Medicine Nonfiction Reflection

On Trusting Doctors.

There exists a particular physician who many in medicine regard as a quack: She has argued that HIV does not cause AIDS. She has written many pieces stating that vaccines are toxic and cause diseases such as autism, depression, and SIDS (sudden infant death syndrome). Within certain circles she enjoys great popularity. Her medical doctor credential lends her an authority that these circles highlight in their efforts to denigrate medicine.

I know her. Our paths crossed at one point during our medical educations. At that time, she and I worked in the same hospitals and saw people who experienced not only profound illness, but also suffering related to poverty, violence, racism, and other factors that impact health.

At that time, she believed the science that HIV causes AIDS. We never talked about vaccines, but I know that she believed the science of immunology and molecular biology. She and I, along with others in our cohort, exercised critical thinking when reading and discussing journal articles.

She and I were never close, but we were friendly. She was the first person to acknowledge my engagement. We were sitting across a table while someone gave a lecture. She pointed at her fourth finger, then pointed at mine, now adorned with a ring, and gave me a bright smile.

Many years have passed since we last saw each other. I wonder what happened to her.

To be fair, our beliefs and practices share some overlap: She apparently doesn’t prescribe medications at all. I try to avoid prescribing medications when possible. She has reportedly helped people come off of medications. I have, too. She encourages the application of exercise and other nonpharmacological interventions. I do, too.

From what I can tell, those are the few characteristics we now share.

If I am honest, I feel more anger than disappointment about her practice. As I understand it, she apparently charges over $4,000 (yes, over four thousand dollars) for an initial evaluation (that lasts for two hours) and one follow-up appointment. Every 45-minute follow-up thereafter costs almost $600. It also sounds like that people who wish to see her must fill out a questionnaire, which she uses to screen people into or out of her practice.

How many people can afford to pay $4,000 for an initial evaluation? Yes, I understand how scarcity makes something or someone seem more valuable, but $4,000? People who can pay that amount—plus the $500+ for each follow-up appointment—have access to other resources that make options other than medication possible. Furthermore, if her screening questionnaire weeds out people who want (or need) to take medication, that means she is unlikely to see people with moderate to severe symptoms.

Most people don’t want to take medications. Most people try everything they can with the resources they have before seeing a doctor. Unfortunately, the current healthcare system drives and rewards physicians for prescribing medications, even when that isn’t the optimal intervention.

Furthermore, this $4,000+ results in the potential spread of false information. I don’t know what she’s doing during that initial assessment—my guess is that it involves a lot of listening—though I doubt she’s persuading everyone to avoid vaccines or that HIV doesn’t cause AIDS. I don’t know; maybe she is. Though, given her popularity in certain circles, selection and confirmation biases are already active: Only those individuals who already share these beliefs would seek care with her.

As much as the above bothers me, what irks me the most is the seeming waste of her training and talent. Our training paths crossed, yes, but look how they have diverged! She charges literally thousands of dollars to provide care for people who are unlikely to experience significant symptoms. Given the economics of her model, most of the people she sees are likely upper middle class to upper class white people.

The individuals under my care, both past and present, are often people of color with significant symptoms who have few resources, often through no fault of their own. For those who don’t wish to take medicine, we work together to help them obtain a job, secure housing, or avoid the attention of the police. Those individuals who take medicine often find that their quality of life improves by leaps and bounds: They are able to stay out of the hospital. They remain employed. They spend time doing the things that matter to them.

To be clear, upper middle class and upper class white people also experience severe psychiatric conditions. Major psychotic, mood, and substance use disorders don’t discriminate. People without money and access to resources, though, are likely to fall farther and have a harder time catching up once symptoms appear.

Let’s assume for the moment that this particular physician who charges $4,000+ for an evaluation has developed a treatment model that really helps people without the use of pharmacology. Why not share that model? Why not work with researchers and other physicians who can adapt this model to people who can “only” afford $500 for an initial consultation? Or $100? Or $5?

This physician knows how to work with and provide successful treatment to individuals with major mood and psychotic disorders. I’ve seen her work. While I have no doubt that the individuals who are able to spend $4,000 on an initial evaluation are suffering, what about all the other people who suffer who will never be able to afford that consultation? If the treatment model really works, why limit it only to the people who have that kind of money?

Why not ease the suffering of as many people as possible?

Could it be that the powers of confirmation bias, scarcity, and placebo are the keys behind her treatment model? That $4,000+ buys chiefly status and expectation? Does it matter that unfounded, dangerous claims are part of the deal?

Should you always trust a doctor?

Homelessness Nonfiction Policy Systems

How to Prevent All of This?

Some of the people under my care in the jail right now are quite ill. (This statement is always true, but it seems that the intensity of illness is greater now than usual.) As a result, the perennial question seems more urgent now: Is there any way to prevent All of This?

For some of them, it seems that the answer is No. Some of them sought out psychiatric services, attended appointments regularly, and had good working relationships with their physicians and therapists. They shared their concerns with friends and family members; they sought out help when they started feeling overwhelmed. Despite these relationships and support, they allegedly did things that resulted in significant criminal charges. And now they’re in jail.

For some of them, the answer might be Yes. Maybe if they had more people they trusted in their lives; maybe if they had a better connection with the counselor or doctor they saw that one time; maybe if their friends and family had more time and resources to seek help with and for them.

Then again, for some of them, the answer might be No, but for frustrating and sad reasons. Maybe their friends and family did everything they could to help them, but they didn’t want their aid. Maybe they became so fearful for their safety that they withdrew from everyone and, in isolation, their symptoms became worse. Maybe they believe that they are fine; it is the rest of the world that is confused and ill. Maybe their only experience with psychiatrists was involuntary hospitalization: Who wants anything to do with a system that takes away your rights and forces you to accept medication?

Some of these people are so young. To be clear, it’s troubling whenever someone of any age ends up in jail solely because of psychiatric symptoms. But can you imagine being 18, 19, or 20 years of age and landing in jail in the midst of hearing incessant, taunting voices, believing disturbing things that simply aren’t real, and having no visitors because the few people who are in your life are scared of you?

It’s heartbreaking.

At least these individuals come to clinical attention. And many get better: They form relationships; they talk with my colleagues and me; they learn how to get along with others; they reflect on what has happened and how to avoid similar consequences in the future; some take medication to help reduce their symptoms.

But then I think about all the people who never encounter law enforcement and never enter the criminal justice system, but they also experience significant symptoms. How do we prevent All of This for:

  • the man who doesn’t tell anyone any personal information and stuffs his tattered clothes with plastic bags to stay warm
  • the woman who won’t move indoors because she believes that the aliens will execute her if she does so
  • the woman who won’t leave her house because she believes her neighbors are cannibals
  • the man who sits all day on the sidewalk across the street from his old employer because he believes that he will get his job back

What about them? How do we help those individuals when the system ignores those who cannot or will not play by the rules?

Many mornings I see the same woman standing near a bus stop. The bus stop is covered, but she never stands underneath the awning. She stands behind the bus stop, even when it’s raining.

You can smell her—a mixture of sweat, dirty socks, and yeast—from several feet away. Pedestrians move around her the way water swirls away from large rocks on the riverbed.

Two black garbage bags sit at her feet. They are full. Plastic zip-lock bags poke out of one of them.

She is a young woman of color. She wears a dark hoodie that is too large for her slender frame, but it’s not zipped up all the way. She’s not wearing anything underneath the hoodie, not even a bra. An unwashed skirt smeared with dirt covers her legs. Her mangled sandals reveal that she has not clipped her toenails in many months.

She talks to an unseen audience and everyone can hear what she says. Her voice is rich and though her sentences do not make sense, she speaks with dignity.

The other morning the rain wasn’t the usual mist that falls from Seattle skies. The droplets were full and heavy, a shower of dark water as the sky was filling with grey light.

No one was standing in the bus shelter. Her clothes were already damp.

“Excuse me?” I asked. She had raised an arm to make a point in her discussion.

She fell silent and blinked a few times.

“Do you want to move so you’re under the bus shelter? So you won’t get wet?”

She turned her head and looked away.

“I can help you move your stuff. It’s raining pretty hard right now.”

She dropped her arm and turned her head further.

“What’s your name? My name is Maria.”

She glanced at me, raised her arm back up, and resumed speaking: “All in all, we must to the left….”

I stood there for a moment, waiting for a sign. None came. I walked away.