Sunday, October 11, 2009

You May Go Now.

I've learned something important from....reading the comments posted to our blog, listening to people talk, being a person who talks....No one likes to feel their concerns are being dismissed (myself included).

It's a recurrent theme in the comments that are sent to us, especially with regard to medications: a reader has a concern about a medication, feels it isn't working or that the side effects are too severe, and either their doctor does not address their concerns in a way that feels validating or the reader perceives that the doctor does not understand....since I'm not there, I can't say which is happening, but the feeling on the part of our readers is clear.

And just so you know, I've been on both ends of the discussion. I once lowered the dose of a medication, found it to be just as effective at a very low dose, and was told this was a "homeopathic dose." I didn't really know what that meant. In my terms, I had a headache that felt very real to me, and after taking a very low dose of a painkiller, my headache was gone. I wanted the least possible medication, so I stuck with the low dose. I'm not sure what was meant by the comment, but I heard it as the dose I was taking was so low it couldn't really be helping and I must have been imagining it's efficacy. This was my interpretation; the doctor may well have said it was simply to comment on how low the dose of medication was and not as a statement related to either the realness of my symptom or the realness of my response. I suppose I would have preferred to have heard that I must be rather sensitive to the effects of the medication, the "homeopathic dose" comment rubbed me the wrong way.

I've learned there a patients who have unpredictable and unexpected responses to medications. Some people tolerate huge doses of medications, others don't tolerate even small doses. Sometimes people have weird responses, and we don't really know what to make of it. My favorite example of this happened many years ago-- a patient told me he saw "trails" of light when he turned his head which he attributed to the Serzone I prescribed. Okay, that's weird, I'd never heard of that type of side effect from ANY medication. I didn't know what to make of it. The next week, I saw a case report in a journal of three cases of "visual trails" induced by Serzone. Go figure.

So why don't doctors just take patients' word when they say they are having a specific symptom: be it from an illness or from a medication? Why don't doctors hear when patients say they are very sensitive or not and need very high or very low doses of medications? More and more, I think we do.

Why not always?
Here are some reasons:
--Sometimes doctors are dumb.
--Sometimes doctors are egotistical.
--Sometimes doctors are frustrated. Especially if a medication helps an illness but causes awful side effects. And it's not just doctors. Family members will want patients to stay on their medications because they are less irritable, more functional, easier to get along with...even though the medicines cause side effects.
--Sometimes patients lie. This is especially true when controlled substances are involved: So a patient says that he's anxious and absolutely the only thing that helps is 6 mg a day of Xanax and he feels slighted that the doctor doesn't just take it at face value and prescribe it. Or believe that he's dropped the pills down the sink? Or never gotten them from his 90 day mail order company
--Some people are very suggestible and develop many side effects that they've read about. I really do wish there was a way of saying this without the word "suggestible" having a pejorative feel. Can't it just be? In medical school, I once heard someone say you can tell if a patient is simply saying "yes" to everything if they said their hair hurts when they pee (hair can't feel).
--Sometimes patients complain of things we've just never heard of .happening before. I don't think these problems should be dismissed, and I've taken to telling patients that I'm not in their body/head and they really need to be the one to determine if the benefit from the medication outweighs the side effects. This can be a difficult decision in the time while they are waiting to see if the medication is going to be effective.
--Sometimes patients misinterpret their doctor's comments. I'm often told I think such-and-such when in fact I don't think that at all. My doc might be surprised to hear I took the "homeopathic" comment to mean any thing other than 'my, what a low dose you responded to."

Finally, I've learned that patients can have very high expectations of their doctors. People often write in angry that their docs didn't warn them about specific side effects, and they'll mention a side effect to a medication I've never even heard of. It doesn't mean I don't think it happened, it just means it's not the usual for a psychiatrist to warn a patient, hey MedX could make your nose turn green and swell.

I think in psychiatry, we're all still just finding ourselves. So many of these medications are so new, and they efficacy and side effects varies so very much from person to person. Why does one patient get better with no side effects at all from the very first medication, while someone else is on maximum doses of 5 medicines at once, and still another patient has intolerable side effects to a tiny dose of anything?