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PaperclipPerfector  1mo ago (text post)   24618 thread views

Culture War Roundup for the week of April 8, 2024

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From the impression I've gotten from surgeons and doctors who know many surgeons, this doesn't surprise me. Surgeons have a bit of a reputation for being high class technically skilled butchers. They operate on flesh, but their treatment of it is closer to that of a car mechanic than most other doctors. I think they perhaps see it as a very easy case of tumor removal. @self_made_human may have more insight.

Honestly, my approach is, fuck it, why not?

Well, there are actually reasons why not, such as the hope we can find a less ghoulish cure, things like mirror therapy for phantom limb (well, that one's already gone, its just that maybe there's an equivalent), or the fact that they might go on disability.

But if someone who is otherwise healthy and financially sound wants to chop off pretty much anything for any reason, my opinion as a psychiatrist-about-to-start-training is a shrug, presuming I was convinced that nothing else we could do would help.

Surgeons aren't that gung-ho in my opinion, maybe it's because I worked too long in Onco Surgery, but I've seen more cases turned down as non-resectable or not worth it than those that were done knowing it was futile. Surgeons usually want what's best for the patient too, even if it's in conflict with their wallets. They're rich enough that's not the biggest deal.

Chop off a mole, a limb, a dick, anything at all. As long as you make sure you're not a burden on the rest of us, it's not my business, unless you ask me for my advice.

Doctors have a duty to do no harm and you aren't offering a service like any other business but are obligated to either help patient's have improved outcomes, or at least not to harm them.

The attitude "fuck, why not" goes completely against how the medical profession ought to operate and if followed by doctors in practice, it should come with professional penalties. Indeed, this even applies to more mild things. Cardiologists don't tell their obese patients, at least if they are good, "eat what you want, what the fuck do I care", they tell them to change their diet, and to walk around. And much more. And should not be Cardiologists if they don't do this.

Doctors shouldn't help self destructive patients to destroy themselves either totally, or in part. I certainly wouldn't want even a cent to go to pay for doctors doing that. Nor should they be allowed.

Now, medical tyranny of safetyism is another danger of doctors acting unwisely which also goes against proper medical ethics. Indeed in certain studies apparently prisoners of certain demographics, IIRC black Americans, live longer than those of same demographic outside of prison, but maximizing life at expense of imprisoning people would obviously be an undesirable outcome.

Then there is the worst behavior for doctors to hypothetically engage in which is a combination of both. Being too tyrannical where one ought not to, and not guiding patients or restricting them from self harm but indulging in it, where one ought not to. With some of the covid measures and lockdowns and the trans issue and the OP issue we can see that they can coexist among the medical establishment.

Anyhow, ideally we would see from doctors some level of paternalism but not too much, and focused in the areas it is wise too focus upon, but also seeing "do no harm" as an important principle. Which means not allowing operations described in the OP and then we would need to see the proper way to deal with doctors who abused their position and mutilated their patients. Whether only very severe professional penalties are appropriate, or whether there should be prison time as well.

The attitude "fuck, why not" goes completely against how the medical profession ought to operate and if followed by doctors in practice, it should come with professional penalties.

I think this is what happens when status and money is highly placed on a profession. After a certain amount of time there will be people that just want the associated benefits and resources that lack the mentalscape desired for the profession. Add to that societies of very low trust like India or Latin America and its a recipe for disaster unless you thoroughly vet your doc.

Eh, I take the same argument I do for pharmaceuticals - most people are really stupid, even extremely intelligent people are often really stupid outside their areas of competence, and medicine is just really hard, and if medical treatment wasn't gated by experts and guidelines there'd be a ton of unnecessary and counterproductive treatment.

"I was only following orders" is something we as a society have learned through hard experience is no excuse. People may not relieve themselves of responsibility for doing bad things on the grounds that someone else hired them to do the bad thing; and even if they're hiring you to do it to themselves, it's your responsibility to refuse if they are not of sound mind when they hired you. You don't have the option to say "judging them to be of unsound mind is none of my business"--it informs the propriety of your own actions, for which you bear responsibility, which makes it your business.

I feel like psychiatrists are more skittish because they have gone down the "fuck it" lane before and caused horrors. The healthy and financially sound are surprisingly easy to lead down a garden path.

Eh, that's not really my experience with them. What exactly do you think psychiatrists get up to? Leaving aside the gender-affirming types.

Do you want the long list or the short list?

Off the top of my head, naming only the ones that are undeniable crimes against humanity and beyond debate:

  • abuses of psychosurgery
  • abuses of electroshock therapy
  • political abuse (mostly in communist nations)
  • compulsory sterilization

Going full Szasz and calling mental illness as a category a myth in reaction is probably going too far, but let us not pretend that the field has clean hands. Few other disciplines ought to be as deeply attuned to the depravity mankind can let itself get up to under the proviso of "doctor says it's okay".

abuses of electroshock therapy

Uh, correct me if I’m wrong- @self_made_human feel free to chime in here- but I thought that electroshock therapy was actually an effectual and not-painful technique that was abandoned for complicated reasons including safetyism?

Well, it's not painful anymore, and it does work for at least a while.

The problem is, 1) it causes temporary cognitive deficits (that aren't so temporary if you're doing it repeatedly), 2) it is one of the few things to cause permanent retrograde amnesia (i.e. it wipes a bit of your memories every time, and they're never coming back). Permanent and scary side effects are bad, because a certain percentage of people kill themselves out of revulsion (Ernest Hemingway, for instance, killed himself after a course of electroshock therapy). Once you take that term into account, you wind up with a cost-benefit profile that's not so pleasant.

You are correct, though these days it's evolved into Electroconvulsive Therapy/ECT. Same principle, we just knock people out first and give them muscle relaxants so they don't end up aching all over.

I've considered it for myself, but I'm not sure my depression is quite that bad yet, and it has an annoying effect of minor memory loss, and buddy I rely on my memories for a living. But it's the final backstop for treatment resistant depression, though we've got new things like ketamine therapy and so on.

So it's not gone or abandoned, we've just become more civil about it. It works well when all else has failed.

Why not just try the insomnia cure ? Apparently Italians are keeping severely depressed people up for like 3-4 days straight and it resets their brain to factory setting or something.

Or the botox cure?

So many fairly low-risk therapies out there.

Is sleep deprivation low-risk? There are major negative long-term mental and physical consequences of chronic sleep deprivation, and there are wild (like, 3-4 days in is when the hallucinations usually begin) consequences of acute sleep deprivation, so while I don't know if there are any studies showing long-term consequences of acute sleep deprivation it's definitely something I'd look into before trying out a multi-day stretch.

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have you tried taking vitamin D in the morning? I would really love a bigger sample size than just me suggesting that vitamin D has positive mood effects.

Supplements (including vitamin supplements) are near criminally under researched in the context of regular consumption by humans.

I think I've had like 5 tablets in my life. I was deficient the last time I checked ages ago, but so is everyone in India, as paradoxical as that is.

Can't say I particularly miss the sun too much really.

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n+=1, Vitamin D has positive mood effects.

All well and good, might as well condemn biologists for Lysenkoism at this point.

None of those are really a knock against the field as it exists today. I'm here to dish out drugs, that's why I'm a psychiatrist and not a psychologist.

And most practising psychiatrists, unless they're still seeing patients at 80, have nothing to with any of them really.

None of those are really a knock against the field as it exists today.

Don't get me wrong, I certainly hope and expect that we have learned from those mistakes. I'm just saying that when you have that kind of history, it's justified and expected to be careful.

Psychology/Psychiatry is useful, but it is also dangerous and therefore ought to be treated with a mind to that danger, lest we repeat the mistakes of the past.

And for the record, I do think the exact same thing about biology.

Interesting response. I have always assumed, or more correctly, hoped, that psychiatrists had some degree of expertise beyond psychologists that was not simply the ability to, as you have put it, "dish out drugs."

The dishing out of drugs (for whatever) seems very (read: too to my way of thinking) common in Japan at least. Considering most medical interventions are created with the general human in mind, and are therefore prone to error when prescribed for individuals (whose idiopathic digestive, cardiovascular, endocrine, and central nervous systems are all slightly different), I am sometimes surprised medicines work at all. In fact I doubt that many of them do without causing other issues (see: statins). MDs at least in my own experience as a non-King with no real personal physician of my own, seem more likely to send people to the pharmacy (where, at least here, there is often rigorous questioning and examination of one's 薬手帳 or personal drug diary that everyone's supposed to carry to the doctor, that has every prescription drug you've taken for the last however many months/years logged.) than sit down and ask about diet, exercise, family history, etc. to get at whatever the hell may be causing the current complaint.

I guess I am hoping psychiatrists are at least interested in possible causes--of, say, depression--rather than being focused, from the moment introductions are uttered, on measuring the patient up for which drug will induce the sweet, sweet, happiness (or whatever).

There's plenty of interest in and research being done into the causes of depression, from very many angles, both biological and psychological. I don't think any of it's been productive, but that's a separate issue.

I am not completely unaware that this kind of research is out there, but I think my assumption has always been that psychiatrists are much more aware of the cutting edge of such research, and can therefore apply whatever conclusions have been made to individual cases--assuming individual cases are explored to some degree and not (simply) medicated away. I realize on writing this that I sound possibly naive here, but I, and I assume most people even if possibly not most people here, make this same assumption about most doctors, including gastroenterologists, endocrinologists, surgeons, etc That if I have some physical ailment that they've done the time in med school to not just prescribe some inhibitor or agonist, but they also have some educated guess as to what might have gotten me to the point of peptic ulcer, or insulin resistance, or whatever. Were a doctor to say something like "You're pre diabetic, here's a pill" I see that as a failure of medicine.

Likewise, the psychiatrist. I understand the mind is a locked box to some degree.

I mean, we obviously study most of the same topics as psychologists do, we have the additional benefit of prescription drugs where simply talking to the poor bastard doesn't suffice.

Doctors are in relatively scarce supply, so there's a degree of specialization of labor, if it's cheaper and easier to let the people trained particularly in talking handle that bit, that frees us up to do the job of doling out drugs. But I struggle to think of anything a practising psychologist can do that a psychiatrist can't. I consider the ability to make problems go away with pills a big plus in my book.

But there's a tradeoff here, the time you spend with a psychiatrist who usually charges much more per hour, and that time is better spent with less talking and more prescribing, within reason.

Of course we argue about the causes of depression and try to understand the pathophysiology of it better, but even where we don't get it, at least we have robust empirical evidence that many therapies beat placebo, such that even if it's not actually a deficiency of serotonin, SSRIs still work modestly well in many if not most people. There are plenty of drugs with much more dramatic impact on psychiatric illnesses, I doubt any amount of psychological intervention would cure my ADHD while Ritalin does.

This "talking to the poor bastard" seems to me the point of the profession, or at least, to my mind, should be the pointy edge. The first step. The main thing.

I have precious little faith in psychologists, having known several in my life, but more in psychologists than therapists. Psychiatrists I would hold in highest regard; if there's a hierarchy in my mind they'd be up there at the top of the pyramid.

I suppose your speaking of cure here is relevant. There is this sense that we need cures and of course for many things cures are exactly what we need. I'm just as interested in causes and possible reversibility. Like when your liver is going, taking drugs to help the liver is less of a helpful strategy than quitting alcohol or whatever else you're doing to destroy your liver. That one is doing. Not you in particular.

I don't mean to come at you like this in any sort of aggressive way, I am just a skeptic of drugs in general, as I've said/written to you before.

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