This I Believe

Lally - Sacramento, California
Entered on March 17, 2007

It sometimes takes me as little as thirty seconds to write a script on a prescription pad for my patients. Yesterday, as I scrawled my signature and handed the script to my patient’s mother, I paused to dwell on the training I received in order to fulfill this seemingly effortless task. A task some psychologists believe they are equally qualified to address.

It sounds easy, doesn’t it, just put down the name of the medication, how many times you’re supposed to take it, whether you take it by mouth, inhale it, or heaven help you, take it rectally or some other unpleasant way…, give refills, sign your name, you’re done, “…next!!!” Only it isn’t quite that simple, really.

Let’s start with writing the medication. I have a little training in physiology and medicine. Namely, a BS and MS in Physiology and a medical license obtained after six grueling years. Now I’m in my fourth of five more years of doctor training to become a child psychiatrist. Before I think “medication”, I have to convince myself that medication is indicated at all. With an infected ear, one look and it’s clearly infected.

Mental health is not that straightforward. First, I rule out other medical conditions that might be relevant. I evaluate medications, illegal drugs and herbs the patient is taking to find out if they are conflicting or causing the problem. I might order blood tests. I might order thyroid function tests to make sure the depression does not stem from a diseased thyroid. I evaluate the patient’s social setting and psychiatric background. And, yes, I rely on the pyramid of knowledge and science that it took me eighteen years post high school to accumulate… Easy? Never. Not even in the most apparently obvious situations. Many times I seek collaboration with other doctors and therapists before I feel comfortable diagnosing a mental disorder. I then consider whether therapy might be more helpful than medication.

So, fine, it’s not a purely medical problem. Therapy didn’t help… Now we need medication…. but which one? Wish it was as easy as throwing drug names up in the air to determine which one landed first… But instead, back I go to my medical training, literature review, and collaboration with other doctors. I evaluate my patients’ organ function and consider whether their unique biochemistry might cause problems with each drug I might try. Let’s not forget side effects, drug interactions, how they should handle drug allergies, the list goes on and on… Easy? It’s never easy.

I chose psychiatry because it investigates the final black box of our incredibly complex human machine. I believe that my years of training were well spent helping me to understand the science. Every day there are further advances in neuroanatomy, neurotransmitters and developmental psychiatry. My journey to understand what is still out there will continue till I am dead or demented, whichever one comes first. I believe that it is ill advised to drastically shorten the path that leads to writing that 30 second prescription. It’s not that easy. Even now.