This present Substack article was conceived last Sunday morning when I came upon an article on the front page of the New York Times. The headline was, “This Teen Was Prescribed 10 Psychiatric Drugs. She’s Not Alone.” (That was the headline — not on the supermarket rack, but the front page of the NYT.) Naturally, since I spent half a century as a psychiatrist, and almost that entire time letting people know that I was a <proud> clinical psychopharmacologist, (which is a bit like an undergrad at an prestigious college describing herself as a ‘proud Zionist’), I read the article and wrote the Times a serious, though impassioned, response. They didn’t publish my letter; not even on their web site, which has 1,496 letters written in response, many of them much lamer than mine. I could easily be somewhat paranoid, but I’m not. They have probably labeled me as a <kook>, which is not necessarily inaccurate based on some of my prior letters to them. I assume my email address is filtered out of their entry algorithm, much same the way I hit the “Call Block” button on my phone.
Well, screw you, New York Times. For those of you still with me, here is a link to the article, (in case the headline alone fails to give away its content), and here is my letter which I now publish myself, on Substack.
To the Editor:
I am a retired psychiatrist, who a few years ago was one of those psychiatrists depicted in the article. Let me say that every sentence in this article is entirely true. But because it was written without an overall organizing concept, known as a <clinical trial>, it is an irrational screed.
As treating psychiatrists, not researchers, not bureaucrats, we faced living people in the ‘foxhole’, people in pain. Sometimes the only weapon we had, the only hope we could offer, was a <clinical trial>. A clinical trial is a <process> and it is always acceptable under the right conditions. At best, in the aggregate, clinical trials give questionable results, and any good result cannot be proven to stem from the trial itself or your skill or sagacity. By definition, a clinical trial, using an ’n of 1’, can never be shown <not> to be a random fluke, and thus will never qualify as “scientific”. If you merely tabulate the different drugs people got, and their combinations, as this article did, without considering the context of a clinical trial, then you are rewarded with a squeal of propaganda, headlined by the NYT and ready for tomorrow’s fish.
The psychiatrists portrayed seem so obviously incompetent. So why were they, why were <we>, so rarely sued successfully? The answer is because we weighed the justifications and the evidence supporting our decisions, and the consequences of them as well. Together, with the patient, we evaluated any result. And… we wrote notes, often copious, documenting the above. We, not the expert, or the bureaucrat doing the tabulations, were the ones who had to face the patient and her lawyer. We knew we had better have a damn good rationale for our actions.
By utterly failing to even mention the principle of a clinical trial, the author of this article just retreads old accusations, myths and distortions about “psychiatrists pushing their drugs”. How sad for the author; how shameful for the NYT.
Arnold Rosen, M.D.
As I thought about it, I realized that the idea of a clinical trial was a useful concept in general, and not just of value to the professional. As I have gotten older, (pushing 80, in October), my role in medicine has changed from that of doctor to that of patient. I well remember my patients getting older, retiring, and speaking often about how meeting doctors’ appointments had become like a part-time job. I’m getting close to that point, and doctor’s visits are beginning to fill up my calendar.
The last time I wrote something and posted it on Substack, I described myself as a “newly elderly man in the early twenty-first century”. With this phrase, I pinned myself and my current status to a location in the present time. Recently, I have been thinking about what it means to be ‘newly elderly’. I see myself has having changed in the past 2-3 years, having gone through, as it were, a reverse adolescence. Maybe I will call it a <devolescence>, or a devolving adolescence, in the sense of noticing some changes, over a relatively short period, where things are starting to run down or run backwards.
As a newly elderly man, who is trying to remain cognizant of all the changes going through him and around him, I see myself as beginning to accumulate <appliances>. By that, I mean those medical devices that assemble around us as we age. I am finding that some of the time we spend in our part-time jobs in waiting rooms and medical offices is less for <us>, and more for our appliances, as they go for their periodic maintenance and inspection.
I have had a pacemaker for almost 10 years. Every 3 months it goes for a check-up and I usually make the arrangements, set up the transportation, and keep my appliance company. Last year the battery finally ran down and I was given a new model pacemaker. This new model comes with a ‘base element’ that sits on the bureau near my bed and monitors me throughout the night. Then a week ago, I finally graduated to another appliance. I now have a CPAP machine that also comes with its built-in wireless monitor.
Sondra sleeps only in her nightgown, while I am surrounded by two ‘guardian angels’, standing ever vigilant around me at night. I can look up in the darkness of the bedroom and see them glowing dimly with their red or green lights, merrily monitoring my heart rate and my breathing, and presumably sending the data up to an orbiting satellite for further processing. I think, if I suddenly die in my sleep, the first to know will be some sputnik currently in low earth orbit, hundreds of miles over my head. These devices were never present in my parent’s bedroom; but they will appear more and more in those of the ‘newly elderly’.
But wait, these appliances are not new phenomena. In fact, if I think about them, they have just started coming into my life more often. A pacemaker and CPAP are merely the latest. If I am honest then I have to also count as an appliance my reading glasses, beginning in my late forties, and my own personal use of the computer in the past few years to assist my memory, and manage the accumulation of my own ‘senior moments’.
I personally feel that the computer (whether on your desk or on your mobile phone) will be as necessary and as useful to the newly elderly as reading glasses are to the newly middle aged. In both cases, they are ‘appliances’ to assist you with the <normal> loss of a useful function, i.e., the ability to read small print and the ability to manage short-term memory. Both of these functions are scheduled to <normally> decline at their programmed time in life, and both can be assisted by the correct use of the right ‘appliance’ — reading glasses and the computer. I will likely have more to say about the computer helping with memory in future Substacks. What is important to emphasize now is the fact that while our memories will normally decline somewhat with age, our ‘central processing unit’, our frontal centers that are tasked with planning, logic and organization will not decline with age. Unless they are diseased, (Alzheimer’s, etc.), they should be good to go until the very end — but more on that later.
At this point, I want to mention my CPAP machine and how it ties into the concept of a clinical trial. And in doing that, I am going to mention my son, David Rosen, M.D., who is a hospital trained pulmonologist and certified sleep medicine doctor. In mentioning him, I hope to give a plug for a new enterprise he is starting up, Renuma Inc. Renuma is an online company designed to diagnose, treat and manage sleep apnea remotely. I might have the honor of being his first patient.
Ordinarily, I am opposed to family members treating other family members, but David recognized sleep apnea after I dozed off watching TV, and has been urging me to have it investigated. He agreed to my insistence that I pay for his services like any other client or patient, and that is our arrangement. It makes it a little more palatable for me. (I think optimal medicine is practiced by an empathetic person who can maintain a certain emotional distance. Obviously that distance is not maintained when doctor or patient is family.)
I’m not going to kvetch here. Let me just say, I got the machine because I needed it, and I have had it for over a week. Let me also say up front; it has helped, and I am grateful that I can welcome my CPAP into my circle of appliances. But like anything else, it is new, and the initial days were rocky. I recognize that getting started on a CPAP machine is also a <process>, just like a <clinical trial>. Instead of different medications and differing doses and combinations of psychoactive drugs, things I had managed in my doctor role; with CPAP, it’s different settings, and different pressures and different programs bringing all these elements into play at the proper time. It takes patience and practice. Part of receiving CPAP therapy is to be counseled to persevere and give it time — in short I am pumped up to be optimistic, and not give up too early. It’s familiar and not too dissimilar to the pep talks I gave my patients.
I have to give David credit here. We have been working collaboratively. It’s not necessarily so easy. The machine generates all kinds of data, scores how many apnea events occur each hour, and other such outcomes. Naturally David focuses on that and he is in a hurry to get me better. I am glad for that and he is my guide. He knows the machine and sleep apnea like no one else, but I am the world’s expert when it comes to my body, and my goals may be more subjective, like, ‘did I have a good night’s sleep’? David is very concerned about that as well, probably even more than I give him credit for. I sent him an email reporting on changes I made to some machine settings after I watched a YouTube video. I am very sensitive about boundaries. I might have been a little uncomfortable changing the settings on my own, worried that he might see me as infringing on what should be his professional territory. I did not want it to appear that I was stepping beyond my role as a compliant patient. However, he quickly replied, “You can also look into a free program called ‘sleepyhead’ if you really want to deep dive your machine’s data.” Yep, it’s working.