Conservative versus liberal psychiatry?

[Gotti]

Hey guys,
I'm of liberal background coming from the West Coast, now going to med school in a conservative Southern state. I thought I was very fit for psychiatry because I really am able to empathize with even the most "evil" of patients, believing that everyone has a story of why they did what they did.
Thus, I was a little disappointed during my psychiatry rotation when I found that attendings asked questions that only tried to put patients in a specific categorical diagnosis so as to prescribe the recommended medication. When patients didn't improve, I would suggest psychotherapy or psychoanalysis but attending always gave me the excuse that the patient would "decompensate" under such pressure and instead elected to change their polypharmacy, usually just increasing a bunch of dosages. However, I didn't find that the patients would "decompensate;" I would start talking to the patients for hours about deep issues like child incest or homicide and the patients really appreciated the time I spent with them. One even wanted my business card so I could give him psychotherapy (I know this is "splitting" behavior so I shouldn't get too proud too quick).

Here are my questions then:
1) Granted I'm not a qualified psychotherapist or anything, but is the field really about categorizing people and medications? Or is that just because I am going to school in a conservative state?
2) Are psychiatrists who are very empathetic or sensitive going to be better psychiatrists or do they end up just babying patients? I felt that I was a better psychiatrist than some attendings just because I really empathized with patients and really knew right away what was bothering the patient and what their neurosis was, having many neuroses myself. Do I just have a bad case of hubris and attendings really know what they are doing? Have you guys seen bad attendings? The resident I worked with admitted a few attendings were really bad and we agreed people who couldn't empathize shouldn't have gone into psychiatry. Or is the drill sergeant indifferent approach good for some patients?

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[Anasazi23]

You're a med student. Your attendings have likely forgotten more psychiatry than you're likely to know in the next 20 years. Your bright-eyed, bushy tailed approach to psychiatry would bankrupt the U.S. medical system, create mass malingering brigades and cause satellites to fall from space.

Try social work or psychology if you want to start a rebirthing clinic where the ECT suite used to be.

 

[RookieRoo]

Hi there

I think that attendings have different styles they use. Some try to push patients in order to get them to display symtoms that would not ordinarily come out in an easy-going interview. I had one attending that would purposely interupt patients she suspected of being manic to see if they truly had pressured speach. You should GENTLY ask them why they use a certain method. You may find they are doing some things on purpose to help make the diagnoses.

That said, I think it is good that you are focused on how to best create a good patient-doctor relationship. You should hold on to that. Some folks just get jaded after awhile and loose sight of that.

 

[nancysinatra]

Your bright-eyed, bushy tailed approach to psychiatry would bankrupt the U.S. medical system, create mass malingering brigades and cause satellites to fall from space.

Try social work or psychology if you want to start a rebirthing clinic where the ECT suite used to be.

What's so bad about med students being bright eyed and bushy tailed? I thought we were supposed to be a little like that.

 

[Gotti]

I realize its easy for me as a medical student with plenty of free time to spend extra time with a patient, but what's wrong with an attending spending an extra 30 minutes for one patient rather than having to clock out exactly at 4:00 pm. This post isn't about decrying medications because I really believe they work. But what happened to the intellectual stimulation and philosophizing that psychiatrists are known for. Instead, I find its about checklists and making sure patient X meets Y out of Z criteria for mental disease A to get drug B.

I always thought I was going to do psychiatry my entire life because I just have an innate curiosity about people and even took a year off to travel around the world to explore people and culture.

However, I find myself talking myself out of it and doing something else instead. I'm just hoping someone here will tell me psychiatry is different at other places in the country. An attending who moved here from the east coast said that for a metropolitan city, we were the least tolerant of mental disease and had the fewest social programs that he had seen.

I realize certain patients need different interview styles, some needing babying and some needing tough love, but most of these residents and attendings just try to get through their checklist of questions to ask so that they won't be legally culpable and then switch from one med to another without any rationale. Another attending is so tactless in his phrasing of questions that patients often are yelling or crying or signing out AMA.

I thought psychiatry would be about intellectual stimulation and a little philosophy, but instead its about residents who wanted good lifestyle or foreign graduates who couldn't get anything else. Two residents told me they never have to read anything from any psychiatric thinker like Freud or Jung and psychotherapy was for crybabies and not really emphasized at our program. An attending at the VA said he just fills out PTSD criteria forms for veterans all day. If this is correct, then I feel that a psychiatry residency will not teach me anything that I couldn't read off a DSM IV or a drug side effect profile.

I apologize to all if I have reduced psychiatry to a simplistic model based on a few anecdotes from a 6 week rotation, but I'd like someone to tell me I could learn more about understanding what hurts people from a psychiatry residency than just taking psychology courses at a local community college. Would it be different on the coasts or at a top teir program like Harvard or UCSF?

 

[Doc Samson]

Would it be different on the coasts or at a top teir program like Harvard or UCSF?

In regards to an emphasis on psychotherapy and reading Freud, Jung, Kernberg, Lacan, etc. - Yes, it would be different.

 

[Chrismander]

I think it's great that you're actively trying to maintain your empathy in third year, especially with a difficult patient population--it can be really hard to do!

It's always possible you just have a douchebag attending, so take what i have to say with a grain of salt--this is my view based on my meager psych experience (i'm an MS4), and while i think it's pretty applicable overall, your mileage my vary.

This isn't a "liberal" vs. "conservative" divide. From my perspective, what you're describing/concerned about it isn't even the traditional and hackneyed "medication vs. therapy" divide, it's simply a med school vs. non-med school divide--medicine inherently "categorizes" people based on their symptoms into having various syndromes and diseases. And to a lesser extent, an inpatient vs. (higher-functioning) outpatient divide. Man, i'm on a roll with the divides today.

You're right that everyone has a story for their actions. And for a certain segment of the population (non-personality disordered, no major Axis I disorder, just looking for self-improvement or some such thing), your approach of solely focusing on listening to them, their motivations, etc and being empathetic without actually diagnosing (a.k.a. "categorizing") them might be appropriate. This isn't meant to in any way diminish empathetic listening or whatnot, that really forms the basis of a good therapeutic relationship, underlies a lot of psychotherapies, and in a "purely diagnostic" interview is invaluable in helping you to understand what's going on from the patient's perspective. I just mean to challenge your notion that categorizing is inherently dehumanizing, or at odds with the kind of empathy you describe. Obviously they go together. But you have to understand the patient's syndrome as well as you can, so you can differentiate what's "them" versus what's "their disease", if that makes sense.

But the thing I think you really have to not lose sight of is that you're a medical student on a third year clerkship, which I assume means a locked psych ward. People are on inpatient transiently, so starting intensive psychotherapy is kinda pointless cause someone else is going to have to start all over again in just a few days or a week or two. You're dealing with *severe* depression, mania, psychosis, substance abuse, and lots and lots of personality disorders. Already in this one sentence, I've "categorized" patients into different syndromes--but this is the core of the medical endeavor. Psychiatry believes that these particular syndromes are real, tangible entities. These syndromes can be reliably diagnosed by different doctors, and exist across cultures. They have distinct presentations, distinct natural histories, and respond to different remedies (medication and psychotherapy). When i emphasize that you're seeing serious stuff in the inpatient ward, it's because there *is* another area in mental health that's more nebulous--and what I think Sazi was alluding to when he exhorted you to go into social work/psychology. These are people who may have low-intensity issues with the above, plus more general "life happiness", "personal fulfullment" type goals. These troubles (disorders?)are more nebulous, more subjective, are more influenced/caused by external factors, and don't fall into categories as easily. And this is also where we sometimes get into trouble--folks made a big deal a few months back about anti-depressants not working as well as everyone thought, but how many people who get antidepressants even meet DSM criteria for depression? You need to categorize to be able to make predictions about a patient's course, response to proposed treatment, etc based on the hundreds of other patients with a similar presentation you've personally seen, and the hundreds of thousands of such patients in the literature. For example, you can categorize people into "DSM 4 depression" versus "sort of unhappy" and know in which group the SSRI will beat placebo. Ditto for therapy response: an unrepentent antisocial is not going to respond to any therapy other than the threat of a good and immediate ***-whooping if he crosses society's boundaries, no matter how much empathy is behind your therapy attempt (incidentally, do any of you ever wish you could put in a consult request for your personality disordered patients to Cesar Millan?)

Without this categorizing, all of medicine would cease to exist. But for me, the fun part of psychiatry is that you constantly have to switch back and forth between categorizing and seeing people more holistically, since a good chunk of the business is that nebulous, subjective, non-syndromic stuff, even in someone with a bright clear Axis I/Axis II thing going on. Someone way wiser than me said something like "just because someone has depression/schizophrenia/whatever, doesn't mean that they don't have all the other issues of life that you and I have on top of the illness". Figuring out whether someone's getting kind of sad cause their depression is relapsing or just because we all get a little sad now and again...this is fun.

You brought up a good example of the importance of categorization in your post--a patient that you yourself recognize to be splitting is flattering you on the ward. A "categorizing" approach would help you to recognize when the empathy and listening you want to provide would be most beneficial, and when patient responses to your empathy are actually indicative of anything meaningful. E.g. a borderline sobbing into your bosom that you're the greatest doctor she's ever had, after five minutes of talking to her (during which she tells you nothing she hasn't told a hundred other doctors), and then asking for your business card so you can give her psychotherpy: is meaningless. A super-shy recluse with social phobia presenting to your outpatient clinic cause he wants to get better talking to people, who is able to connect with you because you show him through your empathy that you actually care about him as a person, and as a result he sticks with meds & therapy long enough for them to have a benefit--that's a bigger deal.

I really agree with what the earlier posters here said--a lot of your attendings are flat-out Jedi, man. They may have mysterious and brusque-appearing ways, but learn from them everything you can. More than just categorizing patients with checklist type questions, I would bet that they're adapting their interview style more fluidly than you realize to bring out patient's symptoms, or to handle a given patient more easily based on what the suspected diagnosis is. Treat their interview style the way you would a surgery or a bedside procedure on medicine--ask them to explain a bit about it afterwards, whenever there's time and they seem amenable, especially if you notice them do something different in the interview than they normally do.

 

[Chrismander]

However, I find myself talking myself out of it and doing something else instead. I'm just hoping someone here will tell me psychiatry is different at other places in the country. An attending who moved here from the east coast said that for a metropolitan city, we were the least tolerant of mental disease and had the fewest social programs that he had seen.

What you're describing here is definitely a "liberal vs. conservative" divide, and varies by region. Liberal regions will tend to support more services for the mentally ill, obviously.

I would highly highly suggest that you do a Sub-I at another institution early in your 4th year to clarify these things for you. You might just not like psychiatry period and be more interested in the humanities than "psych diseases" and the day to day work of their treatment. Or your school/region might just suck. If a lot of residents at your program don't seem too interested in psych other than for the (relatively) easy hours, then you're not seeing the best experiences the field has to offer. There is definitely intellectual stimulation in the field. At a very bio-heavy research place that only teaches CBT, that stimulation is going to be mostly receptors and binding coefficients, and RCT's about CBT. At a program that emphasizes psychodynamic therapy or a mix of therapies, the stimulation will be a mix of biological explanations for behavior plus more of the things you're describing--classic works from the field. Either way you're obviously not going to be sitting around in a classroom reading poetry and Nietszche like your care-free college days. But if you're someone like me who digs the humanities and thinks they add to your understanding/appreciation of the human condition, that's what you'll do in all that free time you have after you punch out at 4 from the VA.

If you're interested in some light and enjoyable reading, buy Yalom's "Love's Executioner" for some first hand accounts of therapy. Yalom's really into the humanities in general, and Nietszche in particular, and likes to relate these things to his patients. Quite an enjoyable read.

 

[TheWowEffect]

But the thing I think you really have to not lose sight of is that you're a medical student on a third year clerkship, which I assume means a locked psych ward. People are on inpatient transiently, so starting intensive psychotherapy is kinda pointless cause someone else is going to have to start all over again in just a few days or a week or two. You're dealing with *severe* depression, mania, psychosis, substance abuse, and lots and lots of personality disorders. Already in this one sentence, I've "categorized" patients into different syndromes--but this is the core of the medical endeavor. Psychiatry believes that these particular syndromes are real, tangible entities. These syndromes can be reliably diagnosed by different doctors, and exist across cultures. They have distinct presentations, distinct natural histories, and respond to different remedies (medication and psychotherapy). When i emphasize that you're seeing serious stuff in the inpatient ward, it's because there *is* another area in mental health that's more nebulous--and what I think Sazi was alluding to when he exhorted you to go into social work/psychology. These are people who may have low-intensity issues with the above, plus more general "life happiness", "personal fulfullment" type goals. These troubles (disorders?)are more nebulous, more subjective, are more influenced/caused by external factors, and don't fall into categories as easily.

Good post, Chrismander. I am going to bold an important part of your repsonse to emphasize an important point you made.

A big reason why some attendings work this way is also the billing process. They would love to spend extra time with the patients but are not going to be compansated for their time. This is the reality of modern day managed care. Also after many years of working with severly ill, some attendings do have burn-out and become cynical. You just have to take it with a grain of salt and not let it affect you.

 

[TheWowEffect]

Originally Posted by Gotti
Would it be different on the coasts or at a top teir program like Harvard or UCSF?

In regards to an emphasis on psychotherapy and reading Freud, Jung, Kernberg, Lacan, etc. - Yes, it would be different.

I don't think you should limit yourself to just the "top-tier". There are many other great programs out there which are not so called "top tier" or "ivy league" but are churning out well-rounded residents. You just have to keep your eyes and ears open.

 

[erg923]

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[Doc Samson]

I don't think you should limit yourself to just the "top-tier". There are many other great programs out there which are not so called "top tier" or "ivy league" but are churning out well-rounded residents. You just have to keep your eyes and ears open.

I was referring to the coasts as places that would place greater emphasis on psychotherapy. There are several "top-tier" programs that give psychotherapy fairly short shrift, and even more that pay little to no attention to the history and philosophical underpinnings of psychotherapy. The examples of "top-tier" programs cited (the Harvard programs and UCSF) just happen to fall into the group that are widely regarded to provide excellent psychotherapy training.

 

[Gotti]

Thanks everyone for your poignant replies. I apologize if I come off arrogant or just naive particularly since I am just an MS3. I recognize that most attendants and residents have to worry about things like paying off their loans or taking care of their families.

I do think that I do listen to everything my attendings have to offer and every attending has thought I am eager to learn, but some attendings really don't belong in their specialty especially if they don't have passion for it or even like it to the slightest degree. And I really found this only true in psychiatry, but again, can only relate this to my school, which btw is considered top 15 in psychiatry. However, I know someday someone will think I don't belong in my profession so everything's relative. The question, then, is if psychiatrists become the most cynical of all doctors?

My last word on this is that psychiatry is the one medical specialty that should be held to a higher standard in terms of patient-doctor relationship since the patient is poring his entire life out to you. I know categorizing diseases allows a scientific basis for treatment, but if psychiatry won't take the extra step beyond this standard, then no specialty will.

Thanks for all your reassurances that other programs could provide more of what I'm looking for. I will continue to consider psychiatry for a career.

 

[OldPsychDoc]

...The question, then, is if psychiatrists become the most cynical of all doctors?

Sometimes I think we are both the most cynical and the most hopeful.
For example, we endure the chronic med-seeker, rolling our eyes all the while, yet also can still think to ourselves "Well, maybe I did right by him today. Maybe this will be the one time, the encounter that moves him toward change." I think that we see the best and the worst of human nature stripped naked in front of us and, on our best days, we can dare to embrace it for what it is.

...My last word on this is that psychiatry is the one medical specialty that should be held to a higher standard in terms of patient-doctor relationship since the patient is poring his entire life out to you. I know categorizing diseases allows a scientific basis for treatment, but if psychiatry won't take the extra step beyond this standard, then no specialty will.

No arguments there...

 

[TheWowEffect]

I do think that I do listen to everything my attendings have to offer and every attending has thought I am eager to learn, but some attendings really don't belong in their specialty especially if they don't have passion for it or even like it to the slightest degree. And I really found this only true in psychiatry, but again, can only relate this to my school, which btw is considered top 15 in psychiatry. However, I know someday someone will think I don't belong in my profession so everything's relative. The question, then, is if psychiatrists become the most cynical of all doctors?

Believe me, We have all come across attendings like this. What we can learn from these attendings is the kind of pscyhiatrists we don't want to be. That in itself is an important lesson. Good luck

 

[TheWowEffect]

I was referring to the coasts as places that would place greater emphasis on psychotherapy. There are several "top-tier" programs that give psychotherapy fairly short shrift, and even more that pay little to no attention to the history and philosophical underpinnings of psychotherapy. The examples of "top-tier" programs cited (the Harvard programs and UCSF) just happen to fall into the group that are widely regarded to provide excellent psychotherapy training.

Thanks for the clarification. I think the heartland-based(read midwestern) balanced programs like us deserve some love too....

 

[whopper]

Psychiatry is one of the biggest fields where often times the doctor will not do what the patient wants.

Bipolar patients often want to stay hypomanic. Drug abusers often times want to continue drugs of abuse. Cluster B patients often times need someone laying down the law to them, even if it sets them off.

Compare that to IM-someone with a heart attack will want the best treatment. Someone with GI pain will want that pain stopped. Often times what the patient wants is what the doctor will give them.

Its good to want to do the right thing, but in this field, seemingly more so than others, you need to do the right thing and it often times will not be what the patient wants.

The patient wants percocet? I'll consider giving them suboxone. The patient wants xanax? I'll taper them off of benzos, give them an SSRI if they have an anxiety or depression, but I will not continue the xanax.

And in the long run, you may see that this approach is better, but if you're too much into wanting to be the patient's buddy, & getting their approval you're not going to accomplish that goal.

If you're too much into wanting to quickly satisfy a patient, you will be fodder for malignerers, anti-social pts, drug abusers, & cluster B splitters.

Its nothing about being liberal vs conservative. Its about using evidence based medicine and only putting in anectdotal/theoretical/opinionated approaches when there's no evidence otherwise that can lead you into the right direction.

IF you don't get what I mean, or don't agree with me, I suggest you watch this movie
http://www.netflix.com/Movie/Sister_Helen/70015745?lnkctr=srchrd-sr&strkid=78972085_5_0

Sister Helen was someone who really tried to make a difference & help others, but would take no crap or lies from anyone. Several of our patients are out to use us or the system, and in the long run this only hurts themselves. You have to help them, not allow them to continue the cycle of self destruction.

 

[manwhoisthursdy]

IF you don't get what I mean, or don't agree with me, I suggest you watch this movie
http://www.netflix.com/Movie/Sister_Helen/70015745?lnkctr=srchrd-sr&strkid=78972085_5_0

I second the recommendation! As a film it's okay. But the subject of the film ... what an amazing woman.