen, think of Whitaker as a purveyor of dangerous nonsense, and throw it on the ash heap of silly attacks on medicine, or should we give Whitaker's argument a wide berth and read his book with care? For me, this is not an idle question as I haven't read the book, and I've been wondering whether I should put it on my reading list, and if so, how high should it go?
The answer is that I think Whitaker's probably solidly in the camp of acceptable heresy (which doesn't mean I think he's right, only that I am taking his contentions quite seriously). Anatomy Of An Epidemic is going on my reading list, and may go pretty high, for at least three reasons:
a. Whitaker clearly did his homework. One doesn't need to have a Ph.D. in statistics, or be a psychiatrist, to see that Whitaker researched his subject thoroughly, and for me that counts a great deal. Far too often people hostile to science rely on clinging to single studies as proof of their rightness. Whitaker sought to undertake what appears to be a comprehensive survey of the literature and ask the singularly heretical question is all of our modern therapy making a difference for the better? But even a causal glance at the reviews makes clear that he has done due diligence in trying to assess what the entire field knows. It's entirely possible that his interpretation of the data is flawed, as psychiatrist-blogger Dan Carlat thinks (part 1 here and part 2 here), but he isn't cherry picking data in order to further his pet theory, an intellectual strategy that drives me nuts.
b. Studying outcomes in psychiatry is a tricky business. One of the reasons why AIDS denialism is dangerous nonsense is because it's really not that hard to follow the progression of HIV viral load through sickness and death. In other words, outcomes are pretty clear. I have personally witnessed what happens to some patients who have stopped taking their antiretrovirals (small, nonstandardized nonexperimental data to be sure, but persuasive data nonetheless). In other fields, like cardiology, studying the effect of this-or-that drug is comparatively easy, because you are often measuring death as the main outcome, which as outcomes go is pretty fixed. In psychiatry, by contrast, outcomes are much more slippery: "feelings" are notoriously hard to standardize, and even in more severe cases such as schizophrenia, I remain skeptical that you can easily and cleanly reproduce results in clinical trials. As a consequence, I'm inclined to listen to multiple interpretations of effectiveness data, including those that question the value of the entire enterprise--and I'm inclined to listen to it in a way that I wouldn't if I hear an attack on HIV meds, for which there is far too much data to suggest anything other than their effectiveness.
c. Other people whose opinions I respect think highly of him. It's of course the weakest of the three reasons, but still counts for something. Particularly when one has to deal with sorting garbage from gems, it helps to have a trusted figure offer their two cents. E.g. Carlat: "[Anatomy Of An Epidemic] is the work of a highly intelligent and inquiring mind--a person who is struggling to understand the nature of psychiatric treatment. Put it on your reading list, and join the debate."
It is, and I will.
--br
Needless to say it is a provocative hypothesis, but for the most part it has not yet taken hold in the collective consciousness in the manner of Rachel Carson's Silent Spring, to which vague comparisons could be made. As of now it ranks only 19th in the amazon.com category for "Mental Illness," being edged out by such books as Will I Ever Be Good Enough? Healing the Daughters of Narcissistic Mothers as well as The Sociopath Next Door (which particularly sounds like a remarkably silly book). Part of its modest showing has to do with the media coverage, mostly limited to smaller outlets such as Salon and New Scientist; a local NPR station in Boston covered Whitaker's address to the department of psychiatry at Harvard earlier this month. Time had a brief dispatch, and The Boston Globe published a review, somewhat oddly, by a pediatrician specializing in lung and sleep disorders. Without the media flap, the book's sales appear to have faltered.
This last review by Dr. Daniel Rosen is particularly interesting because he finishes his review, which roundly criticizes Whitaker's contentions, by making a dark allusion to the dangers of agreeing with Whitaker's thinking. "Thabo Mbeki [the president of South Africa at the turn of the century] refused to accept that AIDS was caused by the HIV virus, believing instead that it was a side effect of malnutrition and the medications used to treat AIDS itself," Rosen noted. "Those who would seize the opportunity to cast psychiatry as a discipline into the rubbish heap without consideration for the benefits it has brought to so many would do well to remember how Mbeki’s inability to distinguish between theory and fact exacted such an enormous toll in human life and suffering."
It's an interesting little maneuver because, without explicitly saying so, Rosen essentially proclaimed that Whitaker's book belongs to a completely different class of book than the kind a reader would naturally assume he was discussing, which is to say that Rosen was accusing Whitaker of writing dangerous nonsense rather than acceptable heresy. And the two categories are as different as they could be in the world of science and medicine.
The typical mechanism of scientific progress relies on the establishment of heresies. Let's say we have some model about how stomach ulcers come into being: people think that it's related to stress, and doctors who read the literature prescribe a bland diet and tell people to chill out. Then along comes someone who's been doing biopsies of patients with ulcers and reports a new bacteria that's pretty much impossible to grow, but is clearly there, and thinks that it's this weird new bacteria, and not a stressful lifestyle, that is the cause of ulcers. This someone--after doing further research on his little bacterium--writes papers, gives talks at various conferences, and essentially argues with the scientific establishment that he's right and the old way of thinking about ulcers is wrong. Eventually, enough people are convinced by his data and adopt the new model. What I've just described actually happened and involves the discovery of the bug Helicobacter pylori by Dr. Barry Marshall in Australia in the early 1980's; by the late 1990's the H. pylori model was universally accepted. It's what you'd call standard, acceptable heresy, and science thrives on such a process.
The problem that very simple-minded people frequently are unable to appreciate, however, is that just because science works by overturning conventional beliefs, it doesn't mean that anything goes, or that just because some theory isn't shared by mainstream scientists, it must by definition have some merit. So a lot of writers and thinkers of science distinguish this form of thinking from "acceptable heresy" by regarding it as "dangerous nonsense." In the world of science, the two most dangerous forms of nonsense is that a) evolution isn't really true, and b) man-made global warming doesn't exist. In the world of medicine, the two would be a) vaccines cause autism, and b) HIV is not the cause of AIDS.
Which brings us back to Dr. Rosen's comparison of Robert Whitaker and AIDS denialists: it's Rosen's way of telling people that they shouldn't even bother, that Whitaker's work is not acceptable heresy, but rather dangerous nonsense. And Whitaker got the point of that right away: he posted a same-day reply in his blog at Psychology Today decrying that particular rhetorical trick, calling it "a bit over the top" in what wins points for remarkable restraint.
The question is: who is right? Should we agree with Dr. Rosen, think of Whitaker as a purveyor of dangerous nonsense, and throw it on the ash heap of silly attacks on medicine, or should we give Whitaker's argument a wide berth and read his book with care? For me, this is not an idle question as I haven't read the book, and I've been wondering whether I should put it on my reading list, and if so, how high should it go?
The answer is that I think Whitaker's probably solidly in the camp of acceptable heresy (which doesn't mean I think he's right, only that I am taking his contentions quite seriously). Anatomy Of An Epidemic is going on my reading list, and may go pretty high, for at least three reasons:
a. Whitaker clearly did his homework. One doesn't need to have a Ph.D. in statistics, or be a psychiatrist, to see that Whitaker researched his subject thoroughly, and for me that counts a great deal. Far too often people hostile to science rely on clinging to single studies as proof of their rightness. Whitaker sought to undertake what appears to be a comprehensive survey of the literature and ask the singularly heretical question is all of our modern therapy making a difference for the better? But even a causal glance at the reviews makes clear that he has done due diligence in trying to assess what the entire field knows. It's entirely possible that his interpretation of the data is flawed, as psychiatrist-blogger Dan Carlat thinks (part 1 here and part 2 here), but he isn't cherry picking data in order to further his pet theory, an intellectual strategy that drives me nuts.
b. Studying outcomes in psychiatry is a tricky business. One of the reasons why AIDS denialism is dangerous nonsense is because it's really not that hard to follow the progression of HIV viral load through sickness and death. In other words, outcomes are pretty clear. I have personally witnessed what happens to some patients who have stopped taking their antiretrovirals (small, nonstandardized nonexperimental data to be sure, but persuasive data nonetheless). In other fields, like cardiology, studying the effect of this-or-that drug is comparatively easy, because you are often measuring death as the main outcome, which as outcomes go is pretty fixed. In psychiatry, by contrast, outcomes are much more slippery: "feelings" are notoriously hard to standardize, and even in more severe cases such as schizophrenia, I remain skeptical that you can easily and cleanly reproduce results in clinical trials. As a consequence, I'm inclined to listen to multiple interpretations of effectiveness data, including those that question the value of the entire enterprise--and I'm inclined to listen to it in a way that I wouldn't if I hear an attack on HIV meds, for which there is far too much data to suggest anything other than their effectiveness.
c. Other people whose opinions I respect think highly of him. It's of course the weakest of the three reasons, but still counts for something. Particularly when one has to deal with sorting garbage from gems, it helps to have a trusted figure offer their two cents. E.g. Carlat: "[Anatomy Of An Epidemic] is the work of a highly intelligent and inquiring mind--a person who is struggling to understand the nature of psychiatric treatment. Put it on your reading list, and join the debate."
It is, and I will.
--br
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