Gratification

Medicine and Health Rhode Island, Dec 2003 by Friedman, Joseph H

Many of my colleagues have told me that they discourage their children from a career in medicine. They say, "It isn't like it used to be." They mean the paperwork, the insurance hassles, the delayed and shrinking payments, the increasingly litigious atmosphere, and, most recently, the HIPAA regulations. Hospitalists increase efficiency, but at the cost of the physician-patient relationship when the patient is most vulnerable and needy. I share these problems and concerns, although perhaps not quite as heavily, having a salaried position at an institution; but I have a different point of view. I agree that it isn't like it used to be, that economic issues have exceeded what I thought would be tolerable only a few years ago, that paperwork has become heavier, and that dealing with clerks at an insurance company to get approval for a test or a medication is beyond belief stupid. On the other hand, medicine is still as gratifying as it ever was, and if one puts aside the economics, is still a career worth the effort. When I think about trying something else, I wonder what could provide such emotional and intellectual rewards.

The practice of medicine may be gratifying in many ways. The most gratifying cases are those in which a difficult intellectual problem is solved, resulting in its resolution and a dramatic improvement in a real life situation. Icing on the cake occurs when the patient says thanks.

BR was a 35 year old man whom I met in the forensic unit of the Institute for Mental Health (the old "IMH," currently Eleanor Slater Hospital). He carried a diagnosis of paranoid schizophrenia and was in prison because he stabbed his brother. He stabbed his brother because he was going out with his girlfriend, which may have been true or not, since the patient was clearly psychotic when I met him. I was asked to see him because of severe and dysfunctional involuntary face and jaw spasms which were quite terrible to behold, although not painful. The patient seemed to be reacting to severe pain because his eyes closed, the corners of his mouth curled up and his whole face become contorted. He suffered from "tardive dystonia," a form of tardive dyskinesia, a movement disorder caused by the antipsychotic drugs he had been taking for his schizophrenia. His case was further complicated by the fact that he was suing his psychiatrist and the mental health center he was treated at for causing the problem. Since virtually all patients with schizophrenia are insured with Medicaid or Medicare, or are uninsured, they are almost entirely cared for at the publicly financed mental health centers, each of which has its own unique catchment area. Obviously BR could not be cared for at the current center and his case had been transferred to another center, outside the catchment area. It was clear then, in the late 1980s, that the treatment of choice was clozapine, an antipsychotic drug that was "experimental" in the U.S. until 1991. It was not only the best antipsychotic but was also helpful for the movement disorder. At that time, because it was experimental, an informed consent was required. Almost by definition, a patient in the forensic unit could not give informed consent, so I asked BR to visit me after discharge.

When he came to see me he was less psychotic but still delusional. His movement disorder was still terrible to behold. I outlined how he should start the medication and the potential side effects. I asked him to sign the informed consent. He asked me to discuss the potential side effects again.

"I can sue you if I get a side effect, can't I?"

"This is America. You can sue me whenever you want, for whatever you want. But I can't imagine you winning. You need to understand that I'm doing you a favor. This is a 'compassionate' protocol. I'm expending a fair amount of effort to do you a favor, I've explained what the potential side effects are, and I'm not receiving any money for this."

"Well, if I can't sue you I'm not going to take it." And he left the office.

I frequently told that anecdote, illustrating, as it did, the self-punitive aspects of mental illnesses. About 10 years later the story took a twist. I received a message from my secretary.

"Do you remember a patient named BR? He called to say he had been placed on that medication you wanted him to be on after it got approved. He's back to normal. He said to tell you that his movements went away, that he feels well, that he's working full time and wants to thank you for your advice."

What occupation beats that?

- JOSEPH H. FRIEDMAN, MD