On being a psychiatrist: Is an MD sufficient?

Sigmund Freud

Freud argued that a psychoanalyst did not necessarily need to have a background in medicine. Think about it: would the study of medicine or, alternatively, the study of psychology, anthropology, sociology, history and, of course, the proper way to think about things, i.e., philosophy ideally prepare one to understand the dynamics of the psyche?

At odds with this view, psychiatrists are physicians first. In the US system, following graduation from medical school, they enter a one-year internship, followed by a three-year residency in psychiatry. During internship, a psychiatrist typically splits his time between medicine and neurology (for six months) and six months of inpatient psychiatry. For the next three years, the future psychiatrist gains experience in treating a variety of patient populations (inpatient and outpatient, patients with major mental illness such as schizophrenia, bipolar, major depression or Alzheimer's dementia, illicit drug users, or severe personality disorders). As a trainee, a psychiatric resident learns how to use a variety of psychotropic medications and psychotherapeutic interventions.

It is a lot to master and that leaves little time for anything else.

At the same time, psychiatry is so much more than just making a diagnosis in accordance with the medical model and then prescribing an evidence-based intervention. In psychiatry, an evidence-based appraisal of data is only the beginning, of a psychiatric assessment, formulation, and plan.

By allowing itself to be reduced to an exclusive medical model perspective, psychiatry loses the ability to meaningfully understand the complexity of human experience. This is a complex discussion (HERE for a link) but the point is relatively straightforward.

As the medical model only partially informs a psychiatrist expertise, it follows that psychiatrists need to be more than just evidence-based physicians. A psychiatrist's expertise in describing pathology and offer evidence-based interventions should be comparable to the expertise of any other physician in any other medical specialty. But while the study of philosophy is irrelevant to the outcome of an appendectomy, philosophy plays an organic part in understanding and treating any form of mental illness.

Critical thinking, good humor, perspective, skepticism, and a dialectic understanding of complex facts are as essential to good psychiatric practice as the skills of carrying a psychiatric review of systems and mental status examination.

Thus, a good psychiatrist, while a physician first, also has a working knowledge of philosophy. Which should exude throughout a visit with a patient.

You are not sure where your psychiatrist stands on the above issues? Not a problem.

Email this post and ask for an opinion. If you get a response, please bring it back here.

Discussing, debating, trying to understand each other's perspective will make us all better patients, better doctors, better fellow beings.

© Copyright Adrian Preda, M.D.

On being a psychiatrist: Is an MD sufficient?

Sigmund Freud LIFE

Freud argued that a psychoanalyst did not necessarily need to have a background in medicine. One might argue that to properly understand the dynamics of the psyche one might be better served by studying anthropology, sociology, history and, of course, the proper way to think about things, i.e. philosophy.

At odds with this view, like it or not, psychiatrists are physicians first.  Following graduation from medical school they enter a one year internship, followed by a three years residency in psychiatry. During internship, a psychiatrist typically splits his time between medicine and neurology (for six months) and six months of inpatient psychiatry. For the next three years, the future psychiatrist gains experience in treating a variety of patient populations (inpatient and outpatient, patients with major mental illness such as schizophrenia, bipolar, major depression or Alzheimer's dementia, illicit drug users, or severe personality disorders). As a trainee, a psychiatric resident learns how to use a variety of psychotropic medications and psychotherapeutic interventions.

It is a lot to master and that leaves relatively little time for anything else.

At the same time, psychiatry is so much more than just making a diagnosis in accordance with the medical model and then prescribing an evidence-based intervention. When it comes to psychiatry, an evidence-based appraisal of data should be the beginning, not the end of a psychiatric assessment, formulation and plan.

By allowing itself to be reduced to a medical model only perspective, psychiatry loses the ability to meaningfully translate and enrich the complexity of human experience. This is a complex discussion (HERE for a link) but the point is fairly straight forward.

I would like to propose that psychiatrists should aspire to be more than just evidence-based physicians.

We agree that a psychiatrist's expertise in describing a mental illness and then offer an evidence-based intervention should be equal to the expertise of any colleague in any other medical specialty. But while the study of philosophy is irrelevant to the outcome of an appendectomy, philosophy plays an organic part in understanding and treating any form of mental illness.

Critical thinking, good humor, perspective, skepticism, and a dialectic understanding of complex facts are as essential to good psychiatric practice as the skills of carrying a psychiatric review of systems and mental status examination.

Thus, a good psychiatrist, always a physician first, also needs to have a working knowledge of philosophy. Which should exude throughout the course of a visit with a patient.

You are not sure where your psychiatrist stands on the above issues? Not a problem.

Email this post and ask for an opinion. If you get a response, please bring it back here.

Discussing, debating, trying to understand each other's perspective will make us all better patients, better doctors, better fellow beings.

© Copyright Adrian Preda, M.D.

Philosophy of Psychiatry 101 Part 1

I received a number of interesting comments in response to my Psychology Today "Psychiatry on Trial" article.

One of these comments in particular makes for a good summary statement for some of the more important issues in the ongoing debate about psychiatric classification/nosology and intervention. I decided to present both the comment and my response as a separate article on my blog with the hope this will serve not only as a good introduction but also stimulate a discussion about values and ethics in psychiatry.

I will present my response over a series of shorter articles as the comment is rather complex and as I do plan to split hairs a bit in my discussion. If you are interested in following this please look for the response over a numbered series of future posts under the title "Philosophy of Psychiatry 101". All articles will be linked together for easier navigation.

First, here is the text of the comment in its entirety:

Submitted by Amused Reader (AR) on March 23, 2012 - 11:39pm.

"The reality is more complex..

I am not one of those who believes that psychiatry invented mental illnesses.  Of course, there are many mentally disturbed people out there and we cannot deny this reality if we want to be honest. 

I think what psychiatry is rightfully criticized for calling any kind of emotional disturbance an "illness" and offering a drug for each kind.  Currently, psychiatry doesn't do anything more than merely managing unwanted behaviors and emotional states and it's not even clear whether this is due to the effects of the chemicals in the drug or a placebo effect.  The illness can't be cured if the cause of it is not known but this is what psychiatry tries to do. It pretends that it could cure mental disturbances while not knowing what causes them which by definition is a fraud.

I do believe that certain people have to take medications such as schizophrenics, anyone with a recent psychotic episode, severe OCD cases, PTSD, Bipolar I and such.  Those and only those could qualify as true mental illnesses where meds may be the only way to make those people's lives manageable. (By the way, managing the illness and curing it are two completely different things and on that basis psychiatry has not cured anyone yet.)  All other conditions are not illnesses, they are emotional disturbances created by deep inner conflicts or moral dilemmas or conflicts between the inner needs and the external pressures from the environment. When someone is depressed, it may well be because they sacrifice who they truly are for the sake of not being rejected by others and because of other reasons that have nothing to do with them.

Adverse and stressful environment could alter our brain chemistry but instead of addressing the real reason why we are depressed, which is difficult life circumstances and also inner struggles, the psychiatrist will hand us a drug prescription. This way we don't have to change anything about ourselves and our lives.  All we have to do is just take a pill that will help us cope with the unhealthy environment.  It's as if someone held your hand over fire and when you started screaming from getting burned they'd give you a pain killer instead of letting you put your hand away.

Depression may be cured without drugs if people ask themselves what they are sacrificing and why and if they get the courage to do what they want with their lives whether it's approved by others or not.  What I find insane is when an individual is labeled as mentally ill and is put on drugs only because he or she is not well adjusted to the insane society."

Amused Reader (AR) does not subscribe to the view "that psychiatry invented mental illnesses".

I hope this signals a reasonable position that can be used as a foundation for an open dialogue on the issues. AR further states that "there are many mentally disturbed people out there and we cannot deny this reality if we want to be honest".

This is an important clarification: as AR, most people actually agree that there are "mentally disturbed people". However not everyone holding this view realizes that this position automatically implies acknowledging the existence of a category of illnesses that can be appropriately classified as "mental", in other words, agreeing that mental illness is real (i.e. biologically based)- as opposed to the minority view that mental illness is a social construct summing up a set of specific cultural and social factors.

If the existence of mental illness is agreed upon, the next level of disagreement is about what can be properly defined as mental illness. The issue at hand here is about how to define illness, a concept typically anchored in physical (biological) dysfunction, in a context where there is very little if any hard physical evidence of dysfunction. The mind, essentially a function of the brain, is such a domain of inquiry. This is AR's very point next when he states that "psychiatry [can be] rightfully criticized for calling any kind of emotional disturbance an 'illness'". This and "offering a drug for each kind" is a summary statement  of the most common charges that are brought up against psychiatry

To clarify AR makes two different claims:

1. That psychiatry calls any kind of emotional disturbance an illness.

2. That after the labeling is completed, psychiatry then proceeds to offer a drug for each kind.

Both statements are false.

First, it is of essence for any psychiatric work-up and diagnosis to consider a differential diagnosis. This is no different that the process of medical diagnosis in general, where the doctor's expertise is called on to differentiate between the many different causes of the same presentation. An internist will use his skills to differentiate if a cough stems from a common cold, heart attack, or pulmonary edema. Similarly, a psychiatrist will differentiate between feeling upset because of a normal mood variation, a recent loss, depression, or maybe because of persistent auditory hallucinations.

Ruling out normal reactions (which account for the majority of "normal" or minor emotional disturbances) is part of any psychiatric diagnostic work-up and it is in fact one the operational criteria required by DSM before more severe diagnoses are given. The reason being precisely to prevent labeling "any kind of emotional disturbance as a mental illness".

Second, psychiatry's unjustified use of the label "illness", which is implied here, is equivalent with psychiatry inventing mental illness, which AR's claimed it was not the case in the first place.

The reason for which I am pointing it out is that slippery classification and rapid change of positions are unfortunately common place in today's anti-psychiatry debate. For the sake of dialogue we should all weed out any inconsistencies, especially those that we might have unintentionally committed.

[To follow.]

© Copyright Adrian Preda, M.D.