Creativity and intellectual stimulation in Psychiatry?

[Vallion]

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Hi guys,

I'm going into my final year of med school, and I'm having some serious dilemmas with trying to pick a specialty.

Medicine hasn't turned out as I hoped it would. I find that most of it is rote memorization and regurgitation with little to no room for creativity and intellectual stimulation. I don't know if I can spend an entire career just rehashing clinical algorithms and guidelines.

Thus I was drawn towards psychiatry - a field where you get to learn about the whole person, where each patient's "story" is interesting and drastically different from the next, where there is more room for creativity or "art" if you will since you are dealing with the complexities of human behavior and thought. Indeed many people seem to see psychiatry as the most "artistic" specialty in medicine.

However, I've been disappointed thus far during my psychiatry rotation. I did enjoy interacting with patients, and learning about their story, and I find psychopathology very interesting, but I didn't experience the "creativity" that everyone was talking about. Nor did I feel intellectually stimulated. I felt that I was just going through a checklist of questions, trying to fit the symptoms into some arbitrary DSM, and then following therapeutic guidelines (that aren't really based on the most compelling evidence).

I'm not sure if my experience was representative of the depth of clinical practice in psychiatry. Maybe when you're actually practicing and managing patients on your own, it's more stimulating and 'creative'? I feel that psychotherapy would probably involve creativity and critical thinking, but it seems that most psychiatrist don't do psychotherapy anymore and just do med management.

Anyway, can anyone provide some insights into this topic? Do you find that psychiatry involves creativity and intellectual stimulation? Can you explain?

thank you

 

[Jorje286]

There's creativity and art in pretty much every field of medicine. Medicine is an art in itself. It takes skill, creativity, years and years of experience, intellect and yes, pure hard work to practice quality medicine. Mere memorization will not hone your observational skills, make you directed to the right questions and avenues when you gather history, let you do a precise physical/mental exam with great attention to detail or build critical clinical thinking. I haven't even touched yet the kind of empathy and communication skills you will need to interact well with patients. You don't learn to play the guitar without memorizing chords and practicing your motor skills - or write literature without memorizing vocabulary and learning grammar. And you also don't learn to practice the art of medicine without memorizing and mastering some very core basic.

IMO, the issue could be with your approach rather than the field in itself. So I'm not surprised that you didn't find enjoyment in psych when you didn't find it in other fields. Psych and other fields are quite different from each other, but there's still much in common. It's the same process of observation, dealing with complaints, gathering history, physical exam, diagnosis.etc. The difference is that psych is about the behavioral aspects of health care.

I think it will be a good idea to find mentors and clinicians who can inspire you. A lot of one's motivation can come from exposure.

 

[notdeadyet]

However, I've been disappointed thus far during my psychiatry rotation. I did enjoy interacting with patients, and learning about their story, and I find psychopathology very interesting, but I didn't experience the "creativity" that everyone was talking about. Nor did I feel intellectually stimulated. I felt that I was just going through a checklist of questions, trying to fit the symptoms into some arbitrary DSM,

Your experience is pretty common.

Medicine (including psychiatry) is all very algorhythmic when you first learn it. One of the reasons for this is that it is very hard to appreciate the nuances until you learn the basics. In some fields of medicine, this means you diagnose by lab value. In psychiatry, by DSM.

Your checklist approach is very MS-3, and appropriately so. Once you become more comfortable with doing a psychiatric interview/intake, you'll find that goes by the wayside. Your interview becomes more organic and conversational and instead of literally asking SIGECAPS sequentially, you delve into the patient's story in a more meaningful way and come to the same information you would from a checklist. You catch more diagnoses and your diagnoses are more accurate because of it.

This takes time. It's something some folks start as MS-4's. Most folks accomplish this during intern year. For an MS-3 to be using the checklist approach is normal. It's just unfortunately a little unsatisfying for folks truly interested in psychiatry.

and then following therapeutic guidelines (that aren't really based on the most compelling evidence).

Therein lies the creativity. You need to be willing to tolerate (and embrace) the idea of treating patients without clear-cut recommendations. You use the data we have and then have to tailor your treatment plan to everything you know about the patient as an individual and couple it with your local environment and personal experience.

Some folks find this intimidating. Others find it extremely satisfying. Which it would be for you requires a little navel gazing.

I feel that psychotherapy would probably involve creativity and critical thinking, but it seems that most psychiatrist don't do psychotherapy anymore and just do med management.

Who gives a $hit what most do? You can have a healthy career doing psychotherapy or focus solely on medication management. Many do a combination of the two. You can tailor your career to your interest and strengths.

You will find if you pursue the field further that there is lots of creativity in psychiatry. It's hard to appreciate it (i.e.: see it) as a 3rd year medical student. You have to walk before you run. A necessary evil.

 

[OldPsychDoc]

I have no patients that I would consider "therapy patients" any longer, but almost every patient encounter involves some degree of creative problem solving to tailor treatment to the patient's specific situation. notdeadyet is correct--at first, everything is very algorithm-driven--but it's only when you know the algorithms that you begin to understand how, when and where to depart from them.

 

[MacDonaldTriad]

OPD continues to impress me. 🙂

You can not want creativity and clarity simultaneously. Psychiatry is an art, probably more than most specialties. If that is attractive, it can be for you. If you need to know what to do, for sure with each situation, there is nothing less objective in medicine.

This doesn't mean that that there isn't room for brilliance and break through bolts of brilliance. Psychiatry is begging for direction and clear algorithm. We just have failed to find it with our meager attempts to implement "what to do when X,Y and Z". Look at STAR*D results. The largest depression study in history, designed to answer all of the questions about what to do. Truth be told, everything was a disappointing in terms of providing direction of what to do next.

Other specialties have this problem. Look at HTN protocols. Talk about evolving algorithms and change.

Not very interesting if you ask me. We all want to do the right thing, but our right thing involves a lot more relationship and handholding than "this is what is wrong and I know how to fix it".

 

[shan564]

Hi guys,

I'm going into my final year of med school, and I'm having some serious dilemmas with trying to pick a specialty.

Medicine hasn't turned out as I hoped it would. I find that most of it is rote memorization and regurgitation with little to no room for creativity and intellectual stimulation. I don't know if I can spend an entire career just rehashing clinical algorithms and guidelines.

Thus I was drawn towards psychiatry - a field where you get to learn about the whole person, where each patient's "story" is interesting and drastically different from the next, where there is more room for creativity or "art" if you will since you are dealing with the complexities of human behavior and thought. Indeed many people seem to see psychiatry as the most "artistic" specialty in medicine.

However, I've been disappointed thus far during my psychiatry rotation. I did enjoy interacting with patients, and learning about their story, and I find psychopathology very interesting, but I didn't experience the "creativity" that everyone was talking about. Nor did I feel intellectually stimulated. I felt that I was just going through a checklist of questions, trying to fit the symptoms into some arbitrary DSM, and then following therapeutic guidelines (that aren't really based on the most compelling evidence).

I'm not sure if my experience was representative of the depth of clinical practice in psychiatry. Maybe when you're actually practicing and managing patients on your own, it's more stimulating and 'creative'? I feel that psychotherapy would probably involve creativity and critical thinking, but it seems that most psychiatrist don't do psychotherapy anymore and just do med management.

Anyway, can anyone provide some insights into this topic? Do you find that psychiatry involves creativity and intellectual stimulation? Can you explain?

thank you

If you showed me the first half of that post and told me that I'd written it 1-2 years ago, I would have believed you (except that I probably would have put a comma after the word "Thus"). I probably said something similar at a lot of my residency interviews.

The second half of your post was very different from my experience, and maybe it was just because I had some good attendings. I actually experienced even more "creativity" than I'd expected, and it started on Day 1.

Unfortunately, I think that the 4-week med student psych rotation essentially teaches you that psych is all about DSM diagnoses and basic pharmacology. It's simply not enough time to learn the nuances. I was lucky enough to go to a med school (in Australia) where our core psych rotation included 1 full week of didactics, 7 weeks of rotations including 1 day/week of didactic/small-group teaching, and an extensive observed H&P exam at the end of the rotation in addition to a written exam. So we essentially had 12 full days of teaching, for which the theme was "here's what the DSM-IV says, but here are the features that we actually see in patients." We also had additional dedicated teaching time at least once a week in which we would do a full H&P, present to an attending, and get an extensive critique of our H&Ps and our presentations.

Now I'm at a residency program at a "top 5" US med school with a strong psychiatric tradition, and while the students here are great, I've noticed that they just don't get enough time to learn everything. In the 4-week rotation, they might have a total of 12 hours of teaching, where we had 12 days. That leads students to think of psychiatry as "SIGECAPS --> Zoloft."

Granted, the standards in the US (especially at my program) are much higher for the students. They're expected to study more and learn more independently. And they spend a lot of time reading/studying... I studied a lot in my psych rotation because I liked it, not because I had to. So the students here end up learning more clinical science than we usually did, since they're used to learning things on their own. But that doesn't work in psych - if you just learn it on your own, you'll learn the DSM criteria. To really learn the "art" part of psychiatry, you have to be taught. If you're not taught about mania by a psychiatrist, you can diagnose anybody with bipolar disorder by just using DIGFAST liberally (as we're currently discussing in another thread).

So, bottom line - you can't appreciate that "art" of psychiatry in a 4-week rotation. I don't know about your institution, but at my program, the interns and sub-I's get an amazing education on how to practice high-quality psychiatry, while the MS3 students just get a brief primer on how to use the DSM criteria and which drugs to use. So if you're really interested in psych, do a sub-I and see how that feels. If you're at a decent program, you might get a whole different view of psychiatry.

 

[splik]

i agree with jorge, there is "creativity and art" in medicine in any field if you want there to be. it's just not true there's something special about psychiatry and most of how psychiatry is practiced is in a fairly checklisty and mindless way. but that is not how it has to be in psychiatry or any field. understanding your patient as a person and their life story is just as relevant in any other field of medicine as it is in psychiatry, though unfortunately many don't want to practice medicine that way. I had some great medicine attendings who would actually get to know their patients as people and find out all sorts of interesting things about them. and there are many many terrible psychiatrists who don't care to know anything about their patients.

and i think the thing that pisses me off the most is people claiming to be "creative and artistic" when actually they are just anti-EBM. there is nothing wrong with guidelines and algorithms as long as you don't take them to be rules to be followed and not deviated from when that is what your clinical judgment tells you is needed. we would be alot better off if the APA or whoever came out with regularly updated clinical guidelines for the management of various conditions. though maybe not the APA as for obvious reasons they always suggest everyone should be on drugs.

 

[shan564]

and i think the thing that pisses me off the most is people claiming to be "creative and artistic" when actually they are just anti-EBM. there is nothing wrong with guidelines and algorithms as long as you don't take them to be rules to be followed and not deviated from when that is what your clinical judgment tells you is needed. we would be alot better off if the APA or whoever came out with regularly updated clinical guidelines for the management of various conditions. though maybe not the APA as for obvious reasons they always suggest everyone should be on drugs.

I often tell people that EBM has made medicine much more formulaic and much less artistic, which is less fun for us, but it's better for healthcare. The reason why I think that psychiatry is a bit more "artistic" than other fields is because our scientific knowledge is still quite limited, which is a bad thing. In order to practice better medicine, I think that we should be more evidence-based and less artistic. But the artistic part is more fun, and that's one reason why I like psychiatry better than IM. And we also have a lot more stuff to learn - the brain is the "final frontier," as people like to say - which means that we can enjoy the continued development of a strong evidence-base in psychiatry. It'll make the field less fun for me, but I think it'll make it better for patients, so I'm happy to help move it in that direction.

 

[billypilgrim37]

Outside of therapy, much of the art of psychiatry is in the assessment. A cardiologist can essentially ask the same 20 questions at every encounter the same way and get useful answers. Different sorts of patients require entirely different approaches to establish rapport and encourage sharing. There's not much art in medication choices (some, but not a lot), and there probably shouldn't be.

 

[shan564]

Outside of therapy, much of the art of psychiatry is in the assessment. A cardiologist can essentially ask the same 20 questions at every encounter the same way and get useful answers. Different sorts of patients require entirely different approaches to establish rapport and encourage sharing.

Yeah, that's what I refer to when I talk about "art" in psychiatry. I get a certain satisfaction when I get an intelligent/guarded psychotic patient to reveal their delusions when they're trying thei rhardest to hide them...

 

[zenman]

I often tell people that EBM has made medicine much more formulaic and much less artistic, which is less fun for us, but it's better for healthcare. The reason why I think that psychiatry is a bit more "artistic" than other fields is because our scientific knowledge is still quite limited, which is a bad thing. In order to practice better medicine, I think that we should be more evidence-based and less artistic. But the artistic part is more fun, and that's one reason why I like psychiatry better than IM. And we also have a lot more stuff to learn - the brain is the "final frontier," as people like to say - which means that we can enjoy the continued development of a strong evidence-base in psychiatry. It'll make the field less fun for me, but I think it'll make it better for patients, so I'm happy to help move it in that direction.

Timely thread since I'm doing a grand rounds presentation next tuesday on "Creativity in Behavioral Health Care. I both agree and disagree with you. Our EBM sucks. The DSM also. I don't think that limited scientific knowledge in psych is necessarily a bad thing because it forces you to bring out that artistic creative side. That's what keeps a lot of us going. I doubt there will ever be a magic pill anytime soon which will target your illness and cure you in 2 weeks. We get all kinds of results, and side effects, with Zoloft for example, in each person. Sure it make help your depression but now your dick won't work. Let me try some Wellbutrin with that. Oh wait, just this week I had a patient who was not having sexual SE with Zoloft but when I augmented it with Wellbutrin, he couldn't get it up. It's like we have to throw a spitball on the ceiling and see if it sticks.

We also know psychotherapy, as well as environment, changes the brain. I personally think therapy is about the coolest thing ever. Just think, that by using words, you can effect change.

If you're interested in therapy, I'd go straight to Bradford Keeney. He's the originator of improvisational therapy, resource focused therapy, and creative therapy. I recently spent 30 hours with him and plan on starting a 2 year mentorship with him next year. He now says therapy should belong in the school of performing arts rather than theoretical explanation. I almost puked when learning CBT, btw. I drove my professors crazy (I had already trained in CAM) when they kept reminding me to focus on EMB. "But Dr. XXX, this Vietnam vet has been treated with EBM for 40 years. Why is he still in treatment?" I do think psych is the most "artistic" field in medicine. Perhaps that why I see more psych people who are CAM friendly. The other day our Chief mentioned that most of what we do is just BS. That's my ramble....

The Keeneys latest book: Creative Therapeutic Technique: Skills for the Art of Bringing Forth Change

 

[whopper]

and i think the thing that pisses me off the most is people claiming to be "creative and artistic" when actually they are just anti-EBM.

Back when I worked on a forensic unit...

Had a patient, in the forensic unit for burning down a home while manic, found NGRI, made obese due to Seroquel and was on a polypharm regimen from Hell. She was transferred to my unit. I got her off all her meds, put her on Abilify. She lost all the weight, felt better, and told me she liked the medication regimen. She was transferred off my unit.

Three months later, I had to evaluate her to see if she could get a level 4 pass. This allowed one to go into the community on passes. She was back on the same freaking polypharm regimen from Hell and was again obese.

This is from memory but it was something to the effect of high dose of Seroquel, Depakote, Klonopin, and Citalopram.

I asked her why she was on it and she told me the attending she had then was the one she had before that put her on this regimen, that the Abilify worked all along, and that she felt she had no choice because she wanted to eventually get her level 4, then 5, then discharge, and if she fought the attending this would likely blow back in her face.

Well she was fine in terms of behavior. I reviewed the records. She did nothing bad that warranted a med change.

I asked the attending why she changed the meds. She gave responses to the effect of --Citalopram, well she's blue. I can just feel it. Yes I know she says she's not depressed but I can just tell. Did you ever diagnose because you could just feel it?- (ME-NO!-not out loud, that's what I'm thinking).
-Seroquel-well you know she needs help. I can feel her pain, that's why there's Seroquel.-
Me: what about the weight gain? -Well the benefits outweigh the risks-
Me: You mean the risks of what? She was stable on Abilify. She denied any side effects to it. She lost weight on it. -The risks of her not getting treatment for what I could tell was a type of blue depression. I know Seroquel and Citalopram treats this. I know it. Abilify doesn't.-

The rest of her responses were about the same regarding the Depakote and clonazepam.

This, IMHO, ain't art. There are times where you have to think outside the box, but IMHO this is only where you're outside the domain of evidenced based medicine, and have little choice. Is it then an art? I don't know if I'd call it that. Even in this area, one should have some rational based methodology and approach. I think one could think of what they do as an art, but art means self-expression. I don't see treating someone as a form of self-expression.

But if someone still thinks it is an art, I can still see that word being used, but I hope none of you are practicing like the attending I mentioned above.

 

[OldPsychDoc]

"I can feel her pain, that's why there's Seroquel."

😱 Was she moonlighting writing Pharma ads????

 

[nitemagi]

EBM is a foundation, but it's limited. Most EBM isn't really generalizable to the population we see, much of the time. Start with it. If/when it doesn't work, move on, and then use whatever works.

If we continue to repeat use of things that aren't working because they're evidence based, we're ignoring the evidence of the patient not improving. That's its own evidence. If they're failing a treatment, something else should be tried, eventually.

If you know much about music improv, which I honestly know only a little, its apparently free form and "creative," but draws from all the music that the individual has listened to. It's as artistic as anything. But It comes from somewhere. Being "creative" in therapy is not about ego, or creating something from nothing, but is really an operator dependent, skill based procedure involving real-time compensation and changes in technique. As a therapist you can draw on as many skills as you've mastered. Train in only 1, you won't seem very creative. Train in many, you may be able to find something useful for the patient that CBT isn't working for.

 

[shan564]

If you know much about music improv, which I honestly know only a little, its apparently free form and "creative," but draws from all the music that the individual has listened to. It's as artistic as anything. But It comes from somewhere. Being "creative" in therapy is not about ego, or creating something from nothing, but is really an operator dependent, skill based procedure involving real-time compensation and changes in technique. As a therapist you can draw on as many skills as you've mastered. Train in only 1, you won't seem very creative. Train in many, you may be able to find something useful for the patient that CBT isn't working for.

That's a great analogy.

 

[SeniorWrangler]

Psychiatry has the intellectual interest that we don't actually know very much about, well, almost anything, and so a psychiatric resident has the prospect of watching great breakthroughs be made during their career. This is what a psych attending told me as a medical student, 20 years ago, and I found it convincing. There have not actually been any great breakthroughs since then, but I remain hopeful. At least the fMRI pictures are pretty.