Clinical Privileges

There is no easy way to tell other people that you have manic-depressive illness; if there is, I haven’t found it. So despite the fact that most people that I have told have been very understanding—some remarkably so—I remain haunted by those occasions when the response was unkind, condescending, or lacking in even a semblance of empathy. The thought of discussing my illness in a more public forum has been, until quite recently, almost inconceivable. Much of this reluctance has been for professional reasons, but some has resulted from the cruelty, intentional or otherwise, that I have now and again experienced from colleagues or friends that I have chosen to confide in. It is what I have come to think of, not without bitterness, as the Mouseheart factor.

Mouseheart, a former colleague of mine in Los Angeles, was also, I thought, a friend. A soft-spoken psychoanalyst, he was someone I was in the habit of getting together with for a morning coffee. Less frequently, but enjoyably, we would go out for a long lunch and talk about our work and our lives. After some time, I began to feel the usual discomfort I tend to experience whenever a certain level of friendship or intimacy has been reached in a relationship and I have not mentioned my illness. It is, after all, not just an illness, but something that affects every aspect of my life: my moods, my temperament, my work, and my reactions to almost everything that comes my way. Not talking about manic-depressive illness, if only to discuss it once, generally consigns a friendship to a certain inevitable level of superficiality. With an inward sigh, I decided to go ahead and tell him.

We were in an oceanfront restaurant in Malibu at the time, so—after a brief rundown on my manias, depressions, and suicide attempt—I fixed my eye on a distant pile of rocks out in the ocean and waited for his response. It was a long, cold wait. Finally, I saw tears running down his face, and, although I remember thinking at the time that it was an extreme response—particularly since I had tried to present my manias in as lighthearted a way as possible, and my depressions with some dispassion—I thought it was touching that he felt so strongly about what I had been through. Then Mouseheart, wiping away his tears, told me that he just couldn’t believe it. He was, he said, “deeply disappointed.” He had thought I was so wonderful, so strong: How could I have attempted suicide? What had I been thinking? It was such an act of cowardice, so selfish.

I realized, to my horror, that he was serious. I was absolutely transfixed. His pain at hearing that I had manic-depressive illness was, it would seem, far worse than mine at actually having it. For a few minutes, I felt like Typhoid Mary. Then I felt betrayed, deeply embarrassed, and utterly exposed. His solicitude, of course, knew no bounds. Had I really been psychotic? If so, he asked in his soft voice, with seemingly infinite concern, did I really think, under the circumstances, that I was going to be able to handle the stresses of academic life? I pointed out to him, through clenched teeth, that I had in fact handled those particular stresses for many years, and, indeed, if truth be told, I was considerably younger than he was and had, in fact, published considerably more. I don’t really remember much of the rest of the lunch, except that it was an ordeal, and that at some point, with sarcasm that managed to pass him by, I told him that he ought not to worry, that manic-depressive illness wasn’t contagious (although he could have benefited from a bit of mania, given his rather dreary, obsessive, and humorless view of the world). He squirmed in his seat and averted his eyes.

A boxed bouquet of a dozen long-stemmed red roses arrived at my clinic the next morning; an abject note of apology was tucked in at the top. It was a nice thought, I suppose, but it didn’t begin to salve the wound inflicted by what I knew had been a candid response on his part: he was normal, I was not, and—in those most killing of words—he was “deeply disappointed.”

There are many reasons why I have been reluctant to be open about having manic-depressive illness; some of the reasons are personal, many are professional. The personal issues revolve, to a large extent, around issues of family privacy—especially because the illness under consideration is a genetic one—as well as a general belief that personal matters should be kept personal. Too, I have been very concerned, perhaps unduly so, with how knowing that I have manic-depressive illness will affect peoples perception of who I am and what I do. There is a thin line between what is considered zany and what is thought to be—a ghastly but damning word—“inappropriate,” and only a sliverish gap exists between being thought intense, or a bit volatile, and being dismissively labeled “unstable.” And, for whatever reasons of personal vanity, I dread the fact that my suicide attempt and depressions will be seen by some as acts of weakness or as “neurotic.” Somehow, I don’t mind the thought of being seen as intermittently psychotic nearly as much as I mind being pigeonholed as weak and neurotic. Finally, I am deeply wary that by speaking publicly or writing about such intensely private aspects of my life, I will return to them one day and find them bleached of meaning and feeling. By putting myself in the position of speaking too freely and too often, I am concerned that the experiences will become remote, inaccessible, and far distant, behind me; I fear that the experiences will become those of someone else rather than my own.

My major concerns about discussing my illness, however, have tended to be professional in nature. Early in my career, these concerns were centered on fears that the California Board of Medical Examiners would not grant me a license if it knew about my manic-depression. As time went by, I became less afraid of such administrative actions—primarily because I had worked out such an elaborate system of clinical safeguards, had told my close colleagues, and had discussed ad nauseam with my psychiatrist every conceivable contingency and how best to mitigate it—but I became increasingly concerned that my professional anonymity in teaching and research, such as it was, would be compromised. At UCLA, for example, I lectured and supervised large numbers of psychiatric residents and psychology interns in the clinic I directed; at Johns Hopkins I teach residents and medical students on the inpatient wards and in the outpatient mood disorders clinic. I cringe at the thought that these residents and interns may, in deference to what they perceive to be my feelings, not say what they really think or not ask the questions that they otherwise should and would ask.

Many of these concerns carry over into my research and writing. I have written extensively in medical and scientific journals about manic-depressive illness. Will my work now be seen by my colleagues as somehow biased because of my illness? It is a discomforting thought, although one of the advantages of science is that one’s work, ultimately, is either replicated or it is not. Biases, because of this, tend to be minimized over time. I worry, however, about my colleagues’ reactions once I am open about my illness: if, for example, I am attending a scientific meeting and ask a question, or challenge a speaker, will my question be treated as though it is coming from someone who has studied and treated mood disorders for many years, or will it instead be seen as a highly subjective, idiosyncratic view of someone who has a personal ax to grind? It is an awful prospect, giving up one’s cloak of academic objectivity. But, of course, my work has been tremendously colored by my emotions and my experiences. They have deeply affected my teaching, my advocacy work, my clinical practice, and what I have chosen to study: manic-depressive illness in general and, more specifically, suicide, psychosis, psychological aspects of the disease and its treatment, lithium noncompliance, positive features of mania and cyclothymia, and the importance of psychotherapy.

Most important, however, as a clinician, I have had to consider the question that Mouseheart so artfully managed to slip into our lunchtime conversation in Malibu: Do I really think that someone with mental illness should be allowed to treat patients?

When I left the University of California in the winter of 1986 to return to Washington, I was eager to continue teaching and to obtain an academic appointment at a university medical school. Richard, who had gone to medical school at Johns Hopkins, thought I would love it. At his suggestion, I applied to the Department of Psychiatry for a faculty appointment, and I started teaching at Hopkins within a few months of moving back East. Richard was right. I loved Hopkins straightaway. And, as he predicted, one of the many pleasures I found in being on the Hopkins faculty was the seriousness with which teaching obligations are taken. The excellence of clinical care was another. It was only a matter of time. The issue of clinical privileges was bound to come up.

With the usual sense of profound uneasiness that for me accompanies having to look through official hospital appointment forms, I stared at the packet of papers in front of me. In imposing capital letters THE JOHNS HOPKINS HOSPITAL was written across the top of the page. Scanning downward, I saw that it was, as I had expected, an application for clinical privileges. Hoping for the best, but expecting the worst, I decided to tackle all of the straightforward questions first; I quickly checked “no” to a long series of questions about professional liability, malpractice insurance, and professional sanctions: During the previous application period, had I been involved in any litigation involving malpractice or professional liability? Were there any restrictions or limitations in my malpractice coverage? Had my license to practice ever been limited, suspended, subject to any conditions, terms of probation, formal or informal reprimand, not renewed, or revoked? Had I ever been subject to disciplinary action in any medical organization? Were there any disciplinary actions pending against me?

These questions, thank God, were easy to answer, having managed thus far, in a ridiculously litigious age, to avoid being sued for malpractice. It was the next section, “Personal Information,” that made my heart race; and, sure enough, before too long I found the question that was going to require something more than just a checkmark in the “no” column:

Five lines down was the hangman’s clause:

I read back over the “Are you currently suffering from” question, thought about it for a long time, and finally wrote next to it “Per discussion with the chairman of the Department of Psychiatry.” Then with a sinking feeling in my stomach, I telephoned my chairman at Hopkins and asked him if we could get together for lunch.

A week or so later, we met at the hospital restaurant. He was as talkative and funny as ever, so we spent several pleasant minutes catching up on departmental activities, teaching, research grants, and psychiatric politics. With my hands clenched in my lap and my heart in my throat, I told him about the clinical privileges form, my manic-depressive illness, and the treatment I was receiving for it. My closest colleague at Hopkins already knew about my illness, as I had always told those physicians with whom I most closely practiced. At UCLA, for example, I had discussed my illness in detail with the physicians who, with me, had set up the UCLA Affective Disorders Clinic and then, subsequently, with the doctor who had been the medical director of the clinic during virtually all of the years I was its director. My chairman at UCLA also knew that I was being treated for manic-depressive illness. I felt then, as I do now, that there should be safeguards in place in the event that my clinical judgment became impaired due to mania or severe depression. If I did not tell them, not only would the care of patients be jeopardized, but I would be placing my colleagues in an untenable position of professional and legal risk as well.

I made it clear to each of the doctors I worked closely with that I was under the care of an excellent psychiatrist, taking medication, and had no alcohol or drug abuse problem. I also asked them to feel free to ask my psychiatrist whatever questions they felt they needed to about my illness and my competence to practice (my psychiatrist, in turn, was asked to communicate both to me, and to whomever else he thought necessary, if he had any concerns about my clinical judgment). My colleagues agreed that if they had any doubts whatsoever about my clinical judgment they would tell me directly, immediately remove me from any patient care responsibilities, and alert my psychiatrist. I think that all of them have, at one time or another, spoken with my psychiatrist in order to obtain information about my illness and treatment; fortunately, none have ever had to contact him because of concerns about my clinical performance. Nor have I ever had to give up my clinical privileges, although I have, on my own, canceled or rescheduled appointments when I felt it would be in the best interests of patients.

I have been both fortunate and careful. The possibility always exists that my illness, or the illness of any clinician, for that matter, might interfere with clinical judgment. Questions about hospital privileges are neither unfair nor irrelevant. I don’t like having to answer them, but they are completely reasonable. The privilege to practice is exactly that, a privilege; it is not a right. The real dangers, of course, come about from those clinicians (or, indeed, from those politicians, pilots, businessmen, or other individuals responsible for the welfare and lives of others) who—because of the stigma or the fear of suspension of their privileges or expulsion from medical school, graduate school, or residency—are hesitant to seek out psychiatric treatment. Left untreated, or unsupervised, many become ill, endangering not only their own lives but the lives of others; often, in an attempt to medicate their own moods, many doctors will also become alcoholics or drug abusers. It is not uncommon for depressed physicians to prescribe antidepressant medications for themselves; the results can be disastrous.

Hospitals and professional organizations need to acknowledge the extent to which untreated doctors, nurses, and psychologists present risks to the patients they treat. But they also need to encourage effective and compassionate treatment and work out guidelines for safeguards and intelligent, nonpaternalistic supervision. Untreated mood disorders result in risks not only to patients, but to the doctors themselves. Far too many doctors—many of them excellent physicians—commit suicide each year; one recent study concluded that, until quite recently, the United States lost annually the equivalent of a medium-sized medical school class from suicide alone. Most physician suicides are due to depression or manic-depressive illness, both of which are eminently treatable. Physicians, unfortunately, not only suffer from a higher rate of mood disorders than the general population, they also have a greater access to very effective means of suicide.

Doctors, of course, need first to heal themselves; but they also need accessible, competent treatment that allows them to heal. The medical and administrative system that harbors them must be one that encourages treatment, provides reasonable guidelines for supervised practice, but also one that does not tolerate incompetence or jeopardize patient care. Doctors, as my chairman is fond of pointing out, are there to treat patients; patients never should have to pay—either literally or medically—for the problems and sufferings of their doctors. I strongly agree with him about this; so it was not without a sense of dread that I waited for his response to my telling him that I was being treated for manic-depressive illness, and that I needed to discuss the issue of my hospital privileges with him. I watched his face for some indication of how he felt. Suddenly, he reached across the table, put his hand on mine, and smiled. “Kay, dear,” he said, “I know you have manic-depressive illness.” He paused, and then laughed. “If we got rid of all of the manic-depressives on the medical school faculty, not only would we have a much smaller faculty, it would also be a far more boring one.”