Monday, March 09, 2009

My Sister Says...


So when I give a medication recommendation I talk about why I think the medication would help, I talk about what it treats, what the side effects are and what the risks of taking the medication are. That's a lot of information to absorb all at once so I ask my patients if they have any questions about what I've said. Most of the time they decide to take medication, sometimes they don't. When they decide not to take it they've got good reasons, most of the time.

The only bad reason I've heard is: "I talked to my mother and she heard bad things about it, so I'm not going to take it."

Every inmate has a sister, a girlfriend, an aunt or a mother somewhere with some health care training. All of these family medical advisors know more about psychotropics and are more reliable sources of information than I am, apparently.

I try to be generous and remember that maybe there are idiosyncratic issues here, like maybe the patient did have a weird reaction to some medication that he doesn't remember but his mother does, or maybe there are multiple family members who all had the same problem with a certain medication so he might too.

But usually it's just a matter of trust. The inmate's LPN sister has taken care of him all of his life, has rescued him and given him shelter and sent him money when he needed it, so what she says about medication goes.

It reminds me of a story I heard when I was an intern. My attending went to visit his mother, who was in the hospital for elective surgery. He offered her some advice about her anesthesia, and she responded: "I'll talk to my doctor about that." Her doctor was an intern. My attending was the chairman of the anesthesia department at a major academic institution.

So I guess it goes both ways when it comes to being the family medical advisor. Are you the family medical advisor? Do you want to be? And if so, do they listen?

26 comments:

Anonymous said...

I'm anaphylactic to CT contrast.

My son (10yrs old at the time) had a hockey injury and the ER doc wanted a CT done. We shared the info about my reaction, worried maybe my son would have a similar reaction. The doc basically blew us off because my son is not me, and therefore assured us he would be fine.

About 30sec after the contrast was given, his throat completely closed off, and he went into respiratory arrest.

While I understand the reaction of a Rx in one family member doesn't automatically promise the same reaction in another..it can and does sometimes happen. Hopefully most people don't have such extreme side effects from psych meds, but I can see how they might not want to take a med if a family member had a bad reaction to it.. you just never know.

Anonymous said...

So what is this thing you have about launching into blog posts with the word so? High school was a long time ago methinks.

PINKROSIE said...

Please may I ask the experts a Q?

Is the following a *BOUNDARY VIOLATION* in therapy?

Therapist tells patient gradually, the following, over 9 months of therapy.....

He is living with someone who does not really understand him, nor he her

He never meets anyone he could have a relationship with

He is unhappily married + his marital counselling has failed and he will be moving out

His wife has asked for a separation

He will be getting his own place soon........

He suggests patient attend a conference, which will involve being away for a week, + which he said he MIGHT attend

He had secret friendship with colleague, which he impied involved oral sex, of which his wife knows nothing !

Is this just normal banter etc? He knows his female patient is unhappily married.........Could he be manipulating her?? If so, WHY??

PINKROSIE said...

....but he NEVER contacts her outside the therapy 50 minutes, no emails, no calls etc....in fact he told her, he is too busy to reply to emails !!!

Anonymous said...

PLEASE CAN ONE OF THE EXPERTS GIVE AN INSIGHT HERE???

Anonymous said...

Yes, it is a boundary violation in so many ways!!!

Anonymous said...

Well, I ask advice of my psychiatrist on medical issues (in cases where I am already seeing an appropriate specialist about the physical condition). I feel that asking my psychiatrist in this situation is similar to asking a relative who is an MD in a different specialty. I give my psychiatrist's opinion somewhat higher weight than the specialist in the physical condition, though usually my shrink addresses my anxiety and is able to add medical knowledge to the discussion to help relieve my anxiety. Still I should probably be giving more weight to the physical specialist though they rarely "waste" time addressing patient anxieties. Ex: I had hand surgery today. I was concerned because the tumor appeared from the outside to have grown through the joint. It seemed by my way of thinking "impossible" to remove and in fact is a recurrence of the tumor which was removed from that finger 2 years ago. My psychiatrist reassured me by telling me hand surgeons are amazingly skilled and that the surgeon will view this as routine not "impossible". In fact the surgeon said he "got it all" but that it in fact WAS growing straight through the joint as I suspected.

Anonymous said...

As a wise instructor said over and over, "be guided by your patient." While this advice was given to a class of wilderness first responders (who are trained to figure out how to deal with a variety of medical issues that might pop up days away from help and with a lightweight med kit), this also applies to physicians and others with higher/other training.

Though you have an extensive knowledge of pharmacopoeia and rich clinical experience, you do not have access to extensive knowledge of your individual patients. They and their close people generally do, though may or may not lack insight. Still, if there were reasonable alternatives available, I'd be inclined to heed the patient's preference. (They absolutely won't accept a nonrebreather oxygen mask? Let's try a nasal cannula and see if that helps enough with perfusion -- if not, let's try the mask again.)

And hey, just because the sister is "only" an LPN doesn't mean that she doesn't also happen know a lot about various medications proposed for the patient. "She heard bad things about it so I won't take it," however, does sound like an annoyingly low burden of proof on the part of the patient (and perhaps a different issue).

Still, I applaud you for generally giving your patients the benefit of the doubt, at least in cases where it makes sense. Doctors who think they know what's good for the patient better than the patient (or patient's parents) have, unfortunately, made some unfortunate mistakes with regard to some people in my family over the years. It can also be a matter of medical opinion/art. Ask three doctors, get three answers/ solutions/ treatments. It can sort of be a question of choosing the occasionally ambiguous "best" answer on a multiple-choice exam.

Harmony Sweetpea said...

So true about inmates always having someone in the family who happens to be somehow associated with a psych related field. Or at the very least, 'My girlfriend is studying to be a psychologist'. And you think, then why is she dating you? As a case study perhaps? Some things never cease to amaze.

Honey said...

PLEASE CAN DINAH OR CLINKSHRINK ETC please answer Pinkrosie??

I am also having a problem with boundaries in my therapy and would appreciate an insight into what is happening here???..............

**PLEASE HELP!!!***

Anonymous said...

yep, i second that.....i would like to hear the expert's view on what is happening to PINKROSIE in therapy!!!

Comment anyone?

mysadalterego said...

Am I the family medical advisor? Yes. Do I like it? No. But I think that aside from answering specific issues, which I hate, or for friends of Mom, when I hear the story third-hand, I have managed to instill a sense of how medicine works, to stay away from unnecessary procedures, to keep care as primary as possible...how different specialists see things. That feels like a good educating job.

Anonymous said...

Clink,

I have a different point of view.

When I was on my 4 med psych cocktail ( I am now down to 1 and tapering off of it), my mother when she was alive, thought the meds were not doing me any good. I blew her off as being ignorant about mental health issues.

As I think about all the damage these meds caused which includes a hearing loss, I cringe at the above statement. Obviously, there is no guarantee that things would have been different if I had listened to her earlier but I will always wonder.

Sometimes a mother or sister really does know best even though they don't have medical training.

As far as listening to doctors with top credentials, a dermatologist listed in the local magazine as tops in his field nearly committed malpractice with both my mom and me. I call it an error of arrogance because he refused to listen to us.

I had told him I couldn't take epinephrine due to another med I was on and he gave it to me anyway before removing a mole. As a result, I got moderate heart palpitations. Fortunately, that is all that happened.

He tried to prescribe a med to my mom that she felt was contraindicated and was quite arrogant when she refused to take it. When my mom checked with a pharmacist, that person verified she was right.

Needless to say, we found another dermatologist.

AA

Fat Doctor said...

For the record, I defer all family medical questions to my sister because I don't want the blow-by-blow description of a distant cousin's struggle with diarrhea or whatever.

Recently, a patients cousin demanded a CT which was completely not indicated. I (kindly) explained that a CT wouldn't give us any useful information. He implied that if his cousin were insured, she'd get the test. My patient, meanwhile, is getting upset and starting to think she needs this CT.

First, I established that the cousin has no medical training or background. Then I explained to both of them that she would need to lie flat for a CT and given her particular issue that would be painful, that a CT is a $1500 expense she could avoid, and if they still wanted a CT I would be happy to transfer her care to a physician she could trust. They baced off and we patched things up.

Later that day, they requested a change of physician. The next day, I touched base with the new doc. He, too, would not order the CT, so the patient and her cousin left AMA.

Just can't please some people.

Ladyk73 said...

Pinkrosie.....

A therapist should not talk about themselves unless it would benefit the client. Any therapist who would talk about their own relationship issues has boundry issues. Yes the person has had a boundry violation. It may be in your best interest to terminate therapy with this person. If you are involved in a large practice or clinic and will not let you change therapists....I would ask to speck to the supervisor.

Ladyk73 said...

I am the youngest, slightly nuts, and happen to have worked in healthcare for 10 plus years. My family drives me crazy...cause they don't listen to me.

My brother, with his fancy Phd, is the patriarch of the family, who know little about medicine. If a family member is sick, I sometimes pressure people to go to the doctor or er, and he disagrees with me just to spite me I think.

Anyways, my father got really sick a few years ago...and my brother and I got into an arguement and my mother always takes his side. Anyways, I was right.... diagnosis and all.

I am now my parent's health care proxy (even though I am the youngest).

Now I am a social worker in a trauma one hospital. I've seen alot of stuff.

In my case, I try to convince my family to FOLLOW the doctors advice.

Aqua said...
This comment has been removed by the author.
Anonymous said...

So yeah I was chewing on a wad on a gum, cracking it ya know and like so it was uh losing the flavor so I spit on the sidewalk and uh yeah like so it really sucked that it was my last piece and so i like had to go and uh yeha well never mind I bummed a butt off a guy on the corner he was like whatever and I was like so... and yeah that was it that was pretty much my day it was um yeah good, i guess.Or maybe just so so.

LEMON-HEAD x said...

hey guys...come one!! can someone PLEASE give pinkrosie an insight into why this therapist is telling her all this stuff!!!

WHERE ARE THE PSYCHIATRIST GUYS???

YOU SHOULD BE ANSWERING THIS.......

Anonymous said...

Pinkrosie, Honey, Anonymous (one of them), and Lemon-Head x:

Shrink Rap is not a question-and-answer blog and the Shrink Rap bloggers do not offer second opinions over the Internet. Ladyk73 has answered you beautifully. If you would like to hear more about what the Shrink Rap bloggers have to say about boundaries and boundary violations, please see their posts with that tag. http://psychiatrist-blog.blogspot.com/search/label/boundaries

Anonymous said...

Whoah there is a lot of hubris in expecting that your degree gives you the right to expect someone you just met to trust you more than someone they've known all their lives. Meds (which and whether) are always a judgement call, and there are two sides of it - there's the side that knows the pharmacology (you) and the side that knows the patient (the patient and their family).

And it's not like there isn't a LOT to be worried about in psychiatry as a profession - the history of the profession, the fact that the understanding of the neurobiology is in its nascent stages, and the current influence of pharmaceutical corporations on the research and practice. People who are skeptical about these drugs are NOT crackpots.

Absolutely when I've considered medications, I consulted my doctor, and I've talked to my friends and family and people who've experienced the medication for themselves or know people who have. I'm totally unapologetic about that - it just makes sense.

Lemon Head x said...

DITTO for me....and further, if you look at the behaviour of Jung, who ended up shagging Sabina Spielrein etc, not forgetting Freud etc , the Psychiatry has a dodgy history at best.

Added to that the partial influence of bib boy pharamceuticals and well.......unless you are suicidal, shrinks should be avoided. Any Shrink I ever met had MAJOR personal issues......+ a broken home life, probably because their patients drove them round the bend !! Just don't chose Psychiatry as a profession....or you may end up like your patients, if not worse.............

PINK ROSIE said...

no...it may not be Q + A, but I was only asking for an insight from a professional........, which is after all, what this blog is doing..............

Anonymous said...

Pink Rosie

Since the professionals have expressed that they do not plan to answer you, I will give you my thoughts as a fellow psychotherapy client.

A therapist should never "come on" to a patient. Ever. The way you have grouped these isolated comments, it certainly seems he may be committing boundary violations.

That being said, perhaps you are thinking romantic thoughts about him and as a result of that you might be more aware of things he says that might hint at interest in you. I am not saying this is the case, but it's something to think about when considering the situation.

You might just ASK him. Why does he bring up all this personal information? My psychiatrist brings up personal information at almost every session, but I can see how the example fits my situation and is an example of something he's trying to explain to me. When you list isolated comments all together as you do, it seems damning, but perhaps he had a reason for each comment.

I don't think there is ANY reason a therapist should discuss an out-of-marriage affair or sexual act though, so it seems hard to put that into the category of an appropriate example.

Why not say something like "I feel you have been too revealing about your relationship with your wife and colleague, and that information makes me uncomfortable. Why have you been telling me this? Isn't this sort of information a boundary violation of some kind?" In other words, put it back on him and see what he says. Find out if you are reading the situation correctly before you just dump him as a therapist and move on. You have 9 months invested. Give him a chance and allow him to express his thoughts behind telling you this. If you quit,you'd have to start all over with somebody else, or else you'd end up out of therapy.

If you can't do that, though, and you feel vulnerable, and feel that these comments are "advances" he's making towards you, perhaps just quitting would be easiest for you. You have to evaluate your vulnerability level and ability to speak up, which will be very difficult in this case.

wetnurse said...

PinkRosie,

I completely understand and support all of the reasons why the ThreeShrinks are not commenting.

I also understand that your instincts are telling you that something may be very wrong, and perhaps you do not know where else to seek guidance.

Follow your instincts.

They are correct.

Jonnie D said...

well i DON'T understand why a shrink can't give an opinion into pink.r's situation.......WHY NOT BE UPFRONT AND JUST EXPRESS AN INSIGHT?? EG would the shrinks seek a new therapist??

Just don't see what the big deal is............especially when they could help somebody!! you know, like doctors do??!!!