Stuck On The Treatment Treadmill

California is known as “The Golden State” and some have called it “The Land of Milk and Honey.”

The Beverly Hillbillies noted that it was the home of “Swimming pools – Movie stars.”

That should be encouraging for people like my 27 year old, freckled, red-headed patient.   After all, he had a pool cleaning business. But he was nervous — really nervous.

He did not have full-blown panic attacks, though he certainly fit the criteria for generalized anxiety attacks. Sometimes he did get a “heart in the throat” kind of feeling; something which some people would have called a “truncated anxiety attack.” But he had a lot of them and they really didn’t cramp his style very much.

He did not sleep very well, confessed that concentration was poor, and had great difficulty trying to find any interest in collegiate academics. As a result, his grades suffered considerably. And while I could potentially chalk this up to him falling into a category of males who may be better equipped for trade school than an actual 4-year college (based on patience; not necessarily intelligence), I didn’t believe this to be his case at all.

This guy was anxious.

He had a small pool-cleaning business. All things considered, he should have been doing quite well. Pool and landscaping services can be serious business in Southern California. But his really wasn’t. He had worn out at least one, maybe a couple of assistants. He liked to work and he wanted more pools, maybe to expand. He just couldn’t seem to get there. He had been given nearly every anti-anxiety medication known to man. Unfortunately, none of these did much for him. And now here he was, sitting in the office in front of me, telling me that it was not worth my time to write him a prescription because he would not take it.

The antidepressants like Prozac and Zoloft were “like water,” he said. And I generally hate prescribing benzodiazepines (Xanax, Klonopin, etc.) due to the risk of addiction associated with them. His pulse was a little fast at 96. Blood pressure was sometimes a little raised, but he had seen a general physician who told him that he was simply a young, nervous guy with no particular need for medication. I instructed this “young, nervous guy” to get some lab work done. Surprisingly, the part of his medical records reserved for this was just plain empty. Nobody had run any labs on this guy? Obviously, he needed them. Sometimes, things like that happen in counties where purse strings are held particularly tightly.

What was more amazing to me was that other psychiatrists who had seen him later – decent folks – had not tried anything but more of the same. There was not a single note that indicated anything other than “moderately effective; continue medication trials,” or something to that effect.

The tests came back. The young man was a peripheral hyperthyroid. All of the hormones made by the thyroid were present. I printed out an extra copy of the test results and handed it to him in a sealed envelope. I told him that I was pretty sure his problem was not psychiatric. I believed that adequate thyroid tests were in order, and based on others whom I had found with this condition, I knew that the need for surgery was a possibility.

He took the lab tests, got an appointment, and hesitated a little bit before taking the thyroid medication a general physician prescribed to him. He never saw me again, but went back to see the doctor, whom I found out later had “slipped in” several patients with me who were not getting better.

That doctor, an older gentleman and a friendly man, told me excitedly, “He says he loves you, and that you are the most wonderful person he has ever met. He is still cleaning pools for now but he wants to study some stuff at the community college. He says you gave him his life back. He’s got no symptoms whatsoever. I’ll see him again in three months, to see how he is doing.”

“Why?” I asked the older doctor, who was obviously nonplussed.

“Why?” he responded. “I just told you he was doing well, and I am going to see him again to make sure he continues to do well. He thinks the world of you. I thought you would be happy.”

I wasn’t.

“If he has no symptoms, and he’s being followed by some kind of a general doctor for thyroid medicine, why isn’t he the hell out of this clinic?”

I had so confused this older doctor that I began to wonder if he would ever see straight again — so I laid off.

I decided to see if our young patient was still receiving psychotherapy. He was. Moreover, he had received some intensive personality testing after the thyroid exams had been requested and results received — and my note about this being a thyroid case was officially in the chart.

Now the psychotherapy supervisor was an R.N. She had medical credentials, and was nobody’s fool. She agreed the personality testing had no clear indication and made no sense whatsoever. We agreed to speak with the psychotherapist, especially because his notes did not include a psychiatric diagnosis.

The personality testing was admittedly excessive, but I suppose the county had wasted more. But why therapy? The young (male) psychotherapist told me that “he still needs psychotherapy because he still has a dysfunctional family.”

I grabbed my chest as if I were having a panic attack. I diverted my gaze which I thought surely would have withered him.

“I have a dysfunctional family. About 89 percent of the population says they do. It is probably closer to 98 percent, since people lie on questionnaires a lot. I treat my dysfunctional past by being a psychiatrist for a living, and it works pretty well.”

“He needs support.” he said.

“I usually get mine from my husband,” I retorted, and the older nurse held my hand, in an effort to calm me down a bit. She told the male psychotherapist that he would see her privately, later.

When we were alone, I asked her what was happening. She informed me that she had some experience as an insurance reviewer. She took it upon herself to tell me the reality of the system.

“Nobody ever gets dismissed,” she said, plainly. “The administration won’t accept the loss of capitation.”

In other words, the amount of money allotted to the clinic was a function of how many people were being treated. As such, we weren’t going to treat one less person, even if that person happened to be better.

She consoled me with the reassurance that the psychotherapist was not too much of an idiot, and was probably not making the patient any worse. I remembered a similar experience years before, in a Department of Veterans Affairs medical center. There, I had done a long and involved course of therapy with a veteran who had been raised by his grandmother and had lived under the impression that his mother was actually his sister!

We worked it through, and we did great work. He had no symptoms, and I thought he didn’t need the clinic any longer. However, he was told (by my supervisor) to come back in a couple of weeks. I later found out, it was for the exact same reason. If you ever thought, for a moment, that the purpose of medicine in these United States is to cure you, I have had countless experiences just like these. As a result, I am now convinced that curing people is not the function of medicine. Rather, it’s generating money for practitioners, as well as for the companies who make drugs and treatments and investigational examinations.

The truth is, if we were actually to cure our patients, many kinds of commerce might  very well disappear from the face of the earth.

Sticking to what I know, mainstream psychiatry survives in most places where I have been a practitioner on every-three-month medication management (read “maintenance” sessions).

I remember the day, bewildered as only a practitioner of natural medicine (which can be obtained repeatedly without a prescription) can be, that we would have to change our marketing, our whole approach with the public, because patients were getting better and did not need to see me anymore.

What the short-sighted and greedy don’t recognize is that we will never run out of sick people.

We will never put ourselves out of business.

So we must do our best for each patient and not try to keep them in treatment to insure a steady flow of work – and income.