I.
I am not entirely sure how common it is to get so bored on vacation that you voluntarily return to your old workplace and accidentally start practicing medicine. Probably not very. But recently, thanks to certain flight disruptions in Dubai which I do not need to elaborate on, I found myself stranded at home in India far longer than anticipated.
I was going stir crazy. My parents, who maintain a baseline level of mild disappointment that I ever emigrated, suggested I go informally shadow the psychiatry department at my old hospital. "See what psychiatry is like at home," they said. "Maybe you will learn something."
I was already experiencing a profound disillusionment with psychiatric training in the UK, and my previous exposure to the Indian equivalent was highly idiosyncratic. During my internship at this same teaching hospital, my psych rotation had collided perfectly with the initial Covid lockdowns. Outpatient services were entirely shuttered. Any ward patient capable of bipedal locomotion was immediately discharged.
I spent those two weeks checking vitals in the female suicide ward and conversing with a very pleasant schizophrenic gentleman who had a hyper-specific obsession with light fixtures. He had been living on the ward for a decade (no next of kin and nowhere to send him after discharge except to the streets, and then the cops would drop him right back on our doorstep) and had somehow become a genuinely competent amateur electrician. I personally witnessed him replace multiple malfunctioning bulbs. He did very solid work.
So when my parents broached the idea of visiting, I agreed. It was mostly curiosity mixed with a bit of nostalgia. That intern year was almost certainly the worst year of my life, but people assure me this builds character. I thought it would be nice to show up as a glorified medical tourist and see what my Indian counterparts were up to.
II.
After pulling a few strings, I arrived at the outpatient department. It was exactly as crowded and poorly ventilated as I remembered, though stopping just short of actual asphyxiation. I located my point of contact, a second year postgraduate trainee, and optimized my posture to fit onto a partially vacant seat without crushing a colleague's purse.
The initial wave of patients presented with the classic poorly differentiated psychosomatic complaints that are the norm in developing countries. When your native language lacks a dedicated lexeme for "depression", psychological distress predictably routes itself through somatic channels. It manifests as a vague stomach ache or random peripheral tingling. We prescribed pregabalin, gabapentin, or amitriptyline, depending on mood, handwriting and the current phase of the moon. The patients were generally just thrilled to have seen a doctor at all.
Eventually, more interesting cases arrived. Because I was actively peering over my colleagues' shoulders, they generously suggested I take a crack at handling some of them myself. Sure, I thought. Why not?
I quickly came to regret this decision. I have a laundry list of complaints about British psychiatry, but I was not quite prepared for the reality of the Indian clinic.
First, the documentation varied from poor to completely nonexistent. My once finely honed ability to decrypt physician scribbles into valid pharmacological interventions had totally atrophied. Furthermore, the patients were terrible historians. I do not mean this as a moral failing; it is just a downstream consequence of local selection pressures. Government hospital care in India is free. This strongly selects for patients who are overwhelmingly poor, undereducated, and often separated from the physician by a formidable language barrier. Add the baseline communication difficulties of psychiatric patients, and taking a history feels like trying to reconstruct Herodotus from a copy that fell into a blender.
But it was a good challenge. I wanted to prove I could still read between the lines.
Almost immediately, I encountered a truly spectacular case of polypharmacy. We had a lady on lithium, valproate, and approximately a dozen overlapping medications. When were her lithium levels last checked? My best guess is shortly after the universe discovered helium-helium fusion. Thyroid function? The only confirmed fact was that she theoretically possessed a thyroid gland. She had coarse tremors, which could have been caused by literally any combination of the chemicals in her bloodstream. I consulted a senior resident, and we agreed to slash the regimen down to the bare minimum and demand some actual blood work before she returned.
III.
The cases only got weirder. Consider the medical tourist from Bangladesh. He had early onset schizophrenia, but he was relatively stable on his current regimen. Why had his parents brought him across an international border? They claimed they could not source brand name amisulpride in Bangladesh. A quick Google search suggested this was highly improbable, but here they were.
To make matters worse, the family was incredibly vague about his actual medication list. Besides his known antipsychotics and thyroxine, he apparently took a mysterious pill every morning. What was it for? They had no idea. What was it called? A mystery. What did it look like? It was a small tablet.
It is a miracle I did not tear my hair out. After another consult with the attending, we switched him to a more easily sourced variant of amisulpride and advised the family to stockpile six months of it before going home. As for the mystery pill, we essentially applied Chesterton's Fence to psychopharmacology. Chesterton's Pill was deemed structurally load bearing for this mixed metaphor. It clearly had not killed him yet, so we left it exactly as we found it.
My final patient was a six year old boy. His mother presented a constellation of complaints: he was hyperactive, liked staying up late, and lacked focus in class. It looked like a textbook case of ADHD. But given his age, I thought it was worth digging deeper. I learned he was functionally illiterate, possibly dyslexic, and his teacher had explicitly told the mother to get him evaluated.
Then the mother casually mentioned his "fright."
During normal daily activities, the boy would suddenly freeze. He would look incredibly distressed, and then he would get the human equivalent of the zoomies. He would sprint around the room. After the running stopped, he would approach his mother or older sister and bite them. Sometimes he bit hard enough to draw blood. He could not explain why he did this or what he experienced during the episodes.
I looked at him again. He was a perfectly normal, fidgety kid missing a few baby teeth. There were no obvious signs of hydrophobia, though I mentally filed rabies under "highly unlikely but technically possible."
I had absolutely no idea what I was looking at. I debated the case with a colleague. I suggested ADHD comorbid with Oppositional Defiant Disorder. My colleague argued against ODD because the kid was perfectly well behaved in the clinic. I countered that ODD typically manifests at home first, and is usually restricted to familiar adults. Then I floated the idea that his bizarre running and biting episodes might be complex partial seizures.
My colleague theorized it was an intellectual disability or learning disorder, perhaps part of a broader genetic syndrome. I shrugged. He was probably right. There might be a perfectly neat clinical label for this waiting in a dusty textbook somewhere. Or perhaps this is just another reminder that our diagnostic categories do not actually carve reality at its joints.
We eventually compromised. We prescribed clonidine to manage the behavioral symptoms and cover ADHD to a limited extent, then referred them to a clinical psychologist and an ENT specialist for good measure. I had spent more time on this one child than on my previous three patients combined, and the clinic was simply not built for that level of investigation.
I still have no idea what was actually wrong with him.
To avoid ending on a downer, I was happy to hear that the amateur electrician had, in fact, been discharged sometime in the past five years. None of the current trainees had heard of him. Right after I'd "treated" him? I'll take the credit, if no one's looking.
My parents, for what it's worth, were pleased I'd made myself useful. They remain cautiously optimistic about my eventual return.
I remain unconvinced, but I did find the pace to be California Rocket Fuel compared to my usual fare. Who knows? Maybe I'll get bored of making ten times the money, one day.
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Notes -
The following meant as a genuine question to a professional, not a combative gotcha:
Of all diagnoses that look like they're made up, ODD is the one that has always sounded the most outrageously made-up to me. What do you mean, "not obeying your parents" is classified as a mental illness? Activists who claim that the mental healthcare system is just a tool of state oppression usually come across as hopeless idealists who've never had a schizophrenic try to chew their face off, or indeed, never been a mortified schizophrenic returning to sanity after a try-to-chew-people's-faces-off episode. But on the face of it, the existence of ODD as a condition real doctors take seriously seems like exactly what you would expect if their model of psychiatry was correct. It looks so ludicrously like a gerrymandered way for parents and medical professionals to pathologize and thus de-legitimize the behavior of a lucid but uncooperative patient, for their own convenience or indeed revenge.
So I guess what I'm asking is: do you think a real case of ODD looks more like your Bangladeshi young man who occasionally flips out and bites his family members for no reason, while getting along with them the rest of the time and having no coherent complaint against them? Is that what it's supposed to look like, and thus, the reason why non-obviously-corrupt doctors take it seriously as a diagnosis? It doesn't sound like it, since you weren't sure about the diagnosis in this case. But if not, what is a perfect platonic case of ODD supposed to look like, and how do you distinguish it from a perfectly sane kid who dislikes their authority figures (or authority figures in general)?
Thank you for clarifying, and I'm not being sarcastic. While 99% of the medical professionals who reviewed my post had nothing but praise, there were two pedants and hostile interlocutors who ticked me off. One was a British doctor, who claimed he had studied in India, and accused me of gross clinical negligence, sneering at patients and colleagues for being "beneath me", and went as to far as go claim that I was a med student making things up using an LLM. I had a few choice words for him, but I am pleased to say actual verified psychiatrists are not that picky.
I do not have a very strong opinion on ODD. Mostly because I haven't done an official placement in child psychiatry, this example was literally the first time I tried reviewing an actual small child.
But I do share some degree of skepticism. However, from a pragmatic perspective, I think the diagnosis is fine. Scott has written about this, and I have little to add, but the gist of it is that the purpose of a diagnosis and clinical label is both to identify a "disease", and also to make getting care and intervention significantly easier. Sometimes the latter is more important to the patient or their family. At least it usually gets things covered by insurance.
It is difficult to distinguish between a child with ODD and one that is a petulant asshole. I am not even 100% confident that there's a qualitative difference.
But like the usual example of ADHD, many mental illnesses exist on a spectra, overlapping with the "normal" range. Is someone with a blood pressure of exactly 139/89 (on repeated tests) hypertensive? Not by the definition interpreted maximally strictly and literally, but half the reason we keep doctors around is to exercise clinical judgment and to rely on their discretion. I'd give him a pill to reduce the pressure.
Many cases of ODD age into the similar but technically distinct Conduct Disorder, and many later get diagnosed with Antisocial Personality Disorder, usually when they're old enough to qualify. Referring to my exam notes on Forensic Psychiatry, about half (!) of male prisoners in the UK have ASPD.
Clearly the diagnosis is identifying something. It just isn't as clearcut as we'd wish.
That's not enough. It has to be very unusual and disproportionately bad, by the reference frame of other children of similar age. A 2 yo throwing a tantrum wouldn't count. A 7 yo who refuses to listen to his parents, doesn't respond to punishment, keeps acting out in serious ways? Much more defensible, even if it's a question of degree and not kind.
An ODD diagnosis then, will help with getting psychological help, and very rarely medication (but mostly to treat the very common comorbidities like ADHD).
You are correct it wouldn't be typical. As I note, I am green when it comes to child psychiatry, most of my knowledge is theoretical. In clinic, I thought of it more as a could-be, with non-negligible probability worth excluding, instead of a very likely.
The child will very likely get multiple diagnosis, and even if there does turn out to be epilepsy, there might be other factors at play. I don't think a single disease can suffice.
Then there's the possibility of ID, which very commonly has behavioral issues. If there is ID, it might not be worth an additional diagnosis. Without opening the DSM or ICD, I can't tell you whether a diagnosis of ID would rule out ODD, I think probably. To help explain, when a person with dementia hears voices or feels depressed, we usually do not slap on a diagnosis of schizophrenia at 85 or MDD. Such signs and symptoms are very common in dementia itself, and we use a broader umbrella term called BPSD, but we still do use antipsychotics and antidepressants to treat it.
In other words, a wash. You can make a defensible argument either way.
I am out of my comfort zone, and I won't be lazy and ask ChatGPT because you clearly want my entirely human opinion (in reality, I would be asking ChatGPT myself, it's handy). Perhaps @reo might have something to add, he knows a lot more than I do. Maybe @Throwaway05 even if his OPSEC is so strong and his knowledge base so broad that he could be in anything from IMT to psychiatry to an ER specialist to a dermatologist. Maybe I could ask my peers in India, but ODD is rarely diagnosed here, certainly not as much as in the West.
Or I could ask ChatGPT and interpret the answer for you, it's genuinely up to you. And thank you for the question, it's a good one. I regularly have such doubts myself, for example whether BPD and the new diagnosis of cPTSD are meaningfully different.
While I have no medical knowledge, I highly recommend you use gemini at aistudio with thinking level high. If that's exhausted, I recommend other google accounts or using gemini at gemini.google.com with at least thinking mode.
Free version of ChatGPT is just really really bad. I use AI mostly for complicated math and ChatGPT just fails a third of the time at anything slightly complicated. For harder problems it just cannot solve them. This effect applies to more general questions too. Asking chatGPT if ayatolah is alive also returns wrong answers sometimes.
The main problem with that is, it doesn't have thinking mode on by default and it has very poor judgement about what kind of questions actually need it.
Thank you for the advice, but you are (fortunately) wrong here.
I pay for ChatGPT and Gemini. I am also familiar with AI Studio since the Gemini 1.5 days. I use them regularly, and make sure to pick the good models. I read Model Cards when new LLMs come out! I am a regular on LW and HN haha. I have essays on LLM hallucinations, I argue with people here about how to best use them, from a place of >0 technical knowledge. I tell people about AI Studio like every other week, for the same reason.
I was intentionally refraining from relying on an LLM to answer for me, even if I think the LLM would have done a good job. I checked later, and fortunately, I was right. This was both a courtesy to the person I'm talking to, and because I wanted to check the quality of my own knowledge. Mostly the former.
Thanks nonetheless, I know enough to say that your advice is good, in case anyone needs it more than I did.
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Listen nobody here wants me to bitch about the decline in surgical skills training driven by laparoscopic and robotic surgery. It is poorly received every time! Every time!
So we talk about this psych bullshit instead because it is interesting and has more relevance to the average person.
For you-
I'm 110% not a child psychiatric and I did not examine this patient but weird behavioral stuff is usually Autism or ID in the U.S. The need to rule out some medical pathology is of course important (and obviously needs to be done with any patient with a presumed psychiatric diagnosis). That said this is a distant ass culture from mine and I'd have questions about how these things do and don't manifest in those culture. India strikes me as a place that would have a ton of variety and not variety in cultural presentation that would require a steady hand and clear eye to notice and distinguish with the other pressures (ex: time, resources) in play.
For OP-
You are hitting on one of those questions that is super valid and at the same time once you have training you forget it is valid. No shit "don't pathologize the normal human experience" is wise lol. It's very much baked into how the DSM thinks about things but beyond that too - being six foot four is more or less normal being seven foot four will have tremendous impact on your health, life expectancy, and experience of existence. But sometimes we forget this is an actual thing people worry about
Also, things like ODD exist to be like the pornography of psychiatry - give some labels and descriptions to "I know it when I see it" stuff.
Kids being difficult is normal. Some kids are "holy shit."
One of the ways to tackle this is by focusing on appearance in a number of environments. Kid acts like a bored little shit in church and school? Yeah fair. You leave em to their own devices at home and they also can't function? More likely to be pathology.
The real world does get in the way sometimes with overly dictatorial parents, attempts to get school accommodations, teens and adults relying on TikTok for stuff - but there is a real phenomena being targeted here.
Additionally, psychiatry is a bit looser than medicine - ADHD symptoms can be best explained by Anxiety, Depression, latent Bipolar disorder, medical illness, permanent brain damage, resolvable brain damage upon further development, substances, specific environmental factors, disordered personality.
Try sorting this shit out in a 15 minute appointment with a patient or family who already "knows" what the diagnosis is. Giving the diagnosis triggers further resources (including medicine) but doesn't always mean an understanding of the underlying mechanisms.
In the U.S. we shuttle things from Psychiatry to Neurology once we understand them (schizophrenia used to be early onset dementia, then we figured out what dementia was and punted it over). If something is still a psychiatric problem it means it is quite a bit more tenuous and complicated than a nevus or blood pressure evaluation.
Hey, don't be so harsh. You do have an audience for that diatribe, even if it might just be me. Let it all out, I have a father who I cannot accuse of lacking surgical skills even if his expertise is in laparoscopic surgery (and he is world-class at it, if I say so myself). This is a safe space.
Thank you for taking the time to indulge both of us. I am relieved to not be accused of being too wrong.
Among the many things I've seen that I've neglected to write up so far, was a patient who came to us that day with vertigo and double vision. She clearly had strabismus, as I could tell when I made eye contact (singular). No, there were no psychiatric symptoms, even after questioning. The people who accept and direct new patients to the relevant clinic are less than perfectly reliable, and that is without getting into some of the very questionable referrals I personally observed. We sent her off to neuromedicine, medicine and ENT, they deserve a taste of their own medicine. They've done much worse.
It's a travesty! Junior attendings lack effective experience! Nobody has experience with disaster cases! Open conversions are always in the worst circumstances! Hundreds to thousands of hours of extra training time!
Ultimately the switch is a good thing but it causes some skills deficits which are especially problematic in the US with the way our training works.
My favorite for this is autoimmune encephalitis, seldom seen, often missed, never fails to make the psychiatrist feel like the smartest person in the world and everyone else feel like a dumbass.
Boo. I genuinely was looking forward to a longer, more detailed polemic! I am zooted on stimulants, and not in a mood to study, so medicine-adjacent cognition is a good way to fool myself that I'm doing something productive.
I will note I have never heard another surgeon say this, at least in India, and I know more surgeons than can fit in a large OR. At least while maintaining aseptic conditions.
Then again, specific laparoscopic training is not a core part of the surgical curriculum, from my understanding. I have had my own seniors approach me, asking for my dad's number so they could ask him to teach them laparoscopic surgery with proper depth. He is somewhat famous for being a good, albeit short tempered teacher. My dad tried teaching me too, though all I can say is that I didn't drop the camera or cut off anything too important.
(He also taught himself laparoscopic surgery using a textbook, sometime in the 90s. Once again, deadly serious. He was a pioneer in these parts. I am but an ant in comparison.)
I would agree with you, if I had ever seen a case of autoimmune encephalitis. Best I've got is a genuinely unresolved case provisionally (so long it became permanent) diagnosed as extremely treatment resistant schizophrenia, where we excluded it and half of WebMD as differentials. My boss had to book a private plane to send him to the only ward in the country that would take him, this is not a joke or exaggeration. This is in the UK, and the government paid for all of it. I'm sure you're jealous, I hope you're jealous, give me one reason to not desperately wish I was in your place :(
(I will take a concession that you wish you didn't have to worry about insurance)
Basically the issue is that the required case volume to become proficient in modern surgical modalities is a lot more than with classic open cases. Decent surgical residencies can theoretically get you enough cases for bread and butter procedures but for less common things it gets harder. Consider how much harder it is to orient and to appreciate anatomy through a lap, and with a lap to ably use your technical skills (less of a problem with robots).
Surgical residency is already long and miserable enough, adding more years just isn't feasible.
Additionally things don't go wrong enough, which is good, but you need experience with things going wrong in a controlled environment to be able to provide quality care when you are on your own.
This means that many junior attendings aren't really fit for purpose and need hand holding, academic work, or enhanced engagement from their partners. None of which is good and it isn't really a solvable problem, especially with the push to condense training.
Also, usually the intern year for surgery is wasted on floor monkeying only pretty much.
Thank you for elaborating, I'm appreciative.
Ah. So this is universal, speaking from experience in the UK and India. I've heard even other postgrad trainees (in the UK) make the same complaint.
alarms blare
You've activated my attending trap card. Basic intern year scut work (both inside surgery and outside of it) isn't actually wasted. You learn valuable tools like "writing that fucking note quickly" and "nurse management" and "sick vs. not sick."
Certainly the modality has some yield issues at times, but the gain in fluency and skillset is real, with variable spaced repetition of more traditional surgical skills.
Also is what separates us from midlevels.
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This is really interesting, I’ve heard about this phenomenon before but never first hand.
Are those depressed patients aware at all that their mood could be low or that there’s something psychological bothering them? Or do they experience their depression purely in psychosomatic symptoms?
I’m wondering if this could be an explanation of the part of the rise in depression/anxiety/mental health conditions in modern societies, or even the mental health gap between liberal and conservatives. Previous generations/less developed countries don’t have better mental health (in fact, from stories I heard from older family members, it might have been far worse in the past), but they’re just unaware of their own mental scape, and lack even the words to describe the concepts we take for granted.
I had a similar question on my SSC post, so I'll reproduce my response:
Not necessarily! Psychosomatic complaints are all too common even in developed, English speaking countries. It's not like many patients in India won't express their feelings in terms that directly match with standard (English) psychiatric nomenclature. Plenty of people will use the closest equivalent for "low mood, apathy, agitation etc etc" even if the language lacks a specific term for depression. After all, I'm sure people got depressed well before it was recognized as a clinical syndrome, or had ADHD and autism before the modern taxa evolved.
Of course, cultural idiosyncracies do matter, and some diseases genuinely are culture bound or spread by social contagion (see Scott's posts about the latter, especially anorexia).
It's also not necessarily the case that our diagnosis of a psychosomatic cause is perfectly accurate. Optimistically, one can say that my peers were exercising clinical judgment. Pessimistically, they were quick to pattern match and put people in buckets. There's no law of medicine that says you can't have depression and actual gastric reflux or peripheral neuropathy. The lonely old lady with backpain might well have arthritis, and we do try and check. We just have very little time to do that checking.
I'd say that in the absence of a widespread understanding of "depression" as a clinical condition, most of these patients are coming to see a doctor because of their perceived bodily ailments. They do not envision themselves as depressed, but will still acknowledge sadness, anhedonia etc. But what they claim to seek is relief from physical suffering, and said suffering often but not always comes from psychiatric intervention. I am genuinely unsure if they understand the link, but people do seem to know that the psychiatry department deals with the mind and that they didn't just pick the wrong door.
At some point, someone made the judgment call that the underlying issue was psychiatric, so they ended up in the outpatient clinic. On the other hand, when I was an intern in the medicine department, we had plenty of patients my seniors deemed to be psychosomatic who were treated the same way, but ended up there by some sorting mechanism I'm not familiar with.
I read a very convincing article arguing that the gap is an artifact (I think it claimed that when specific terminology was adjusted, the purported mental health gap vanished), but I'm afraid I don't have a link handy. If I remember who said it, I'll share. It might even have been Scott.
Probably: [Do conservatives really have better mental well-being than liberals? by Schaffner.
Thank you! That's what I recall.
PS: I'm able to confirm that that child was slated to have an EEG.
Good, great, news. Hopefully, the kid will have a final diagnosis and may he get treated accordingly. Fingers crossed.
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I see their point and I agree with a nuanced take on the gap, but I'd also argue that this specific part of their argument isn't a clear cut case as "it's explained by factors associated with ideology, not with ideology," when those factors are things like marriage, patriotism, focus on income increases, and especially religiosity, which are essentially the entire point of conservative ideology. The "ideology" is that those things are good and you should pursue them.
On the contrary, I don't think you can separate "finding meaning in political activism, focusing on inequality as a social problem, and being less likely to marry and more likely to divorce" from the ideology of liberalism, which says those focuses or decisions are a good thing.
It's possible that conservatism improves mental health for people who benefit from the things they say are important. What's fascinating is that, among liberals, focusing on the things that they say are important, particularly political action and activism in the face of inequality, actually lowers mental health. That's in the paper, and they cite research to support it.
They present this version of the research consensus:
But their arguments in this part of the paper don't actually attack this point for me; they seem to separate "ideology" from "things associated with the ideology" because they've carved out that conservatism is specifically and only "a system-justifying ideology that seeks to rationalize the existing political, economic, and social order," and things like religiosity and marriage aren't actually a part of it. In other words they extracted the most negative possible element of conservatism and are evaluating the ideology based on that, while excluding any positive elements of it as "factors associated." IMO, that to me is question-begging of the silliest kind that could only come from academia.
The authors wouldn't say this, but it's possible that system-justification and aligning yourself with "the existing political, economic, and social order" is actually the adaptive or correct response to the world. In other words, it may be that even their negative minimized version of conservatism is right, and my concern is that a huge portion of their argument assumes it must be wrong. That question has to actually be asked.
I did like the part of their argument where questions about mood remove the gap -- I don't doubt that's true. But I also don't think that focusing on daily mood is the best way to maximize mental health. Even psychotherapy doesn't necessarily think that's a good thing! Perhaps finding a comforting, meaning-generating, peace-infuzing ideology in the midst of,
is actually the way people experience positive mental health, and staring too deeply down the barrel of those things leads to imagining bodkins.
But this is of course the central axis on which political debate has hinged since, unironically, Marx. But the thought cannot be rejected out of hand that the opiates of the masses are medicines.
This phrasing is bizarre. Does it imply that actually, differences in status have nothing to do with personal performance?
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very interesting sharp point. thanks for that.
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Very entertaining. I will ask, however, where you may stand ethically, writing publicly about such patients? I'm not sure of the standards.
It's a very good question, and one that has generated a lot of discussion over the years. Self_made's milieu (sorry I'm too boomer-core to actually tag you but I imagine you'll see this) is likely less intellectually masturbatory than mine, part of that is training locations, part of that is also just how things are with the way healthcare and the world has changed.
As physicianing becomes just a job, and the role is more maligned than deified, the idea of those special obligations (and privileges) we used to have goes away. This may be a bad thing, but it is.
Some thoughts.
Hypocratic Oath - It's dead. Many schools have gotten rid of it in general or replaced it with woke screeds. While ethics is taught, it's often head cudgeling "professionalism" ethics. Thinking abstractly about moral pulchritude is gone. I usually blame everything on wokeness, and will do so here.
Official ethical guidelines are often shockingly self constructed or not actually enforceable. The Goldwater rule is pretty famous on this front. This is further complicated by the fact that much of practical ethical behavior is locked into a complex web of federal and state laws that are generally not actually explored by the legal system and can be mutually incompatible (ex: mandatory report this is one jurisdiction but CAN NOT in another jurisdiction, but what happens if care crosses state lines?).
A classic question like "do I report the alcoholic school bus driver" is fraught as hell and younger generations have basically been taught not to engage with the question and to report to risk management.
Basically ethics has been beaten out of the curriculum.
Engaging with your specific question -
Oliver Sacks famous wrote about specific patients. Ish. He also famously made a bunch of stuff up. Conveying the meaning without the details (and with a mild to moderate to sometimes excessive level of alteration and fabrication) is one way to tell the story. Hat was written in 1985 - it's an old argument.
I am unsure how much Theodore Dalrumple fuzzed his patient stories, but he is considered politically unpopular because he illustrated reality as it is. Life at the Bottom is important because it's real, regardless of the reality of the specific patients, but if they are real specific people the value still makes it worth sharing.
For me - when I've written my patients stories here and on our predecessors with my old handle, I generally tried to write about patients whose stories are common or obscured enough detail that many docs would say "did this happen to me?"
This isn't to say I'm judging self_made. Writing to process training is a time honored and important way to not fucking go crazy and become a bad physician, especially for someone whose story has taken them to a place where the other ways of processing are less available.
India is a big country, with many Indians (citation available on request). I genuinely don't think that you can uniquely identify anyone I've ever written about, barring myself. A schizophrenic man from Bangladesh? A young kid with behavioral issues? Victims of polypharmacy? Good luck narrowing that down to less than a thousand people.
Interestingly enough, this scenario is pretty explicitly addressed when it comes to the ethics curriculum and guidance for British doctors. I would be expected to warn the patient to desist from dangerous drinking, and if they disclosed drunkenness on duty or continued to drive, I would be legally obligated to report them to the DVLA so that their license gets yanked. This applies doubly so for bus and truck drivers (I refuse to call them lorries).
https://www.bevanbrittan.com/insights/articles/2017/patients-fitness-to-drive-and-reporting-concerns-to-the-dvla-dva/
There is a lot of bloviating about ethics here. UK medicine is obsessed with the topic. It was half the grade on the exam that gatekeeps most postgraduate training.
There exists a massive top-down push to reinforce the image of doctors as a noble, duty-bound cadre of esteemed professionals. That self-conception is gradually fraying in the younger generation, because we sure as hell aren't paid or treated like we're special.
I figured the UK had a culture of ethical handwringing but that you might be spared it due to location.
Like I said not criticizing you for your post however we see one of the Common Points which is that even without identifiable information patients can read it that way, and it does generate consternation and distrust at times. Not necessarily a reason to not do it.
With respect to the bus problem - don't report so that the guy feels comfortable opening up and can get treatment and harm mitigation is often selected as the answer.
I think, on a empirical basis, that this effect is insignificant. Med influencers make significant amounts of money and acquire fame by attracting patients using case reviews, and I don't think Scott has ever suffered for it.
Would be ranked very low here in the UK. The best answer would be to try and warn him to cut down on drinking (if he just happens to be an alcoholic but doesn't disclose driving while drunk) first, and then if he persists or outright admits to drunk driving, the doctor is to inform him that he's duty bound to report to the DVLA.
I don't know about elsewhere but Med influencers are widely mocked and attacked, one guy at Mayo just had his career tanked. Some of this is probably jealously but with the exception of saint Glaucomflecken most medfluencers are trash.
Also I believe Scott lost his job and had to start his own business because of his writing.
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Since none of this contains patient-identifiable information, I'm in the clear. And for all anyone else knows, this might be an entirely fictional scenario with all characters simply fractured fragments of my psyche. I am also a dog on the internet, woof!
Beyond that, it depends on the jurisdiction, and even the UK isn't anal enough to come after me for something so trivial and vague.
It isn't an accusation, just a question. I remember that William Carlos Williams story The Use of Force and never felt he had betrayed some confidentiality (and as you say it was probably at the very least fictionalized.) But maybe he did.
I tend to write about real people to a degree, and though I do fictionalize, unless I'm writing for historical record, Im only bound by the somewhat less mystical rules of social politeness, not the Hippocratic oath.
My apologies, while I didn't interpret it as as a challenge, I was slightly snarky in my reply because of an unrelated internet argument.
When it comes to formal case reports or research publications, there are relatively bright lines doctors are expected to follow. This varies heavily from place to place, but for example, I can use a CT scan of a patient in a publication without their express consent, as long as I make sure things like name or ID is reasonably redacted.
When it comes to random writing on the internet, there is some grey, but mostly "nobody really cares." If I had mentioned actual names (and someone then raised a complaint) and provided very specific information, the GMC could theoretically come knocking (assuming they could then identify me, I doubt Reddit would care, they're not the same as the UK government, even if they're their attack dogs).
I mean, if I was writing about the UK. They don't care what I do in India as long as I don't break local laws or get into trouble with the police/local regulators. If I was in the UK, there is a small but non-zero risk associated, but once again, depends on what exactly I say. The British equivalent of this story, as written, would be fine.
Never swore it. I'm not kidding. Some places don't hold particularly high opinions of some long dead Greek bloke who said that doctors shouldn't operate on kidney stones. Not even the modernized version. It's not legally binding anyway, there are actual laws and professional codes of conduct that supersede it.
Again I am faced with what is probably a fundamental difference between you and me. Could be generational. You seem often to seek out the snark; I'm far more traditionalist. And it's hard to know how seriously you take something when reading comments online. A lot of the people who post here, for example (here being the Motte in general) seem extremely hostile and angry in ways that have only become normal since the late 90s or whenever it was and phpBB.
I guess my larger point was not "will you get in trouble?" rather "Do you have second thoughts?" from the viewpoint of integrity as a doctor. Within an hour after my first and only substack post I had at least one person sending me a message saying "It's her, right, this is her?" with a name--all because I had posted the first name of a person and enough context that, in 2025, identifying real people from internet descriptions is relatively simple. I felt slightly bad about this, but my readership is not significant enough that it would matter. Probably. The southern women I know don't actually like anyone to know anything about them at all, but that may just be my social circle.
Anyway, carry on.
For what it's worth, I'm not being sarcastic when I say I have a low opinion of the Hippocratic oath.
Seriously "do no harm"? Am I allowed to use a needle to prick skin. Oh, that shouldn't be taken at face value, and there's some kind of implicit utilitarian calculus involved? Why doesn't it just say so?
There's a reason very few institutions use the original oath, leaving aside the random injunction against operating on kidney stones.
Not particularly! I've certainly never had anyone identify a particular person on the basis of a post. The closest was when I was almost geographically doxxed, but the person doing it was acting mostly out of curiosity. There's no way for a casual actor to identify anyone I've described, and it's far too late to deploy the kind of OPSEC that truly motivated actors would have issues cracking. In other words, pray for me and not for anyone else I've written an ink-portrait of.
Well, you're an unusually sincere person. I like to think that I'm usually sincere and honest, but yes, I do enjoy a helping of sarcasm. At the very least, British humor appeals to me on a spiritual level.
I would argue that it should instead be understood under an informed-consent framework, where it's only "harm" if informed consent is violated. You still need asterisks for treating unconscious patients first on the assumption that they'll retroactively consent to it afterwards, but it at least preserves "harm" as something which ideally shouldn't be happening at all and should always be minimized, rather than something which is sometimes actively necessary.
I mean, I doubt Hippocrates had modern informed-consent guidance in mind when he came up with it. The core issue is that the original is horribly dated, and even modernized versions are very far from clear when it comes to concrete operational advice. Nor are they necessary, we have medical regulators and legislation to cover professional ethics, and their authority supersedes the oath.
Perhaps. I think I'm with Scott in believing that there is important, difficult-to-replicate social power in the solemnity of a time-honored oath, as distinct from the bureaucratic fuss of laws and guidelines. It's easier for an overconfident doctor to think his confidence in his personal judgement should embolden him to voerrule the letter of Subsection 7B of Amendment Fifteen to the O.V.E.R.L.O.N.G.A.C.R.O.N.Y.M. guidelines for the state of New Guernsey, than to tell himself that his confidence in his personal judgment should embolden him to overrule the sacred internationally-recognized pledge that all western doctors have taken since before the birth of Christ.
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"Unusually sincere." That's a new one for me.
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Love your posts bro.
Doesn’t even matter the subject - it’s just enthralling.
Write a book.
And come to America, specifically Florida, I want to read your multi part write up dealing with our insurance, our minorities, and our whites.
E: absolutely insane that you still have a Reddit account that’s 11 years old. I find that sort of thing fascinating as well.
Thanks <3, whatever level of homo is socially acceptable these days haha.
I do, but it's about a cyborg psychiatrist who does way cooler things than I do. Also on hiatus, because his not-as-cool creator has a lot going on.
If you want a non-fiction book or memoir, I don't think I've quite got the material yet. It usually takes a lifetime to build that up. My job is usually (and thankfully) quite boring and mundane most of the time. I seem to come across something worth writing about once every few months or so, and the majority of the time it makes more sense as an essay.
I would if I could! I still harbor hope of moving to the States one day, at this point I would happily trade all the headaches American doctors face for the ones I have, let alone the massively higher pay. If not, I'm sure I'll visit at some point, and I would happily swing by if you'd have me. What's a gator but a very ornery dog? I can handle those just fine.
Eh, it's there, I mostly use it to lurk these days and occasionally post. The closest I came to violating Reddit's TOS was Motte-posting, and that hasn't been an issue since I migrated here with everyone else. My engagement levels dropped drastically. Even if I had something to say, there are few places I'd want to say it, or where I'd expect a good reception. Culture War? That's here. Less controversial stuff? I happily crosspost.
In general, I think I'm a pretty good citizen by Reddit standards. I've only once been banned, on /r/SSC of all places for tangentially referring to the Motte as the place for CW issues, and that was quickly overturned on polite appeal. For what it's worth, it's less self-censorship than it is the fact that I do not enjoy engaging with the average Redditor.
Just an add on: if you want to read a book where the setting is psychiatry by a very Americana author with a wide array of interesting, hipster leaning books to his credit, read this:
https://www.amazon.com/Visible-Man-Novel-Chuck-Klosterman/dp/143918447X
He also has a book where he takes a road trip to places in America where famous musicians died. Just kinda meanders about in the area. Interesting guy.
I'll take a look, thanks for the rec!
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I don't see anything fascinating about that. Many people (including me) have the same distinction.
I’ve been banned 23 separate times (I just checked) and that doesn’t count the immediate auto ban based on IP.
Which says a lot about me of course.
It’s just a story about the ideological drift of the entirety of the internet from libertarian to progressive.
Anyone that can navigate that sort of mind field over the last decade has my respect.
My account's still going at just shy of 15 years. The only place I'd ever expressed any political views were the SSC and Motte reddits. Anywhere else, exposing my preference to believe things that are true rather than politically convenient would have definitely gotten me banned.
I’ve expressed plenty of political views but those are all on /r/suomi and the only ban has been a 2-day one for that particular subreddit (which has notoriously biased mods). I can’t imagine getting site banned is that easy by accident.
Sadly, I know most of my online acquaintances would burn me in effigy if I was ever honest about my trans thoughtcrimes. But maybe I'm overestimating how common site-wide permabans are on Reddit.
I suspect you'd get away with a lot more if you wrote in some other language than english.
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Incredible. I barely interacted with reddit and usually lost interest before any given account could be banned, but once one got the hammer, I've never gone back.
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It’s easy enough: Only get into politics in languages other than English.
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"fright" as sudden freezing + incredibly distressed = looks like ictal fear.
zoomies + sprinting around room + severe biting = motor automatism. can be sign of temporal or frontal seizure. (running around = cursive seizure)
He could not explain why he did this or what he experienced during the episodes. = ? post-ictal amnesia.
liked staying up late = maybe just maybe, he may have an inkling that the episodes are more common in night (=nocturnal seizures).
overall, i am supportive of your CPS diagnosis aka Focal Impaired Awareness seizures. But either primary frontal origin or actual mesial TLE spreading to Frontal. Definitely next step should be EEG if episodes are frequent (or sleep deprived EEG) and/or MRI brain (epilepsy protocol). it may be surgically treatable also.
Call the Resident, if possible.
Thank you for taking the time to write that up! It aligns with what other neurologists have said on Reddit, and my attempts to dig deeper.
I didn't get that impression, but I'm not going to make strong claims either way, this clinical assessment was far from ideal. If I had the time, I would have drilled deeper, specifically looking for any temporal patterns, but at the least the mom didn't mention it. In her words, the boy just liked staying up late, and that's more likely to be because he's got a phone.
Sadly, that probably wouldn't help. It is very difficult to contact a patient like that (EMR? What EMR?) and nobody would bother short of an acute emergency. At least we arranged a followup in a month, and I expect that the other doctor will probably be there. I'll drop him a text anyway, just in case it makes a difference!
Most likely, it wouldn't help for this patient. But the discussion of such things (of course, without PII) helps in keeping in mind that sometimes (/few times / rarely), there is a possibility that there is an actual structural cause (which may even be treatable surgically) behind the patient's symptoms. If we are able to find that out, then the suffering of the patient and his near-dear ones (in this case, mother and sister) will be reduced. And when we are able to do that, that gives so much satisfaction. Yes, there are costs, there are frustrations of being unable to diagnose or unable to treat or the patient refuses to undergo or their kin refuse because of any of the million reasons. But that is part and parcel.
But. That discussion helps you, that resident doctor, me, any other doctor who read your substack / reddit post / this post, and can connect the dots. Something became from unknown unknown to known unknown. Something which has the possibility to become from a behavioral / social mind thing to structural-brain abnormality (the diagnosis has not been confirmed, so the jury is out on that).
so, please keep writing such brilliant and interesting stuff.
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Fascinating! I am once again in awe of the TV showrunners of House who realised that a medical mystery could be swapped for a crime mystery.
Aggression related to panic attacks?
He'd be dead, wouldn't he? Survival time is usually less than a week after symptoms appear, though I'm surprised to learn you can have morbid rabies for months or years before symptoms show up.
EDIT: google AI lied about its sources but 'within a few days' does seem accurate: https://my.clevelandclinic.org/health/diseases/13848-rabies. Other sources say one to two weeks: https://www.canada.ca/en/public-health/services/diseases/rabies/for-health-professionals.html
Very unlikely! Even plain old panic attacks would be unusual at that age, let alone such a specific kind of aggression. They're also not usually associated with amnesia or dissociation, more like hyper-focus.
After I posted on /r/Medicine, I had a few actual senior neurologists show up. They lean towards my hypothesis that it's some kind of seizure activity, but there's no consensus on whether it's a temporal lobe one, a different kind of focal seizure such as one affecting the frontal lobe, or if there's a slightly different variant called absence seizures that might be causing sleep issues and poor academic performance. The only real way to know would be an EEG, which would hopefully be identified the next time they attend (I regret not insisting on it, but I was a guest and deferring to those with more local expertise).
My mention of rabies was mostly sarcasm. The kid would have a lot of other issues before they (might) end up biting people. It would have been glaringly obvious and even here, with less than perfect triage and routing, very unlikely to show up in the psych OPD. But yes, if it was rabies, he would be done for.
I was about to claim that it's impossible for rabies to be latent for years, but apparently there are a handful of claimed cases?
https://www.nejm.org/doi/full/10.1056/NEJM199101243240401
I am not sure how much to trust them. Either way, it's rare. But funny excerpt:
Makes sense. I was thinking that 'inability to explain' or denial at that age might be simple inarticulacy / fear of adults or authority rather than literal amnesia or dissociation.
The child was quite extroverted and responsive when talking to me or my colleague. If he was the shy type, he's better at hiding it than I am haha.
I can't really comment on his articulacy. My Hindi is far from the best, and his mother was the primary informant. But he sounded... fine?
If this was a once off? Kids do dumb things for no good reason. So do us adults. But the repeated pattern and general picture points towards something in the DSM and not "just a rambunctious boy child". But what precisely? Impossible to answer authoritatively with the information I have at present. I hope I do get to see the followup and final diagnosis, but I wouldn't bet on it.
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