What Do They Think Their Job Is?
Over in wordweaverlynn's journal, she posted a particularly ugly story about how her psychiatrist didn't check drug interactions and she had a horrifying couple of days. That she came out of those horrifying days alive and without an emergency trip to either the medical or the psychiatric hospital is just the luck of the draw.

In the comment thread, I said that psychiatrists don't think drug interaction management is their job, and firecat quite reasonably asked what they think their job is.

Disclaimers:

1) What follows is NOT an apologia for the psychiatric profession, just an analysis.
2) Not all psychiatrists are alike: the range is vast and many attentive, caring people are members of the profession.
3) I am not a medical professional and I don't play one on TV. At the same time, I am a keen observer of the medical establishment, and I pay what feels to me like a lot of attention.
4) I have never had occasion to ask for or take psychiatric medications.

***

As near as I can sort it out, Kaiser psychiatrists (like the one who took such bad care of wordweaverlynn) see a patient every 15 to 30 minutes, all day every day. They listen as much as they care to or can, write prescriptions, and "Next!" You might as well take a number just like in the butcher shop. They have no economic incentive to see more patients; they just have a corporate structure which evaluates them on number of patients seen. Non-HMO psychiatrists ostensibly have somewhat more time per patient, but to balance it out, they have an endless burden of insurance forms, only some of which they can pass on to their staff. And they do have an enormous economic incentive to see as many patients as possible. Most of both groups now give patients email access, which means that nights and weekends are spent answering email as well as phone calls. And they all have malpractice insurance, which protects them from the worst economic consequences of their mistakes.

Everyone I know (call it something like 20 people) on multiple psychoactives spends a good portion of their time monitoring everything from dry mouth and sleepiness to shaking limbs and nonsituational rages. Most of them, no matter how much they hate the side effects and side-effect management are really, really glad to have access to these drugs at all.

I think many of the doctors have convinced themselves that psychoactive drug interactions are simply part of the experience of taking more than one psychoactive drug. I think they believe the interations are an unpleasant consequence of access to medication, and the patients should simply "expect" a certain amount of inconvenience. (Yes, any doctor who treats wordweaverlynn or any patient with comparable health issues should be paranoia-level aware of the seriousness of her allergies and the increased risk she faces from possible interactions, but ask her how hard it is to get anyone to believe her about that seriousness.) I think they have a sub rosa feeling that monitoring drug interactions is a slippery slope which they would spend their lives at the bottom of if they took the responsibility to track it seriously, so they don't. They figure they'll hear from patients who have side effects. They figure they'll hear from those patients anyway.

In Lying, Sissela Bok makes the crucial point that lies look different to liars than they do to those lied to. Drug side effects look different to patients than they do to doctors. My father used to quote comedian Jonathan Winters in his M.D. role saying, "It doesn't hurt a bit. I've done it a thousand times. Oh, you mean hurt you!" I suspect Lynn's psychiatrist would be as angry as she is if he or his hypothetical daughter had Lynn's experience. But his patients aren't people, exactly. They're interchangeable short-term encounters, some of whom will have bad experiences.

"Next!"