Physicians First

Just recently, the Illinois legislature set aside a psychologist prescribing bill after initially supporting it.  (The Illinois Psychiatric Society’s president, Eldon Trame, MD, gives a nice summary of the whole process here.)

What led me to explore what happened in Illinois was an article in the most recent issue of Psychiatric Times, “Why Psychiatrists Are Physicians First,” by Sharon Packer, MD.  That article brought into the sharpest focus the importance of thorough medical training for those who prescribe pharmaceuticals of any kind, psychotropic or otherwise. Dr. Packer concisely describes her experience with a social worker, who was speaking with one of Dr. Packer’s patients, calling her to demand that she change the anti-depressant she had prescribed for the patient because, according to the social worker, it was causing the patient nausea and other GI issues.

Dr. Packer outlines how her medical thinking process instinctively kicked in and, after processing her patient’s answers to her questions, led her to refer her patient to an internist that afternoon. The rest of the story is bittersweet:  “I will not detail everything that followed, except to say that … even a pitiful 24 months’ survival rate is still superior to the 24 hours that awaited [my patient], had her nausea been written off to the effect of an SSRI.”

The article implicitly makes another important point – psychiatrists can’t forget that they are physicians first. Their differential diagnoses must include medical causes for psychiatric symptoms and deal with them effectively. Hallucinations can be caused by neoplasms, thyroid disorders, and brain infections. Depression is a common symptom of a mile-long list of medical conditions. Mania is not always a symptom of bipolar disorder. Failing to deal with the possible medical causes will defeat any psychiatric treatment rendered and may deprive the patient of the chance to seek appropriate treatment.

Psychiatrists need to learn about the patient’s medical history as fully as possible, getting the medical records or documenting their unsuccessful efforts to obtain them. Focusing solely on possible psychiatric causes of the patient’s symptoms is not enough.