Psychiatrist as Gatekeeper

Lately I've been pondering one of my professional roles, that of gatekeeper.  Among my other duties, I help patients access things they already know they want, but cannot get without my help. Often this boils down to writing a "doctor's note": documentation to excuse a work or school absence, qualify for a discount transit pass, receive state disability payments, and so forth. The government or employer relies on me to verify the patient's entitlement claim. Metaphorically I stand at the gate, deciding whether to grant my patient passage. This role seems slightly odd if I think about it too long. After all, I do not work for the government or my patient's employer, and do not really owe them this service. I act on behalf of my patient. Yet professional ethics compel me at times to write reports exactly contrary to a patient's reason for seeing me in the first place. For instance, sometimes I must say that, in my view, a patient no longer qualifies for state disability. Although I work for my patient, I can end up opposing his or her wishes (which may be different than his or her ultimate interest).

Perhaps the starkest example of this is applying an involuntary legal hold when a patient is acutely suicidal or otherwise dangerous.  Psychiatrists tend to think of this as acting in the patient's best interest -- reassuring ourselves that most patients would thank us later when in a calmer and more rational state of mind.  In fact, many do.  However, some critics of psychiatry point this out as evidence that we are "working for the state," not our patients.

A related awkward twist on the gatekeeper idea is my growing role as a medication gatekeeper. By this I mean being asked to write a "doctor's note," in the form of a prescription, for a medication the patient has already decided he or she wants. A number of potential patients call nowadays having researched their symptoms online, or in some other way having concluded they need a specific medication. They are not seeking my professional opinion or advice, just the prescription.

As with the other kinds of "doctor's notes" mentioned above, professional ethics compel me to do a good-faith evaluation, and only write the prescription if I believe it is medically indicated. A few patients have fired me in frustration when I did not write the prescription they wanted, my carefully explained rationale notwithstanding.

This is another situation that seems slightly odd if I think about it too long. For one thing, prescription drugs are available from other countries online and without a prescription, although ordering them this way is illegal in the U.S. and potentially dangerous. Thus, in calling me, patients who could otherwise order directly online are taking extra time and expense to get medications the legal and safe way. Yet they are doing so in a manner that attempts to sidestep the safety features built into the process.

Government oversight and regulation of drugs in the U.S. extends back to the late 1800s and saw a turning point in the 1938 Food, Drugs, and Cosmetics Act.  Soon after its passage, the FDA began to identify drugs considered unsafe for direct use by patients; they would require a physician's prescription.  However, all legal medications were available over-the-counter until the Durham-Humphrey Amendment of 1951, which revised the 1938 Act to formally distinguish between prescription and over-the-counter medications.  This was when physicians became medication gatekeepers.  The idea was to protect the public from itself, to impose controls on the use of substances that are addictive, easily misused, laden with common and/or dangerous side-effects, or carry other possibly hidden risks.

However, Americans have decidedly mixed feeling about the state's role in "protecting the public from itself."  Traditionally, liberals have favored it and conservatives have opposed it when an issue (e.g., gun control) is framed as one of safety.  Conversely, when an issue (e.g., recreational drug use) is framed as a threat to the moral fiber of a community, conservatives favor state control while liberals oppose it.

Prescription medications carry both safety and "moral fiber" implications, and often I feel caught in the middle of these swirling political eddies.  Not only am I compelled by professional ethics to be a medication gatekeeper if someone sees me for a prescription, it frequently strikes me as the only sensible arrangement.  I know about diseases, drug interactions, and other important, relevant facts that the average person does not.   In some cases self-prescribing would be like walking through a minefield blindfolded.  But other times I find myself wishing the patient had left me out of the equation entirely and simply ordered online.  Adult Americans make many, many decisions for ourselves that may be ill-advised and shortsighted, but we are free to make them anyway.  In those cases I feel I am part of an interaction that neither party really wants.

Being a gatekeeper is not why I became a psychiatrist.  For most of us, it is an awkward, ill-fitting role for a profession that ideally reflects empathy, collaboration, and cooperation.  I much prefer being a medication advisor than a rubber-stamper (or roadblock); fortunately, psychotherapy is by nature collaborative and rarely feels like gatekeeping.  I am sure I will continue to ponder all of this, and I welcome your thoughts as well.

Almost a speaker for Wyeth

In my last post, I wrote about how the pharmaceutical industry funds half of the continuing medical education (CME) of doctors, and the risk this may pose for bias in what doctors learn.  The influence of industry money on health education goes far beyond this, though.  In 2004 I learned first-hand how insidious this influence can be.

I was the medical director of the mental health clinic at California Pacific Medical Center (CPMC) in San Francisco.  One day the hospital's Community Health Resource Center asked me to participate in a public talk on depression and its treatment.  The seminar at a large downtown hotel would feature an actress named Delta Burke who had triumphed over her own depression, a representative from the Mental Health Association of San Francisco, and myself.  I would spend 20-30 minutes on recognizing clinical depression and outlining treatment options.

I've been an educator my whole career, and was immediately enthused by this opportunity.  It was sponsored by my hospital, the Mental Health Association of San Francisco, and a public relations firm I had not heard of, Porter Novelli.  Although I was wary of drug companies using such talks as marketing tools, there was no apparent industry connection.  I agreed to do it, and asked the caller for any written materials they had to clarify the format.

A number of weeks passed.  It may have been only a week before the talk when I received a press release, an outline of the event, and a promotional flyer headlined "Life Beyond Depression: Delta Burke Speaks Out."   I learned that San Francisco was the fourth stop of a national tour called "GOAL! (Go On And Live!)" featuring Ms. Burke.  Her message was that, "... it is possible to virtually eliminate the emotional and physical symptoms of depression and go on and live."

I, too, was listed as a speaker on the press release.  It said I would "discuss the warning signs of depression, highlight treatment options, and explain why the virtual elimination of symptoms is the goal of treatment."

The repetition of this "virtual elimination" phrase made me suspicious.  I went to the GOAL website (now defunct).  It looked like an innocuous public education effort about depression.  There was no mention of any specific antidepressant, although "virtual elimination" was mentioned there, too.  Then I saw that the site was copyrighted by Wyeth Pharmaceuticals, makers of the antidepressant Effexor.  It all started to make sense: Effexor's advertising campaign at the time touted the drug's ability to lower scores on the Hamilton Depression Rating Scale to near-normal levels, i.e., to "virtually eliminate" symptoms.

I explored the Porter Novelli website until I found a page that described their public relations efforts on behalf of their client Wyeth and its product Effexor, including the GOAL website and the series of talks by Ms. Burke.  (Although that page is now gone, this blog entry from 2002 clearly links Wyeth, Porter Novelli, the "virtual elimination" phrase -- and even Dr. Nemeroff, who was the lead investigator of the study that triggered Wyeth's promotional campaign.  A 2002 Wyeth press release documents the campaign as well.)

I felt I had been duped.  I imagined turning the tables by standing at the lectern in the Grand Hyatt ballroom, and instead of giving a talk crafted by Wyeth's PR firm, I would instead astonish everyone by revealing the subterfuge.  I would declare that the audience and I were lured there under false pretenses, as a crass marketing ploy.  My denouncement would make the papers.

Of course, it didn't happen that way.  I told the Community Health Resource Center I refused to participate in a veiled pharmaceutical promotion, and suggested they follow suit.  Instead they called my chairman to find a last-minute replacement, while someone from GOAL called and pleaded with me to reconsider.  My chairman opined with some irritation that our department was obliged to provide someone.  And so he did the talk himself, presumably extolling the "virtual elimination" of symptoms just as Wyeth and their PR firm had planned.

My chairman and the Community Health Resource Center, and perhaps the city's Mental Health Association as well, saw this event as constructive public outreach despite the commercial overtones.  I could not.  It concerns me when education for the public, or CME for physicians, conceals a disguised ulterior motive.  For me, this experience underscored how easy it is to re-brand product promotion as education, and how vigilant we doctors must remain in order to avoid unwitting enlistment in those commercial efforts.

What is a psychopharmacologist?

Sometimes potential patients ask whether I am a psychopharmacologist.  Often they are not sure what the word means, but have been advised to seek one by a doctor, family member, or friend. A psychopharmacologist is a psychiatrist who specializes in medication management.  It is a self-applied label, as there is no special credential or license for this.  All psychiatrists are qualified to prescribe medication.  Some make this a primary practice focus, and develop expertise with complicated medication issues.  Others virtually never prescribe medication, focusing instead on psychotherapy or some other aspect of practice.  Most psychiatrists, at least here in the Bay Area, are somewhere in between.

I am not a psychopharmacologist.  My practice leans toward psychotherapy.  Nonetheless, like most psychiatrists, I have prescribed plenty of medication over the years.  I weigh a variety of treatment options, and try to avoid a "one size fits all" approach.  Rarely, a situation of great medical complexity or mystery arises in which I believe a patient would be better served by a true specialist in psychiatric medication — a psychopharmacologist.  To be honest, it doesn't happen very often.

Colleagues as patients, and vice versa

Yesterday I was called by a psychotherapist who had referred a few of her clients to me in the past (she provided the therapy while I prescribed medication for the same people).  This call was not about a typical referral, though.  The therapist sought a medication evaluation for herself. Most of the medical field accepts without question that colleagues can treat one another.  A dermatologist looks at an internist's rash, the internist treats the dermatologist's high blood pressure.  It doesn't matter that they share some of the same patients.  The perception is that the dual roles of patient and professional colleague do not conflict.

Psychiatry has been different, particularly during the era when traditional ("psychodynamic") psychotherapy was the field's main tool.  In such therapy, the relationship is not incidental to the treatment provided.  It is the treatment provided.  The relationship-in-the-room takes the place of blood tests and brain scans in collecting data, and the place of medications and surgery in helping a person change.  Mixing this essential relationship with other types of roles — colleague, family member, golf buddy, or worst of all, lover — simply ruins it.  It also opens the door to unethical exploitation, as the therapist may unduly influence the patient in this other role.  Professional codes of ethics for psychiatrists and other therapists condemn dual-role relationships for this reason.

But what about medication management?  Most psychiatrists do little, if any, psychotherapy anymore, leaving that to psychologists, social workers, marital and family therapists (MFTs), and others.  When psychiatric treatment is medication and not the relationship itself, then the usual situation in medicine seems to apply.  Couldn't my colleague, the psychotherapist who called, see me for a medication evaluation just as she could a dermatologist or internist with whom she shared patients?

Although she only sought medication services from me, I can't help but think like a therapist.  I imagined the awkwardness of later speaking with her about a shared case if she divulged strong feelings related to her job.  I imagined I might expect less of her as a colleague if I knew her inner pain, yet this could shortchange the patients we shared.  I was concerned I might treat her differently as a patient, since I already knew her as a colleague.

I politely declined, and suggested ways for her to find a psychiatrist she doesn't work with professionally.

The reverse situation of "patient first, colleague second" has also come up.  A few patients of mine are themselves therapists, and occasionally ask to collaborate on a case.  I invariably decline, citing the dual-role concerns above.  It feels less clear when ex-patients later become therapists, and then refer their own clients to me.  Any word-of-mouth referral is a compliment, and the truth is, I have accepted such referrals.  But I still wonder about the potential clash of roles.