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WWHJPEVD? [Jun. 29th, 2012|10:06 pm]
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I am in Cincinnati to study with a psychiatrist at the local hospital. This is important because I want to get a job next year, and studying with him allows me to put "studied with psychiatrist for a month" on my resume and turn in a letter of recommendation from him.

Unfortunately, most doctors are very busy and don't want students; most who do only take students from prestigious American medical schools, which are kind of a cartel. I asked a somewhat sketchy company to find a doctor for me, hoping that the somewhat shady company wouldn't necessarily have contracts with somewhat sketchy doctors. I am no longer entirely sure that hope was justified. Here are some of the things that have happened over the past two weeks:

- One of the patients we were seeing displayed a certain symptom, and was prescribed a certain treatment. I asked Dr. S. whether the treatment still would have been appropriate if the symptom had been slightly different. Dr. S. got extremely upset and told me if I insisted on wasting his time with hypotheticals I would never learn anything. Then he delivered a long impromptu lecture on how everyone thinks they know everything, and it's his job as a teacher to convince them that they don't, and by the end of my time with him by goodness I would no longer believe I knew everything and that I was so great I could waste his time with hypothetical questions.

- Another patient had hyponatremia, a potentially dangerous medical condition. I was surprised that he was in the psych ward and not in the medical ward being treated for his hyponatremia, and asked Dr. S why that was. Dr. S responded that despite all his teaching I still didn't understand learning and I thought I knew everything and if I was so smart and knew which ward every patient should be in why didn't I just run the ER since I obviously believed I could do a better job of it than the ER doctors (he eventually told me it was because the hyponatremia was very mild, which was a perfectly reasonable answer). After this I finally learned my lesson never to ask him any questions, which makes being in a far-off city for a month to learn from him kind of a waste of a month.

- Another patient was a registered sex offender; it would be a privacy violation to tell the whole story, and I don't want to excuse his offense, but suffice it to say the situation was complicated and kind of sad. So Dr. S was doing a follow-up interview of him in a crowded room full of other patients and hospital workers (which is definitely not Best Practice) and mentioned, pretty loud "SO, I HEAR YOU'RE A REGISTERED SEX OFFENDER, AREN'T YOU?" I don't know if the patient was too embarassed to admit it, too impaired to remember it, or what, but he got really upset and insisted he wasn't. Dr. S started yelling at him in the middle of this crowded room: "WHY ARE YOU LYING TO ME?! YOUR CHART SAYS YOU ARE A REGISTERED SEX OFFENDER? DO YOU THINK I'M STUPID?" This is definitely not best practice.

- A new patient hadn't met me before, so I introduced myself and told him it was nice to meet him. He held out his hand. I shook it. Dr. S yelled at me. "Do not touch patients inappropriately! Would you hug a patient? Would you kiss a patient? No! Who do you shake hands with? Your friends? Is the patient your friend? No! He is a patient!" After that I just sort of awkwardly smiled whenever a patient held out his hand to me during an introduction. Notice that every other doctor I have ever met including other psychiatrists happily shakes hands with their patients.

- Dr. S kept telling me that I had to do what he said because I had to learn how to interact with patients, and patients would end up hating me unless I changed my personality to conform to proper psychiatric standards. On a whim I looked up his name on ratemds.com. After quite a few patient reviews he ends up with a score of 1.2/5, the lowest I've ever seen any doctor get on the site, and comments are all variations of "NEVER EVER GO TO THIS GUY".

- Dr. S asserted various completely false or horrible statements, like that it was impossible to fake psychiatric signs and a good psychiatrist could catch them 100% of the time (cf. the Rosenhan experiment), that manic patients never enjoy being manic and I was an idiot for thinking anyone could enjoy a mental disorder (cf. any work ever written on mania), and that I should shape up or I would never be able to practice psychiatry anywhere except low-paying jobs like a prison working with criminals or a VA hospital working with veterans who are "maybe a little better than criminals". This one I just sort of stood there with my mouth open and then warned him never to say that in front of an actual Ohio-an (he himself is a recent Indian immigrant). I don't like the guy, but I wouldn't wish what the Ohio-ans would do to him if they heard him say that on my worst enemy.

So I thought I had him figured out and as long as I didn't ask any questions or answer any questions or challenge any of his ridiculous statements I would be fine. Then came today.

A drug rep came by, bought the office a nice lunch, and then gave a talk on a new drug that synergizes with antidepressants. It actually seemed like a cool drug, and he presented a few results from a study that said it was super-effective. I have been socialized by my father to view pharmaceutical reps as the agents of the Devil, but this guy seemed very nice and he didn't say anything that was obviously false.

After the meeting I thanked Dr. S for letting me attend. He asked what I thought, and I told him it sounded like a very promising new drug and I was anxious to read more about the study he'd mentioned.

He asked why I wanted to read the study.

I said I wanted to see if the drug was really as good as it sounded.

He told me that the drug rep had just told us the study said the drug was as good as it sounded.

I said yes, I'm sure it is, but you know how it is with studies, sometimes you have to read them and make sure they really prove what they say they prove.

He began to show his Upset Face, and shoved the study at me. He pointed to the three names on it. I didn't recognize any of them, but I'm not exactly familiar with the psychiatric experts. "Drs A, B, and C have put their names on this study," he growled at me. "They are very famous. Are you saying they're liars?"

"Uh...no?" I said. "I don't even know them. I just think it's a good idea to double-check any research put out by a pharmaceutical company."

"Of course you don't know them. Because you are a student. You do not know anything. And yet you think you know better than Dr. A, B, and C. You think you know better than the FDA, who approved this drug. You think you know better than everyone. You do not understand evidence."

This is the part at which I probably should have shut my mouth. "Actually, there's quite a bit of evidence that not all published studies are accurate. In particular, studies by pharmaceutical companies find positive results significantly more often than studies by independent agencies, according to a meta-analysis by Lexchin et al. And according to analysis by John Ioannidis and others, publication bias and spurious correlations make many published studies doubtful at best."

(I can actually talk like that. It's not a useful skill, and I've never not regretted it, but I can.)

So of course he told me that I didn't understand medicine and that I wasn't ready to practice medicine in America and that he would be writing me a terrible letter of recommendation so that everyone I tried to get a job from knew I hated learning.

So after thinking it over for a little while, I blame myself for not thinking of the cultural angle. He's an Indian immigrant, and I already vaguely knew in that culture asking high-status questions is a way of, well, questioning them, as opposed to politely showing that you're interested like here. And disagreeing with them is a way of saying that you hate them, as opposed to here where it's a polite way to start a conversation.

On the other hand, he has been in the country twenty years, and every other Indian person I know is lovely.

Also, the company that found him for me billed this as an "American acculturation experience" for foreign medical students, meaning part of his job is supposed to be teaching me about American culture. Which he does with relish; every time he corrects me he usually adds something about how I have to learn how these things work in America. See, he thinks I'm from Ireland. I told him like three times that I was born in America and lived here for twenty years and that I was just in Ireland for medical school, but I don't think he understood me and he keeps introducing me to patients as "my Irish student". So we have the spectacle of this extremely Indian guy with a very heavy accent lecturing an American who's lived here twenty plus years that "this is how we Americans do things". It would be pretty funny, except that finding it pretty funny would be racist so I will dutifully avoid doing so (also, the cool thing about America is that occasionally that kind of thing can totally legitimately happen. This just wasn't that time.)

So there goes my letter of recommendation. I'm not even sure I can put this on my resume, because I worry someone might ask "Well if you did that, why didn't you get a letter of recommendation?".

But I'm not too upset. I think I've collected enough honors and such to get a job without him if I'm lucky. And in a weird sense, it's actually really really encouraging.

What do I mean by "encouraging"? Well, I keep hearing people make accusations against doctors and the medical profession. In real life, it's usually that they're power-hungry assholes who think they're God. On the Internet, it's usually that they're idiot savants who may know medicine but have so little grasp of statistics that they can't be trusted with the slightest amount of research or important scientific decision-making.

All the doctors I have hitherto met have defied both of those stereotypes. I must have worked with literally hundreds of doctors by now, and to a person they have all been absolutely lovely people who sacrifice their time and comfort to do anything possible for their patients without it affecting their ego more than a healthy amount. They've also all been not only on top of the latest research, but on top of the controversies around medical research and at least as well educated about the statistical biases and pitfalls they face as the Internetizens who are criticizing them.

This made me worry in one of two directions. First, it made me worry that the disconnect between doctors and laymen is so great that people just have a completely unfair and irrational loathing for doctors, and that as a doctor, no matter how hard I worked I'd have the same chance of impressing society in general as a black guy hoping to placate his Klansman neighbor by baking delicious pie. Or second, it made me worry that I was part of the problem - that I'd already been so thoroughly inducted into the medical profession that I had literally lost the ability to see the sort of things that annoyed patients; that I had become so thoroughly a member of the establishment that its research biases were now my research biases and I was literally incapable of seeing anything wrong with them. That I would have to make a desperate effort to break out of my reference frame and do better than a peer group that sometimes seemed so far ahead of me I could barely touch them.

And I'm encouraged because it turns out it's not something complicated like that at all. It turns out some doctors are just really sucky people, and I just hadn't met them yet. Phew!

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