Tuesday, June 13, 2006

Dilemma.

I've made a rule here: "No medical advice is given on this site."

But suppose that a commenter says: "To taper a med, do A, B, and C." Does that violate my rule? Should I delete the comment?

And if another commenter states that such a taper is unwise or even dangerous, what then? Is that medical advice?

Why does it matter? Each day, people ask Google about "stopping meds." Each day, Google leads some of them here. Note the active, growing comment thread. Baldrick says:
"one of the problems with the internet is that large numbers of people with rare conditions/reactions/discontinuation reactions congregate in one place. They may or may not have atypical ideas, metabolisms or disease presentations."
A crucial point...one that I wish I had made, myself! But Baldrick also says: "To taper meds, do a, b, and c." (You see where I'm going here.) Another commenter vehemently disagrees with Baldrick, and says that such a taper should not even be posted.

I'm trying to walk a tightrope. I've tried to say: "Some think A, and I've seen B, but please talk to your doctor." I believe that I'll have to start monitoring things more closely, and delete anything that might be construed as "advice."

Your thoughts are most welcome. (Add: I've republished the original post, with updates.)

13 Comments:

Blogger Dr John Crippen said...

Shrinkette

That's a fascinating question. I had not really thought of it, and I am thinking aloud now. Most of us blogging doctors have standard warnings that we do not give medical advice to patients. And certainly, when I get emails (or comments) asking specific questions about the writer's health, I always refer them back to their doctor. We all agree with that.

But are you now suggesting that we should remove all comments that suggest medical treatment on one sort or another? Surely not. I think we can discuss medication and treatments in general terms, as long as it is not patient specific. Trivial example : it is best to finish a course of antibiotics. More controversial : you write a post saying that the ritalin group of drugs are grossly over prescribed; or that you recommend epidurals in labour; or that you hate (as I do) the use of pethidine in labour. Different views on when and for how long to prescribe HRT. The list is endless.

I think you may be being too resrtictive. Particularly on yourself. We WANT to hear your views on psychiatric drugs and their use. That is one of the reasons for reading the blog!


John

10:50 AM  
Anonymous Roy said...

I agree with John. To expect that you are responsible for others' comments is not reasonable (at least, not to me). Blog visitors come with the expectation that comments represent a range of thoughts... many common, some uncommon, a few bizarre.

It is up to the reader to discern the difference. Perhaps we should add to our disclaimers something to the effect that, "Visitors also understand that any comments on the site are not approved or authorized by me, and should not be construed as personal medical advice."

After all, if the guy next to you at the drug store tells you that sniffing Preparation H will relieve your swollen sinuses, are you gonna do it? (btw, it *does* work, but who wants to?)

12:01 PM  
Anonymous Anonymous said...

John/Roy:

Although I resonate to some degree with your points… there is some context missing here. The original commenter—a physician— described a “how to” tapering strategy that was rather crude, potentially dangerous, and included the phrase “when the brain turns to sherbet.” With aprox. 36 million people taking antidepressants in the U.S. alone… driving cars, operating machinery, firearms, air traffic control instruments, etc, it makes sense to remove a potentially dangerous comment.

Regarding the quoted comment about the internet being a place of congregation for atypical people/reactions, etc… While it’s true that this is a self-selecting population and that the people that are having temporarily lovely reactions to antidepressants aren’t on the internet talking about it, the phenomenon of antidepressant withdrawal is neither rare nor is it the product of an atypical idea. To use the internet as a catch-all explanation for unpalatable outcomes is a mistake. I am not suggesting that the doctors participating in this forum are necessarily doing this but too often I’ve heard of people including physicians scapegoating the internet in a way that is self-serving and intellectually lazy.

The internet forum that has helped me through the protracted hell of antidepressant withdrawal receives 21 million hits a year and one of the most charming aspects of our atypicality is that we provide common sense tapering strategies (consistant with the guidelines of Stahl) that preserve functioning and decrease the probability of a negative or tragic outcome. Although we always insist that people work with their physician it is often an uphill battle as they (especially GPs) tend to be dismissive and cavalier. When they do provide assistance it is often a recipe for brain sherbet.

2:11 PM  
Anonymous mchebert said...

Shrinkette:

That was a fascinating thread. I usually keep my postings on a more personal and emotional level, and rarely address specifics about therapy. The few times I have I have gotten bitten.

From what I could see most of the reaction to your post was an emotional response to the problem of Paxil withdrawl. That's how it usually is; people get worked up over clinical discussions and recommendations if they feel they have been hurt by similar recommendations in the past.

I thought the attacks on psychiatrists were especially uncalled for. I get indignant when patients complain that "all doctors want to do is write pills." I am an internist for heaven's sake -- pharmacotherapy is what I do! If you don't want drugs go see a priest or a therapist. But don't complain that the hardware store doesn't sell eggs. That's not what hardware stores are for.

As for the issue about issuing medical advice, I tend to agree with Dr. Crippen. It is a free country, and we should be able to discuss medical issues in public as long as we do not apply them to individual cases.

I know I sound callous for saying this and will probably be lambasted for it, but people who troll the internet looking for solutions to their medical problems get what they deserve. It is a rock-bottom ethic of medicine that you cannot render an opinion about a patient without seeing him physically first. The physical exam is not some antiquated joke. It is necessary for good care. Thia is not a hard concept to get, and patients should understand that.

I cannot understand why people would trust the medical advice of people who do not know them. But if you do, I am libertarian about the consequences. If you bungie jump off a bridge without checking the length of the tether first, that is on you. You have no business blaming the bridge builder if you hit the ground.

3:08 PM  
Blogger On the Same Page said...

Given the fact that anyone can access, for example, Entrez/Medline, Medscape, WebMD, purchase the PDR, etc. and see original research outcomes, medication "reviews," clinical case presentations, and clinical indications, I fail to see how anyone is ethically "liable" for the actions of a random visitor to a medical discussion. The prescribing information for numerous medications, including therapeutic dosages and administration, are found in every issue of Time Magazine. But I do not believe that this is the issue at hand. I found your Paxil withdrawal post as a defensive reaction to an unfair "advertisement" of your blog as a place to ventilate against all psychiatrists. It seems to me that Anonymous' comment of a site where, "we provide common sense tapering strategies (consistant with the guidelines of Stahl)," to the tune of 21 million hits, would cause Dr. Stahl great consternation over the replication of his practices or their derivation on the open internet. That is why he wrote a copyrighted book titled the "Prescriber's Guide," with a targeted audience, prescribers, in mind. As mcherbert points out, if someone is willing to utilize a medication withdrawal regimen without the advice and monitoring of their prescribing physician, they have, to borrow a phrase about lawyers who defend themselves, a fool for a patient. Nevertheless, if I, for example, post the "recipies" for methamphetamine or crack cocaine (already adequately covered) on my blog as a point of, say, scientific discussion, I should not be so naive as to imagine that someone will not attempt a utilization. Obviously, we cannot control every blog variable, but those we can, it seems to me we should.

4:56 PM  
Blogger Spiritual Recovery said...

I've made a rule here: "No medical advice is given on this site."

You are an identified psychiatrist with a blog. Unless you refuse to discuss your profession at all, there's going to be talk of medicine. How you might choose to deal with it depends on how much time you want to invest in moderating comments. I'm guessing, you have better things to do with your time.

I would suggest that you alter your disclaimer to read something along the lines of: "I do not give medical advice in this blog aside from "Talk to your doctor." You can only be responsible for your own behavior, not the behavior of every potential respondant.

I think the least attractive option is to remove any comment deemed "troublesome" although you could take a hard tack on that if you wish to do so. If that's the direction you're going to go I'd recommend that you also add that to your introduction so that commentators are duly advised prior to participating. Something along the lines of: I reserve the right to remove any post I feel is not suitable for my viewing audience," would cover it.

On the other hand, if you make that kind of statement you're obligated to follow through on it or it's meaningless. Any time you remove someone's post you open yourself up to accusations of bias, censorship, favoritism, etc. It's also possible that your efforts will not be warmly embraced by the participant who has been silenced. What you may think is irresponsible may be what they think is a perfectly valid perspective. If they have others who agree with them... It could get messy. Bear in mind that you're a psychiatrist, and you might be silencing someone who falls into "client" territory. There's a different kind of dichotomy at play.

An alternative approach might be that if a statement is made you feel uncomfortable with, you could counter with a new comment, noting your discomfort and why you feel as you do. This would enrich the discussion as opposed to closing it down and even allow a really bad example to be used as a good one. In some instances, this won't even be necessary because a reader may have already addressed your concern. This is good, because it means you'll spend less time moderating and soothing hurt or angry feelings.

I think the primary value of the internet is the ability to disperse information to a wide audience so I would aim towards opening discussions as opposed to closing them. I also think there's some fantastic medical sites out there, including the variety formally known as "self-help" and "peer-to-peer support".

I thought the attacks on psychiatrists were especially uncalled for. I get indignant when patients complain that "all doctors want to do is write pills." I am an internist for heaven's sake -- pharmacotherapy is what I do! If you don't want drugs go see a priest or a therapist. But don't complain that the hardware store doesn't sell eggs. That's not what hardware stores are for.

Try to consider that if people go to see a psychiatrist it may be their expectation that their doctor will engage in discussions with them, just like you might expect that you'd find a hammer in a hardware store. If that's the expectation, some dissappointment may be in order. Also try to consider that not every doctor (or hardware store) offers sterling quality or top-notch service. Unless you're being criticized personally, it's not always necessary to respond defensively. Sometimes the criticism is warranted, for doctors are no less human than the rest of us. They can be found in a range of technicolor variety ranging from exemplary to downright horrid.

5:54 PM  
Anonymous Anonymous said...

Foo,

Your point about research findings, the PDR, etc makes no sense whatsoever. And this thing about Stahl.... "*consistant with* was was the operative phrase. Not once has anybody from the website I alluded to referenced that book. Our knowledge came from hard won experience. You have picked the most peripheral non-issue and really said nothing. Weren't you the one who to a patient who was practically writhing in pain from the sloppiness of your profession.

Perhaps the most disturbing aspect of these threads—beyond the fact that removing a post containing dangerous medical advice should even have to be debated—is the defensiveness toward and disregard for those who have suffered from negligent medical care with tragic consequences. The doctors in these threads have been quick to identify and implicitly pathologize the “emotion, anger, rage” etc in patients’ posts but slow to acknowledge the story behind those emotions. It is shocking to me how little you seem to be able to learn from patients… that you could be so mired in this incestuous culture of dope that you can’t see the casualties. “Got what they deserve????” “Fool for a patient????” How could you say that to anyone?

While the permutations of irony that hang over these threads are becoming too numerous and nauseating to track, it’s interesting that readers of your site are now contacting the former patients that have posted on this site and asking them for more information about their experience.

I won’t be bothering you anymore. I have offered you a valuable, reasoned viewpoint, and you don’t seem to be able to do anything but weakly defend your livelihood. How hard would it have been for you to respond to the two people who poured their hearts out in the original post with “I am sorry that happened to you. Some doctors aren’t up to speed. This shouldn’t have happened. You should have been given informed consent. You were given misinformation. Thank you for helping me to better understand, x, y, z.” How hard would that have been??

5:58 PM  
Anonymous mchebert said...

To anonymous above,

Some people (yes, I mean you) never, never get it. As I said above, the key to any medical relationship is the RELATIONSHIP, i.e. the doctor physically seeing the patient. See my discussion of this above.

In these types of threads, doctors get a repeated beating for not crying over the stories of the patient-posters (your comment: "How hard would it have been for you to respond to the two people who poured their hearts out in the original post with “I am sorry that happened to you. Some doctors aren’t up to speed..."). No doctor worth the weight of his or her diploma would pass judgment on another doctor without examining the patient in question. I can't understand why you don't get that.

Doctors defend one another because we know that medicine is pretty damn hard to practice and that what looks like an obvious mistake from a second hand story often turns out to be not so simple when you review the case first hand.

I have been dismayed at how many people think they can make medical judgments based on highly inaccurate internet comments. You can't judge doctors or patients like that. Why is it a "valuable, reasoned viewpoint" to argue that a doctor should admit fault for another member of his profession over a matter in which the most important facts are not in evidence?

If you can't play by the cardinal rule -- don't make the diagnosis until you have examined the patient -- then please, don't play the game.

10:59 PM  
Blogger Fallen Angels said...

All arguing aside, the bottom line is this is Shrinkette's blog. She can do whatever she wants here.

1:35 PM  
Blogger Ex Utero said...

Shrinkette,

on my blog I can do what I want. Lately I've been writing about medicine during the plague and comparing various characters to promininent medical bloggers (all in good fun).

Your dedication (well half dedication) is here:

http://talesfromthewomb.blogspot.com/2006/06/plague-town-anthology-part-2-zelda.html

Hope you like it.

3:20 PM  
Blogger Greg P said...

Time to stop the (mental) hand-wringing.

With or without a notice, you can delete any comment you want to, just like you can rip a political sign out of your yard if you want.

Many of our patients, whether we're able to accept it or not, are looking for an excuse to change or stop their medications. They will look until they find one that seems to absolve them of responsibility. If I have patients who by their behavior do not wish to follow my recommendations, I absolve them of their sins and release them to their own good behavior, along with wishing them well with finding a doctor to their liking.
If they do not trust my recommendations, I have no interest in trying to help them find solutions.

12:38 PM  
Blogger Spiritual Emergency said...

Well, here's some food for thought...

McHebert has stated that "Anonymous" just "doesn't get it. What continues to surprise me is the way "some" (by no means, "all") blogging professionals also seem to be missing an essential point.

I grant that I'm only offering an opinion and readers are welcome to take it or leave it as they see fit. That said, when I read the blog or post of someone who identifies themselves as a professional, I'm going to assign it a little more weight than someone who has no experience in the field. That means that if you identify yourself as a mechanic in the online environment, I'm going to expect that you know a little about engines. If you identify yourself as a chef, I'm going to expect to see some handy tips or tasty recipes. If you identify yourself as a doctor, I'm going to expect to see some compassion, some empathy... along with a certain degree of knowledge and skill.

I suspect however, that some professionals who blog are not all that interested in presenting that side to me or their other readers. I wonder if they're trying to present their more human side -- the side that says, "I can get annoyed and pissed off too!", or, "Hey, this is how tough my job really is. Just listen to the b.s. I have to put up with in the course of trying to do my work!"

I confess that if I listen with a "patient's ear" what I hear is "We doctors have to stick together!" and "Why should you care about them? Put your own needs first!" If I listen with a different kind of ear, I hear "I'm feeling picked on and defensive" or "There's just no pleasing everyone, so you might as well please yourself!" It's a different kind of frustration being expressed.

For what it's worth I think shrinkette manages to walk a fine line between the two aspects fairly well. I also think Anonymous had a good point and that he/she may have departed the conversation with their faith in the "doctoring profession" substantially battered as a result of their interactions here. I think I understand their perspective quite well.

I find myself wondering if mchebert "gets" that as long as someone presents themself as a professional there's going to be a different kind of expectation attached to their words -- is he/she aware of the message he is sending? Are you aware that what you say here defines and presents your professional body to a very wide audience? Do you know how you come across to a "patient" or "client"?

On the other hand, perhaps it's we readers who don't get "it". Perhaps your (collective) purpose in "speaking" is not to present your "professional side" at all, and if we hold you to that standard we're doing you a diservice from one human being to another.

Either way, there seems to be plenty of room for fear, suspicion, animosity and distrust. I'd like to think we could do better than in writing each other off with no interest in developing solutions. After all, when a client/patient comes to you, they generally arrive in a wounded state. Meantime, we're the butter on your bread -- you need "us" too.

6:47 PM  
Blogger Spiritual Emergency said...

With or without a notice, you can delete any comment you want to, just like you can rip a political sign out of your yard if you want.

You can, but it's probably more courteous to state your intent to rip them out at will up front. It also may prevent political signs from being planted in your yard to begin with and thus, save both sides the frustration of even going there.

6:59 PM  

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