Thank you so much! Fantastic piece! After 40 years as a family physician, I completely agree with watchful waiting and made my encounter times longer, bringing people back again to further evaluate and brainstorm with the patient.
Thank you! You know what’s especially sinister to me? You wisely note his symptoms were partly from “a home he did not feel safe returning to.”
In pediatrics, no joke, even if you tried to explain that to the AAP or the pharma funded “experts,” they would tell you snottily, “well, doc, as a matter of fact, poor home dynamics are a risk factor for mental illness.” And they would double down on the diagnosis and the drugs!
I wrote about this at length here regarding adhd, both the absurd rapidity of the diagnostic process (a 2 min questionnaire) and the absolute insistence that it’s never the fault of a boring teacher or the parents’ divorce, it’s always coincidentally the kid’s frugally medical problem:
“I am informed by my colleagues that divorce, the death of a loved one, and other such instances of ‘adversity’ are “a strong risk factor” for developing ADHD. That’s one way to put it!
Don’t let the pharmaceutical salesmen gaslight you: it is normal for a child to struggle when his family is destroyed. I would worry far more about an eight-year-old who takes a family break-up in nonchalant stride.
If pediatricians are to have any role as regards the broken homes we encounter far too often, it should be as advocates for stable, married families, not as pill-peddling accomplices to the devastation that adults wreak on their children. What prescription will give a child her family back? We ought to fight for the children in our care, not excuse their soul-hurt with medical jargon (which is meant to absolve parental guilt), while making the innocent child doubt the validity of her own pain. Doctors simply pile adversity upon adversity—and prime suffering children for a lifetime of pharmacological dependence—when we teach kids that their normal emotions are a sickness in need of a cure.”
Excellent article. Poor provider listeners, metrics, lack of resources, insurance company nonsense, unrealistic expectations, pharma, etc…….The list is long and all of medicine contributed.
One of the huge benefits of AI in medicine is that the law and practice will ventually be changed so that treatment decisions can never be based on 'a.diagnosis', but on an explicit probabilistic differential diagnosis (with stated error preferences), progressively updated and recorded.
Thank you. I agree with the heart of this: an openly stated, regulalry updated differential is close to what I mean by holding a diagnosis as a hypothesis. My caution is that a probability on a screen may also feel just as final as a label if no one is there to revise it. The updating is the part that takes time, and time is what our system gives us least.
This superbly written commentary by Dr. Gogtay MAD ME STOP and ponder the profoundness of its declaration. Beautifully written by an experienced psychiatrist — I found myself totally empathizing and wondering (like Dr. Gogtay) how many children have been (and continue to be) falsely labeled, and then treated for years (decades) with drugs for the wrong diagnosis? And then about the "crossover" of premature closure resulting in the wrong diagnosis that clearly occurs in virtually ALL medical specialties. Were I still in academics — I'd make this MUST reading for all those in training (as well as for all experienced providers). Mind-boggling ...
Thank you, Dr. Grauer. You named the part that worries me most: once a label is in the chart, treatment can run for years before anyone asks whether the label was right. And you are right that premature closure is not unique to psychiatry. We simply have no tests to catch it.
Thank you so much! Fantastic piece! After 40 years as a family physician, I completely agree with watchful waiting and made my encounter times longer, bringing people back again to further evaluate and brainstorm with the patient.
Thank you! You know what’s especially sinister to me? You wisely note his symptoms were partly from “a home he did not feel safe returning to.”
In pediatrics, no joke, even if you tried to explain that to the AAP or the pharma funded “experts,” they would tell you snottily, “well, doc, as a matter of fact, poor home dynamics are a risk factor for mental illness.” And they would double down on the diagnosis and the drugs!
I wrote about this at length here regarding adhd, both the absurd rapidity of the diagnostic process (a 2 min questionnaire) and the absolute insistence that it’s never the fault of a boring teacher or the parents’ divorce, it’s always coincidentally the kid’s frugally medical problem:
https://gaty.substack.com/p/synthetic-children
“I am informed by my colleagues that divorce, the death of a loved one, and other such instances of ‘adversity’ are “a strong risk factor” for developing ADHD. That’s one way to put it!
Don’t let the pharmaceutical salesmen gaslight you: it is normal for a child to struggle when his family is destroyed. I would worry far more about an eight-year-old who takes a family break-up in nonchalant stride.
If pediatricians are to have any role as regards the broken homes we encounter far too often, it should be as advocates for stable, married families, not as pill-peddling accomplices to the devastation that adults wreak on their children. What prescription will give a child her family back? We ought to fight for the children in our care, not excuse their soul-hurt with medical jargon (which is meant to absolve parental guilt), while making the innocent child doubt the validity of her own pain. Doctors simply pile adversity upon adversity—and prime suffering children for a lifetime of pharmacological dependence—when we teach kids that their normal emotions are a sickness in need of a cure.”
Excellent article. Poor provider listeners, metrics, lack of resources, insurance company nonsense, unrealistic expectations, pharma, etc…….The list is long and all of medicine contributed.
One of the huge benefits of AI in medicine is that the law and practice will ventually be changed so that treatment decisions can never be based on 'a.diagnosis', but on an explicit probabilistic differential diagnosis (with stated error preferences), progressively updated and recorded.
Thank you. I agree with the heart of this: an openly stated, regulalry updated differential is close to what I mean by holding a diagnosis as a hypothesis. My caution is that a probability on a screen may also feel just as final as a label if no one is there to revise it. The updating is the part that takes time, and time is what our system gives us least.
This superbly written commentary by Dr. Gogtay MAD ME STOP and ponder the profoundness of its declaration. Beautifully written by an experienced psychiatrist — I found myself totally empathizing and wondering (like Dr. Gogtay) how many children have been (and continue to be) falsely labeled, and then treated for years (decades) with drugs for the wrong diagnosis? And then about the "crossover" of premature closure resulting in the wrong diagnosis that clearly occurs in virtually ALL medical specialties. Were I still in academics — I'd make this MUST reading for all those in training (as well as for all experienced providers). Mind-boggling ...
Thank you, Dr. Grauer. You named the part that worries me most: once a label is in the chart, treatment can run for years before anyone asks whether the label was right. And you are right that premature closure is not unique to psychiatry. We simply have no tests to catch it.
Beautifully stated. Thank you for this thoughtful essay.
Thank you for reading, and for the kind words.