“Deeming individuals ‘non-decisional’ for misinformed beliefs that are not representative of a psychiatric illness is inappropriate, unfairly medicalizes the narrative and incurs a risk of further public distrust of the health care system.

It is not the province of psychiatry to adjudicate uncomfortable social discourse so much as to elicit it. Empathic listening — curiosity rather than social judgment — has always been the most profound and powerful tool at our disposal, and it must remain so.”

Charles Hebert is a psychiatrist.

He shares his story and discusses his KevinMD article, “Can patients just say no to treatment?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show we have Charles Hebert. He is an internal medicine physician and psychiatrist, and he wrote the KevinMD article “Can patients just say no to treatment?” Charles, welcome to the show.

Charles Hebert: Thanks, Kevin, very much for having me join you today.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Charles Hebert: Yeah, of course. I started out in South Texas and grew up there for the most part, but then abandoned ship and went to New England to do my medical training at Brown University in Providence, Rhode Island. I was there for undergrad as well as for medical school. Somewhere around maybe the third year or so of my medical school training, I became very invested in the intersection between mental health and behavioral health, as well as just general physical health.

At the time, it was sort of a fledgling idea, but there were about a dozen or so residency programs that did dual training towards dual board certification in internal medicine and psychiatry. Chicago’s program at Rush actually was one of the best that I knew of, and I’m a little bit of an urbanite, so coming to a city was an easy sell. So I ended up in Chicago and have actually been there since I finished my training.

I have now been on faculty for some time in a dual capacity, doing hospital medicine wards as a hospitalist, an internal medicine physician, and then directing our psychiatric consultation service. So I perform psychiatric consults out to our non-psychiatric wards, which ends up being a nice way to use both halves of my brain. So that’s my present role.

Kevin Pho: Tell us about some of the challenges that you see typically on a daily basis, some of the challenges you see with that intersection between internal medicine and psychiatry.

Charles Hebert: Yeah, I think one of the things that I think is most appealing to me, but also challenging, is that the threats that patients face from threats to physical integrity, like, say, being diagnosed with a terminal illness or anything that actually has a real chronic course, are radically different from some of the things that are stressors for a lot of people who aren’t facing such conditions. I tell my residents and trainees that threats to physical integrity are not the same thing as a flat tire, or perhaps actually losing your job, or breaking up in an otherwise stable relationship. So it tends to actually be very jarring for patients, which is actually part of what I enjoy, the crisis intervention piece.

Where I practice, I think there’s a real healthy respect for the integration of the two, and that your physical health has real bearings on your mood, and your mood in turn has real bearings on your physical health. I think the pandemic that we’re in has actually really put a magnifying glass over that concept, and now I think that idea has more traction than before. But it’s still a challenge to actually get some places to recognize that the two of them are really intertwined.

Kevin Pho: All right, let’s talk more about your KevinMD article. It’s titled “Can patients just say no to treatment?” Now, for those of you who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Charles Hebert: Of course. When I was originally conceiving of this idea, Kevin, this actually started out as a piece around compassion fatigue, which I had seen so much of in some of my partners in hospital medicine. I’ve had the experience with the pandemic of both directly treating COVID patients as a hospitalist and internist, and then also the experience of actually tending to their behavioral health needs as a consulting psychiatrist. When I wrote this piece, it was in January, right around the time that Omicron was surging, so our wards were full.

Like I said, it started out as a piece on compassion fatigue, but as it took shape, what really actually captured my interest was some of my partners who recognized the misinformation around vaccination for COVID-19. We were seeing a great deal of that on our wards, and it was leading actually, I think, to a large inpatient unvaccinated population, which was true in most places throughout the country.

I had a colleague who came up to me and said, “Wouldn’t it be possible, shouldn’t it be possible, that if people are making judgments about vaccination that are based not on the science but on uninformed ideas or misinformation, couldn’t they just simply be judged to be non-decisional? And if they’re non-decisional and don’t have decisional capacity, could a surrogate actually enter into the equation and say, ‘Hey, I recommend actually vaccination against COVID-19 in this instance’?” And there are some trickles of that idea in other places throughout the world, where a court has gotten involved or a surrogate decision-maker has gotten involved because the patient actually was felt to be non-decisional.

It was just an interesting idea that I’d never actually come across yet. Is it our role in psychiatry, as a mental health profession, to insert our influence or insert our judgment around a patient’s decisional capacity on this precise issue? The paper that I wrote, or the piece that I wrote, argues that that’s not psychiatry’s place. I really don’t think it’s actually our role to intercede in that way. And our way out of this pandemic, to increase vaccination rates, I don’t think is for us to go around judging people non-decisional, regardless of whether or not their choices are based on misinformation or on the science.

Kevin Pho: So what are some of the reasons that you came up with to back that decision?

Charles Hebert: Yeah, I think one of the biggest ones that I’ve noticed is that throughout the pandemic, as people have formulated their ideas around what may work and what may not work for COVID, both in terms of vaccination or acute treatments, the things we’re presently using, like dexamethasone, and even those that we’re not using, like ivermectin, which some patients have really asked me about and said, “Is this something that could be utilized?” As different people have developed their own ideas and beliefs about what could work, there’s been a pretty profound distrust of the medical system that’s come forward in some communities.

So I think one of the biggest reasons that I argued psychiatry shouldn’t have a place in this argument, that it’s just not a good use of our skill set, is because it would further elicit or embolden that distrust. I really think the place for us, and this is kind of how I close the piece that I wrote, is to be curious, to be empathic, to listen to why it is people might have ideas against vaccination, and offer education around those where possible. Or sometimes it’s actually happened that we’ve had people who have come to us and said, “Look, I got the first dose of the vaccine and had a horrible reaction to it.” And avoiding judgment at all costs, I think, should be our position, because otherwise I think we further exacerbate that distrust that’s already present.

Kevin Pho: Now, tell me a success story. Has there been a case where you’ve talked to a patient who initially was resistant to the vaccine, and you used some of your techniques that you just talked about to empathize with that patient, and eventually convinced that patient to change his or her mind about the vaccine?

Charles Hebert: Yeah, so again, I’m an inpatient physician, so we’ve just recently, in the past several months, started offering vaccination in the inpatient setting. Based on our stock and supply, we’ve had some available, and so we’ve done so, trying to reach those populations that otherwise might not have access and end up in the hospital on account of contracting COVID. So I won’t say I have too many success stories, but I do think we’ve moved the needle a little bit through some of the bedside conversations I’ve had with patients.

A lot of times, I think what has worked has been to identify a loved one or a partner or a friend, even just a simple acquaintance, who actually has a success story of their own and has said, “I got the COVID vaccine, and nothing happened.” That distrust is really paramount. And so, on the opposite end of the spectrum, identifying someone for the patient that they have a great deal of trust in, somebody that they cherish, somebody they really love, and seeing actually that they had a good outcome has really gone the distance.

So I think my approach has been just to ask the patient and inquire, “What are your concerns? What are your worries?” Now, were those the same worries and concerns of someone who did get vaccinated, where it went smoothly? And that seems to be pretty powerful.

Kevin Pho: Now, are there scenarios where patients, if they refuse treatment, can be deemed non-decisional?

Charles Hebert: Yes, there are absolutely scenarios, and that’s a big part of my workflow as a psychiatrist: to see people in the inpatient setting, patients who may not formally know the risks or the benefits or the alternatives of what they’re proposing, or what’s being proposed as a health care recommendation, a clinical recommendation. That could be for a colonoscopy, a blood transfusion, a surgery, an experimental investigational drug trial, any of a number of things, Kevin. So those situations definitely come up as part of my workflow.

Kevin Pho: So when you get consulted for issues like that, take me through your workflow and thought processes when determining whether someone is decisional or not.

Charles Hebert: Yeah, so it begins with their cognitive understanding of what the proposed medical recommendation has been. That means the risks of going forward or forgoing the procedure or the recommended treatment, the benefits of going forward with it, and then, if they can, offering a reasonable alternative. Is there another way that we could get to the same place without this intervention, this medication, this surgery, whatever it might be that’s on the table?

And then the real challenge, but also, I think, the most gratifying part of my workflow as a psychiatrist, is that it should be something that’s also commensurate with their beliefs, who they are as a person. This gets back to, like I said, why empathy, and just simply trying to understand the position that the patient is in, has so much value in psychiatry. Two people might choose very, very different paths knowing the risks, the benefits, and the alternatives of the same intervention that’s proposed, just because it will affect their lives differently. That’s what’s called evaluative understanding, making that choice and applying it to who you are as a person.

So it begins with those three pillars, but then it’s also trying to assess: Does this fit? Is it consistent with who you are as a person and how your life might play out going forward?

Kevin Pho: Now, after you wrote this piece, where you deemed that someone who did not take the COVID vaccine cannot be deemed non-decisional, what was the general response to it? And that particular physician who asked you that question, after he read your judgment? What’s the general response from the clinician population?

Charles Hebert: Yeah, I hope they actually saw what I wrote. I don’t know with certainty that they did. But I will tell you that I think the general response was that it was really well received. I think many of my peers, particularly those in psychiatry, thought, “Yes, this is not a place for us. Our place is to educate, our place is to listen, our place is to be curious, but not to offer social judgment. That shouldn’t be our place as a field.”

So, as interesting as it is, and I can understand how some people might get to this as physicians, again, compassion fatigue: Couldn’t we move the needle a little further if people who are guided by misinformation were felt to be non-decisional? I think most of us felt that idea does not have traction, and erred on the side of empathy. And so I think, by and large, it was well received.

Kevin Pho: We’re talking to Charles Hebert. He is an internal medicine physician and a psychiatrist. He wrote the KevinMD article “Can patients just say no to treatment?” Charles, you mentioned compassion fatigue a few times during our conversation. Give a formal definition of what that is and how that has been manifested in terms of what you’ve seen in the inpatient wards.

Charles Hebert: Yeah, I think actually the way that we conceive of it is that it may be sort of a pseudonym, or a synonym perhaps, for burnout. I think burnout, personally, is much further on the spectrum. I think all of us, on a given day, might feel some measure of compassion fatigue, which is the idea that you have no more to give, and that you may not have any further sympathy or, as we were talking about, empathy towards a patient’s situation. Burnout, to me, is a place that is more chronic, that is more day in, day out. But on any given day, based on the clinical circumstances that we face, a person might have some measure of compassion fatigue, just feeling that their tank is empty and that they’re spent in that given moment.

Good examples that I can think of are early on in the pandemic, back in 2020, when COVID first arrived in the United States. Many of us were inundated in the inpatient wards, in the ICUs. And I actually, just based on how it is we came to the pandemic at my institution, was a disciple towards doing some wellness rounds and staff support, psychological support for those of us in the ICUs. It was very evident that people were just emotionally drained and exhausted. And at that point, it wasn’t fully related to misinformation and ideas around the COVID vaccine, because the vaccine wasn’t actually out for use yet.

So it can come from different places. But the heavy burden of taking care of patients when there seems to be either no way out or, as we’re talking about here, also misguided information influencing a person’s choices, particularly around an illness that is preventable, I think leads to some of that compassion fatigue, that inability to care as much as you otherwise would, and that feeling of being spent.

Kevin Pho: Now, from your perspective as a psychiatrist, what are some ways that clinicians can address compassion fatigue?

Charles Hebert: Yeah, one of the biggest ones, I think, that I didn’t realize until I was deep into my own training, was to bounce ideas off of your partners. I think going it alone never really works well, Kevin. I was surprised in training. People told me, “You’ll get great training and supervision and guidance from your faculty, from your attendings, your supervisors.” But some of the best training that I got was from people who were my peers, at my stage, who were in the trenches the same way as I was.

And so I think even for those of us that are now out of training, and it’s certainly held true for our house staff, but even for those of us that are now out in practice, you make your friends in a foxhole. So it’s useful, I think, to bounce ideas off of people. We saw some sort of gallows humor that sometimes came forth. People found humor in the situation, even if at times it was sort of morose, because they needed to laugh. They needed to break through that, and that’s a social experience, something that you can’t easily do alone.

So the best guidance I can give, or at least one piece thereof, is just to use your partners, use your colleagues, because odds are, if you’re feeling something, they’re probably feeling something similar. And keeping it inside and not commiserating about it is just likely to lead to more of that compassion fatigue.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Charles Hebert: Yeah, I think, far and away, I’ve been really impressed, Kevin, that sometimes, like I said, when a person, say, refuses COVID vaccination, going back to the article that I wrote, it’s been tied to misinformation. But I won’t say once in a blue moon, but in certain instances, it’s happened often enough, even though it’s sometimes rare, that people have very legitimate reasons for refusing it, because they tried it, like I said, and then maybe developed an anaphylactic reaction or had a blood clot develop, and so it frightens them to proceed further.

I think my take-home point would be to avoid social judgment. Even though I think many of us have become resigned, and that compassion fatigue still lingers, it’s easy to judge. But part of the joy of working in psychiatry is to hear people’s stories. And while people may end up in the same place, nobody’s process or journey towards that same place, let’s say not moving forward with vaccination, nobody’s process or journey is the same.

And so being curious, I think, is probably my take-home point, and that by itself, if we just try to understand what a patient’s journey has been, and soften the blow a little bit, and eliminate some of the frustration that we sometimes feel around misinformation.

Kevin Pho: Charles, thank you so much for sharing your time and insight, and thanks again for being on the show.

Charles Hebert: Yeah, of course. I appreciate the opportunity. Thank you.