Wednesday, November 07, 2012

Best In His Field

We have a new patient in his late 20's.  He thinks there is an emblem on his brother's head telling him to kill him, and believes words are coming out of his own neck that others can hear.  Thought broadcasting.  Schizophrenia.  Pretty straightforward, actually.  The job of the hospital at this point is assessment of danger and function, connecting him with services and benefits, seeing what antipsychotic might work, etc.

He had psychological testing 2-3 months ago at The Grand Psychiatric Hospital, the famous, Ivy-affiliated one in the 617 area code.  The one that historically looks down on the others, including us many times in my direct experience.  So we sent for said testing, which turned out to be four paragraphs of rather pedestrian Rorschach interpretation. Nothing more - no WAIS, no PAI, not even an MMPI, House-Tree-Person, TAT, nuttin'.  I did have to talk to the testing psychologist in order to get the fax number for the release of information and give her our fax.  The PhD wanted to engage in conversation that the testing clearly showed the patient had schizophrenia.  She had referred him on to Dr. Mufson, who she thought was the best psychiatrist in Boston and the only one she referred to.  And shazaam! Dr. Mufson had also thought that the patient was definitely schizophrenic.  We should call Dr. Mufson, she thought, to discuss this.  She spelled his name, gave me the address, email, phone, and fax.  She listed his affiliations, how she knew him, and why she thought so highly of him. She kept coming back to this, as if trying to extract a promise from me that we would call him.

Dr. Mufson thought he should eventually be on clozapine, she said.  That's the other name for Clozaril, she reminded me.  Well, fine.  That "eventually" tells me that Dr, Mufson noticed that he had improved but been undertreated on risperidone, and had a non-trial of Geodon because no one told him or his mother to take it with food, unfailingly, or it doesn't work.  Thanks ma'am.  I'll make a note of it.

I'm sure he's just fine and all that, but we didn't bother to call him.  It is analogous to bringing your kid to the ER, the nurse and the MD both thinking his leg is broken, taking an X-Ray and seeing that it is broken, and them asking you to wait for treatment.  Because tomorrow, tomorrow Binky, the best orthopedic guy in all the Northeast will be in, and he will look at the films.  Which he will look at and say "This kid has a broken leg.  What the hell do you need me for?"

Bethany over at Bad Data, Bad described a similar scene, in which the patient had traveled past many quite decent hospitals to get some standard medical care at a top-flight hospital's ED.  But it's not just a patient problem.  It's a provider problem as well.

BTW, this is part of why I am not excited by either having Obamacare or not having it.  I have a bias against such large federal interventions because citizens pressure politicians to pass them at great cost, thinking that somehow these sorts of problems will fade into the background forever.  But they don't.  Human beings do dumb stuff, and they don't stop just because someone passes a law that says things will be better now.  OTOH, I don't have a free market faith that says these things will be minimised if we just let the natural ebb and flow of success and failure operate on its own.

Both solutions are insane.  Got that? Mankind is fallen and both solutions are insane.  We do things to try and make treatment better, and generally, we have succeeded, gradually and painfully in improving medical care.  Long may it wave.  But if even PhD's can be counted on to say stupid things, what hope have the rest of us to consistently avoid it?


Dubbahdee said...

Only in hindsight do we see the genius behind the Emancipation Proclamation. At the time, both sides thought Lincoln was completely over the edge.

Only in hindsight do we see what a disaster lay in ceding Sudetenland to Hitler. At the time most people thought it the prudent course.

And so many things that happen we never figure out what box to put them in. Most things, I think.

I can't say I'm thrilled with ACA, but now at least I sort of know what I'm dealing with. There is a certain cold comfort in that.

Assistant Village Idiot said...

I agree that predictability and stability in government have a value in themselves.

Sam L. said...

Well, you do understand that most of us, not being highly trained professionals who went to all the best schools, tend to have more doubts about our knowledge--we know we don't know everything.

Dubbahdee, you know what you're dealing with? 2000+ pages of legalese and 16K new IRS agents lead me to believe that I will be dealing with impenetrable language that says just what "our betters" say it is. YMMV.

Texan99 said...

I'd never advocate the free market as a system for insuring that all the stupid or crazy people (or their guardians) will achieve good results for themselves. The free market will never eliminate error. What it will do is make it more possible for some people to get good care with a lot of skillful effort. In contrast, a government-run system will work tirelessly to remove that option in favor of ensuring a broader reach for (an ever-lowering level of) mediocracy.

james said...

I do a lot of programming, and Pelosi-care makes me very nervous. We had a semi-broken system already with some perverse incentives built into it somewhere, and the fix we were given is an unread pile of patches to existing laws. That's the equivalent of coding a program without testing: the "big bang" approach. "Did it compile? Give it to the customers and cross your fingers."

Erin said...

AVI, I came to the same conclusion after several years of hearing my husband's work stories. (For the rest, he does IT work for a fairly large teaching hospital). Some have tried to argue these nurses, surgeons, specialists, are all intelligent in their own fields and the technology of computers may just be a different field that requires a different kind of intelligence. I don't know, though. If a heart surgeon doesn't know to check to see if the computer was unplugged and that's why it won't turn on before he calls IT or if another doctor doesn't know how to locate a certain medical program on his computer because an upgrade change the icon's picture and moved it to a different spot on the screen, well then that just seems like a basic problem solving and critical thinking deficiency to me!

james said...

Once asked why he insisted on using handsoap for shaving instead of shaving cream despite the discomfort, Einstein replied, "Two soaps? That is too complicated."

I suppose if you want to devote all your thinking to general relativity or to figuring out how to treat patients, you want the rest of your world to "just work."

Of course, somebody else said specialization is for insects.

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