Week of 4.1.19

The article focusing on Anne Harrington and the hubris of psychiatry was interesting in its approach to the science of psychiatry. The discussion of how psychiatry conducts treatments first and then attempts to rationalize the result was interesting. Treatments such as lobotomies, use of ice baths and insulin induced comas without empiric evidence of the effectiveness of treatment seems contrary to the practice of medicine. I agree with the conclusion of the article which comments on a broader dialogue between psychiatry and other social science in order to better generate a holistic approach to treating mental health which does indeed have a wide range of implications for society.

The article discussing duplicate medical records is also interesting, I was surprised to learn that it was initially mandated by congress, but a little confused as to why they chose not to mandate the use of a single system as appose to multiple vendors of EHR. However, the fact that other countries such as Norway are already using well developed EHR which decrease redundancy offers a pretty good template for the united states to follow.

Regarding the first article, I believe the difficulty in seeing Psychiatry through more objective lens has much more to do with an impression the general public has that environmental factors play a greater role in it than in other diseases, when, in fact, many of them don’t- schizophrenia and bipolar disorder, for example, have a much stronger genetic predisposition than many (if not most) prevalent conditions.

Just like any other “general medical condition”, psychiatric disorders have risk factors, disease progression, classical presentation, diagnostic tools etc. Their definitions are based on the same scientific method- observation and a repeated pattern that allows a conclusion and a categorization.

The development of new diagnostic criteria and new clusters with each new DSM is another thing that is a misconception. Hypertension definitions and targets change with basically any new consensus (as is expected with all the new studies released every year), and yet I don’t see the same commotion towards trying to diminish their importance or trying to state “hypertension doesn’t exist”.

And as for treating vague diseases like ague and dropsy, who knows if 300 years from now they won’t laugh at how today our definitions were vague as well? Many other very well established disorders (fibromyalgia, irritable bowel disease, to name a couple- not including literally any disease with “idiopathic” in its name) have no particular understanding on their exact mechanism either.

Psychiatry, in my view, has no more hubris to it than any other medical field- it provides relief, increases in life expectancy and quality of life. Cure may be extremely rare, but other than infectious diseases, in which other specialty isn’t it?

The article on forensic psychiatry is very interesting. It is such a complex and difficult area that most general forensic doctors cannot deal with it- it takes a forensic psychiatrist. The fact that they rely so much on history and have such limited additional tests to be able to give a definitive causation really intrigues me, especially when manipulation by the interviewer can be such a factor.

Having rotated through multiple psych rotation I feel that the article article “Psych: Incurable Hubris” Accurately demonstrates that psychiatry is a difficult and unique specialty given the lack of a tangible source of disorder or pathology. However, I feel that the article is remiss and using the term hubris, and that “misguided hope” would be a better qualifier. While the road to hell is paved with good intentions and these physicians are guilty of “overreaching” the fundamental desire to understand the pathology of mental illness remains firm. While the manner in which physicians evaluate the pathology may be questionable at the time, it may be necessary in the name of progress and reform.

The second article regarding forensic psychiatry was fascinating, given that it is a specialty that is often mentioned but never fully discussed, especially in the era of true crime television. It was interesting that such a highly specialized practice was so multi-faceted, abs dependent of patient history (far different than other specialties). I am looking forward to the unique opportunity to experience the blend of law and medicine that forensic psych allows on my forensic psych rotation.

In the article regarding mixups between medical records illuminated the Overwhelming communication failure that overshadows current medical practice. We have all witnessed inconsistencies in medical documentation in the hospital and the clinic, and have even watched as these inconsistencies have been exacerbated by EHR. How many times have we created a “new patient” when we can’t find an old one? How many times have we copied and pasted patient information without challenging the validity? While I agree that something needs to be done and there is no quick fix, it will be interesting to see how the modern health system chooses to address this short coming. I find it even more intreging when methods relying on incredibly unique features (iris scanning) is suggested as it raises an entirely new dilemma: what is the cost of patient identification, is it patient privacy?

In my opinion, the article entitled "Psychiatry's Incurable Hubris" brings to light the fact that medicine and medical research is not where it should be where mental health is concerned. Still, more emphasis and effort needs to be placed on researching the pathology of mental disorders as is done with non-psychiatric related conditions such as cancer. This needs to be done especially in the Caribbean where mental conditions are often ignored and left untreated and patients are instead just described as " crazy" or " wicked" when justifying their "abnormal" behavior. More research into the pathology of mental conditions will also help to remind and to reinforce to medical practitioners that patients comprise of both body and mind.
This ties in well with the second article which discusses forensic psychiatry. I've never really thought about the importance of forensic psychiatry outside of watching Crime Scene Investigation series on television. It helps to bring to light that impact and importance this field of medicine has on the future of an individual who has committed a crime. It also helps to emphasize that medicine extends beyond the hospital and ensures that justice is indeed served in cases where offenders are in fact afflicted by mental disorders and should be treated and given a lesser sentence or individuals who had all their mental faculties while committing the crime and should be punished to the fullest extent of the law.

While I feel that the article written by Mr. Greenberg was a bit harsh and overly critical (aka polemical), it did have some valid points. For a very long time psychiatrists were called quacks and psychiatry itself was seen as a pseudoscience. In fact, many people still view it this way. I believe this is due in part to a lack of hard scientific evidence about the pathophysiology of mental illness. While I don’t agree with the tone of the article which suggests psychiatrists are merely fumbling around in the dark, all they have to go off of his hypotheses. We believe that a serotonin imbalance is responsible for depression. We believe that a dopamine imbalance is responsible for schizophrenia. We believe that a problem with the locus cereuleus is at the root of panic disorder. See what I mean? Maybe someday this conundrum will be remedied, but for now we must work with what we have available to us.
I found the article about forensic psychiatry interesting. I did not realize all the different things that forensic psychiatrists do. I suppose I assumed it was just interviewing criminals, but there is a much broader range than that.

Forensic psychiatry seems like a fascinating subspecialty of psych and a good fit for people who have an interest in getting more exposure to the jurisprudence aspect of medicine. Being the doctor who decides whether or not a defendant is insane is quite a responsibility and it would be very interesting to sit in on one of these interviews and see the interview process involved with making such a decision.

The other article raises many fair points about how the field of medicine has not yet discovered the exact mechanisms for many of the psychiatric drugs used and why they are effective. It makes sense for us to want to seek out answers for these kinds of questions so we can perfectly explain how a medication will help a patient's mental illness. Unknown mechanisms and "idiopathic" illnesses are still abundant in other areas of medicine as well. As long as these medications treat the illnesses that they are purported to work on (hopefully with minimal side effects) then our mission as doctors is accomplished. Hopefully, continued research and development in the medical field will allow for us to have a more nuanced understanding of these medications in the future.