Transcripts For CSPAN2 Booknotes 20140215 : vimarsana.com

Otherwise, i dont feel that they really represent clinical approaches or ideas about illness that are grounded in science. Cspan well, you can see them on a regular basis on public television. First of all, what do you know about any of them . Guest i know that Christine Northrup did, in fact, have a pbs special and she wrote a book called womens bodiesmy gosh, im blanking on it, butand itshe had wide, wide viewership. And, in fact, all three of them, Deepak Chopra and i believe andrew weil as well have had specials on pbs. So thats a huge viewership. And their books are bestsellers. So clearly, they appeal to people. But some of the messages that they put out, i think are, as i said, not really grounded in experimental work. They talk about therapies that have not been proven. And Christine Northrup in particular is put forth as a Womens Health expert, and yet, some of the truisms that she was putting forth reminded me of sort of a bad parody of freud. What she said, for example, was that certain kinds of emotional states can cause thyroid illness or cancer or blood clots, this sort of thing. And we have no evidence of that so i would be. Cspan what would she say, if she were here . Guest thats a good question. I know in her book, she consulted something calleda person called a medical intuitive. And this is someone without any real Clinical Training but can examine your body or your aura and tell you what kinds of traumas your body has registered. And, in fact, in her case, she said her body had registered a rape between ages 20 and 25. And she thought back, well, thats when i was in medical school, and i know i wasnt raped. at least she didnt invoke the repressed memory. but maybe i was traumatized or violated in some way. and her interpretation was that she had been mistreated by her male colleagues or somehow oppressed during her training. I mean, she believes this, obviously. Her book was uneven, because, in fact, there were some things in it that i thought were quite accurate. She had a good discussion, for example, of silicone breast implants, which was accurate and i thought the advice she gave to women was wellinformed. So it wasits uneven. Cspan why do the three of them sell, you know, probably millions of books and theypeople watch their programs and go to their events and lectures . Guest yeah. I think theres a great investment, really, and romanticism about health. I think people want to feel that they are in control. In a lot of ways, i think they are in control in terms of diet and exercise, the kinds of things we know we can do. But there is a mystical dimension that these folks bring in, and i think that it appeals to people who perhaps arent especially scientifically literate. I mean, thats a problem we have today. We know that alternative medicine is very popular, and there are several reasons for that. One is that it might actually appear to work in many cases. And the reason for that is that most conditions for which people go to doctors are actually timelimited. They do go away by themselves. So that if you were to take st. Johns wort for depression or some other kind of healthfood store remedy and it appeared to work, itits often because it was a timelimited event to begin with. Also, we know that alternative practitioners are famous for spending more time with patients, and thats something, unfortunately, in an era of managed care that conventional physicians cant often do. And we also know that there is something called the placebo effect. Its not that powerful when it comes to severe conditions like cancer, but for emotional problems and for minor illnesses that can be mediated through stress, that can be very powerful. So there istheres ample reason why people might believe that it actually works. But i know that if i had cancer, i certainly would not go to andrew weil. Cspan what is the placebo effect . Guest the placebo effect is when a person experiences some relief, when theyre given a medication or some sort of interventionit doesnt even have to be medication; it could be some process called therapeutic touch, which is very popular now, which in fact youre not even touched. The idea is that an apocryphal energy field that surrounds you is being smoothed out and this will promote healing. But that when some sort of healing intervention is offered to an individual, they may experience relief and sometimes that relief is even measurable. For example, that they might be sweating less if theyre very anxious. But, in fact, there was no, what we call active ingredient in that, kind of a sugar pill. And it can be very powerful, and its not all suggestion, although some of it is suggestion, of course. Probably the idea that one is being cared for or soothed by another person, just that variant, that human interaction, you know, can be mediated through our stress system, through the hormonal system. That itself can have effects on cardiovascular activity and our immune system. So its a very interesting phenomenon. And itin fact, it is being studied and would be interesting to harness that. Cspan where did you go to med school and when . Guest i went to medical school between 1980 and 84. I graduated from Brown University school of medicine. Cspan why did you go to med school . Guest well, i went to medical school actually after i experienced an illness. And i had that illness after undergrad, and it was an infection. And a very common treatment for that infection was steroid medications. Not the kind of steroids that body builders take. Not anabolic steroids, but whats called catabolic steroids or prednisone, a common one that people probably have heard of. And it was very effective. I was on a high dose. And it turned out that i got profoundly depressed from taking that medication. When the medication was tapered offand its a medication, in fact, you cant stop abruptly; you have to taper it offthen i was fine. But it was really a transforming experience for me because i hadi mean, everyone experiences, you know, blues now and then, but id never experienced such a profound and desolate kind of depression. And as i said, thank goodness it was timelimited, but it made me realize that there are people who are suffering with what we call endogenous depression. Its not caused by some chemical they took or some medication side effect. That its essentially their own neurotransmitters revolting. Its something that was a part of them. And i thought that was such a harrowing experience for me, yet such a relief that it could be turned off by taking this prednisone away, but that there were people for whom that couldnt be the explanation. And this was something they had to worry about perhaps returning because, as we know, depression can be a recurring phenomenon. And so i decided i wanted to go into psychiatry. And thats why i went to medical school. Cspan where had you gone to your undergrad . Guest cornell . Cspan where was home originally . Guest queens, new york. Cspan any medicine in your family . Guest no. None. My parents, neither of them had gone to college. Cspan so there you are, psychiatry was the subject. Did you gowhen you get a psychiatrists degree, do you have to get a medical doctorate degree first . Guest yeah. You have to go through four years of medical school, and then there is a residency period. Pretty much everyone does an internship, which in my case, it was a general medical internship. So i had a year in st. Raphaels hospital in new haven of being a real doctor, you know, doing tosurgery for two months, internal medicine for about eight months and its just essential to forming your identity as a physician and, of course, learning invaluable physiology and clinical techniques. Cspan and where did you go thengivea little bit of your work history since you got out of med school. Guest graduated medical schoolok84, and then, of course, i did thisthen i did the internship. Then you do three years of residency, so thats four years total postgraduate. Cspan whered you do your residency . Guest i did that at yale. And i thought i was going to go on and do research, become an academic psychiatrist and do research in schizophrenia. Ive always found that to be the most fascinating and really tragic of all Mental Illnesses. But it turned out that if one were going to pursue that in an academic setting, there were really two main kinds of Research Paths one could follow one was neuroscience, either in the lab or what now we know as pet imaging, you know, functional imaging of the brain, but pretty strict neuroscience. Or whats called services research, something that is not really that patient near, where you look at the best ways to provide services to patients, basically and in hospital settings and clinic settings. And that seemed too sterile to me, even though its very important work. So what i was really interested in was descriptive psychiatry or phenomenology, and in schizophrenia, a lot of that had been done in the late 1800s. So there wasnt that much opportunity. So right around that time, the earlythe mid80s, crack had come on the scene, and it was assumed that crack would induce the same sort of mental status changes in addicts and drug users that methamphetamine did, you know, speed kills, speed freaks, back from the 50s and 60s. And so it was assumed that we would see a lot of cocaineinduced psychosis, and i thought, well, thats an interesting way to study thought disorder, which was the essence of schizophrenia that i was interested in. Ill do it by studying drug addicts. And it turnedand i did. And so i became an expert on addiction. But it turned out that cocaine did not produce the same kind of psychosis and psychiatric symptoms that methamphetamine did. It was quite interesting, actually. What it could produce in a subset of people if theyd taken a high enough dose was a kind of timelimited paranoia, as opposed to a fullfledge psychotic profile of hallucinations and delusions that was seen in some heavy methamphetamine and speed users so that was one of sort of my Early Research career in cocaine abuse psychosis. Cspan where did you go to do that . Guest i did it at the west haven va. Cspan innear yale . Guest yes. Associated with yale. Cspan methamphetamine is what . Whats it look like . Guest well, it could look like a powder. Cspan and how do you. Guest i mean, it comes in pills. I mean, it used to come in pills. Just, you know, you can still get, i think, dexeryl and dexedrine in the pharmacy. But methamphetamine is made now in clandestine labs, and it looks powdery. Cspan what do you do with it . Guest and people who inject it, its called crank. Sometimes. Cspan you mean with a needle, you inject it. Guest yeah. You can inject it with a needle and you can also crystallize it as one can do with cocaine and smoke that. And its highly addicting and its even more dangerous than crack because its more neurotoxic. So you could really do neurological damage that lasts, and it produces a more intense derangement. And you read in the newspaper, these horrific crimes of fathers decapitating their sons. I remember this and i mean, horrible murders. I think karla faye tucker, actually, committed her murders while on speed. Cspan what about crack . What is that . Whats that look like . Guest crack is cocaine. It looks exactly like if you take hard candy, the pineapple hard candy from lifesavers and hammer it, youll get little pieces that look exactly like crack. And the reason i know that thats a good visual substitute is because we did some research on trying to induce craving at the west haven va, craving for crack in crack addicts and see if we could blunt it with certain medications. So. Cspan so you went from there at new haven to where . Guest well, in 90in 92, i applied for something called the Robert Wood Johnson Health Policy fellowship because, after nine years in new haven, i thought i wanted to move on. And i also was getting a little bit frustrated working at the va. Now thats not a particularly new reaction. Doctors who work at the va, its a special kind of an institution. In fact, its almost more of a social institution than a medical institution for a lot of these patients. And my patients, a lot of them were, vietnam veterans, were using the benefit money that they got from being serviceconnected to buy their drugs. Now here i was running a drug treatment unit, and yet, my patients and my efforts were being undermined by the very benefits that these men were getting because they would use it to finance their habits. Now im certainly not saying they didnt deserve those benefits. These are serviceconnected benefits. If someones 100percent serviceconnected, they can get up to 2,000 a month taxfree. Thats quite a lot of money. And i dont mean to imply for a minute it wasnt deserved. Obviously, they risked their lives. But it was certainly holding them back. And a number of the other patientsnot everyone in a va gets veterans benefitssome of the patients also got ssi, supplemental security income. And supplemental security income, up until 1995, actually recognized addiction as a disability. So people could get income maintenance by virtue of being an addict; in other words, by virtue of being so intoxicated that they couldnt work. And again, i thought this was a perverse incentive. It kept financing patients habits, and also, they knew that if they got better, that income would cease. So it was a very, very regressive kind of thing. And i thought there had to be ways to use these benefits so that we could essentially use them as an incentive to recovery, as opposed to almost an inducement to stay sick and dysfunctional. I also realized that i couldnt do that as one person. Frequently, id say to the patients, you know, if only we could have access to your money and help control it for you, that would really help you a lot. and theyd agree with me all the time and then tell me they would break my legs if i tried. So i appreciated their honesty, of course, but i knew that if one were going to reform these kinds of systems and give out benefits in a way that was constructive for patients, as opposed to, you know, keeping them mired in destructive behaviors, this had to come at the administrative level or some larger level. It couldnt come from me at the va. So i applied for this Health Policy fellowship to see if there was any way to influence thinking about disability benefits to people with Mental Illness and especially to people with addiction problems. Cspan now when did you get to San Francisco . Guest i never was in San Francisco. Cspan oh, i thought i read in your book that you were inyou did something out there. Guest no, i didnt. Actually, a book revieweranother reviewer misinterpreted that as well, so maybe it wasnt written that clearly in the book. What i was referring toi never was in San Francisco, but what i was referring to was actually one of my first encounters with what i call politically correct medicine. Cspan oh, ok. Guest and it was about something going on at San Francisco General Hospital. Cspan how did you find thathow did you come in contact with it . Guest i found out about it because a colleague of mine had been in a meeting sponsored by the American Psychiatric association. And there, they were discussing something called multicultural treatment. And San Francisco General Hospital was a place in which this was very avidly endorsed. And asthe more he told me about it, the more i was stunned. Basically, what was going on there and whats still going on there is a division of the inpatient unit, the psychiatric inpatient units in San Francisco general are divided up by race. Essentially, its identity politics moving into psychiatry there is a black unit. Its called the black focus unit. Theres a unit for hivpositive patients, one for asians, hispanics and women. None for white men, brian, so i. Cspan whywhat do you think of this . Guest i think that its perverse. I think that when it started out in the 70s, it started out with two specialty units one for asians and one for hispanics. And at that time, it made perfect sense because there were a lot of unacculturated immigrants. They didnt speak the language. It made the most sense to have a unit that had doctors and nurses who spoke the language and other patients who also understood the customs and again spoke the language to be together, and that would enhance treatment. And that made perfect sense. But when special units for gay patients, for gay schizophrenics, for black schizophrenics, for example, started to be formed, i thought that the clinical imperative was giving way to basically victim politics. And, in fact, i did interview some of the folks involved with the San Francisco project, and the rationale for itit didnt seem to me that it was in the best interest of patients at all. I mean, the idea behind the black focus unit, for example, was that in order for patients to readjust, in order to go back out in the community and live more productively, they had to really come to terms with the fact that they were victims of racism. And much of the staff training focused on that. Many of the groups for patients focused on that. It turned out, though, after a few years, there was so much rancor and so much almost paranoia among the staff about race politics that it became an inhospitable environment for white trainees. So now its one of the few units at San Francisco general, which is a major Teaching Hospital at the university of San Francisco medical school, that doesnt have any trainees because the environment, the milieu, just got too touchy. Thats not healthy for patients. And ironically now, again, in this age of managed care and, you know, efforts to keep costs down, patients are inthey come in very sick. Some of them are committed. I mean, theyre literally forced against their will because theyre so psychotic, they really dont even knoware dangerous to themselves or others, they have to be essentially committed and theyre there for such a short period of time that theres really only enough time to stabilize them on medication. So in a sense, it becomes moot, i think, at this point. But the philosophy behind it that basically, we have to treat patients as members of Victim Groups rather than as individuals who are suffering is a very destructive trend to me and, in fact, one thats becoming quite popular in the counseling profession, and thats where multicultural counselingi didnt make that term upis taking off. Its endorsed by the american counseling association. I went to their meeting last year. And that was onein fact, that was the theme of the meeting diversity and multicultural counseling. And its a very, very perniciousthere are three basic tenets to multicultural counseling. And i must say, this is not done with people who are wildly psychotic. Its done with people who have problems living, difficulty adjusting, minor depression or anxiety. But the three tenets of multicultural therapy are, first, that the therapist, the counselor, assumes that the most important aspect of a patients psychological landscape is her membership in an oppressed groupassumes that. The second is that whatever distress this patient is suffering from is inevitably due to his or her bumping up against racism, sexism or some sort of oppressive force. And thirdly, that for the patient to get better, he or she will have to engage in some sort of social activism, which only makes sense, of course, if you believe that its the environment thats largely responsible for your psychic distress, then thats got to be the thing that you seek to change. Now when you think about it, this is the antithesis of therapy. Therapy should be about selfobservation. It should be about taking responsibility for choices. It really is often agood psychotherapy is about learning how peoplehow an individual unwittingly sabotages himself. When you have a student who thinks he wants to bego to medical school and you have to wonder then why did he miss his mcat exam and why does he, you know, fail organic chemistry and that sort of thing. And thats verya very rich source of neuroses, as we say, to mine, but its not about blaming. Its not about externalizing. Its about looking inside. And you cant do that if youre focusing on oppressive forces. Cspan when did you first come to washington . Guest 1993, through that fellowship, the Robert Wood Johnson Health Policy. Cspan how long did you do that . Guest that was about a year i worked with senator nancy kassebaum. Cspan on her staff . Guest yeah. On her committee staff. She was the Ranking Member on the health and Human Serviceslabor and Human Services staff. Cspan had you been political before you got to this situation, or do you consider yourself political today . Guest no, id never been political at all. I never voted until 92. Andno, i never was. Cspan because youre using yourthe title of your book, pc, m. D. , politically correct, m. D. Guest yeah. No, i understand. And when iin fact, when i went to work for senator kassebaum, i went to work with her because the Robert Wood Johnson fellowship the fellows in that fellowshipit had been going on since the 70shad so routinely worked for democrats so they just begged somebody to go with a republican, and i thought, well, ok. I will. it turned out to be the most magnificent experience. And i guess i did become somewhat politicized after it. I switched parties and joined the republican party. But. Cspan did you workat some point, you worked in dc here inwhat . A clinic . Guest yes. I workedsince 95, ive been working in clinics. I work now in a methadone clinic. Cspan where . Guest in dc. Its anortheast. Its about two miles on the other side of the capitol, down on maryland avenue. Cspan and what do you find when you go there . What kind of folks are in the methadone clinic . Guest well, our clinic is mainly for working poor. We do have maybe a 25percent medicaid population. But mainly, its people who pay for their methadone and who hold down jobs. Cspan whats the racial mix . Guest i want to say about 5050. Cspan ok. Guest the staff is almost all africanamerican, but theand the doctor who owns it is africanamerican. Cspan because you write a lot about race in your book and whats going on in pc, m. D. Medicine and all this, do you see much racism in your clinic . Guest no. I seeno, i dont see much racism. Cspan do you see much racial politics in your clinic . Guest not as itnot as far as the relationship between the counselors and me and the patients go. Cspan do you see a lot of what youre talking about in your book in the clinic . Guest actually, what i seeyes. What i talk about in my book is really an effort towell, the book is really an expose of what i call Political Correctness in medicine, the idea that disease and even behavioral dysfunction are primarily caused by social injustice and that doctors and especially Public Health professionals should take on social justice as a mission. I reject that, but thats this trend i call Political Correctness. And i see it in many venues. I dont see it in my clinic. In fact, i described to some of the counselors there that the multicultural therapy that i saw going on at another dc clinic that i did work in, and they thought it was bizarre and. Cspan where is that . Guest oh, that was with the Dc Superior Court. Its since been shut down and started up again, in, i think, a more healthy and clinically productive way. Cspan what was going on there and what did you do there thats different than where you are with this methadone clinic . Guest yeah. At this clinic i worked in, itas i said, it was part of the Dc Superior Court so our patients were courtordered. In fact, the context was something called a drug court. Ill just explain that to you very briefly. Drug courttheyre now very popular. There are about 500 of them across the country. They started in 1989. And the idea is to divert nonviolent addict offenders into treatment, to try to distinguish between the criminal addict and the addicted criminal and take the person who, but for a habit, wouldnt have committed a minor crime and not incarcerate them, but send them to treatment. And im all in favor of that. In fact, i know from my own experience and from a lot of research ive done that that kind of coerced treatment works especially well because it ensures retention in treatment programs. And we know thats the best predictor of outcome. Well, that said, dc had a drug court. Andbut the clinic which i went to work in 95 was inhabited by counselors who did endorse this multicultural approach, and thats how i first became aware of it. And so we had our patients, almost exclusively black men in their 20s and 30s. The majority of them were functionally illiterate. Few of them had high school diplomas, let alone geds. They didnt have much experience in the legitimate work force. And we could have done so much for them. As i said, they were our captives. We have them five hours a day for a minimum of nine months. We could have set them up with apprenticeships and ged courses. But instead, they spent hours in groups beingcounselorled groups in which they were inculcated in their victimhood. They talking about racism and how youre oppressed black men. One day, i came in and they were doing art therapy, coloring in stencils of the african continent in the spirit of ethnic selfpride. And the patients themselvesif this isnt the tragedythe patients themselves thought this was a terrible waste of their time. Cspan whos teaching them that, white or blacks . Guest both. Cspan and the psychiatrists there are. Guest no psychiatrists. Cspan no psychiatrists. Guest my goodness, this hasnt seeped too far into psychiatry. Psychiatrists and psychologists are still among the most sophisticated mental Health Professionals. You know, if you imagine sort of a pyramid like this in terms of number and training, psychiatrists at the very top. Psychologists close up there. Then the social workers, another band, and then at the bottom, counselors whosome of them are excellent. Ive worked with some of the most wonderful counselors. A lot of them have had the advantage, of course, of being addicts themselves. So they have enormous experience in having had thatyou know, lived through it and recovered, and theyve also got some technical training. And theysome of them have been the most wonderful, but othersand those were the ones i worked with in 95 i cant say that they were the most wonderful. And you learn this in schools of counseling. If you look on the. Cspan where . Give us an example where you would learn this. Guest oh, you can learn it at the university of connecticut at bridgeport. You can learn it at the university of oregon. Any school that has a department in counseling, that gives graduate degrees in counseling, has either aoffers either courses or a concentration in multicultural therapy. Cspan well, how did you come abouti mean, seeing all this up close. I mean, were you the only psychiatrist at the superior court . Guest i was. I was. Cspan how many people were there, total . Guest patients . Cspan i mean, on a given day, how big a facility was this . Guest i want to say about 150. Cspan where was it located . Guest it was located on f street up there near the Judiciary Square metro station. Cspan and you had come to work every day to do what . What was your job . Guest my job was to do intakes on people. Basically, its the equivalent of a physical, an admission physical. This would be sort of an admission mental status exam and, typically, they were negative. In other words, we didnt have patients, by and large, who were actively hallucinating or suicidal. I mean, most of them were drugyou know, drug abusers with. Cspan and go back to thewhat were thethe business about filling in africa or coloring in africa . Whathow did that come about . And why would they do that . Guest thats just one of the exercises that the. Cspan to teach them what . Guest ethnic selfpride. I mean, i am as skeptical as you are, and then. Cspan did it work . I mean, was there any. Guest i dont think so. No, there wasnt anywas there any followup . No, but the patients themselves were really quite distraught over this. They felt that it was a complete waste of their time. You could almost argue its not so much what they were doing, its what they were not doing. Doing the kinds of things that would help these people be employable and moderately educated, the tworeally, the two advances that these folks could make that would inoculate them, at least somewhat, against relapse to drugs and crime. Cspan does this book come out of that experience . Is that the first reason you thought about writing a book like this . Guest that was the first reason. Cspan and when did you thinki mean, how long has this book been in the making . Guest well, probably since then. I started writing about this multicultural therapy, then about a year later, i became interested in a report that got a lot of Media Coverage of the notion that africanamericans were more likely to suffer from high Blood Pressure, which is true. They are, about twice as likely, but that the reason for this isas discovered by a professor at Harvard School of Public Health and published in the american journal of Public Healthwas because they suffered the stress of being discriminated against. Cspan is this alfred poussaint . Guest no, but he is there. Hes a psychiatrist. Cspan cause hes in the book and. Guest . There. He is. Cspan yeah. And does he have the same theory that racism causes hypertension . Guest he might have that theory. I know that he is in favor of considering racism a Mental Illness. Hed written a book about that recently and he had an oped, i remember, in the New York Times right after buford furrow, that whitei believe he might have had white supremacist ties, in la a few summers ago, shot somein a synagogue and then killed an asian man, i believe. And that prompted him to write the oped in the times that racism should be considered a Mental Illness. And in fact, that was brought before the American Psychiatric association once, i believe, in the 70s, and hei believe he was part of athe effort to have the apa designated as such and put it in the dsmat that time maybe dsmi, the diagnostic and statistical manual, you know, the handbook of diagnoses they rejected that. Cspan is there any proof that you know of that on this question about racism that causes physical reaction on the part of anybody thats not of the white race . Guest sure. Well, i havetheres no question in my mind that any kind of stressful situation can cause a physiological response. I mean, weve known that for ages. I mean, stress causes changes can cause actually changes in the immune system, usually prolonged stress. But certainly can lead to Blood Pressure elevation, hormonal changes. Thatstheres nothing new about that. But when one looked at her data. Cspan whose . Guest . Whichthe data of the professor at harvard who wasconcluded that the stress of discrimination was responsible for this disparity and high Blood Pressure. When you look at the data, they didnt hold upin a nutshell, she sought to measure discrimination, which is hard to do admittedly. I mean, thats a very hard thing to do. Her scale was zero. In other words, they asked about fourthey had a good sample size, about 4,000 patients and asked themand these were patientsfairly young patients who were going to a kaiser clinic, i think, in california somewhereasked them have you ever been discriminated against in your life . so zero was one designation; one or two times and three or more. Those were the three categories lets just stipulate that the responses were meaningful. But what shewhat they found, she and her colleague, were that you didnt see itthe kind of direct relationship, the kind of positive relationship you would expect, which is to say that the level of Blood Pressure would track with the reports of discrimination so that those who said they were not discriminated against would have the least Blood Pressure, the lower Blood Pressure readings and so on. You didnt find that at all. I think in black men you found a negative correlation. In other words, those reporting no discrimination had the highest readings. Among women, there was something called a ushaped curve where those who said they had no discrimination had the highest Blood Pressure. Those who said they had three or more had the highest, but those with twoone or two had an intermediate. Anyway, it was all over the map. And what most researchers would conclude from that kind of distribution of data wasin fact, there is no correlation. But instead, what these researchers invoked was something called internalized oppression, the idea being that the folks who claimed to have no experiences of discrimination really did, but that either they didnt register it consciously as discrimination because they had such a low selfregard that they felt this was just acceptable behavior. This is the way we should be treated in society, hence internalized oppression. You know, it didnt even register as an aberrant event. Or perhaps, they found it too painful to report. These were the explanations. But thats not a falsifiable explanation. In other words, it could be invoked to explain anything. So its not really scientifically rigorous. Cspan define some of the terms you write about. Whats an indoctrinologist . Guest well, that is a term that i made up. Actually, a patient of mine made it up. He said he was going to the endocrinologist, but he garbled it in such a way it was a great neologism and i thought, this really fits these folks, so its a word that i coined to describe Public Health professors and other Health Professionals who feel that our health is so completely at the mercy of social forces that there really is Little People can do to safeguard their health and accordingly, that the effort of Health Professionals really should be to encompass social justice and itin fact, the former dean of the Harvard School of Public Healthand schools of Public Health in general really are ground zero of this movementis quoted as saying, a school of Public Health is like a school of justice. The american Public Health association is quite politicized. They have lots of policy statements, some of them make perfect sense. They talk about lead exposure and good policies for preventing that. But they also have policy statements on Campaign Finance reform and on the war in nicaragua and earned income tax credits. And this certainly is moving away from the fundamental mission of Public Health which is developing the scientific and practical basis of disease and injury prevention. Cspan whats a consumer survivor . Guest consumer is the politically correct word for psychiatric patient. Cspan consumer . Guest yes. In fact, youll. Cspan well, politically correct among what group . Guest among some of my colleagues, certainly among the folks who run the center for Mental Health services, which is a part of hhs that gives out the block grant for state Mental Health funding, certainly among advocates for the mentally ill. The word consumer is basically an effort to negate the hierarchy, really, between the doctor and the patient that, unfortunately, has come to be seen asby some of them a kind of malignant relationship with the powerful clinician who is somehow oppressing the helpless patient. Its very distressing world view. Thats consumer. But consumer survivor is a special species of consumer. And the survivor is not one who has survived schizophrenia as in a Breast Cancer survivor, but one who has survived Mental Health services. Cspan whohow many of them. Guest how many of them are there . Cspan yeah. Guest yeah, thats a very good question. Ive tried very hard to get a count. Im going to say a few hundred and you might think, so why are they important if there are just a few hundred of them . but theyre fairly wellorganized. These are former mental patients, actually, and you have to wonder how sick they really are if they could organize so well. They frequently work with the Civil Liberties lawyers and they arethe most radical of them are virulently antipsychiatry. They feel that the system has actually made them sick, that its been wholly irresponsive to them and their goal, in factthere are twotwo goals that they share. One is to either obliterate the system all together, depending on who you talk to, but the other is to infiltrate the system and essentially have the consumer survivors be treating their fellow consumer survivors. Now where they are palpably destructive is that they lobby in a fairly effective way against involuntary commitment laws for the most severely mentally ill. And certainly, as a psychiatristi mean, no one wants to lock up a patient against his or her will. But there are some individuals who are just so dangerous to themselves or others this has to be done. And in particular, wed like to be able to require that some patients take their medication. Its wellknown that schizophrenic patients who are not medicated are more dangerous and are more prone to commit violent crime. This is a not a politically correct thing to acknowledge, but there is ample data to support that, that unmedicated they are more dangerous than the average population. However, were not saying certainly that bring back the asylums at the same scale they were in the 50s, you know, certainly not. Wed like a lot of these folks to be living independently and many of them can if they take their medication. The problem is that maybe halfup to half of all people with schizophrenia dont even know that theyre sick so they dont even know they have to take it. And this would be a Legal Mechanism for enforcing them taking this medication so they can live independently and safely. Cspan whats the politics of publishing this book . Its put out by perseus group, thebasic books. Are they known to publish a certain kind of book . Did you have any trouble getting it out, i mean. Guest no. Cspan . cause its coming from the point of view it is . Guest no, in fact, the editor i had, Joanne Miller had been after me since, gee 93 to write a book. I used to have a column in a monthly newspaper for psychiatrists called the psychiatric times and i would always write about these sorts of phenomena. So she knew where i wasmy orientation. Cspan what are yourwhat number of things are you involved in that we havent talked about . For instance, yourehow much of your time is spent with the methadone clinic now . Guest its very part time. Im there about three half days a week. Cspan what else are you doing . Guest oh, im also a residentim a fellow, excuse me, at the American Enterprise institute. Cspan and what do they want you to do . Whats that job like . Guest well, thats probably the greatest job you could have im on a twoyear fellowship. Its not over yet. And basically, the charge has been to pursue whatever seems interesting to me. I mean, im in their category of social welfare. I mean, they do divide up, obviously, the scholars into areas, so im in social welfare and i believe within that there is individual and social responsibility. So im in that. So its. Cspan how do you get that . How did you get that position . Guest well, actually, the president of aei, chris demuth, id known him for a few years, just through mutual friends and thejust a lot of friends that i had happened to be scholars there so i got to meet him and id written a monograph for him in 97 on drug treatment. So he got to know my work and then he gave me a small grant to help support this and so just through years of knowing him and him getting to know my work. Cspan now when you walk in a meetingthese meetings of all these groups that you talk about in here, what are their reaction to you when they see you . I mean, do youare you among friends or do people say, uhoh, here she comes. Shes out to get us . Guest actually, the reaction has been among a lot of my colleagues, very positive. As you can imagine, most people are people of common sensebut a lot of folks feel inhibited about expressing my reservations, as i do in one of my chapters, for example, about affirmative action in medical school, although a lot of people are very concerned about it. And their reaction is thank goodness somebody said this. And in fact, that was really one of my major goals in writing, in addition to describing these trends, i really wanted to embolden my colleagues and it turns out thati hadnt realized this ahead of timebut, probably the single constituency, natural constituency of this book is Public Health professionals andso ive spoken to a number of deans at schools of Public Health and others who are extremely supportive and rather relieved that this is now being talked about. Ive, of course, gotten the requisite, you know, hate mail as well and been called byi think i was called the most dangerous psychiatrist in america, although i think Hannibal Lecter is more. Cspan you do get in a lot of discussion about affirmative action in colleges today. Whats the law . Guest you mean medical schools . Cspan i mean medical schools, yeah. Guest yeah. Well, the lawthe bakke case, i believe that was 1978, just ruled that race could not be a sole criteria for admission. Its certainly part of the criteria used. You would have thought that when prop. 209 passed in california, it would have had a big effect on racial preferences. It had an effect on the number of applicantsminority applicants that applied to medical schools. It did have that effect. But it didnt have much of an effect at all. In fact, i think its fair to say it had no effect on the double standard that was used in admissions. And that double standard has been going on ever since bakke and is going strong today and is endorsed, i think, very forthrightly by many of the organizations within medicine, especially the association of american Medical Colleges. Cspan but if youre white, black, asian, whatever your background is and you want to go to med school, do they differentiatei mean, if youre a minority, do you come in at a lower grade now . Guest yeah. Cspan can you . Is that legal . Guest you know, i would thim involved actually in a reverse discrimination case right now as an expert witness. A student at thewhos challenging the university of maryland for exactly those practices. I dont see how it can be legal, but its ongoing and theres ample data, much of it from the aamc. Cspan whats that mean, aamc . Guest oh, association of american Medical Collegeswhich support racial preferences, but ample data from them. Theyve been collecting itmeticulous data sets for years showing, in fact, that there is quite a discrepancy between the scoresthe mcat scores, Medical College Admission Test scores, and grade point averages of minorities who apply vs. White and asian students who apply. Cspan what happens when, you know, someone gets into medical school and they have a lesser score . Now what happens to theirdo they get out of medical school on the same percentage that the others do . Guest yeah. Thats a goodwell, good question, of course. They probably dont. Theres a fair amount of data showing that the failure rates on the boardsone takes twoyou take two series of boards. Medical school is four years long. Theres a board after the first two years and then after the second two years. The failure rates are multiple times higher for the minority students who were admitted with the poorer grades. Now its very important to distinguish between, of course, minorities admitted with good grades. Competitively, they do fine, just perfectly fine. But those who are underprepared at admission have much higher failure rates on these tests. They take longer to graduate. There is a higher dropout rate and theyre more likely to have problems as residents if they go on to the next phase. Cspan theres a footnote and ive underlined it so we may be missing some important points here. Youll remember it. the percentage of black and hispanic students getting bachelor of science degrees has remained constant, as have those racist percentages of college graduates. Ella cleveland, personal communication with the author, january 6th no one really understands why medical school is relatively unpopular among these students. Perhaps some are discouraged by the high educational debt that they will assume by the loss of position autonomy in the world of managed care. do they really think about those kind of things, you think . Guest i think some people do. I dont know if thatthey got that information from the aamc and i dont know if they derived that through any kind of formal survey or theyre just inferring. But managed care certainly has had an influence on the attitudes of certainly practicing physicians who say they wouldnt do it again. Cspan well, what did you find about all of usabout going to people that look like us as doctors . I mean, do blacks want to go to blacks. Guest yeah. Cspan . And asians to asians and whites to whites . Guest good question. Well, that is, in fact, the rationale for racial preferences in medical school, which is to say its a little different thanfrom affirmative actioni mean, as racial preferences, not affirmative action. Affirmative action im all in favor of, which is outreach. But as far asthat is the justification for racial preferences in medical school, that the only way we will close the socalled health gapthe fact, for example, that we have higher infant mortality rate in africanamericans babies and higher death rates from higher incidence of diabetes and Heart Disease and so on, is if we have more africanamerican doctors, which is different from the rationales for racial preferences other places. There its more principled. Even though i personally dont agree with those principles, that theyre the principles of compensating for a past injustice or for diversity for diversitys sake. But in medical schools, its practical and one would think it could be empirically tested. But i tried to look at proxies for an empirical approach. In other words, what patients say. Do patients really want to see . Do minority patients really care that much . The best survey i could findthere were several. The best one i found was from the Commonwealth Fund and it was done a few years ago, interviewed 4,000 patients from every ethnic group imaginable and asked them a series of very detailed nested questionswhy do you choose your doctor, this sort of thingand they werein one question they gave patients 13 possible reasons they could use to choose a doctor, ranging from convenience of Office Location to he was my race. and in almost everywell, in africanamericans and hispanics, a little less so in asians, that wasthat ranked last whether or not it was the same race. And they asked patientsthey asked a subset of people, for example, who changed doctors why did you change . and only 2 percent of them said, so i could get a doctor of my same race. the highest percentage i found was in a smaller studies, i thought not quite as welldone, but where up to 25 percent of africanamericans, for example, said they preferred a black doctor. Interestingly, in that study, 12 percent of africanamericans explicitly said they did not want a black doctor. But nevertheless, maybe one in four. So there may be some preferences. And im also for people, of course, exerting their preferences. Cspan how much federal money is involved in this whole issue were talking about . How much can be influenced from this government and this town . Guest well, in terms of the consumer survivors we talked about, a lot, because theyand thats why i wrote about them. Otherwise, who would care, except that they leverage their influence with federal dollars. They are largely supported through hhs and that could stop overnight depending on who takes over the lead agency there, which is called samhsa, Substance Abuse and Mental Health services administration. For example. Cspan what kind of money do they get . Guest probablyadding up, im even guessing here, i dont think its even more than 15 million or 10 million. So, you know, in terms of big money, its not that big money. But it is leveraged fairly effectively. These consumer survivors try to reach patients in hospitals, patients whove been discharged and try to encourage them often not to take medication, as i said, do some pretty heavy lobbying and i found that politicians are especially uninformed about the kinds of interventions that are needed for the severely mentally ill and terrified, of course, of seeming as if to violate civil rights, you know, by recalling the era of the asylum where there were some abuses certainly. Cspan on the back of your book you have some endorsements. One of them is someone who would not be considered a conservative or a republican, wendy kaminer. Guest right. Cspan she writes feminists and other liberals who have long protested the medical professions rightwing biases should heed satels wellargued critique of the pc leftwing medicine. how did you get her to write that . Guest ive actually been a fan of wendy kaminers ever since she wrote im dysfunctional, youre dysfunctional and, actually, shes a libertarian. I think shed call herself that as opposed to a liberal, and shes basically someone who respects data when data exists. And so i asked her. Cspan whats your goal in life . Where do you go afteri mean, when is your aei fellowship over . Guest its over in the fall of 2002. Cspan so what then . What do you want to do . Guest well, id like to do i think what im doing now, but at higher levels of visibility and influence. I have thought about returning, at the same, though, i have thought about working with schizophrenic patients again and devoting more of my time to clinical work. Maybe youve once interviewed someone named fuller torrey. Hes a psychiatrist. Actually, hes local. And a schizophrenia researcher, has a lot of influence on policies, written some wonderful books and he has started a group called the treatment advocacy center. Its located in arlington, and its efforts are directed towards reforming these commitment laws. But with that background, i have thought of working with that group to perhaps developing a model kind of asylum. I realize thats a word now that has so much baggage, but a very benign one for the most severely mentally ill that could be a model and it would be residential and it would beit would have elements that actually borrow from some of the days of dorothea dix of the moral treatment of the mentally ill where it was quite dignified actually. The patients had working farms. They worked with animals. They workedthey were selfsustaining. And that kind of an environment plus the medications we have today, which are far more sophisticated, i think could make for a very humane setting for that small minority of severely mentally ill people who just cant live independently. Cspan heres what the cover of the book looks like pc, m. D. how Political Correctness is corrupting medicine, by sally satel, m. D. Thank you very much for joining us. Guest thank you. This is a little over an hour. In the spring of 1970, the war in vietnam was raging. American battle deaths in vietnam now number 40,142. And at home antiwar protesters and Law Enforcement officers were violently clng