Saturday, May 5, 2018
The Doctor, the Patient and the State
The social contract for the family physician patient relationship is generally simple except for communicable disease. The doctor’s primary concern is the patient. Yet if the doctor finds that the patient has the plague they are obliged by law to report the patient and initiate quarantine. The needs of the many override the needs of the individual. Until that moment the patient voluntarily seeks help from a doctor who voluntarily gives help to the best of their ability. When public health considerations intervene the voluntary nature of the relationship changes and treatment may be involuntary such as quarantine.
In the clinic this week we shared with some black humor how doctors and nurses are the first line contact with communicable disease. This usually means children pass along to the family physician the viruses. Yet with mass migration and the increasingly peculiar vetting processes for illegal aliens the potential communicable disease considerations have increased. It is even more likely to increase as Justin Trudeau without consultation with nurses or doctors has invited the sickest of the world to come to Canada for free health care.
In psychiatry the issue is the greatest for all the profession. Not only do we as doctors have the obligation regarding communicable disease but also we carry the public health responsibility for intervening when a patient’s behaviour or statements make them a risk to themselves or others.
Further there is the matter of diagnosis. Much of psychiatry began in asylums. Asylums historically were a kind of jail. 75% of male deviance ended up in the traditional jail whereas 75% of female deviance ended up in the asylum along with the assortment of gender neutral disorders like brain injury and schizophrenia.
When a patient gets a ‘bad’ diagnosis like ‘cancer’ they don’t argue with the family physician for a ‘better’ diagnosis like a ‘flu’. They accept the ‘evidence’ and expertise. This is not true with psychiatry.
Psychiatry is a field with fashionable diagnosis like ‘bipolar disorder’ and unfashionable diagnosis like ‘malingerer, factitious disorder, anti social personality disorder, borderline personality disorder, substance abuse disorder, heroin addict etc. Psychiatry is also a field where unfashionable diagnosis can often be made safely in hospitalization or in the asylum or jail but are potentially dangerous to make in the private office setting.
Patients have repeatedly threatened my life, my dogs life and my family life for diagnosing substance use disorders. Yet substance use disorders are a principle cause of workplace injury and are directly associated with motor vehicle accidents, domestic violence and wide range of conditions. Further substance abuse disorders are highly treatable and the vast majority are curable. Yet they were once called ‘cancer of the brain.’ Once the diagnosis is made the insurance company and the patient’s workplace commonly require urine testing to confirm compliance with treatment. If you want to keep your job you must remain abstinent but that means you can’t continue to fly planes on cocaine or work as a male surgeon drunk as a skunk or be a female police office with a love for opiates. A week doesn’t go by in my practice when some patient has told me how impaired they are hasn’t said, ‘You’re not going to report me doctor. You are n’t going to write that down. You’re supposed to be helping me. My family doctor helps me. The other psychiatrists just said I had depression.” Did you tell them you drank a bottle of tequila a day, smoked a rock and shot up a gram. “Well, no, they never asked?’
These are the women and men who commonly complain to the College of Physicians and Surgeons and find that the College of Physicians and Surgeons ‘understands’ and ‘supports’ them and punishes the bad doctors whose life is made a living hell by doing their job. They always know that the doctors who previously colluded with the patients and often the patients are the sources of deaths and injuries in the community as a result of their untreated psychiatric conditions, well, they’re not face any consequence for ‘negligence’. Psychiatric negligence is rampant and especially true in the counselling and psychological fields where every drunk or addict can be sure to find a friend.
The joke remains that a person is not an alcoholic unless they drink more than their doctor, drink more than their judge or drink more than their College administrator. There’s a serious collusion between the state which profits from the sale of drugs and is presently expanding it’s territory in this market after years of warring with their principle competitors for drug profits, the underworld
The trouble then arises for the doctor. Collude with the dangerous patient. Support their mental illness, knowing that such support, like hiding leprocy diagnosis in times gone by, ensured reward and protection from the patient but of couse puts the society at risk. To date the doctors who collude with patients and wittingly break the law face little consequence and much reward. Psychologists and counselors are commonly participating in the ruse and rarely hold themselves accountable.
The other area where this triangulation is rampant is in insurance and work. The patients increasingly demand from a doctor a ‘diagnosis’ that keeps them off work and continues their disability payments.
In the war soldiers shot themselves in the thigh to get off duty. Today women are extremely adept at this given the vast array of fashionable psychiatric diagnosis available to them. That’s not to say that men aren’t equally adept, the stories overlap, but the ‘stories’ really are often more gender bases, women claiming ‘fatigue’, while men ‘claim’ pain and immobility. The problem arises when a patient says they can’t sit for an hour but take plane flights to and fro distant countries like India, the man off work for back arche golfs and plays squash every day.
Increasingly Insurnace companies are hiring private eyes to video tape women who can’t leave the house for work but are captured on social media living it up on a shopping spree with girlfriends in Los Vegas. Men who can’t walk to work are filmed playing soccer. Meanwhile there is no consequence for doctors who do not report these discrepancies.
The doctors are asked by the patient to essentially lie on their behalf to the insurance company and the greatest tragedy is that if they do ‘ not ‘ collude’ with the patient who is often an entitled psychopath, a princess, or narcisist, the College of Physicians and Surgeons will punish them. The patient ‘kills the messenger’ by false allegations and outright lies and character assasinations and uses the inexperience and lack of education of the College of Physician and Surgeons to punish doctors who don’t ‘underwrite their bullshit’ (as the saying goes in the workplace).
I have diagnosed a dozen or more patients as malingerers. An academic head of psychiatry seeing how much harm this brought down on me despite my always being vindicated begged me not to make this diagnosis any more and said that he never made it. It explained to a large extent his rise in the politically correct rise in system. Not a terribly bright individual but compliant and he really didn’t like hearing how I’d had my windows shot out after I diagnosed alcoholism and drug addiction after my colleague had been only diagnosing depression.
It’s cost me personally the loss of hundreds of thousands of dollars. I’ve also diagnosed an equivalent number of ‘factitious disorder’ which is essentially a ‘malingerer’ (liar) but is doing it ‘unconsciously’ so does not have ‘legal intent’. I’ve also diagnosed hundreds of cases substance abuse. I’ve also diagnosed dozens of pedophillia cases and had dozens of cases where a patient came to me and the consequence of seeing me was that they were hospitalized as a threat against society. I’ve also diagnosed and reported hundreds of cases of communicable disease which has resulted in the patient being ‘required’ complete treatment rather than being allowed to continue diseased. Mostly I’m just thorough and truthful. Though truth is no longer recognized by those who claim we’re in a post modern society. Truth was one of ‘Canadian values’ till we were overnight told that there was no such thing as ‘Canadian value’. I loved Dr. Kellie Leitch for her being that ‘voice in the wilderness’.
Doctors who are apponted to administrative positions do not have any experience like this, and if any do, they can only cite one or two cases. They have stopped being ‘doctors’ and are now ‘police’ as their function is no longer for patients or even society but beurocratically , they are willing to ‘collude’ as part of the ‘negligence’. As everyone knows (to quote Leonard Cohen) the ’system’ is broken.
Most people avoid treating the difficult patients. The sick are sidelined by the more robust who manipulated the system for their own nefarious ends. Those most likely to cause trouble, those most likely to lie and complain,are the ones my medicine colleagues call ‘psychiatric’. Everyone wants to treat the garden variety mood disorder and anxiety disorder or grief reaction. But borderline personality disorders and antisocial personality disorders are anathema.
The fallacy is the ‘ends against the middle’. The fact that millions of people voted for a president is sidelined today by mob justice where a lying prostitute can command millions of dollars of resources and time without anyone questioning the ‘waste’ and why a single voice can derail a government when millions have voted democratically for that government. It’s not like we can judge given our drama teacher pays more attention to hair stylists and wardrobe changes than silly government details like ‘budget’ which are expected to ‘take of themselves’. Bob Dylan was premature in saying the ‘times are a changing’. Certainly we continue to have 21st century physicians, surgeons and nurses and other scientists and technological trained geniuses but we are all increasingly limited by tribal government and 19th century bureaurcracies and the occasional judge who clings to a wig. As corruption and favouritism in the system increase competence and excellence decline.
In forensic psychiatry and in criminal law the psychiatrists, doctors, judges and lawyers all have the STATE with its guns and power backing them. The doctors usually gather in institutional clinics and referrals are vetted carefully and there’s a whole lot of muscle and guns about. The community psychiatrist and increasingly all doctors are circling their wagons, joining in groups and its’ not surprising that only immigrant doctors will work in the outback given the peculiarly upper class and urban nature of more and more regulations.
“It’s peace time.” my military friend shares. ‘The peace time Captains are commonly these Ottawa type desk jockeys who haven’t actually spent ‘real time’ or ‘recent time’ in the field. They rise by doing the least fighting physically and the most time politically. “ “The enemy is always camouflaged. It’s too dangerous for the political career soldier. He and his wife would rather be on the party circuit.” This sergeant had been tasked with keeping some French Canadian officers safe so they could collect their Boy Scout Active service badge to assist their promotion. He didn’t think much of them and wished he didn’t speak French so well that he was tasked with their ‘safety’.
Psychopaths are chameleons and charm and deceit are their weapons of choice. The military friends I have and the police friends I have all share with me the incredible disconnect between the ‘reality’ of the workplace and the pot smoke filled drunken rooms higher up the hieararchy where some of their seniors are desperately people pleasing trying not to offend the psychopaths and sociopaths. In the field where we are facing the dangerously insane, the malingerers, psychopaths and sociopaths all wanting to use the system for personal gain or revenge , we now know we have literally no support. Our backs aren’t covered. We’re out beyond the wire and if anything goes wrong we will be sacrificed. “That’s the way we feel on the streets,” says my detective friend. “That’s the way we felt beyond the wire,” says the military captain friend.
There’s no consequence to the doctor who doesn’t diagnose alcoholism, malingering, antisocial personality, for the benefit of the patient. With the correct treat can actually consider treatment and stop being a risk to themselves or their fellow man or woman, at home or in the workplace. There is no reward from the College or from Insurance Companies for the doctor who gets a person back to work even though work is the best defence against disease and helps the individual and the society.
There’s a group of bikers I’ve had the honor to ride with. They have separated themselves from the overall group of veterans by calling themselves ‘combat veterans’.
I simply ask another doctor how many times he’s made the diagnosis ‘malingerer’ , ‘factitious disorder’, ‘borderline personality disorder’ or made the initial diagnosis of substance abuse disorder in the community. If he hasn’t , he may not know it, but he’s a part of the problem. Certainly not in any league I belong too. He might just be a poor diagnostician, a light weight, a “wannabe”. He probably has lots of opinion but really probably knows shit. He’s often just a coward , a clever person climbing the career ladder, ’ a ‘colluder’ and ‘kiss ass’ , ‘liar’ or any of the other terms we give this ‘smart’ ‘team player’. My military friend says they’re the first ones to die in combat.
“I have also noted watching consults from the university over the last few years that my academic colleagues are simply not asking certain questions any more . The terror is systemic and negligence grows.”
I remember a woman I waw once. She had fulminating breast cancer. She was my patient the last days of her life. She was aboriginal. Today we’d all collude and say what had occurred was ‘racist’ . It had nothing to do with being native. I was just really bad medicine that the police doctors of the College had not protected her against
She’d been to a half dozen doctors over the last few years complaining of pain in her breast but had been unwilling to take off her bra because she was ashamed of the ‘rash’. I was the only doctor who took the time and professional risk to convince her to let me see her breast. (The Feminist such male doctors perverts and sex offenders.)
When I saw her she had a fumulgating mass. The liver metastastases diagnosis was followed. I could feel the lumps on her liver but no one had examined her liver before that. She was a very modest person. I’d had to care to convinced her to let me examine her. That’s the reason I had her admitted to hospital. She at least had good medical care in her final days of life. I often wonder how many hundreds of thousands or millions of Canadians have died due to ‘negligence’ because really no one cares about ‘negligence’ of the garden variety kind, the systemic kind, that is cancerous with todays’ beurocracy.
That’s health care today. State focussed medicine masquerading as ‘patient’ focussed medicine. It’s what occurs when a state of fear dominates the field and toxic administration is made up of ‘yes men’ ‘yes women’ notoriously inexperienced but people who are willing to ‘maintain the appearances’, go through the motions. You can only know them by asking them directly and their inadequacy and inexperience becomes apparent by the lack of diagnosis and their their lack of difficult cases.
When I worked in forensics , my mentor the Harley Street forensic psychiatrist, departmental head, world renowned doctor had just had his life threatened, a patient tried to strangle him with his necktie. It was around the time I was held hostage by a patient and my life was seriously threatened so I ‘d talked to him.
He said ‘you can’t work in this field without scars. You don’t need to lose a limb but you can’t get out without having scratches anymore than a soldier couldn’t make it through the worse combat situations in the war without having scratches. Everyone who works in the front line can show you scars. ‘ If they can’t show you they’re just talking. There’s a lot of talkers. You’ll see.
I was honoured to be invited to ride with the combat veterans that day.