The forensics psychiatrists argue that like judges ‘rate your doctor’ reviews were inappropriate for psychiatrists because the best psychiatrist will invariably make enemies.’
I was the supervisor in the psychiatry emergency and the dangerously insane ward in asylums and a consultant in jails. It is rare for regular doctors to ‘certify’ or mandate to be hospitalized or take the freedom. Diagnosing a borderline personality disorder, psychopath, narcissistic personality disorder, or antisocial personality disorder or alcoholic or addict isn’t a welcome diagnosis that brings praise and thanks. Neighbor does cancer but cancer is a diagnosis which isn’t ‘blamed’ on the doctor’. Second opinions don’t change the diagnosis of crack addiction and yet the diagnosis of crack addiction can affect a persons employment or insurance. As a family physician I was never offered money to ‘lie’ to the insurer. As an addiction medicine specialist I have been offered money and threatened if I don’t change my ‘opinion’. I did run into this issues when i worked at a street clinic diagnosing STD’s and being told ‘you can’t tell my doctor because my wife /husband can’t know I have ‘gonorrhea’. Yet a public health requirement was that the contacts had to be notified. Diagnosing HIV was a lot harder for me and patients than when I diagnosed cancer but the patient didn’t ’blame me’ and rarely believed that the ‘diagnosis’ would go away if the doctor was just silenced.
I was very ‘popular’ as a family physician. I was told when I came into psychiatry that I must realize that not only can’t I please everyone I will for certain make enemies.
I have reported a number of pedophiles who told me they were doing these things despite my telling them that I was required to report these behaviour if they persisted, I’m not required to report them if someone said they ‘did’ something, The law is exacting .It allows people to talk of their past but as a psychiatrist I am required to protect people from future negative behaviour if I believe the risk is there., Pedophiles have told me and argued that they would continue have sex with children and that it was their right. I reported them. They have hated me since. They have made one or more comments on ‘rate your doctor’.
I had fired a crack addicted staff member and they wrote several scrurillous comments on ‘rate your doctor’. Their boyfriend threatened me and threatened my staff. I was disappointed that we faced so much risk in our work and had so little protection from authorities. I worked with ‘victims’ and know the limits to what police and the legal system can do. I was a member of the Canadian Civil Liberties and Psychiatrists against political abuse of psychiatry so know the challenges judges and legislators face. I’m a libertarian at heart but having worked in prisons think the anti police people are generally ignorant. I’ve known psychopaths who would just as soon kill you as play golf with you. Fortunately when I’ve offended one they have a list and it doesn’t take long before they are hostile towards someone else.
After family medicine and psychiatry where I specialized in Borderline Personality Disorder and PTSD, I did a specialty in Addiction Medicine. As a psychiatrist I worked in the north and in reserves where they couldn’t get doctors to go. Most family physicians and psychiatrists avoid patients who are actively addicted or even those in recovery. They are commonly psychotic and often emotionally in a state for ‘for me or agin me’. There’s a lot of paranoia and black and white thinking.
Cherry picking is a way a psychiatrist can be popular. I was impressed with one colleague who only saw dependent women patients The patients never got better or changed but were mothered and soothed. She was a good businesswoman too and fired any patients who didn’t appreciate her. Originally psychiatrists were taught to help patients most by ‘working through their negative transference’ but now there we are taught to work with people who have a ‘positive transference’ and mostly medicate. The rich can afford psychoanalysts but today one is lucky to even see a psychiatrist once as psychiatrists are encouraged most to just see people for one visit every 6 months like other specialists. Given half my patients don’t have family physicians and at least that many can’t afford any therapy let alone psychologists I continue to talk to patients as psychiatrists do asking them about their work, relationships ,intimate and friendship and their recreation. Restricting interaction to questions about medication response is safe and good business but it presumes someone else is doing addressing all those other areas of the persons life. The result for me is making hundreds of diagnoses and identifying multiple problem which were ‘missed’ by patients and others but were critical to the medical and psychiatric care.
The other way to be a popular psychiatrist is to ‘enable’. This is where you agree with the negative behaviour. Counselors are commonly faulted for this,. It’’s a marvellous business model and supported by the College of Physicians because “enablers” don’t attract complaints. Saying things like ‘of course you need a little cocaine’ and ’prescriptions of opiate for minor pain” are very popular with certain individuals.’ The best ‘enabling’ psychiatrists are those who do not address ‘accountability’ but rather ‘triangulate’ and agree with the patients saying ‘of course your boss is an ass’,(the 10th job in 2 years). ‘your mother in law is a bitch’. “Your ex , all 50 of them were narcissists’ is very attractive to personality disordered folk especially borderlines. I have been the first one to ‘diagnose’ addiction in countless individuals who have been seeing doctors and psychologists and counselors and psychiatrists for years. It doesn’t bring a ‘thank you’ if the ‘lie’ has been working up to then.
I have made very important enemies by reporting a senior physician who caused the death of a patient and tried to deny and falsified records. Back in those days I thought like Clint Eastwood, the good guy and the bad guy. I now know there’s a ‘nest’. I encountered an ‘alcoholic department’. People also rally to protect their own. A bad judge had to be so bad that his brothers and sister judiciary found him at fault for falsely calling my a liar. I was very thankful for the lawyers but not at all pleased to have let myself get caught up in his illness I did catch a hospital administrator stealing money from the medical equipment so thought I should report that the money for an incubator had gone to decorating his office. I was even more incensed when he stopped paying for the oxygen tanks to be filled and I was trying to resuscitate a person and had to get another tank which had oxygen. My surgeon colleague said it had happened to him but he was afraid to complain because administration has all the time in the world to battle and he just wanted to do surgery. I was told I should be more Canadian and not ‘rock the boat’. The hospital now requires a non disclosure agreement from the doctors. There are no whistleblower protections in Canada like there are in the US. Even then I wouldn’t like to be Assange. While I might have a tendency to see a ‘popular doctor ‘ as one who is ‘political’ and plays it safe I know colleagues who are amazing individuals and I’m doing my best to learn from them. First and foremost those individuals are amazing clinicians and secondly they have a bed side manner which I admire. Lawyer’s and administrators and especially beurocrats wouldn’t last a week in the active clinical world of addiction pscyhiatry except by avoidance.
The good news for me is I have a story of the bad judge, or a drunk pharmacist or the stealing hospital administrator. These stick out because they are rare. I’ve worked with dozens of BC and Manitoba Judges and a half dozen American judges and they have been the most amazing people, really, really really. The lawyers I have worked with in the majority have been truly caring and educated and not at all like media sometimes portrays them. Today I believe that 90% of journalists give the 10 % of good journalists a bad name. By contrast 98% of judges I have known like my heads of psychiatry and medicine and surgery reassure me. The bad applies are few and the good apples are the norm. The hospitals with exceptions have been generally well run but really I’m thankful to be able to work from my own clinic and other peoples clinics because I’m no longer institutionally inclined. I admire people who are. My brother worked in government and had amazing skill for accommodation. I thought he was a pretzel but my congressman friend says politics is like herding cats and it’s a good day if you can convince them to get up and move at all. I’m not political. I’m a clinician and it’s been a great experience to have the decades of education and years of experience to still be able to help people.
I have opinions and that means I have declared biases. I do use evidence based data and refer people to scientific literature to challenge the misinformation that is now common in media especially social media.
I don’t like the ‘hollow men’ and the attempts of the people pleasers and those who learn to talk” beaurocracese” - lots of talk but no substance or matter., Politicians recently have been making all manner of statements but not giving proof. Intellectualization and politics are not scientific. Emotionalism isn’t either
Psychiatry is biological, psychological, sociological and spiritual, Prescribing a medication, psychopharmacology, is well researched. Canada’s CANMAT is the best reference available. I am disappointed that so many Canadians are graduating high school and college without training in scienfic method or logic and fallacies. Patients become very anger when I say I can’t prescribe them something because their friends or social media says it is good for them., I can lose my license to practice medicine if I maim or kill people. Some 30 to 50 thousand people later I am very blessed and thankful especially to my teachers and for the researchers that I haven’t harmed or killed people. Like all specialists I may have to do more than one trial of therapy to get the right answer. As a family physician when I was very popular it was common for me to have to try several antibiotics to cure pneumonias and other serious infections. Psychiatry attracted me as a specialty because it was the most difficult.
I’m very thankful for pharmacology. I’m also thankful that as I was training psychoanalytically I was asked questions that ‘offended’ me. These ‘emotional’ charged areas are the “cathetic areas.” Something is triggered, The ‘transference’ is central to psychiatry especially the psychology of psychiatry. If someone upsets you the next question in psychiatry is what does that remind you of in your child hood. Usually it is a mother or father or sibling. That’s what the Menninger Triangle is all about. Freud challenged about his cigar smoking said ‘sometimes a cigar is just a cigar’. Today there is a dumbing down of the ‘process’ so more likely someone might say a cigar is a Freudian slip. ‘Political corrrectness’ rules in society. Challenges to ‘freedom of speech’ are reported daily.
I suspect that I’m under attack because being a member of WPATH I agreed with the age of 18 for sexual surgery. I also distinguised ‘cosmetic surgery’ from ‘gender affirming surgery’ and was personally ‘attacked’ as not being an ‘ally’ of the victim transgender. Meanwhile I’d treated hundreds of transsexuals providing the assessments for surgery required in Montreal and Vancouver without special payment for those letters. I’d treated dozens of very complicated medical cases and fought on behalf of transgendered people who were persecuted. I was told that I had to be ‘100%’ behind requests for cosmetic surgery .or I wasn’t an ally. Surgeons respected me beause I’d done a year of surgical training and knew what they needed to serve. The same occurred when I objected to patient not getting methadone and suboxone and equally for supporting methadone and suboxone in the jail When something is controversial and you are taking the middle path you are likely to be hated by both extremes. I misss the certainty that extremists feel and the terribly lonely place that being moderate brings, arrows and bullet wounds front and back.
So often people confuse , ‘the doctor didn’t listen to me’ with the ‘doctor didn’t agree with me’. Commonly, especially mentally ill patients who have no knowledge of logic and courts believe they’re right and they have just enough time ‘you will agree with them’. The trouble is that applies for the rich who pay themselves for a counsellor who will agree with them and will listen ad infinitum so long as the sound of Ker Ching is heard in the back ground. I work for the patient and the health care system. I’ve had a 2 year waitlist and there’s been a horrendous shortage of psychiatrists and Psychiatric services for decades. The ‘catchment’ figures for government psychiatric services run around 30 % in some studies while collectively the private clinics services are 80%. People prefer a family physician to a walk in clinic mostly. I keep my waitlist short in the last decade by turning away cases that are better managed elsewhere. Most of my colleagues turn away addiction and personality disorders. A half of my practice is that group of patients who are most likely to complain. My colleague who only sees schizophrenics is a great doctor but least likely to have a complaint because schizophrenics don’t complain,
I was impressed with our Supreme Court Judge from UBC who argued that the courts needed to be more transparent. I’ve believed in radical transparency but politically and economically libertarianism as opposed to authoritarianism is on the rise. I wonder about ‘sharing’ when I see that people view ‘honesty’ and ‘truth’ as ‘weakness’.
I have no plan of retiring or leaving as so many of my favourite colleagues have done to avoid the harsh demanding climate with burn out and lack of resources , I’ll muddle along today. In the last months dozens of my patients have expressed hope that I will continue to work. I say I have to pay the bank for my car and mortgage and am enjoying my work and have no reason to leave yet. But they’re just thankful for care and someone to sign their papers. Half my patients don’t have a family physician. People with an axe to grind, the patients I refused to give more controlled substances to than indicated or the ones angry that being on benzodiazepine I am taking them off because the college demands this as does the latest research. When I wouldn’t write more Xanax for a patient pulled out a gun and showered me what he could do. I didn’t give him more medication and certainly didn’t say ‘make my day.’ I did tell him though if he killed me no other doctor would ever prescribe him Xanax, It’s a tough withdrawal and it took a year for him to get clean. Recovery is a challenge and abstinence is a major achievement but today so many people are encouraged to opt for ‘palliative care’ rather than ‘cure’ when a ‘cure’ is possible but costly financially.
I’m against ‘MAID” for the mentally ill too but I’m not allowed to explain why. I have let people die on my watch when I could have kept them alive but know that our government refuses to date to accept ‘external review’ of MAID for the mentally ill. Government t has a conflict of interest in letting poor people die when what they want is better housing and mental health services they can’t access but are being offered ‘death as healthcare’. The dead don’t complain. . I don’t make friends by suggesting politicians in favour of MAID lead the way with themselves or their family members. Canada has long had a two tier medical system, for the rich and for the poor. The rich often get care in the US .
Despite all criticism I am here because I think our College and Health Care Premier and UBC are doing a good job in very difficult times. I love our Doctors of BC association. I see Ottawa as a problem more tthan Victoria on any day. I believe that when people are open and honest that we can improve, individually and collectively. Shining a light into the darkness is restorative. I feel blessed to have been a psychiatrist and known such remarkable teachers and patients. Critics are a dime a dozen. I am sensitive to ‘ad hominem’ and appreciate constructive criticism over destructive criticism. Yet I know several psychiatrists who have stopped seeing people with addiction or personality disorders so they can avoid the complaints which are the norm and common in these populations.
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