Random Thoughts

Haven't been posting too much lately. Have been too focused on longer posts and not enough on the many little thoughts kicking around in my head.

Sunshine
It's sunny again! Also, I get to walk to my placement for a couple weeks, which is amazing. I used to walk everywhere - for a while nearly an hour each way to-and-from work - and I loved it. It's been a nice change of pace to be getting some exercise in the sun, especially given the lack of exercise I've been getting otherwise.

Overdiagnoses
Medicine suffers from both a hive mentality as well as a lack of accountability for those who choose to follow their own path. Many conditions are overdiagnosed in the population, some due to widespread misdiagnoses by broad swaths of clinicians, others due to outliers whether ahead of the curve or behind it. Psychiatry is particularly susceptible to these problems, given the subjective nature of the field. I'd like to draw attention to one diagnosis that I've seen more than I would expect and in situations that don't seem to be applicable: Borderline Personality Traits.

True Borderline Personality Disorder is very disruptive and can be exceptionally hard to treat even with the emergence of DBT as an established, evidence-based therapy. Borderline Traits are, by definition, not significantly disruptive. There's room for this diagnosis, but often I've seen it employed when a patient is simply difficult. Borderline Personality Traits in isolation don't typically get treated, so perhaps it's not the most troubling diagnosis. Still, I find this trend a little too close to pathologizing traits which are, at the end of the day, not really a pathology, just something we as clinicians don't really like very much.

Hockey!
It's playoff time! The junior team I support is crushing it. The AHL team I'm supporting - bandwagon style mind you - is doing pretty well too. The NHL playoffs are actually interesting, with Chicago, LA, and Anaheim all bowing out in the first round! I only went 5/8 in my first round predictions though, so that's pretty bad... picked the Blackhawks and Panthers, which didn't work out. Also picked Anaheim and I really wish I hadn't, because I've always thought Nashville gets dismissed too easily. They're a really good team now that they have some real forwards in Forsberg, Johansen, and Neal. Looking forward now to the 2nd round match-up between Washington and Pittsburgh, not because of any Crosby vs Ovechkin bull, but because both teams are playing really, really well right now.

Naturopathy
The story of the Albertan parents who tried natural medicine for their child with meningitis is everywhere, so it's worth taking a second to touch on. There's a role for "natural" interventions, traditional medicine and alternative medicine. It can and frequently does co-exist with conventional medicine without much difficulty. However, it's hardly a harmonious co-existence. Fault for this can be placed on both sides, but the fault is far from symmetric. Conventional medicine is too dismissive of what benefits can be gained from non-conventional approaches. At a sheer minimum, placebos work and while there's moral hazard in actively participating in prescribing placebos, I don't think there's anything wrong from encouraging people to use their own placebos, if it seems to improve their quality of life. Reiki is high-quality bull-crap, but it's not going to hurt anyone so long as they still use conventional medicine when appropriate. Our resistance to alternative approaches means we're providing what is likely adequate, but suboptimal care.

The flip side is that non-traditional medicine overpromises. Most non-traditional interventions are not based in evidence and some can be quite harmful, but a balanced, honest discussion of pros and cons does not appear to be forthcoming. Worse, many practitioners seem unaware of the problems with the treatments they're offering (and getting paid for). That can lead to some serious issues, as the Alberta case demonstrates. These are fortunately not that common, but still far more common than they should be.

Point is, on both sides of the aisle, conventional medicine and non-conventional medicine, we could do a lot more to work together for the benefit of our shared patients. However, there should be no false equivalence - we need to change our attitudes, they need to change their actions.

Investment vs Consumption in Healthcare

It's no secret that healthcare budgets these days are under stress. As provincial governments look with concern to current healthcare costs, as well as to potential future healthcare costs with our graying demographics, there's plenty of incentive to minimize spending within the medical community.

While I disagree with some of the approaches being taken, it's a worthy goal - not everything in healthcare is cost-effective, and there's good reason to think that freeing up money for other social expenses could be more be more beneficial than many direct medical expenditures. It's also an opportunity to dig into the role of medicine in our society and what we actually expect for the rather large sums of money we throw at our healthcare system.

Healthcare comprises both elements of investment (expenses which are expected to yield an economic return) and consumption (expenses which are not expected to yield an economic return but which hopefully confer benefits to longevity or quality of life). That's a bit too sharp of a split - in reality, all healthcare should be improving the quantity and quality of life of patients and most expenses tend to have some sort of an economic return, even if that return falls below the medical expense and wouldn't be worthwhile as an investment alone.

However, the degree to which we priority each element - investment vs consumption - tells us a fair bit about how we view healthcare's role. These priorities in turn can dictate how much we spend on healthcare overall.

Right now, in Canada and much of the rest of the western world, the focus is on consumption. When people rally for better access to medical services, it's usually for the immediate impact on patients' quality of life. Likewise, when analyzing an intervention's merit, we tend to focus on cost-effectiveness, using metrics like cost per Quality-Adjusted Life Year (QALY). These capture quality of life gains, and analyze all medical interventions as though they were consumptive in nature, but generally ignore economic returns on expenditures.

It's difficult to view and analyze healthcare from an investment perspective, however. For one, it's really hard to accurately measure return on investment when it comes to medical interventions - QALYs or similar metrics are much easier to determine. Second, doing so requires making judgments on the economic worth of individual people (or groups). Most of us are pretty uncomfortable thinking of human lives in economic terms. Physicians especially try to avoid these judgments, as they can devalue certain groups, especially the vulnerable and those in need of the most help.

Yet, there are some broader programs that make no direct judgment on individual worth, yet would have clear beneficial investment components in addition to their meaningful improvements on quantity and quality of life. Mental health is a major one. It hits adolescents and younger adults frequently and is a significant impairment when it comes to productivity at work or school. Individuals who are not currently working are also at high risk for mental health problems, particularly the elderly with dementia and/or depression, of course, but compared to many other medical services we provide, the benefits from investments in mental health more frequently affect individuals who could be more economically productive if optimally treated. When we start making the hard choices about which programs and services are worth funding, it may be worth putting a higher emphasis on economic returns - it might make our tax dollars go a little bit further and lessen the burden of our healthcare expenditures.

I'm rambling a bit, so I'll wrap up by saying this: we want to be healthy and our medical system is a major part of that. However, healthcare does more than just improve health and other social services play a big role in improving health overall. It's worth taking a step back every once in a while to reevaluate our priorities in medicine, to be critical about what how best we can serve the societies we live in, and how some parts of our healthcare system - even the helpful parts - might not be worth the cost when compared to alternatives.

Likes and Dislikes in Psychiatry

Finishing my Psych block, time once again for a reflection on the rotation with my "Likes and Dislikes" series.

1) Oh regular hours, how I missed you

After months of long, drawn-out hours, Psych has been an oasis in the desert. My days were typically 8-9 hours long with the odd day ending quite early. Start times were reasonable. Even the 24-hour call shifts weren't bad, at least by comparison - they were technically home call, so I got to leave the hospital on occasion, and generally got more sleep than on other rotations. I had the odd shift where I got only a small amount of rest, but it didn't feel that exhausting, maybe because I was rested going into it and had time to recover afterwards.

You never quite realize how tired you are until you're not tired and on Psych, I felt rested for perhaps the first time in months.

2) Once again, I like talking to patients

This long into clerkship, some themes are start to reoccur, and this is definitely one. When I can help a patient just by talking to them, I feel great. This is what I got into medicine to do! Psych provides a lot of those opportunities. Even when counselling isn't the main role Psychiatrists fill (other mental health workers seem to do that more often), it's a big part of a lot of interactions with patients and as a result, I thoroughly enjoyed those interactions.

3) Well, maybe not all patients...

The one part about Psych and patient interactions I didn't like was that the exchanges often had an adversarial component to them. When many patients are being admitted to hospital against their will, it kind of comes with the territory. The mental chess that gets played in some cases - while extremely interesting - was also rather draining. I understand that the conflict between patient and provider has a purpose, and that in working against a patient's wishes the physician is doing their best to help the patient, but it's not necessarily something I want to be doing on a regular basis.

It became obvious to me fairly quickly that my preferred patients were those who had ego dystonic conditions - the ones that they want to fix, like depression or anxiety. Individuals who didn't recognize or didn't want to fix their mental health issues weren't as interesting to me. I'm glad there are people dedicating their lives to helping these individuals, because they do need help, but I'm not sure I want to be one of them, at least not on this frequent of a basis.

4) The Happiness Test

I find Psychiatrists in general to be a bit of an eccentric group, so it's sometimes hard to tell their emotional state, but for the most part, the people I interacted with passed this test with flying colours. They were happy! Not joyous per se - this wasn't rainbow sunshine land like Peds was - but they seemed contented at the least.

I wrote off Psych as a potential specialty to match to almost immediately. The reasons behind that choice seem misguided and trivial now - if I had to give a Top 5 of specialties to match into right now, Psychiatry would almost certainly be on there. They say you can't really tell if you're a fit for a specialty until you see it first-hand. In this case, I agree.

Between Optimism and Cheerfulness

The Ontario Medical Association sends me magazines from time to time, and while a lot of the material doesn't apply to students, it does give some insight into the lives, activities, and viewpoints of a subset of practicing physicians. One article by Dr Darren Larsen caught my eye, and you can find it in blog form here. In short, it's a spirited defense of cheerfulness and optimism, in response to a perceived criticism from a colleague.

I consider myself an optimist. I believe that things, overall, are getting better and that there's a lot we can do to make them better. In that sense, I agree with the article - it's very important to keep a positive outlook on life! More importantly, I don't believe, as Dr Larsen asks at the beginning of their post, that optimism alienates people.

However, being optimistic wasn't the full criticism. The comment was that Dr Larsen was "as usual, overly cheerful and optimistic". And while he ably defends his optimism, he ignores the slight against his cheerfulness, and these are two very different traits.

Cheerfulness can be a problem. Cheerfulness can make others feel worse about their own negative feelings. Worse, seemingly cheerful individuals can disguise their own negative emotions under a veil of cheer. In the workplace, overly cheerful individuals are often viewed as annoying. Cheerful individuals may be the least productive. When helping patients in despair or experiencing depression, or trying to rally physicians - many of whom are also going through despair or depression in the form of burnout - cheerfulness might not be the best emotion to display in order to reach these people.

In smaller doses and over time periods, of course, cheerfulness is great. But on a regular basis, at high intensity, cheerfulness may simply be inappropriate. Same goes for every other emotion, attitude, or mood. None should ever be present always, but all can be useful depending on the situation. No one wants a coworker who's angry all the time, but there are instances when anger is appropriate! Equally true for fear, and sadness, and disgust...

You know what? I just realized half-way through this post that I'm trying to put in words what "Inside Out" already said far more capably in movie form. Anyway, go and watch that movie, it's amazing.

In any case, Dr Larsen ends with a quote from Winston Churchill who says "For myself I am an optimist – it does not seem to be much use to be anything else." On this I am in complete agreement. However, few people would accuse Churchill of being overly cheerful. There are times to be cheerful. There are times when cheerfulness is inappropriate or unhelpful. As we strive to make improvements in our lives and the lives of others, it's worth drawing on the full range of emotions available to us - even the negative ones have their role.