94 Comments

Don't forget there is a large segment of people who think doctors are gods. You, or they themselves, could say anything about them and that population would dismiss it as gossip. Doctors could admit their own vulnerability by declaring their own mental illness in the exam room with just the patient as the only audience and that patient would brush off the admission by believing the doctor was just going through a temporary hard time which will resolve itself soon.

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What about the option: patiens don't care? 😅

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I have no idea who won this debate but reading both arguments was fantastic!!! More of this please. Debate and let the chips fall where they may. I’m going to show this to my students to teach them how to disagree agreeably. Maybe Vinny and Adam can debate a physician’s sartorial preferences next.

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I'm a psychiatrist with bipolar disorder

disorder, working in France

I voiced my mental illness publicly this year. Been stable for years.

6 months later I get a letter from health authorities saying I'm unfit to work because of that - based on my social media profile.

Actually did an interview with Ghaemi where I'm clearly sane.

My wife and colleagues didnt notice anything either, but I guess these guys know better.

Now I'm getting into the lawyers and such.

Christ.

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Do MDs/DOs need to open their Souls to their patients/public?…After what we have seen on how totally quiet 99.99% of these physicians were/are about the damage from both hospital care of CoVID folks(presumed to be COVID cases) and the realization of the massive complications of the vac their inner psyche must be extremely corrupt and ethically damaged. Atoning for THEIR SINS would go a LONG WAY for a return to humanity within the profession however purging their “masters” from the elite stage would too be needed. The mask of deceit and unethical behavior must be removed starting with tossing the Peds/CDC kid’s vac schedule, banning any COvID vac, indicting the main scheme/scam players and purging the FDA/CDC of corrupt and unethical political operatives…and withdraw from the WHO.

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I voted Undecided, and then No. I’ll make s statement I can only back up with experience, not data, but in fifteen years of clinical work, I have become convinced that patients and providers both thrive when the provider sets very clear boundaries.

I share quite a lot with my patients in an informal manner- how my pets are doing, how my garden is doing- and also in a deeper way, as being a human is difficult and profound, and I’m grateful to be a collaborator with patients who are in the process of healing.

But I never want to burden my patients; they are coming to me to focus on their problems, not mine. It’s one thing to chat about a shared history of sciatica or a tense neck and how to stretch to support recovery of either, but it’s an entirely different emotional weight to share about serious mental health challenges.

Doing my job well means setting aside my own concerns while serving someone else; it’s my responsibility to seek my own support from others in a position to serve me, and that is never the person receiving care from me.

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Sep 27Liked by Adam Cifu, MD

Vinay you definitely need a PCP - this is pretty clear from world data. Thet will take a holistic view, assist communication and referrals to other members of your needed health team. Will help you work out undifferentiated illness and help you with preventative care and Lifestyle medicine. You deserve to have a primary care physician!

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Amen

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And. Interestingly, a similar topic, related to pilots, was being discussed here today:

https://open.substack.com/pub/drmcfillin/p/risking-lives-at-30000-feet-faas?r=9qoh9&utm_medium=ios

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Ha- thanks, Vinay, for changing my mind. I absolutely want to know what my doctor’s up to before taking serious medical advice.

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I think there is a difference between choosing a doctor because you saw their disclosure - part of Vinay’s position - and having a doctor you are already seeing disclose their mental illness in the exam room at a patient’s office visit. I think most patients don’t really WANT to know that information and would prefer the visit stay focused on THEM. We have to be careful not to talk about ourselves too much - they really don’t want to hear it.

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If ever there was an argument for individual, tailored treatment, mental health is the field. The support system available to the patient is the true treatment, rather than the hour in the office. The hour might provide the tools, but it cannot erase patterns of behaviour. The hour might draw attention to these patterns, but this introspection requires insight to divulge the patterns. In providing an example of our own health struggles we limit the patient's opportunity to get to this divulging. The fact that the patient is in the office means they trust the clinician has the ability to work with them. A personal struggle might make one relatable, but it will also oblige the clinician to take a side either in judgement or support, the middle ground of observer/navigator could be more easily lost to patient perception. An example might be, although controversial, a sex addict treating a sex addict or drug addict etc. Should this be immediately obvious to the patient? Does it do either party any good? Obviously there are moral and ethical dilemmas that play out as well as legal pitfalls. There is limitations on sharing our own lived experience as well, where one clinician shares, does it now compel another, unreasonably to that clinician, to share their experiences in order to "break the ice"? Clinicians who are veterans might clear this up in minutes, but there's a deeper level to consider. We all have moments alone with our thoughts, a place of solitude where we are the only ones present or privy, what cost is there to giving that up to throw open the door to our minds? How does the patient tactfully withdraw from that situation? Will the interview lose authenticity if the patient tries to play a role other than their own?

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Sep 26Liked by Adam Cifu, MD

The answer is no, but not for Dr. Cifu's reason.

First, this will never be the case:

"Someday, people will treat medical and mental illness the same way. We will see no difference between hypertension and depression."

And it shouldn't because I reject materialist reduction. There are a number of reasons too long for here. But I will just say this: the photon. It has no mass and therefore is not matter. Since not every thing is matter; materialism cannot correct.

But even if Cifu's reasoning was correct that supports my ultimate position. I don't want to generally know about any of a doctor's medical problems! Sharing your person medical problems is a form of narcissism. Your toe fungus, depression, AFib are irrelevant. You don't need to humanize yourself; every patient even a baby knows you are a fellow human.

Less sharing with the general public. Share with your spouse, close friends, family, your own doctor, your counselor,and/or your confessor.

This is a good rule for everyone. Less public sharing and more being incrementally better at your job and at being a good neighbor.

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Heather,

I read your comment after posting mine.

I might be swayed if confession of a physician’s illness was done cautiously, well after the start of treatment, and on a case by case basis.

For instance, perhaps you are seeing a medical student who has suffered, say, a manic episode with hospitalization. She/he has recovered, is reliable about taking their medication but feels hopeless about their future because they were psychotic. And if their medical school is like most others, EVERYBODY KNOWS, and they are already experiencing distancing, eye rolls and other fear based behavior, it might work well to say that you have manic-depressive illness (I prefer this term also; the other makes it sound like a battery). You can also use yourself and your experience to help emphasize the importance of always taking their medication and having a trusted psychiatrist on speed-dial.

This gets even more important if they re-locate and are initially disoriented and overwhelmed—which we all were. It can have a different meaning to them, tho’, that they need to on the lookout for.

Any depression arises, at least partly, from a sense of hopelessness, helplessness and loss. The relocating med student will experience all three. If you have been their most trustworthy support, then ongoing phone contact with you might be important until they find a new psychiatrist.

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From a psychiatrist’s viewpoint:

Transference happens in every relationship. In psychotherapy it is used therapeutically to promote change.

So, what is it? It is a series of assumptions about the other person based on prior experience with others, particularly the experiences with one’s parents or other authority figures.

There are negative transferences which generally means the patient doesn’t stick around for the full course of treatment.

If you let a patient know much about your conditions or worse, you confess to certain facts about your personal life, it may unburden you but it will burden them. They will make adjustments to what they tell you based on their experience with that other person(s) and what they now think they know about you.

The “House of God” rule # 4 applies here: “The patient is the one with the disease.”

They will find your feet of clay, anyway, without you showing your feet.

Positive transferences include trust, and if the majority of the patient’s experiences were with trustworthy authoritarian figures, then that trust will automatically be transferred to you. If those figures didn’t lie a lot, then they’ll generally believe you are telling the truth. They’ll even forgive you a lie or a misrepresentation if your other behavior is trustworthy.

If you introduce more reality than they can glean from your office, your clothes and your car, it can cause more difficulties.

They will automatically adjust their behavior to suit whatever it is that they believe about you.

If you want to assure a pt. about the efficacy of, say, an antidepressant, it’s better to say, “Studies have shown. . . “ or “Several patients of mine have reacted well to . . . “ than to say, “This antidepressant really works! It helped my depression!”

Also, no matter how well that antidepressant worked for you, other people can respond differently with different side effect profiles.

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Psychiatrist here. I disagree with this as a blanket statement. I would use self-disclosure like this judiciously. I am in private practice working closely with mostly high functioning professionals psychodynamically. I am in long-term recovery from an alcohol use disorder and I do sometimes tell people if I think it would benefit them to know that. For example, I have a recovering physician in my practice who was so clearly struggling with deep shame and regret around substance abuse that it felt like a real opportunity to give them some much needed perspective. I shared this early on because my judgment was that they would benefit. A year later, they came into session and thanked me for that disclosure specifically. I would also add that I personally have seen a psychoanalytic psychiatrist for many years who modeled appropriate thoughtful self-disclosure which I always felt was shared for my benefit. The effect over time was a deep and abiding trust in the relationship.

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deletedSep 30
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You had a bad experience with someone who over disclosed to you in the context of a bunch of other bad behavior. That is so clearly not what I’m talking about. Furthermore, in recovery treatment, most of the people working seriously with these patients are in recovery themselves and it is very very common for them to be open about that. These patients are highly stigmatized by the medical system, even more than your typical patient with mental health complaints. They know that most professionals that they encounter don’t understand addiction very well. I am careful about who I tell, but it usually contributes a lot when I do. Especially if they are in 12 step, which many of them are. The depth of understanding that I have about 12 step is not something you would get as a nonmember and people who are working a serious program want to get into the weeds about what they are doing week to week with their sponsor. Sometimes it is just bloody obvious that I got sober in AA because no one else would know and understand the material in such a way. Also, not everyone can tolerate an analyst who is very opaque. That works for the people that it works for. Other people find it cold and dysregulating, particularly if they have had a parent use the silent treatment as a punishment. Fortunately, there is room both for people who take a more traditionally abstinent approach and for those who take a more modern relational approach.

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Thank you for your insight- very helpful when considering interactions with patients.

And all references to “The Rules” gets a like…

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Great answer!

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Always love a reference to "The House of God". It was published right at the end of my residency and fellowship training---great timing.

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Sometimes the doctor will tell you they are crazy indirectly. I scheduled an appointment with a new PCP this spring. The email I got confirming the appointment had a whole two paragraphs on COVID precautions, along with a push for masks and COVID vaccines. Very useful information. I cancelled the appointment immediately and scratched that doc off my list.

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Another indirect signal I remember: once I met with an internist in his office after the exam and noticed a fish tank overgrown with algae with the poor fish gasping and swimming upside down. I pointed to the fish and said, "Where is your compassion, doctor," and walked out.

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Great point that illustrates there are many clues to help assessing someone's character.

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I note that a number of comments remark that it makes the physician more "human". Of course there are dozens of ways to exhibit your humanity and perceptive people will always get it. Personalizing it may come across as self-serving and Lord knows we get enough of that on the internet and popular media.

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