Readers' and Author's Responses to "The Disappearing Patient"

Scott A. Joseph, MD; David M. Magder, MDCM, FRCPC; Peggy Finston, MD; David J. Hellerstein, MD


October 18, 2007

To the Editor,

The problem, as I see it, is that psychiatry has been forced to fight for its very existence as a specialty, chopped away at by psychologists on one side and the nefarious and despicable aims of managed care on the other. I escaped to New Zealand, where I have 30 minutes per follow-up, 1 hour for a new evaluation, no double booking, and therefore I can talk with my patients. I also have no managed care imbecile telling me how long I can see my patients. The problem is the American medical system, and the answer is not more regulation or government interference, but less. Doctors should be allowed to unionize and fight for better working conditions for themselves; this will also benefit patients. When psychiatrists are given time to think and do not need to justify every treatment decision with questionable "hard science," then the humanities will return.

Scott A. Joseph, MD
Diplomate, American Board of Psychiatry and Neurology
Rotorua, New Zealand



To the Editor,

I just listened to and read Dr. Hellerstein's address on "The Disappearing Patient." The points he raises I think are of great concern to the practice of psychiatry. In this attachment, I am sending a copy of the Presidential Address of Gerald P. Koocher of the American Psychological Association, in which he addresses the same issue from a different perspective when he devotes an entire section to the "demise of psychiatry."

I think Dr. Hellerstein is right when he refers to the danger of psychiatry becoming "neuroradiology lite." As a psychiatrist who practices what I believe is an integrated approach to clinical medicine, blending medications with a cognitive approach to psychotherapy, I have long felt that the basic sciences must learn from the observations made in the clinical setting and vice versa. I have been fortunate to have exposure and access to a great deal of the psychological literature from my undergraduate days to the present time. This has enabled me to teach my patients to interpret and understand their symptoms in constructive ways.

I am in private practice and also work one day a week in the Mood Disorder Clinic of the Centre for Addiction and Mental Health/University of Toronto Department of Psychiatry. I think that the fee structure of the system in which I work, while having flaws, enables me to treat a wide variety of individuals with severe illnesses over long periods of time. I believe that helps me maintain a more holistic perspective on patients' lives. Dr. Hellerstein's remarks deserve widespread discussion and debate.[1]

David M. Magder, MDCM, FRCPC
Toronto, Ontario


  1. Hellerstein D. The Disappearing Patient. MedGenMed. 2007;9:34. Available at: Accessed August 31, 2007.



To the Editor,

I hope "The Disappearing Patient" is one of many attempts to define what ails psychiatry. In my view, it's not the patients, aka "consumers." In my 30-year psychiatric career, I've seen our field plummet from an impassioned, if a little grandiose, adventure to an oppressively "scientific" (read detached) existence. The drumbeat of "evidence-based medicine" has become a whine. We have made some less than creative or honest trade-offs along this 35-year path. Studies turn out to be a poor substitute for an informed and personal doctor-patient relationship.

What's happened? My view: Over the past 3 decades, we have lopped off our right brains in an ill-fated attempt to legitimize what we do in the eyes of our "hands-on" colleagues. Studies make what we do real, and the pill has become the symbol of our authenticity. The only hang-up is that patients don't agree. All this ego stroking does nothing for them. And perhaps more troubling, we have allowed ourselves to be defined and directed by the pharmaceutical industry. Again, another desperate attempt to establish ourselves with the medical world: "We, also, are okay."

About a year ago, I wrote an APA official about this very issue:

Due to chronic pain, I've developed an interest and practice combining acupuncture/energy treatments with more standard psychotherapy/medication strategies. I think our profession is missing an opportunity to expand how we address emotional disorders. We're too locked into neurotransmitters to see beyond the synaptic cleft. (That is a joke.) Working with energy fields helps medication become more effective. Unfortunately, most professionals see this as an either/or proposition. Either Western medicine or alternative. But not both. (Both is what has enabled me to keep working and not go on disability.)

I've approached psychiatric institutions (some academic, some with "complementary departments") without response except from the residents I've presented to. They're enthusiastic. But not those who set the agendas. Like many repressive traditions, psychiatry now holds fast to "truths" that falsely assure a footing in the healthcare consumer scramble.

To me, we're being narrow and defensive about an area that could breathe new life into a field that has been robotized into symptom checklists and diagnostic codes. Where's the passion? When I trained in psychiatry eons ago, we weren't afraid to creatively embrace what was not already approved of. Fritz Perls, Milton Erickson, anything was considered game if it might be effective. In my view, the times have changed and our courage has faltered. What we seek now is to reduce treatment to a no-fault formula or algorithm. In doing that, we dismiss intuition and the individuality of both patients and ourselves. Frankly, psychiatrists don't need to commit suicide. They will die of boredom.

This remains my view today. The Web cast was good but needs to go deeper. What's wrong with psychiatry won't be "cured" by a few humanity courses.[1]

Peggy Finston, MD


  1. Hellerstein D. The Disappearing Patient. MedGenMed. 2007;9:34. Available at: Accessed August 31, 2007.



Author's response:

In response to my WVE, "The Disappearing Patient," I received dozens of emails from all over the world -- from the United States and Canada, from Australia, France, Britain, Italy, Brazil, and Iran. They came from psychiatrists and other physicians, psychologists, and nurses, as well as many patients and family members. Nearly all correspondents were in strong agreement with the points my editorial raised, though many went further in their criticisms of current-day psychiatry.

One psychologist said, "It is, I must say, heartbreaking to observe people being 'treated' for everything from depression through psychoses virtually exclusively by attempts to manipulate their neurochemistry whilst disregarding their social and subjective experiences." A psychiatrist commented, "I rarely open the 'green' APA journal because the neuroradiology is so irrelevant to my daily practice that I don't bother." In the words of another psychiatrist, "I often tell people that psychiatry as a profession is 'circling the drain' as we surrender to biological explanations of behavior and hide our heads in FMRI machines and PCR labs. There is so much more to us, as human beings, than can be defined by those pictures and gene maps."

Many correspondents were concerned with the impact of this excessive biological reductionism on patient care. This includes a lack of self-observation: as one psychiatrist said, "So many of the practitioners of psychiatry today have never turned an eye inward, that the profession is becoming populated with psychiatrists who cannot self monitor." Beyond that, as a psychologist in the Midwest United States observed, "the local psychiatrists rarely hear anything the patients' families tell them, nor do they seem to care. If the patient's difficulties are in a great part emotional/social/environmental, rather than purely biologically based, psychiatrists locally do more harm than good." A patient with treatment-resistant depression described a fruitless trek from one doctor to another. "The person in here," she said, "has been ignored in 'the collusion of anonymity.'"

These letters (and the ones reprinted here) reflect what I believe to be a strong current of dissatisfaction with today's reductionistic psychiatry, emanating from "consumers" as well as "providers." They describe a variety of adverse effects from such a model of practice. These include the often-irrational limits imposed by managed care and reimbursement policies, as Drs. Magder and Joseph describe, as well as inappropriate generalization from limited biological evidence, as Dr. Finston describes. Most notably, in reading the main journals of American psychiatry, including the American Journal of Psychiatry and the Archives of General Psychiatry, one would never know the existence of, not to mention the strength of, such discontent. Dr. Finston aptly observes that, "studies make what we do real and pills have become the symbol of our authenticity. The only hang-up is that patients don't agree." Neither do many providers!

The main journals of internal medicine, including JAMA and The New England Journal of Medicine, have realized the need for such dialog and make space for narrative and stories and discussions.[1] Wouldn't it be refreshing to have a place in psychiatric journals for such dialog as well? It wouldn't solve these problems, but it would be at least a start.

David J. Hellerstein, MD
Department of Psychiatry, Columbia University
New York State Psychiatric Institute
New York, NY


  1. Rutherford B, Hellerstein DJ. The humanization of medicine and the dehumanization of psychiatry. Academic Psychiatry. 2007; In press.


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