The disaster of “15-minute psychopharmacology check-ins”

A

s a psychiatrist, I’m often called upon to help other physicians determine whether a patient has the ability to make medical decisions.

It’s called “capacity” — and as long as the individual can express his choice, understands the risks and benefits of the treatment, and is able to rationally make his decisions, he can stay in the driver’s seat. Sometimes a person is unconscious or otherwise incapacitated and can’t make his own medical decisions, in which case a guardian — often a family member — is appointed to do what the patient would have wanted. I myself learned much about navigating this turf from a famous frum psychiatrist named Dr. Paul Appelbaum, a former president of the American Psychiatric Association who literally “wrote the book” on this (it’s called Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals).

Most of the time it’s clear cut: A sedated patient can’t express what he’d like to do and therefore he won’t have capacity. A patient with schizophrenia might say some atypical things about aliens to scare his cardiac surgeon, but as long as he understands the need for his angioplasty procedure, he’s likely to have the capacity to make the decision to opt for treatment.

One of the most frequent reasons I get called to help other physicians rule on the issue of capacity is a breakdown in communication. I was in my third year of med school, and that particular freezing winter morning, I stood silently behind a team of senior physicians on the surgical floor examining Mrs. O’Leary, an elderly widow who had fallen down the icy steps outside her house. The diagnosis was clear, as was the recommended course of action, but the poor woman was ready to refuse an operation to fuse her broken vertebrae.

“I can’t do it,” she told Dr. Fletcher, an orthopedic surgeon who proudly wore a military-style mohawk to indicate his former status as a flight surgeon in the Marines. “I’m just too afraid of going under the knife.”

Dr. Fletcher was furious and clearly used all his brute strength not to scream when he told her, “Then let’s not waste your precious time.” He ripped a legal document off her chart and asked Mrs. O’Leary to sign it, indicating that she was declining the procedure and choosing to go “against medical advice.” Dr. Fletcher then callously walked off, shaking his head and telling the rest of the team, “She’ll never walk again but that’s her own fault, not mine.”

And while he was legendary for having a temper that was even shorter than his haircut, I couldn’t just sit back and watch this happen. So perhaps having more chutzpah than my role on the team justified, I — Dr. Fletcher’s lowly medical student — piped up and asked him, “With all due respect, Dr. Fletcher, aren’t you worried that maybe there is a bit more we can do to help Mrs. O’Leary out?”

With a gaze that was meant to crush a less-motivated individual, Dr. Fletcher barked at me, “You wanna be a psychiatrist? Go get her into the operating room and page me when she’s ready, or don’t plan on showing your face around here anymore!” It was a threat that I assume he meant, so I decided to put my money where my mouth was.

“Yes, sir,” I acknowledged my commanding officer, and proceeded back to the patient’s room in the hope that a more sensible discussion could persuade her in the right direction.

In fact, the ensuing conversation was calm and simple. I sat down on the chair next to her and introduced myself as a medical student on the team. Mrs. O’Leary was happy to speak with me — a welcome change from the fuming maniac she had just met, even though he happened to be a top surgeon. I explained to Mrs. O’Leary that her decision would be respected, but that fear of an elective surgery to fuse her spine was nothing compared to the consequences of refusing the procedure and becoming a paraplegic.

In the end, she told me, “Thank you for taking the time to explain it to me. I’m infinitely more scared of being confined to a wheelchair than I am of a surgery, even with Dr. Fletcher. Just tell him to work on his bedside manner!”

I left the last comment out when I paged Dr. Fletcher to let him know that we’d be operating on Mrs. O’Leary later that day.

“I see you put your money where your mouth is,” he begrudgingly blessed me.

But the truth is that it’s not only angry ex-Marine orthopedic surgeons who are too brief with their patients. The great disaster of the “15-minute psychopharmacology check-ins” that have infested the field of psychiatry have led to many similar difficulties. I see plenty of patients for a second-opinion consultation, some of whom have already visited with any number of top-tiered psychiatrists in the previous months. They’ve been assessed by good docs, so it’s not like the patients haven’t been given the right diagnosis or treatment recommendations. But without having had someone to provide them with the time and patience to explain their condition in layman’s terms and to discuss the recommended interventions, few individuals will be willing to try a pill, even if it might be a life-saver.

Given the stigmas associated with mental illness in the frum community (and in the world at large), psychiatrists must be ready to answer their patients’ questions and to help them understand their unique situation. Is mental illness genetic? In many cases there is a genetic component. Are there any natural remedies besides medications? Exercise and good sleep hygiene are critical in treating most mental illnesses. Can talking to a psychologist or a social worker help? There are many psychotherapies that have been proven to be effective in helping people to recover. Do I have to take the pills that I’m being prescribed? You don’t have to do anything, but sometimes medications can help people to recover — and I believe that the benefits outweigh the risks, otherwise I wouldn’t be recommending the treatment.

I recently asked a sh’eilah to Rav Avigdor Nebenzahl, rav and posek of Jerusalem’s Old City, about what to do when my patients ask me to make a decision for them. In summary, he answered that I should make the decision to the best of my ability. The unspoken message was that I should have siyata d’Shmaya in choosing wisely and being a successful shaliach.

Sometimes people are well informed enough that they make their own decisions. Other times it’s my job to help my patients to fully understand their situation, in order that they can make the right choices themselves. So I daven to Hashem that He keep giving me the time — more than just a “15-minute psychopharmacology check-in” — to spend with my patients and the wisdom to help them to fully understand their particular condition and the recommended treatments. When this prayer is heard, I can then say another one: that my patients should be successful on whatever path they choose.

Originally featured in Mishpacha, Issue 702. Jacob L. Freedman is a psychiatrist and business consultant based in Israel. When he’s not busy with his patients, Dr. Freedman can be found learning Torah in The Old City or hiking the hills outside of Jerusalem.  Dr. Freedman can be reached most easily through his website www.drjacoblfreedman.com