Jay D. Amsterdam and Leemon B. McHenry : The Paroxetine 352 Bipolar Study Revisited : Desconstruction of Corporate and Academic Misconduct
Daniel Kanofsky’s comment on Edward Tobe’s comment
I was drawn to Edward Tobe’s thoughts on the limitations of current psychiatric practice:
"The emphasis on prescribing drugs as the major psychiatric contributor to treatment without knowing the patient has become an unfortunate consequence of insurance industry control of medical care initially through the formation of HMOs. Today, psychiatrists perform a 'med check' that may range from 10 minutes to 30 minutes during which a patient, often not in remission, is psychiatrically evaluated to determine medical and psychological changes and current mental status, response to pharmaceuticals, changes in their life, compliance, and ability to function vocationally and avocationally. The psychiatrist writes prescriptions for drugs with minimal knowledge of the patient. Drug sales benefit."
These sentiments are not only felt by many practicing psychiatrists but also by medical students as they do their mandatory third year psychiatry rotation. Our group at Bronx Psychiatric Center has tried to make the teaching of clinical psychiatry a more enriching experience by embracing the biopsychosocial model. In 2014 Dr. Allen Frances commented on the need to put more emphasis on this approach in a Lancet opinion piece entitled "Resuscitating the Biopsychosocial Model." He writes: "The biopsychosocial model of psychiatry was very short-lived. Developed in the 1970s it was reduced to merely a biological model within two decades under the combined pressure of Big Science, Big Pharma, and economic expediency... Big Pharma has also had a large role in the promotion and profiting from biological reductionism, with the misleading marketing ploy that symptoms result from a chemical imbalance that requires a chemical solution. And psychiatrists are increasingly being relegated to an administrative role of writing prescriptions for patients they barely know after only a brief visit" (Frances 2014).
Dr. Frances would prefer an alternative perspective: "The various models for helping patients with mental health disorders each express only part of the truth and provide their own brand of substantial benefits - all are necessary, but none is by itself sufficient. A combined biopsychosocial model is the only way to form a rounded, three-dimensional view of mental disorders, and to appreciate the humanity of the people who have them" (Frances 2014). Our group has attempted to do this by exposing medical students to assertive community treatment team home visits.
Assertive Community Treatment (ACT) is a team treatment approach designed to provide comprehensive community-based psychiatric treatment, rehabilitation and support to persons with serious and persistent mental illness, such as schizophrenia. ACT services are available 24 hours per day, 365 days a year. Beginning 13 years ago, the Bronx Psychiatric Center ACT team invited third-year medical students to join ACT team staff (psychiatrists, social workers, nurses, peer specialists and vocational counselors) on their rounds. Over these years, clerkship students spent one day of their psychiatry rotation going into the Bronx with the ACT team to see patients and their families. At the end of the clerkship, the students were asked to complete a voluntary, anonymous survey of their entire clerkship experience. We were surprised to learn how many students felt medical student training is deficient in teaching the biopsychosocial model. The ACT team experience appears to partially correct for this deficiency (Kanofsky, Woesner, Bronovitski et al. 2019). Below are some student comments from our report.
· "You gain a sense of what patients’ lives are like in a way you simply never would otherwise. It's a valuable opportunity and also somewhat disconcerting when considering that in times past home visits and the insight that comes with them were the rule not the exception."
· "It was particularly helpful to see patients in their home environments, truly contributing to the biopsychosocial model by seeing their quality of life. It was also eye-opening to see the different apartments in the Bronx and the living situations of patients. I will never forget some of the patients we saw, in particular, seeing the side effects of antipsychotics, the refrigerator contents of another patient, and the chance to talk to these patients. I think the ACT team visit is an important aspect of psychiatry that all students should experience."
· "One of a kind experience that is different from anything else in medical school."
· "... medical education often pays a great deal of lip service to the abstract ideas mentioned above (knowing one's patients as whole people , understanding their social environment, being a dedicated physician in the service of one's patients, etc.). In practice, however, this frequently amounts to little more than rhetoric, with activities like lectures, discussion groups, and evaluations making up the the bulk of time and effort devoted to developing these crucial values and ideas. This is probably not so much a shortcoming in medical education itself as a product of the way medicine is practiced today. Nevertheless, the ACT team visits were a refreshing exception to this rule. I would strongly recommend that future medical students be given the opportunity to observe them."
Our group believes ACT teams are an underutilized medical student teaching tool that can convey the biopsychosocial model as a starting point for understanding the grand intricacies of clinical psychiatry.
Frances A. Resuscitating the biopsychosocial model. Lancet Psychiatry. 2014; 17:496-7.
Kanofsky JD, Woesner ME, Bronovitski D, DaCosta I, Geliebter M. Rare encounters: Medical students give assertive community treatment team visits rave reviews. Primary Care Companion CNS Disord. 2019; 21(2):18m2388.
October 8, 2020