Consult-Liaison Education Medicine Nonfiction Reflection Systems

Reflections While Writing About Psychiatry

I know I haven’t posted in a while. Someone presented me with the opportunity to write a section on psychiatry for medical students. This is wonderful (an opportunity to influence future physicians!!!) and terrible (GAAAAH there’s so much in psychiatry!!!). Between thinking about psychiatry at multiple levels at work and thinking about the foundations of psychiatry while writing the section, I’ve felt cognitively impaired when thinking about what I should write here.

But the thinking never stops… and here are some reflections I’ve had over the past two months while writing:

The differences between what physicians and patients want. Many medical students choose medicine because of the opportunity to help people in a very real way: In helping people improve their health, physicians help people experience a better quality of life. This is rewarding for both patient and physician. Right?

As physicians go through training, they learn the heartbreaking lesson, often repeatedly, that it’s not that simple.

Sometimes people want physicians to help them in ways that physicians can’t or won’t. Some people want medicine that will make the cancer go away and never come back. Other people want pain medicine or sedatives for short-term relief, though the long-term consequences are problematic and potentially devastating.

Other times, people reject the best help that physicians offer. Some people will not take insulin, even though it will prevent prevent worse outcomes from diabetes. Other people don’t want to see any physicians, even though medical interventions for their conditions are simple and effective.

Many medical students assume that patients will only be grateful for and accepting of the help physicians offer. That assumption is wrong.

But this is part of the “art” of medicine, right? How do physicians and other medical professionals help people when we don’t have an intervention that “works”? How do we help people who don’t want the help that we know “works”?[1. There are, of course, strategies we learn as psychiatrists to address how to help people who don’t want the help physicians offer. The problem is that the issue then gets cast as a “psychiatric problem”, when it, in fact, is a “human relations problem”. Psychiatrists often feel frustrated when some physicians either want us to have the doctor-patient relationship in their stead or, worse, when some physicians assume that a Disagreeing Patient is a Mentally Ill Patient.]

The psychiatric conditions that psychiatrists don’t encounter. I’ve worked in a variety of settings—in clinics, hospitals, a crisis center, a jail, homeless shelters, housing, and on the street—and, despite all that exposure, I have never met with someone with a diagnosis of somatic symptom disorder or factitious disorder. While both conditions are rare, my colleagues in primary care and emergency departments see people with these conditions more frequently. Those same people don’t want to see a psychiatrist.

When we think about systems that take care of patients, sometimes we need to remember that the patient isn’t always the actual patient. Sometimes the best way psychiatrists can help these patients is to help the physicians who actually see them. If we wipe our hands and say, “Well, they won’t see me, so that’s not my problem,” what are we doing? If there are barriers in the system that prevent us from helping our colleagues, how can we work together to remove them to increase the likelihood we can help them?[2. This is an argument for “integrated care”, which refers to the integration of physical and behavioral health services. Unfortunately, how these services are paid for often creates barriers… which is exactly why we need more physicians involved in advocacy and leadership.]

Conversations on what is “wrong” instead of the experience of being ill. While in training, physicians learn how to diagnose and treat conditions based on what is “wrong”. We learn the characteristics of the condition, its underlying causes, and the treatments that often correct it. However, we don’t spend a lot of time learning just how much the condition afflicts people.

To be fair, there is so much to learn in medical school and beyond. Furthermore, physicians, as a population, like to solve problems. This temperament was likely present in all of us even before we went to medical school. If talking and listening won’t actually fix the problem, but doing Something actually will, why don’t we just do the Something and get on with it?

Because of this focus on Fixing the Problem, some people assume we are uncaring. That assumption is often wrong, too.

There are also other forces at work: Physicians often don’t have as much time with patients as they would like to listen, provide education, and offer encouragement. Those are Receptive skills and, while complementary to, are often not as glamorous (or billable) as Problem-Solving skills. All of us—in health care or otherwise—often forget that healing occurs with both Receptive and Problem-Solving skills.

I’m grateful for many reasons to have this opportunity to write for medical students. A major reason is the chance to explicitly go back to the basics. Examining the foundation reminds me why I chose to go into psychiatry in the first place, highlights (again) just how much I don’t know, and challenges me to consider what is actually important in my clinical work. And let me tell you, knowing the doses of various medications is not actually important. That’s stuff you can look up. As Dr. Edward Trudeau said, what is actually important is “to comfort always”.[3. The full aphorism attributed to Dr. Trudeau is “To cure sometimes, to relieve often, to comfort always.”]