Booknotes

DR. SALLY SATEL, AUTHOR, "PC, M.D.": How Political Correctness is Corrupting Medicine"): Well, I guess it would depend on what show they were going to appear. If it was a show about alternative medicine and about new age philosophy in medicine, I'd think that they were perfect representatives. Otherwise, I don't feel that they really represent clinical approaches or ideas about illness that are grounded in science.

DR. SATEL: I know that Christine Northrup did, in fact, have a PBS special and she wrote a book called "Women's Bodies"--my gosh, I'm blanking on it, but--and it--she 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 that's a huge viewership. And their books are best-sellers. 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 women's 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...

DR. SATEL: That's a good question. I know in her book, she consulted something called--a 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, that's when I was in medical school, and I know I wasn't raped.' At least she didn't 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 well-informed. So it was--it's uneven.

DR. SATEL: Yeah. I think there's 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 aren't especially scientifically literate. I mean, that's 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 time-limited. They do go away by themselves. So that if you were to take St. John's Wort for depression or some other kind of health-food store remedy and it appeared to work, it--it's often because it was a time-limited event to begin with. Also, we know that alternative practitioners are famous for spending more time with patients, and that's something, unfortunately, in an era of managed care that conventional physicians can't often do. And we also know that there is something called the placebo effect. It's 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 is--there's 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.

DR. SATEL: The placebo effect is when a person experiences some relief, when they're given a medication or some sort of intervention--it doesn't even have to be medication; it could be some process called therapeutic touch, which is very popular now, which in fact you're 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 they're 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 it's 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 it's a very interesting phenomenon. And it--in fact, it is being studied and would be interesting to harness that.

DR. SATEL: I went to medical school between 1980 and '84. I graduated from Brown University School of Medicine.

DR. SATEL: 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 what's 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 off--and it's a medication, in fact, you can't stop abruptly; you have to taper it off--then I was fine.

But it was really a transforming experience for me because I had--I mean, everyone experiences, you know, blues now and then, but I'd never experienced such a profound and desolate kind of depression. And as I said, thank goodness it was time-limited, but it made me realize that there are people who are suffering with what we call endogenous depression. It's not caused by some chemical they took or some medication side effect. That it's essentially their own neurotransmitters revolting. It's 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 couldn't 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 that's why I went to medical school.

DR. SATEL: Cornell?

DR. SATEL: Queens, New York.

DR. SATEL: No. None. My parents, neither of them had gone to college.

DR. SATEL: 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. Raphael's Hospital in New Haven of being a "real doctor," you know, doing to--surgery for two months, internal medicine for about eight months and it's just essential to forming your identity as a physician and, of course, learning invaluable physiology and clinical techniques.

DR. SATEL: Graduated medical school--ok--'84, and then, of course, I did this--then I did the internship. Then you do three years of residency, so that's four years total post-graduate.

DR. SATEL: 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. I've 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 what's 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 it's 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 wasn't that much opportunity. So right around that time, the early--the mid-80s, 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 cocaine-induced psychosis, and I thought, `Well, that's an interesting way to study thought disorder,' which was the essence of schizophrenia that I was interested in. I'll do it by studying drug addicts.

And it turned--and 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 they'd taken a high enough dose was a kind of time-limited paranoia, as opposed to a full-fledge 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.

DR. SATEL: I did it at the West Haven VA.

DR. SATEL: Yes. Associated with Yale.

DR. SATEL: Well, it could look like a powder.

DR. SATEL: 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.

DR. SATEL: And people who inject it, it's called crank. Sometimes...

DR. SATEL: Yeah. You can inject it with a needle. And you can also crystallize it as one can do with cocaine and smoke that. And it's highly addicting and it's even more dangerous than crack because it's 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.

DR. SATEL: Crack is cocaine. It looks exactly like if you take hard candy, the pineapple hard candy from Lifesavers and hammer it, you'll get little pieces that look exactly like crack. And the reason I know that that's 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...

DR. SATEL: Well, in '90--in '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 that's not a particularly new reaction. Doctors who work at the VA, it's a special kind of an institution. In fact, it's 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 service-connected 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 I'm certainly not saying they didn't deserve those benefits. These are service-connected benefits. If someone's 100-percent service-connected, they can get up to $2,000 a month tax-free. That's quite a lot of money. And I don't mean to imply for a minute it wasn't deserved. Obviously, they risked their lives. But it was certainly holding them back.

And a number of the other patients--not everyone in a VA gets veterans' benefits--some 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 couldn't 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 couldn't do that as one person. Frequently, I'd 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 they'd 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 couldn't 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.

DR. SATEL: I never was in San Francisco.

DR. SATEL: No, I didn't. Actually, a book reviewer--another reviewer misinterpreted that as well, so maybe it wasn't written that clearly in the book. What I was referring to--I 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.

DR. SATEL: And it was about something going on at San Francisco General Hospital.

DR. SATEL: 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 as--the more he told me about it, the more I was stunned. Basically, what was going on there and what's still going on there is a division of the in-patient unit, the psychiatric in-patient units in San Francisco General are divided up by race. Essentially, it's identity politics moving into psychiatry. There is a black unit. It's called the Black Focus unit. There's a unit for HIV-positive patients, one for Asians, Hispanics and women. None for white men, Brian, so I...

DR. SATEL: I think that it's 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 didn't 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 it--it didn't 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 it's one of the few units at San Francisco General, which is a major teaching hospital at the University of San Francisco Medical School, that doesn't have any trainees because the environment, the milieu, just got too touchy. That's not healthy for patients.

And ironically now, again, in this age of managed care and, you know, efforts to keep costs down, patients are in--they come in very sick. Some of them are committed. I mean, they're literally forced against their will because they're so psychotic, they really don't even know--are dangerous to themselves or others, they have to be essentially committed and they're there for such a short period of time that there's 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 that's becoming quite popular in the counseling profession, and that's where multicultural counseling--I didn't make that term up--is taking off. It's endorsed by the American Counseling Association. I went to their meeting last year. And that was One--in fact, that was the theme of the meeting: diversity and multicultural counseling.

And it's a very, very pernicious--there are three basic tenets to multicultural counseling. And I must say, this is not done with people who are wildly psychotic. It's 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 patient's psychological landscape is her membership in an oppressed group--assumes 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 it's the environment that's largely responsible for your psychic distress, then that's 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 self-observation. It should be about taking responsibility for choices. It really is often a--good psychotherapy is about learning how people--how an individual unwittingly sabotages himself. When you have a student who thinks he wants to be--go 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 that's very--a very rich source of neuroses, as we say, to mine, but it's not about blaming. It's not about externalizing. It's about looking inside. And you can't do that if you're focusing on oppressive forces.

DR. SATEL: 1993, through that fellowship, the Robert Wood Johnson Health Policy...

DR. SATEL: That was about a year. I worked with Senator Nancy Kassebaum.

DR. SATEL: Yeah. On her committee staff. She was the ranking member on the Health and Human Services--Labor and Human Services staff.

DR. SATEL: No, I'd never been political at all. I never voted until '92. And--no, I never was...

DR. SATEL: Yeah. No, I understand. And when I--in 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 fellowship--it had been going on since the '70s--had 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...

DR. SATEL: Yes. I worked--since '95, I've been working in clinics. I work now in a Methadone clinic.

DR. SATEL: In DC. It's a--northeast. It's about two miles on the other side of the Capitol, down on Maryland Avenue.

DR. SATEL: Well, our clinic is mainly for working poor. We do have maybe a 25-percent Medicaid population. But mainly, it's people who pay for their Methadone and who hold down jobs.

DR. SATEL: I want to say about 50-50.

DR. SATEL: The staff is almost all African-American, but the--and the doctor who owns it is African-American.

DR. SATEL: No. I see--no, I don't see much racism.

DR. SATEL: Not as it--not as far as the relationship between the counselors and me and the patients go.

DR. SATEL: Actually, what I see--yes. What I talk about in my book is really an effort to--well, 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 that's this trend I call political correctness. And I see it in many venues. I don't 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...

DR. SATEL: Oh, that was with the DC Superior Court. It's since been shut down and started up again, in, I think, a more healthy and clinically productive way.

DR. SATEL: Yeah. At this clinic I worked in, it--as I said, it was part of the DC Superior Court so our patients were court-ordered. In fact, the context was something called a drug court. I'll just explain that to you very briefly. Drug court--they're now very popular. There are about 500 of them across the country. They started in 1989. And the idea is to divert non-violent 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, wouldn't have committed a minor crime and not incarcerate them, but send them to treatment. And I'm all in favor of that. In fact, I know from my own experience and from a lot of research I've done that that kind of coerced treatment works especially well because it ensures retention in treatment programs. And we know that's the best predictor of outcome.

Well, that said, DC had a drug court. And--but the clinic which I went to work in '95 was inhabited by counselors who did endorse this multicultural approach, and that's 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 didn't 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 being--counselor-led groups in which they were inculcated in their victimhood. They talking about racism and how you're 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 self-pride. And the patients themselves--if this isn't the tragedy--the patients themselves thought this was a terrible waste of their time.

DR. SATEL: Both.

DR. SATEL: No psychiatrists.

DR. SATEL: My goodness, this hasn't 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 who--some of them are excellent. I've 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 that--you know, lived through it and recovered, and they've also got some technical training. And they--some of them have been the most wonderful, but others--and those were the ones I worked with in '95 I can't say that they were the most wonderful. And you learn this in schools of counseling. If you look on the...

DR. SATEL: 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 a--offers either courses or a concentration in multicultural therapy.

DR. SATEL: I was. I was.

DR. SATEL: Patients?

DR. SATEL: I want to say about 150.

DR. SATEL: It was located on F Street up there near the Judiciary Square Metro Station.

DR. SATEL: My job was to do intakes on people. Basically, it's 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 didn't have patients, by and large, who were actively hallucinating or suicidal. I mean, most of them were drug--you know, drug abusers with...

DR. SATEL: That's just one of the exercises that the...

DR. SATEL: Ethnic self-pride. I mean, I am as skeptical as you are, and then...

DR. SATEL: I don't think so. No, there wasn't any--was there any follow-up? 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 it's not so much what they were doing, it's what they were not doing. Doing the kinds of things that would help these people be employable and moderately educated, the two--really, the two advances that these folks could make that would inoculate them, at least somewhat, against relapse to drugs and crime.

DR. SATEL: That was the first reason.

DR. SATEL: 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 African-Americans were more likely to suffer from high blood pressure, which is true. They are, about twice as likely, but that the reason for this is--as "discovered" by a professor at Harvard School of Public Health and published in the American Journal of Public Health--was because they suffered the stress of being discriminated against.

DR. SATEL: No, but he is there. He's a psychiatrist...

DR. SATEL: ...there. He is.

DR. SATEL: He might have that theory. I know that he is in favor of considering racism a mental illness. He'd written a book about that recently and he had an op-ed, I remember, in The New York Times right after Buford Furrow, that white--I believe he might have had white supremacist ties, in LA a few summers ago, shot some--in a synagogue and then killed an Asian man, I believe. And that prompted him to write the op-ed 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 he--I believe he was part of a--the effort to have the APA designated as such and put it in the DSM--at that time maybe DSM-I, the diagnostic and statistical manual, you know, the handbook of diagnoses. They rejected that.

DR. SATEL: Sure. Well, I have--there's no question in my mind that any kind of stressful situation can cause a physiological response. I mean, we've 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. That's--there's nothing new about that. But when one looked at her data...

DR. SATEL: ...which--the data of the professor at Harvard who was--concluded that the stress of discrimination was responsible for this disparity and high blood pressure. When you look at the data, they didn't hold up--in a nutshell, she sought to measure discrimination, which is hard to do admittedly. I mean, that's a very hard thing to do. Her scale was zero. In other words, they asked about four--they had a good sample size, about 4,000 patients and asked them--and these were patients--fairly young patients who were going to a Kaiser clinic, I think, in California somewhere--asked 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. Let's just stipulate that the responses were meaningful.

But what she--what they found, she and her colleague, were that you didn't see it--the 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 didn't 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 U-shaped 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 two--one 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 was--in 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 didn't register it consciously as discrimination because they had such a low self-regard that they felt this was just acceptable behavior. This is the way we should be treated in society, hence internalized oppression. You know, it didn't even register as an aberrant event. Or perhaps, they found it too painful to report. These were the explanations. But that's not a falsifiable explanation. In other words, it could be invoked to explain anything. So it's not really scientifically rigorous.

DR. SATEL: 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 it's 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 it--in fact, the former dean of the Harvard School of Public Health--and schools of public health in general really are ground zero of this movement--is 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.

DR. SATEL: Consumer is the politically correct word for psychiatric patient.

DR. SATEL: Yes. In fact, you'll...

DR. SATEL: 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 as--by some of them a kind of malignant relationship with the powerful clinician who is somehow oppressing the helpless patient. It's very distressing world view. That's 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.

DR. SATEL: How many of them are there?

DR. SATEL: Yeah, that's a very good question. I've tried very hard to get a count. I'm 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 they're fairly well-organized. 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 are--the most radical of them are virulently anti-psychiatry. They feel that the system has actually made them sick, that it's been wholly irresponsive to them and their goal, in fact--there are two--two 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 psychiatrist--I 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, we'd like to be able to require that some patients take their medication. It's well-known 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, we're not saying certainly that bring back the asylums at the same scale they were in the '50s, you know, certainly not. We'd 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 half--up to half of all people with schizophrenia don't even know that they're sick so they don't 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.

DR. SATEL: No.

DR. SATEL: 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 was--my orientation.

DR. SATEL: It's very part time. I'm there about three half days a week.

DR. SATEL: Oh, I'm also a resident--I'm a fellow, excuse me, at the American Enterprise Institute.

DR. SATEL: Well, that's probably the greatest job you could have. I'm on a two-year fellowship. It's not over yet. And basically, the charge has been to pursue whatever seems interesting to me. I mean, I'm in their category of social welfare. I mean, they do divide up, obviously, the scholars into areas, so I'm in social welfare. And I believe within that there is individual and social responsibility. So I'm in that. So it's...

DR. SATEL: Well, actually, the president of AEI, Chris DeMuth, I'd known him for a few years, just through mutual friends and the--just a lot of friends that I had happened to be scholars there so I got to meet him and I'd 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.

DR. SATEL: Actually, the reaction has been among a lot of my colleagues, very positive. As you can imagine, most people are people of common sense--but 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 that--I hadn't realized this ahead of time--but, probably the single constituency, natural constituency of this book is public health professionals and--so I've 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. I've, of course, gotten the requisite, you know, hate mail as well and been called by--I think I was called the most dangerous psychiatrist in America, although I think Hannibal Lecter is more.

DR. SATEL: You mean medical schools?

DR. SATEL: Yeah. Well, the law--the Bakke case, I believe that was 1978, just ruled that race could not be a sole criteria for admission. It's 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 applicants--minority applicants that applied to medical schools. It did have that effect. But it didn't have much of an effect at all. In fact, I think it's 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.

DR. SATEL: Yeah.

DR. SATEL: You know, I would th--I'm involved actually in a reverse discrimination case right now as an expert witness. A student at the--who's challenging the University of Maryland for exactly those practices. I don't see how it can be legal, but it's ongoing and there's ample data, much of it from the AAMC...

DR. SATEL: Oh, Association of American Medical Colleges--which support racial preferences, but ample data from them. They've been collecting it--meticulous data sets for years showing, in fact, that there is quite a discrepancy between the scores-the MCAT scores, Medical College Admission Test scores, and grade point averages of minorities who apply vs. white and Asian students who apply.

DR. SATEL: Yeah. That's a good--well, good question, of course. They probably don't. There's a fair amount of data showing that the failure rates on the boards--one takes two--you take two series of boards. Medical school is four years long. There's 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 it's 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 they're more likely to have problems as residents if they go on to the next phase.

DR. SATEL: I think some people do. I don't know if that--they got that information from the AAMC and I don't know if they derived that through any kind of formal survey or they're just inferring. But managed care certainly has had an influence on the attitudes of certainly practicing physicians who say they wouldn't do it again.

DR. SATEL: Yeah.

DR. SATEL: Good question. Well, that is, in fact, the rationale for racial preferences in medical school, which is to say it's a little different than--from affirmative action--I mean, as racial preferences, not affirmative action. Affirmative action I'm all in favor of, which is outreach. But as far as--that is the justification for racial preferences in medical school, that the only way we will close the so-called health gap--the fact, for example, that we have higher infant mortality rate in African-Americans babies and higher death rates from higher incidence of diabetes and heart disease and so on, is if we have more African-American doctors, which is different from the rationales for racial preferences other places. There it's more principled. Even though I personally don't agree with those principles, that they're the principles of compensating for a past injustice or for diversity for diversity's sake. But in medical schools, it's 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 find--there 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 questions--why do you choose your doctor, this sort of thing--and they were--in 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 every--well, in African-Americans and Hispanics, a little less so in Asians, that was--that ranked last whether or not it was the same race. And they asked patients--they 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 well-done, but where up to 25 percent of African-Americans, for example, said they preferred a black doctor. Interestingly, in that study, 12 percent of African-Americans explicitly said they did not want a black doctor. But nevertheless, maybe one in four. So there may be some preferences. And I'm also for people, of course, exerting their preferences.

DR. SATEL: Well, in terms of the consumer survivors we talked about, a lot, because they--and that's 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...

DR. SATEL: Probably--adding up, I'm even guessing here, I don't think it's even more than $15 million or $10 million. So, you know, in terms of big money, it's not that big money. But it is leveraged fairly effectively. These consumer survivors try to reach patients in hospitals, patients who've 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.

DR. SATEL: Right.

DR. SATEL: I've actually been a fan of Wendy Kaminer's ever since she wrote "I'm Dysfunctional, You're Dysfunctional." And, actually, she's a libertarian. I think she'd call herself that as opposed to a liberal, and she's basically someone who respects data when data exists. And so I asked her.

DR. SATEL: It's over in the fall of 2002.

DR. SATEL: Well, I'd like to do I think what I'm 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 you've once interviewed someone named Fuller Torrey. He's a psychiatrist. Actually, he's 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. It's 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 that's 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 be--it 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 worked--they were self-sustaining. 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 can't live independently.

DR. SATEL: Thank you.