How to get over "stigma".

[tr]

She never said she didn't know what motivational interviewing is,

No but she expressed utter skepticism about a type of result that many of us achieve on a regular basis, indicating that even if she knows what MI is she doesn't understand how to do it or what it can achieve.

and just because she takes an extreme position that you disagree with does not mean she has learned "manifestly nothing at all about how to do psychiatry".

Her characterization of psychiatry as ineffective and pointless is completely at odds with my experience of this field. What other explanation is there for this discrepancy?

The reality is the overwhelming majority of psychiatry residency programs suck and do not provide adequate training in psychotherapy or exposure to the full breadth of the field. This, added to the fact the field has historically attracted the dregs, contributes to the appallingly low standard of care, and the terrible practice that represents psychiatry in this country. It is very geographically dependent too, with the quality of care being better in more desirable parts of the country. There are many reasons to be embarrassed about this field. Nancy's posts may be overly negative, but it is also the case that this forum tends to be overly positive

I have no way of knowing whether this is true. I am coastally trained and have no personal experience of programs beyond those where I trained myself.
That said, most of my colleagues are intelligent, sincere, well educated, and seem to do a pretty good job.
At times I see head-scratcher regimens coming in from the community bu I wouldn't say that's the norm.
If nancysinatra trained at a poor program that's certainly unfortunate but right in line with my assertion that she is mistakenly conflating her own poor training experience with a failure of the field as a whole.

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[Rachell]

Listen to your body.

I followed mine and look where it got me.

 

[Information Underload]

The stigma is quite real in terms of how reimbursement is made with insurance companies and how we have a harder time with medical complexity for the higher billing levels.

You think? Psych is king in terms of comorbidity. ADHD breeds ODD breeds anxiety and so on. Every patient admitted to the inpatient unit is an imminent risk of harm to self or others.

 

[Doctor Bagel]

You guys do get that NS's statements are generally a bit hyperbolic, too? She can defend herself, but I'm bothered by how thin-skinned we are. I believe she's also indicated that she trained a prestigious program probably on a coast.

I'll confess to having a day at work recently where I felt like the only useful thing I did was carry some clothing for a patient from one unit to the other (a nurse asked me since I was heading that way).

 

[Merovinge]

You guys do get that NS's statements are generally a bit hyperbolic, too? She can defend herself, but I'm bothered by how thin-skinned we are. I believe she's also indicated that she trained a prestigious program probably on a coast.

I'll confess to having a day at work recently where I felt like the only useful thing I did was carry some clothing for a patient from one unit to the other (a nurse asked me since I was heading that way).

I loved my medicine months. My 3.5 years of psychiatry training was a cruel joke by comparison. We cured no one. We fixed nothing.

You think that's a problem of thickness of skin? These comments, even as intentionally hyperbolic, are toxic and non-factual. There's a difference between trying to be straight forward/honest versus trying to get catharsis for spending 4 years of your life doing something you apparently hate in message boards. I've read good posts by NS and people seem to really like him/her on these boards but some of the comments in this thread are straight garbage and I am glad people are bringing that to light.

 

[Salpingo]

You guys do get that NS's statements are generally a bit hyperbolic, too? She can defend herself, but I'm bothered by how thin-skinned we are. I believe she's also indicated that she trained a prestigious program probably on a coast.

I'll confess to having a day at work recently where I felt like the only useful thing I did was carry some clothing for a patient from one unit to the other (a nurse asked me since I was heading that way).

There are no perfect jobs (especially in medicine), but part of what we do is learn to tolerate the imperfect. This idea of dealing with stigma comes up a lot, with med students, residents and even attendings. Its reasonable to say "I dealt with the stigma by leaving it behind me" and acknowledging that we all buy into the stigma ourselves. In fact, it adds a lot to the conversation. But its helpful to at least give context -- many people have asked why nancy went into psychiatry in the first place, or how they got out of it (we've confirmed nancy is a she?), but that's been absent. There's really no context for some of the claims made, particularly the idea that there is some magical specialty out there or that anything that doesn't prolong life is pointless. We know intimate detail about nancy's mother (which may or may not explain the distaste for those claiming mental illness), but have no clue where or how they practiced psychiatry.

There have been worse cases where some will just make up their background to give themselves validity, and that's a lot sketchier. However, its still discouraging to see people lob bombs at psychiatry and hide behind a shield of anonymity.

 

[smalltownpsych]

I loved my medicine months. My 3.5 years of psychiatry training was a cruel joke by comparison. We cured no one. We fixed nothing. Now, I realize, internal medicine has its problems.

You think that's a problem of thickness of skin? These comments, even as intentionally hyperbolic, are toxic and non-factual. There's a difference between trying to be straight forward/honest versus trying to get catharsis for spending 4 years of your life doing something you apparently hate in message boards. I've read good posts by NS and people seem to really like him/her on these boards but some of the comments in this thread are straight garbage and I am glad people are bringing that to light.

I don't see how that is non-factual or toxic statement. Anyone going into psychiatry looking to cure people is in for major disappointment. My wife recently had a dental procedure that led to a virulent infection necessitating hospitalization and IV antibiotics. Within a couple of days, she was cured. It was dramatic. Open up a blockage in a coronary artery. Blammo! Patient will live and heart will keep beating. There is no analogue in mental health. It is a completely different animal. We are able to alleviate some of the more distressing symptoms. I can "cure" a patient of NSSI in a couple of sessions, but addressing the pervasive effects of the childhood trauma is a whole different issue. I have also worked extensively with chronically mentally ill patients. While stable on a medication regimen, they typically still need extensive support. There are major problems in how we as a society and also us as professionals conceptualize mental illness and I appreciate that some posters step right in it.

 

[northernpsy]

Personally, I wonder if we and society might have a different view of psych if there was a way to keep the focus in psych on treating things that actually do require medication or monitoring by a physician.
I feel like my biggest grievance with my work is that the fact that by default we end up being used to address social problems that don't actually require the input of a physician (though this is a problem other specialties also face, if course).

An obese diabetic person with schizophrenia clearly does need a physician to oversee their health, and I like treating those kinds of patients. A guy who is a homeless crack addict and really just wants a place to crash for a few days doesn't really need to be on inpatient psych, but we have ended up becoming society's safety net for such people so in practice we do see such people a lot. For me at least, the Unspecified Homeless Disorder type of patients are the ones that make me feel like I'm wasting my time. I never feel like I'm wasting my time when I'm treating someone who has an honest to goodness diagnosis of schizophrenia or genuine bipolar disorder because in those cases it's obvious they do need psychotropic medication and other medically based care. I think psychiatry would have a drastically different feel to it if we had a way to set up the social safety net differently so that the psych inpatient unit was almost exclusively things like genuine schizophrenia and less "homeless guy who says he's schizophrenic but is just playing the game".

 

[calvnandhobbs68]

I don't see how that is non-factual or toxic statement. Anyone going into psychiatry looking to cure people is in for major disappointment. My wife recently had a dental procedure that led to a virulent infection necessitating hospitalization and IV antibiotics. Within a couple of days, she was cured. It was dramatic. Open up a blockage in a coronary artery. Blammo! Patient will live and heart will keep beating. There is no analogue in mental health. It is a completely different animal. We are able to alleviate some of the more distressing symptoms. I can "cure" a patient of NSSI in a couple of sessions, but addressing the pervasive effects of the childhood trauma is a whole different issue. I have also worked extensively with chronically mentally ill patients. While stable on a medication regimen, they typically still need extensive support. There are major problems in how we as a society and also us as professionals conceptualize mental illness and I appreciate that some posters step right in it.

It's just so hyperbolic as to be totally useless. Take your quote above. I mean come on, any third year med student who has done a floor rotation knows a significant number of your admissions are social or for chronic diseases you're making no impact on in the acute setting.

I do appreciate northernpsy's sentiment that it seems many inpatient psych admissions are for "unspecified homeless disorder" or "terrible life" disorder.

 

[smalltownpsych]

It's just so hyperbolic as to be totally useless. Take your quote above. I mean come on, any third year med student who has done a floor rotation knows a significant number of your admissions are social or for chronic diseases you're making no impact on in the acute setting.

I do appreciate northernpsy's sentiment that it seems many inpatient psych admissions are for "unspecified homeless disorder" or "terrible life" disorder.

Like my friend the IM doctor said, half of the patients he treats are due to overeating, alcohol, and tobacco. At least he is able to understand that we can't just fix them. Many of the docs think we either should be able to fix these people or we aren't doing anything for anybody. Never the EM docs though. They seem to appreciate us the most, in my limited experience in this neck of the woods.

 

[randomdoc1]

For the most part, I generally learned to stop caring what other people think. Only thing that still gets to me is how my husband still has a huge misunderstanding of what psychiatry is, how complicated it can be, and how much we really do. Recently finished residency and inherited some pretty complicated patients from another psychiatrist. I'm spending a lot of time doing chart reviews, checking drug interactions, making sure labs are up to date, keeping medical comorbidities in mind, etc. Also, a number of my patient's have parole officers and other psychosocial complexities I need to tend to which can require careful documentation. My husband doesn't understand why I spend time outside the time I am physically in clinic to prepare for the patients I will see the following day (he gets annoyed that I read up and some of my out of clinic work cuts into time I could be spending with him). He says "well my friend sees a therapist and I know he doesn't do chart reviews, he just glimpses at the chart about their last visit and they chat for an hour. You must be doing something wrong, it can't possibly be as much work as you are putting into it. Like, when you see follow-ups it's not necessary for you to prescribe that very visit is it? How serious could it possibly be?" omfg...if he only knew. I have a patient scheduled to see me later this week with rip roaring schizoaffective of the bipolar type, multiple run ins with the law, and noncompliance who was finally stabilized on Invega sustenna when inpatient. He's due for his next loading dose at my office visit. Sure...such a casual speciality...we can skip that injection and just chat for an hour. And forget doing a chart review in advance, I should have just seen him blind and knowing nothing about him...because you know, every patient is like his high functioning friend who just sees a therapist to get an opportunity to vent with a nonjudgmental third party. That's all psychiatry is right?

 

[Shikima]

Listen to your body.

I followed mine and look where it got me.

That statement and that moving avatar of yours... hilarious!

 

[Merovinge]

I don't see how that is non-factual or toxic statement. Anyone going into psychiatry looking to cure people is in for major disappointment. My wife recently had a dental procedure that led to a virulent infection necessitating hospitalization and IV antibiotics. Within a couple of days, she was cured. It was dramatic. Open up a blockage in a coronary artery. Blammo! Patient will live and heart will keep beating. There is no analogue in mental health. It is a completely different animal. We are able to alleviate some of the more distressing symptoms. I can "cure" a patient of NSSI in a couple of sessions, but addressing the pervasive effects of the childhood trauma is a whole different issue. I have also worked extensively with chronically mentally ill patients. While stable on a medication regimen, they typically still need extensive support. There are major problems in how we as a society and also us as professionals conceptualize mental illness and I appreciate that some posters step right in it.

It just blatantly is. If you can work all day and never fix or cure a single problem in psychiatry the problem is not the patients, or conceptualization, or any other nonsense. Just off the top of my head for dramatic responses in psychiatry:

1) How about the ragingly manic pregnant lady that you admit after the last hospital discharged her for assaulting too many of their staff who you finally get to court for court ordered medication that regains her senses prior to delivery. Dramatic is the abject horror into complete gratitude her husband (and latter her) express.

2) The patient with schizophrenia who spends the better part of 2 years in an inpatient unit, gets finally stabolized, gets an ACT team, completes college, and oh has held down a job as an RN making serious $$ for almost 10 years without a single re hospitalization.

3) The countless OCD, social phobia, panic disorder patients that are able to be "fixed" after you finish CBT.

4) The kid with ADHD and such bad impulsivity/hyperactivity that family are thinking about leaving him to be a ward of the state who turns around so dramatically on stimulants that he keeps a home, loving family, and got all A's in first grade.

5) The middle aged guy with limbic encephalitis who has severe catatonia, on feeding tube, and scheduled for hospice by his primary team. Comes up to psych floor, we take nursing staff from a med floor to monitor him as he gets IVIG. He's walking/talking/eating a week later having no idea he was scheduled to be sent to die.

And don't get me started on the patient with severe malignant catatonia who you drag the ECT equipment up to the ICU and come in stat over the weekend to bring back from the jaws of death...

 

[smalltownpsych]

It just blatantly is. If you can work all day and never fix or cure a single problem in psychiatry the problem is not the patients, or conceptualization, or any other nonsense. I am not sure if you are actually a psychologist so your experience is different but just off the top of my head for dramatic responses in psychiatry:

1) How about the ragingly manic pregnant lady that you admit after the last hospital discharged her for assaulting too many of their staff who you finally get to court for court ordered medication that regains her senses prior to delivery. Dramatic is the abject horror into complete gratitude her husband (and latter her) express.

2) The patient with schizophrenia who spends the better part of 2 years in an inpatient unit, gets finally stabolized, gets an ACT team, completes college, and oh has held down a job as an RN making serious $$ for almost 10 years without a single re hospitalization.

3) The countless OCD, social phobia, panic disorder patients that are able to be "fixed" after you finish CBT.

4) The kid with ADHD and such bad impulsivity/hyperactivity that family are thinking about leaving him to be a ward of the state who turns around so dramatically on stimulants that he keeps a home, loving family, and got all A's in first grade.

5) The middle aged guy with limbic encephalitis who has severe catatonia, on feeding tube, and scheduled for hospice by his primary team. Comes up to psych floor, we take nursing staff from a med floor to monitor him as he gets IVIG. He's walking/talking/eating a week later having no idea he was scheduled to be sent to die.

And don't get me started on the patient with severe malignant catatonia who you drag the ECT equipment up to the ICU and come in stat over the weekend to bring back from the jaws of death...

Yes, I am a practicing psychologist and yes, I have both witnessed the sometimes dramatic effects of medications for severe mental illness and have been part of the cure for many others. However, it has been my experience that the dramatic is more the exception than the rule and anyone who is looking for that is going to be disappointed in this field where incremental change and improvement over time is more typical. Also, working in systems that are often iatrogenic in themselves can make that even more frustrating. Also, I think have tended to take this specific poster's criticisms of psychiatry more broadly and applied it to mental health treatment in general. Maybe that is too charitable of an interpretation. It is difficult to distinguish the finer nuances of communication from postings on the internet. That's one thing I am sure we can all agree on.

 

[Mad Jack]

There are no perfect jobs (especially in medicine), but part of what we do is learn to tolerate the imperfect. This idea of dealing with stigma comes up a lot, with med students, residents and even attendings. Its reasonable to say "I dealt with the stigma by leaving it behind me" and acknowledging that we all buy into the stigma ourselves. In fact, it adds a lot to the conversation. But its helpful to at least give context -- many people have asked why nancy went into psychiatry in the first place, or how they got out of it (we've confirmed nancy is a she?), but that's been absent. There's really no context for some of the claims made, particularly the idea that there is some magical specialty out there or that anything that doesn't prolong life is pointless. We know intimate detail about nancy's mother (which may or may not explain the distaste for those claiming mental illness), but have no clue where or how they practiced psychiatry.

There have been worse cases where some will just make up their background to give themselves validity, and that's a lot sketchier. However, its still discouraging to see people lob bombs at psychiatry and hide behind a shield of anonymity.

To say psychiatry cannot prolong life neglects the many physical comorbidities that tend to accrue with untreated mental illness.

 

[Merovinge]

Yes, I am a practicing psychologist and yes, I have both witnessed the sometimes dramatic effects of medications for severe mental illness and have been part of the cure for many others. However, it has been my experience that the dramatic is more the exception than the rule and anyone who is looking for that is going to be disappointed in this field where incremental change and improvement over time is more typical. Also, working in systems that are often iatrogenic in themselves can make that even more frustrating. Also, I think have tended to take this specific poster's criticisms of psychiatry more broadly and applied it to mental health treatment in general. Maybe that is too charitable of an interpretation. It is difficult to distinguish the finer nuances of communication from postings on the internet. That's one thing I am sure we can all agree on.

I edited out the psychology comment because I know how easily it can be misinterpreted. I only mean that the practice of inpatient psychiatry is different than most psychologists practices, but I know you have had a very rich practice experience.

It bothers me even more in that context to see people like you say things like "you never fix anyone" is remotely reasonable to say about psychiatry (and I hate it just as much when people say that about neurology, which is frequently in my experience). These things are the exact stigma that the OP is asking how to get over. Not everything in mental health is tiny steps and dramatic changes happened on a regular basis when I was practicing inpatient psychiatry. Ive had a lot more dramatic improvement in patients during my (short) career than most endocrinologists treating DM all day or most nephrologists managing dialysis for the majority of the their practice. Heck we got a lot more wins in psychiatry than most trauma surgeons, although I can see how people would be more impressed with their wins.

Psychiatry is not a great fit for everyone (or most people for that matter, no field of medicine is anymore!). However, psychiatry can be a good fit for someone who wants to have a large impact in the lives of their patients and see people get better from things that others might not even imagined possible. One can definitely tailor a practice to have more "wins" if they need that to keep going.

 

[hebel]

I thought I'd add some support to the criticisms of Nancy's posts. I don't think people are being unreasonable by calling her out. I think her posts are hyperbolic and have a strong tinge of bitterness that I think leads to poor quality posts.

She can give psychiatry the middle finger while walking out the door, but atleast post in a way that is useful to people practicing in or considering the field.

 

[Salpingo]

Yes, I am a practicing psychologist and yes, I have both witnessed the sometimes dramatic effects of medications for severe mental illness and have been part of the cure for many others. However, it has been my experience that the dramatic is more the exception than the rule and anyone who is looking for that is going to be disappointed in this field where incremental change and improvement over time is more typical. Also, working in systems that are often iatrogenic in themselves can make that even more frustrating. Also, I think have tended to take this specific poster's criticisms of psychiatry more broadly and applied it to mental health treatment in general. Maybe that is too charitable of an interpretation. It is difficult to distinguish the finer nuances of communication from postings on the internet. That's one thing I am sure we can all agree on.

I agree that we shouldn't overstate our capacity as acute interventionists. When we start promoting the future of psychiatry as full of TMS, DBS, full of S, I feel like we're signing a check we won't be able to cash. There are people who then expect miracles or to magically transform someone who has no interest in changing.

It sort of begs the question, what is worse - when people undervalue or overvalue the profession?

But to go back to your earlier example of coronary angioplasty, even if you're successful, it doesn't change the person's uncontrolled diabetes, hyperlipidemia, age, poor self-care. And if there was an infarction, there's a 20-30% chance that you'll be dealing with a depressed patient for the next few months (even if your not dealing with the depression itself). Of course, there are interventional cardiologists that love their job despite the flaws, and others who burnout.

 

[Liquid8]

Given that psychiatry has long been touted as a bottom of the barrel speciality that accepts anyone and caters to the most mediocre of doctors, it would be awful for someone to have tried and failed at psychiatry training. If you for a moment imagine grappling with the reality that you weren’t good enough to succeed at one of the “worst” specialities, I think this would be hard to face up to, and when one considers the psychological implications this could be one possible explanation why posters like NS disparage the profession. I’ve had this kind of conversation with trainees who have stumbled at their final exam hurdle – while I’ve seen doctors who transferred into psychiatry after having stumbled in other areas of medicine, there isn’t a lot to fall back on if psychiatry isn’t the right fit. Going through training at times I also had my doubts, thinking that if I couldn’t make it, it seemed like the only transferrable fall back would be General Practice/Family medicine.

Regarding stigma, I remember in my first year out one of my surgical registrars was disappointed that I’d wanted to go into psychiatry. His reasoning was that I’d be more suited to anaesthetics as I was particularly calm under pressure, and psychiatry would be a waste. His view had been tainted by a particularly lazy intern who had left over 200 discharge summaries for the next rotation and had also wanted to pursue psychiatry. At the time my consultant was actually very supportive, acknowledged that it takes all kinds citing the differences between his wife, a histopathologist, and himself who could only see pink and purple in slides. The other surgical registrar thought that DSM should have been up to version 13 by now, but he also didn’t seem to know the difference between incompetence and impotence so I didn’t pay much heed to his view.

Others have stated that psychiatry isn’t for them as it isn’t geared towards instant results, and without biological investigations requires a lot more work than interpreting a blood test or scan to make a diagnosis. My take on this is that psychiatrists are perhaps better at accepting delayed gratification, and if that isn’t your mindset then perhaps it’s not a good fit.

One other thing I’ve observed is that the relative unpopularity of psychiatry may have an unexpected upside. A friend of mine who married a physician once remarked that his wife’s friends felt she was lucky to be with a psychiatrist, as the other medical fields seems to be in oversupply and having trouble finding suitable work. Post qualification, it appears that many specialists are having to do multiple fellowship years or additional qualifications to be in the running for a job in the Australian market. This isn’t the case for psychiatry with new graduates able to start out at private clinics seeing 4-5 new patients a day prepared to pay around the $400 mark.

 

[smalltownpsych]

I edited out the psychology comment because I know how easily it can be misinterpreted. I only mean that the practice of inpatient psychiatry is different than most psychologists practices, but I know you have had a very rich practice experience.

It bothers me even more in that context to see people like you say things like "you never fix anyone" is remotely reasonable to say about psychiatry (and I hate it just as much when people say that about neurology, which is frequently in my experience). These things are the exact stigma that the OP is asking how to get over. Not everything in mental health is tiny steps and dramatic changes happened on a regular basis when I was practicing inpatient psychiatry. Ive had a lot more dramatic improvement in patients during my (short) career than most endocrinologists treating DM all day or most nephrologists managing dialysis for the majority of the their practice. Heck we got a lot more wins in psychiatry than most trauma surgeons, although I can see how people would be more impressed with their wins.

Psychiatry is not a great fit for everyone (or most people for that matter, no field of medicine is anymore!). However, psychiatry can be a good fit for someone who wants to have a large impact in the lives of their patients and see people get better from things that others might not even imagined possible. One can definitely tailor a practice to have more "wins" if they need that to keep going.

I appreciate that you made that change. although you are right that many of my colleagues are too limited in their inpatient experience. What is humorous is that I have many times taken the opposite position to what I have been taking here when discussing with other psychologists who tend to always avoid the word cure, whereas i use it quite often. I think I just like to play devil's advocate. I blame that on my dad who taught me well.

 

[Armadillos]

NS posts always struck me as someone who was motivated to do psych due to personal experience growing up in a family w/or having loved ones w/ psychiatric/personality pathology. A career in psych seems to go either dramatically well or really badly for people with those backgrounds. Several of the best psychiatrists I've worked with entered psych due to life experiences, but on the other side seem a lot of people from that background seem to burn out instantly. Not sure how to predict which way we will swing, I hope I'm not one of the ones to burn out like NS.

 

[clausewitz2]

NS posts always struck me as someone who was motivated to do psych due to personal experience growing up in a family w/or having loved ones w/ psychiatric/personality pathology. A career in psych seems to go either dramatically well or really badly for people with those backgrounds. Several of the best psychiatrists I've worked with entered psych due to life experiences, but on the other side seem a lot of people from that background seem to burn out instantly. Not sure how to predict which way we will swing, I hope I'm not one of the ones to burn out like NS.

I have now encountered some fairly horrifying countertransference from colleagues from this kind of background. Which would be fair enough, but they would strongly resist the suggestion that just maybe any of the opinion they were voicing had any relationship to their family/personal background.

 

[FlowRate]

And don't get me started on the patient with severe malignant catatonia who you drag the ECT equipment up to the ICU and come in stat over the weekend to bring back from the jaws of death...

Huh, that sounds like M&M this week.

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On the topic of the thread, I do find myself wishing people would think of us like any other random given specialty, instead of something different.

 

[TexasPhysician]

Some of y'all must be doing something wrong. I get thanked for improving quality of life, relieving struggles, and mending families.

If you think psychiatry is going to be about simple cures like prescribing amoxicillin for strep throat, then this is most likely the wrong field for you.

To say that hard work and quality psychiatrists can't significantly improve lives is just ignorance. The field can and does a lot of good work.

 

[tr]

What is humorous is that I have many times taken the opposite position to what I have been taking here when discussing with other psychologists who tend to always avoid the word cure, whereas i use it quite often. I think I just like to play devil's advocate. I blame that on my dad who taught me well.

I don't think the prospects for cures in psychiatry are grossly different from those in, say, IM.

Some conditions are amenable to cure (social anxiety, PTSD, substance use disorders).

Other conditions are chronic and need to be managed (schizophrenia, schizoaffective, bipolar disorder).

Same like IM, where you can cure pneumonia but must manage DM-I.

I'll grant that it's not quite accurate to say "the doctor cured the patient" in a psychiatric context as the patient must do the lion's share of the work involved. If one needs to feel like a hero rather than a guide, this probably isn't the right field.

 

[Blitz2006]

Some of y'all must be doing something wrong. I get thanked for improving quality of life, relieving struggles, and mending families.

If you think psychiatry is going to be about simple cures like prescribing amoxicillin for strep throat, then this is most likely the wrong field for you.

To say that hard work and quality psychiatrists can't significantly improve lives is just ignorance. The field can and does a lot of good work.

Yep, and we do save lives too.

2 weeks ago was national suicide week. 42 000 people commit suicide every year in USA, thats 115/day.

If it wasn't for Psychiatrists/Mental Health Workers, that number would be astronomically higher....

 

[nancysinatra]

Well, I haven't read this whole thread since I was here last. And I don't have time to just yet. But apparently, my comments stirred some responses! No surprise there - I figured they would, what with the massively defensive reactionary attitudes you find on this forum, hee hee.

But, I will say this. Most psych conditions can't be cured. Delirium, perhaps? Alcohol withdrawal? But most of them are chronic conditions which we can at best "manage." So that's why I said that we cured no one and fixed nothing. Literally, we do not cure things in psychiatry. Does anyone disagree? I mean, we do not have the equivalent of antibiotics or ORIFs for psych conditions. There is no bariatric surgery equivalent for treating depression, like there is for obesity. (And bariatric surgery has its problems, of course.) Until we have those kinds of treatments, I don't think I personally will be too keen on working in psychiatry. And of course, even antibiotics are having trouble nowadays - the pathogens are becoming resistant. But still, ID is ahead of psychiatry in terms of cure rates, if you measure them using prevalence, mortality rate changes, etc. ID wiped out smallpox and decreased polio rates. Am I wrong? And what did psych do? Which disease did we eliminate? Can we at least discuss this using some numerical facts? If we've seriously decreased the suicide rate, will someone please post those statistics? Thanks!

These aren't value judgments I'm making. It's a factual observation that ID, etc. has more cures than psych. It doesn't make psych worthless - it just means it wasn't for me, because, personally, it all doesn't jive with why I went to med school. I don't want to "manage" chronic conditions. When I go to work, I want to know that I got something done. I want to know that the patient is on the mend, the same day they saw me, hopefully, or else within a short period after that. I also want to know that in the long run, the rate of disease in the population is DECREASING because of my work (even if by one in a million). But chronic conditions contribute to disease prevalence even after the doctor sees the patient. I would personally consider myself having failed in my mission, the one I had when I applied to medical school, if all my patients remained sick enough to contribute to an ongoing disease rate despite my professional lifetime of efforts. To me, that is just not why I'm in this business. I don't want to go to work and push the same rock up the same hill every day of my life. But it doesn't mean I'm incompetent or ignorant, or that I don't appreciate what other psychiatrists are doing.

Now, a lot of people enjoy psychiatry because of the interactions with patients, and the "feeling" part of psychiatry where you sit around and listen to people pour forth about their emotions and sleep problems and their bad marriages, etc. Personally, at least most of the time, that's just not for me. Thankfully there's a lot more to medicine!

 

[nancysinatra]

Yep, and we do save lives too.

2 weeks ago was national suicide week. 42 000 people commit suicide every year in USA, thats 115/day.

If it wasn't for Psychiatrists/Mental Health Workers, that number would be astronomically higher....

Could you provide some statistics to show how psychiatrists and mental health workers contribute to survival rate increases? Any survival rate increase at all will impress me; it doesn't need to be "astronomical."

Just having a national suicide week doesn't prove anything. It's like having a booster club in a town. That doesn't mean the town is some great place to live. In fact, usually, it's the worst towns that have the most active booster clubs. And doesn't every disease have a week now? I'd even bet that the more hopelessly incurable the disease, the more likely it is to have its own week! Which speaks to the intractability of the diseases, NOT to the effectiveness of the treatments for them.

Typically the patients that we actually see and admit who are endorsing SI with a plan are on the lower end in terms of risk (relatively speaking, I mean. Relative to others with SI and a plan). I don't have numbers and so I could be wrong, but my understanding is that actual suicides tend to be carried out by people who want to conceal their risk and therefore we never see them. We do cover ourselves legally, to be sure. We commit lots of people, a majority of whom (I am only guessing) are statistically unlikely to actually carry out a suicide. A few will. It does happen. So definitely commitment saves some lives - but those people get discharged, and their conditions, being chronic, are likely to relapse. So the risk is not decreased to zero just because of our intervention. (Whereas, if you take out an appendix, the risk of appendicitis after that must be equal or pretty close to zero, correct?) And maybe through long term outpatient care we do prevent quite a few other suicides. But that would be hard to measure, right? And because of the drawn out time frame, the survival rates aren't exactly bolting towards the sky. So, while we help our patients, we definitely have a ways to go.

Anyway - and I have posted about this before - I didn't have any interest in suicide when I applied for the match in psychiatry. I was interested in non-borderline personality disorders, eating disorders, amnestic fugue, and brainwashing disorders. That's true to this day. I don't like mood disorders. I care about the patients that have them, but I wouldn't want a career surrounding those problems. Unfortunately that's all insurance pays for these days.

 

[nancysinatra]

You think that's a problem of thickness of skin? These comments, even as intentionally hyperbolic, are toxic and non-factual. There's a difference between trying to be straight forward/honest versus trying to get catharsis for spending 4 years of your life doing something you apparently hate in message boards. I've read good posts by NS and people seem to really like him/her on these boards but some of the comments in this thread are straight garbage and I am glad people are bringing that to light.

I posted what I did because this forum is incredibly biased. With some notable exceptions, there's a tendency on this forum where it seems like the most naive, touchy-feely, defensive people in the entire medical profession gather together and spew forth their insecurities towards anything and anyone who dares to pose even the slightest critical questions about psychiatry. (Granted I'm generalizing and there are many posters who aren't this way, especially longer term ones.) But I don't know of any other specialty forums on SDN that have as much of a Kumbaya cult like attitude as the psychiatry forum. On this forum, almost anyone and everyone is encouraged to go into psychiatry. Anyone and everyone is told how wonderful it is, and how it is SOOOOO much more effective and meaningful and rewarding than all the other fields of medicine combined. And of course, anyone and everyone is told how horrible and soulless internal medicine is. (Of course it's almost always IM that's the bad guy, since it is apparently a stand in for all the other specialties.)

Another thing about this forum - very frequently there are posts about "stigma." I've been on this forum for 9 years and I've read many of them! And they always go the same way. The conversation always leads to the same conclusion, which is that stigma is NEVER based in something worth examining, that it's ALWAYS the fault of other specialties or the ignorant public, and NEVER has anything to do with any possible shortcomings of our own profession. Because we have none.

Anyway that is why I posted the "garbage" I did.

These comments, even as intentionally hyperbolic, are toxic and non-factual.

By the way, show me a hard fact in psychiatry and I'll show you some land I have for sale in Florida. Exactly how do you arrive at the conclusion that my opinions are "non-factual?" They're opinions!!!

 

[splik]

Typically the patients that we actually see and admit who are endorsing SI with a plan are on the lower end in terms of risk (relatively speaking, I mean. Relative to others with SI and a plan). I don't have numbers and so I could be wrong, but my understanding is that actual suicides tend to be carried out by people who want to conceal their risk and therefore we never see them. We do cover ourselves legally, to be sure. We commit lots of people, a majority of whom (I am only guessing) are statistically unlikely to actually carry out a suicide. A few will. It does happen. So definitely commitment saves some lives - but those people get discharged, and their conditions, being chronic, are likely to relapse. So the risk is not decreased to zero just because of our intervention. (Whereas, if you take out an appendix, the risk of appendicitis after that must be equal or pretty close to zero, correct?) And maybe through long term outpatient care we do prevent quite a few other suicides. But that would be hard to measure, right? And because of the drawn out time frame, the survival rates aren't exactly bolting towards the sky. So, while we help our patients, we definitely have a ways to go.

not quite - the issue is that most people who commit suicide are not high risk, because there are more people who aren't high risk than are. it's like how most people who have strokes don't have very high blood pressure, even though significant hypertension is a major risk factor for stroke. but you are of course correct, that we do not see many of the people who kill themselves because they do so before they see a psychiatrist. There is not evidence that commitment or hospitalization saves lives. If anything, the data suggests the kind of short crisis-based hospitalizations we have moved to in the US increase the risk of suicide, rather than diminish it. There is also a tendency for people to conflate those who have suicidal ideation, those who attempt suicide, and those who die by suicide, when they are in fact distinct, if overlapping, groups. Which is to say that reducing or increasing suicidal ideation does not necessarily translate into reducing or increasing suicides. For example antidepressants definitely increase suicidality, and suicidal behavior, but do not appear to increase actual suicides. Similarly DBT has been shown to reduce suicide attempts but has not been shown to decrease completed suicide in borderline patients

 

[nancysinatra]

There are no perfect jobs (especially in medicine), but part of what we do is learn to tolerate the imperfect. This idea of dealing with stigma comes up a lot, with med students, residents and even attendings. Its reasonable to say "I dealt with the stigma by leaving it behind me" and acknowledging that we all buy into the stigma ourselves. In fact, it adds a lot to the conversation. But its helpful to at least give context -- many people have asked why nancy went into psychiatry in the first place, or how they got out of it (we've confirmed nancy is a she?), but that's been absent. There's really no context for some of the claims made, particularly the idea that there is some magical specialty out there or that anything that doesn't prolong life is pointless. We know intimate detail about nancy's mother (which may or may not explain the distaste for those claiming mental illness), but have no clue where or how they practiced psychiatry.

There have been worse cases where some will just make up their background to give themselves validity, and that's a lot sketchier. However, its still discouraging to see people lob bombs at psychiatry and hide behind a shield of anonymity.

I'm reading these responses backwards, so I don't know what was said earlier, but this one is funny! You know "intimate detail" about my mom?? Ha ha! I posted ONE anecdote about how my mom wants a therapy dog letter so she can move into a senior living place, and how she annoys me from time to time with her antidepressant stories. Most audiences would have appreciated that I was joking, but you gotta hand it to a forum full of aspiring psychiatrists to have no idea what humor (even a bad attempt at it) is. Anyway, given that antidepressants are now practically present in all our drinking water, I don't think my story about my mom is all that unique or "intimate." In fact my mom has nothing to do with my foray into psychiatry. The rest of my family is way more messed up than her! But sometimes, I gotta love this forum. I say a few negative things (ok, a lot of negative things) - and people go nuts. It's so predictable! It proves all of my points.

As for your comment - I don't think there is a perfect, magical specialty out there. However I do think the specialty of psychiatry has gone off the rails in our generation. And I don't want to be associated with that. We overmedicate our patients (so does family practice, right? But in a little less chaotic way than we do. And I wouldn't go into family practice anyway). We eagerly promote polypharmacy. We change the DSM every few years because we don't have a clue what we're doing. We dole out disability letters and at the same time claim that we're providing a service to society. But wait - if we're providing a service, disability should decrease. Since it's not decreasing thanks to us, we just blame "stigma." Oh and can I remind you that it was less than 2 decades ago that our very own specialty was promoting multiple personality disorder associated with satanic cults, and actually digging up nursery school lots and destroying people's lives? What other medical specialty has that honor? If you know of one, please tell me! Ok, when our profession decides to have a real conversation about these topics, at the highest levels (not on SDN, but at national conferences, with real outcomes) - then I will start posting positive things. Maybe I'll even tell a story about my dad. Oh wait, maybe not...

 

[nancysinatra]

not quite - the issue is that most people who commit suicide are not high risk, because there are more people who aren't high risk than are. it's like how most people who have strokes don't have very high blood pressure, even though significant hypertension is a major risk factor for stroke. but you are of course correct, that we do not see many of the people who kill themselves because they do so before they see a psychiatrist. There is not evidence that commitment or hospitalization saves lives. If anything, the data suggests the kind of short crisis-based hospitalizations we have moved to in the US increase the risk of suicide, rather than diminish it. There is also a tendency for people to conflate those who have suicidal ideation, those who attempt suicide, and those who die by suicide, when they are in fact distinct, if overlapping, groups. Which is to say that reducing or increasing suicidal ideation does not necessarily translate into reducing or increasing suicides. For example antidepressants definitely increase suicidality, and suicidal behavior, but do not appear to increase actual suicides. Similarly DBT has been shown to reduce suicide attempts but has not been shown to decrease completed suicide in borderline patients

Thanks, Splik. This is an informative post. You hit the nail on the head when you mentioned that we see more people who are not high risk than people who are. That's one thing in particular that frustrates me about psych - that I have to wade through all these pseudo-high risk cases, and pretend they actually are high risk (and document it too, because god forbid, I tell the truth about a malingerer or a borderline patient), in order to get to the few that really are high risk. And by that time, I'm burned out. Why can't I just tell the truth and discharge the non-high risk people from the ER, and even from clinic when it seems that prolonged pseudo-treatment is not getting anywhere? (I don't actually work in an ER right now, or in a clinic. But the point is the same. A lot of psych treatment leads exactly nowhere.)

I'm curious why I so frequently hear from people in our field that we are "making a huge difference" if in fact, maybe either we're not, or we're not sure if we are or we are not. Maybe we make a difference in some areas but then not in others. But regardless, we should be able to state, clearly, what our impact on society is. Right? Or am I wrong??

 

[splik]

Thanks, Splik. This is an informative post. You hit the nail on the head when you mentioned that we see more people who are not high risk than people who are.

no i'm saying the opposite. we see people who are "high risk" but the paradox is most people who kill themselves are not "high risk" based on risk factors simply because there are many more people who are not high risk than aren't. another example would be that women over the age of 35 are high risk of having children with down syndrome, but most children with down syndrome are born to women under the age of 35. hope that makes sense

 

[splik]

I'm curious why I so frequently hear from people in our field that we are "making a huge difference" if in fact, maybe either we're not, or we're not sure if we are or we are not. Maybe we make a difference in some areas but then not in others. But regardless, we should be able to state, clearly, what our impact on society is. Right? Or am I wrong??

well presumably people who are in the field believe they are "making a huge difference". You do not need to delude yourself of this since you have left the field. personally I think I can help people more and provide more value to society as a forensic psychiatrist than as a clinical psychiatrist. I think for the most part we have to satisfy ourselves with making "a little bit of a difference, a small amount of the time". but if you think about it too much, it's kind of depressing.

 

[Nasrudin]

Like many specialties, we work in the quality of life domain. I am convinced, As splik says, i can make a little difference, here and there in terms what we can know about decrease in mortality. Like taking someone off BZD's. Or making sure they get a work for OSA if they can't sleep and have those symptoms.

But the larger point is this. Palliative medicine, like our field, work is in the area of meaning. Palliative medicine doesn't stop death. But it's beauty lies in helping people face it.

Should I go to the palliative medicine forum. And say something as dense as You all are Biased!....? haha. of course. Self-selection is not accidental. Maybe I should tell them that they're a cult, and that they do nothing with their lives. And then, satisfy myself with that opposition.

That doesn't sound fun. Or in any way groovy.

I'll go one further, Nancy. We traffic in interpersonal influence. What's your success rate in that. Mine is pretty good. My job is to make people feel better. It requires charisma, belief, and desire to do that. It might sound like a cult. Because maybe we preparing to be the little leaders of our own little cults. Fine. I have no doubt about what I'm doing. I am shepherding people with weaker emotional and psychic constitutions across the terrain of their lives. And trying to lift their spirits with some companionship therein. There are techniques that have relative success in this with particular individuals. I like that the challenge of being good at that.

I love this work.

Your self-appraisal in this milieu is what it is.

But it is not mine.

 

[clausewitz2]

Like many specialties, we work in the quality of life domain. I am convinced, As splik says, i can make a little difference, here and there in terms what we can know about decrease in mortality. Like taking someone off BZD's. Or making sure they get a work for OSA if they can't sleep and have those symptoms.

But the larger point is this. Palliative medicine, like our field, work is in the area of meaning. Palliative medicine doesn't stop death. But it's beauty lies in helping people face it.

Should I go to the palliative medicine forum. And say something as dense as You all are Biased!....? haha. of course. Self-selection is not accidental. Maybe I should tell them that they're a cult, and that they do nothing with their lives. And then, satisfy myself with that opposition.

That doesn't sound fun. Or in any way groovy.

I'll go one further, Nancy. We traffic in interpersonal influence. What's your success rate in that. Mine is pretty good. My job is to make people feel better. It requires charisma, belief, and desire to do that. It might sound like a cult. Because maybe we preparing to be the little leaders of our own little cults. Fine. I have no doubt about what I'm doing. I am shepherding people with weaker emotional and psychic constitutions across the terrain of their lives. And trying to lift their spirits with some companionship therein. There are techniques that have relative success in this with particular individuals. I like that the challenge of being good at that.

I love this work.

Your self-appraisal in this milieu is what it is.

But it is not mine.

Very much this. For those who require a quantitative metric for the ineffable, quality-of-life-adjusted years are a measure that is used by public health types and at the same time is vastly more likely to capture what psychiatry can do than mortality measures.

It would also be great if we could all maybe resist the urge to proceed directly from "I don't care for X" to "anyone who thinks X is worthwhile is stupid or deluded", but that doesn't seem to be in the offing.

Also, @nancysinatra I am sorry where you have trained and work had never afforded you the chance to divert chronic and frequent hospital users without modifiable risk factors. That sounds deeply frustrating. At the same time, that is a limitation of those specific institutions and not intrinsic to the field as a whole. I have spent a good chunk of the last three months explaining to peoole who report SI why I am not going to admit them.

 

[HarryMTieboutMD]

Back to the original post (I've been grant and manuscript writing so I've missed out)... first, if you love psychiatry (like most of the posters on her besides NS and vistaril), nothing else matters. If you don't like it, then switch (like NS- nothing wrong with that)

But in my experience both in medical school and residency is that in relation to other specialties, psychiatry brings it upon itself. We tend to recruit more passive/pushover people who lack confidence and thus appear "weak" on off service rotations. In reality, most interns suck in the beginning, and if any decent 'tern (psych or otherwise) makes a concerted effort to learn they can perform just as well as anyone else for most things. After a few months I would routinely manage and make (appropriate) changes on my very sick patients (electrolytes all out of whack, volume issues, sepsis, etc) without telling my senior residents, which did irritate them, but whatever. Also, on neurology (where psych 'terns are mostly treated like medical students) I aggressively took more challenging cases because I love neuro and almost went into it. I also corrected the senior resident in front of the attending about something, much to her annoyance, but again, whatever.

As a psych resident, when interacting with other services (ie, on consults, in the ED), I'm blunt, assertive, and direct. I will give pushback and tell people directly that they are wrong. I think it's my athletic background (long time competitive swimmer and runner, now triathlete and marathon runner- Chicago in a little over a week!), but I definitely come to work with a chip on my shoulder and am not afraid to get in other people's faces when they try to denigrate psychiatry. Has it increased respect for psych as a whole? probably not. But do people know what they're getting when I have the consult phone? Yes.

Our chair (who is a National Academy/IOM member and internationally regarded) was an NCAA champion soccer player and played on the US national team and preaches "tough-mindedness", which has been the philosophy of our Department for quite some time. A tough minded psychiatrist will look at the stigma and fight for his or her cause in spite of it.

 

[675015]

Back to the original post (I've been grant and manuscript writing so I've missed out)... first, if you love psychiatry (like most of the posters on her besides NS and vistaril), nothing else matters. If you don't like it, then switch (like NS- nothing wrong with that)

But in my experience both in medical school and residency is that in relation to other specialties, psychiatry brings it upon itself. We tend to recruit more passive/pushover people who lack confidence and thus appear "weak" on off service rotations. In reality, most interns suck in the beginning, and if any decent 'tern (psych or otherwise) makes a concerted effort to learn they can perform just as well as anyone else for most things. After a few months I would routinely manage and make (appropriate) changes on my very sick patients (electrolytes all out of whack, volume issues, sepsis, etc) without telling my senior residents, which did irritate them, but whatever. Also, on neurology (where psych 'terns are mostly treated like medical students) I aggressively took more challenging cases because I love neuro and almost went into it. I also corrected the senior resident in front of the attending about something, much to her annoyance, but again, whatever.

As a psych resident, when interacting with other services (ie, on consults, in the ED), I'm blunt, assertive, and direct. I will give pushback and tell people directly that they are wrong. I think it's my athletic background (long time competitive swimmer and runner, now triathlete and marathon runner- Chicago in a little over a week!), but I definitely come to work with a chip on my shoulder and am not afraid to get in other people's faces when they try to denigrate psychiatry. Has it increased respect for psych as a whole? probably not. But do people know what they're getting when I have the consult phone? Yes.

Our chair (who is a National Academy/IOM member and internationally regarded) was an NCAA champion soccer player and played on the US national team and preaches "tough-mindedness", which has been the philosophy of our Department for quite some time. A tough minded psychiatrist will look at the stigma and fight for his or her cause in spite of it.

How does this not so humble brag address the original post exactly? It seems like the primary concern of stigma was with the lay public, not other services. (" For some reason I care that lay people may not know that psychiatrists are physicians. For some reason I care that people won't know the differences between a psychiatrist and psychologist. All these little, petty things, for some reason, get to me.I know that these are stupid, superficial, and even insecure things. I am fully aware of this. I know I may get judgmental thoughts for saying these things, but I am just being honest with myself so maybe I can get through it.")

 

[Jules A]

How does this not so humble brag address the original post exactly? It seems like the primary concern of stigma was with the lay public, not other services.

At this point I have forgotten the OP and am focusing on trying to figure out how to PM HarryMTieboutMD to ask for a job. I'd be a good fit for his crew.

 

[tr]

Could you provide some statistics to show how psychiatrists and mental health workers contribute to survival rate increases? Any survival rate increase at all will impress me; it doesn't need to be "astronomical."

Aseltine Jr, R. H., & DeMartino, R. (2004). An outcome evaluation of the SOS suicide prevention program. American Journal of Public Health, 94(3), 446-451.
An educational program reduces suicide attempts among high school students (n=2100) by 40%.
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.94.3.446

Mann et al., JAMA 2005, 294(16):2064. Review of 93 studies. Physician education and restriction of access to lethal means reduce suicide rates.
http://jama.jamanetwork.com/article.aspx?articleid=201761

Knox, BMJ 2003, 327:1376. A multilayered intervention targeted at improving mental health literacy resulted in a 33% reduction in suicide among 5 million USAF members
http://www.bmj.com/content/327/7428/1376?linkType=FULL&resid=327/7428/1376&journalCode=bmj

Etc., etc., etc. There are lots of these.

 

[tr]

But, I will say this. Most psych conditions can't be cured. Delirium, perhaps? Alcohol withdrawal? But most of them are chronic conditions which we can at best "manage." So that's why I said that we cured no one and fixed nothing. Literally, we do not cure things in psychiatry. Does anyone disagree?

Yes, I disagree. See my post above. I have helped numerous individuals to be cured of psychiatric afflictions. Most typically social anxiety and generalized anxiety, but also PTSD. Eating disorders and substance use disorders are difficult but ultimately potentially curable (not my area though). Other disorders like schizophrenia and bipolar disorder are not amenable to cure and require ongoing management.

I mean, we do not have the equivalent of antibiotics or ORIFs for psych conditions. There is no bariatric surgery equivalent for treating depression, like there is for obesity. (And bariatric surgery has its problems, of course.) Until we have those kinds of treatments, I don't think I personally will be too keen on working in psychiatry. And of course, even antibiotics are having trouble nowadays - the pathogens are becoming resistant. But still, ID is ahead of psychiatry in terms of cure rates, if you measure them using prevalence, mortality rate changes, etc. ID wiped out smallpox and decreased polio rates. Am I wrong?

If you are comparing to ID you have chosen the specialty which is perhaps uniquely able to effect cures. Most specialties, like psychiatry, have a mix of curable and chronic illnesses, the proportion of which will of course vary somewhat from specialty to specialty. I don't think psych is an extreme outlier among medicine-based specialties.

I do think it's a bit funny that you are holding up bariatric surgery as some kind of yardstick of effectiveness. I have treated a number of patients who are 10-15 years out from various bariatric surgeries and they uniformly have some kind of suboptimal outcome: from the near-universal weight creep to the common nutritional deficiency to the less common but terrifying torsion, ischemia, and loss of long portions of bowel.

Bariatric surgery actually seems to me to mirror a problem I noticed in general surgery, which was that the cure was often worse than the disease. I was struck by the many patients who would come into postop clinic, months after surgery, complaining of debilitating pain from adhesions or whatever, which the surgeon would shrug off with barely an acknowledgement, evidently considering this no barrier to his assessment of his intervention as an unmitigated success.
Ortho is also of concern given accumulating evidence that some of their most common procedures are no more effective than sham surgery.

Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., ... & Järvinen, T. L. (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. New England Journal of Medicine, 369(26), 2515-2524. "This multicenter, randomized, sham-controlled trial involving patients with a degenerative medial meniscus tear showed that arthroscopic partial meniscectomy was not superior to sham surgery"
http://www.nejm.org/doi/full/10.1056/NEJMoa1305189#t=article

And what did psych do? Which disease did we eliminate? Can we at least discuss this using some numerical facts? If we've seriously decreased the suicide rate, will someone please post those statistics? Thanks!

See refs in post above. They're easy to find. This is the type of reading you really should have come across at some point in your psychiatry residency.

 

[Salpingo]

I think this is your papers are misleading and actually do not support things clinical psychiatrists can do to reduce suicide but instead highlight suicide as a public health issue.

the first paper is about suicide attempts not actual suicides (very different things and absolutely wrong to conflate them)

The second paper is very misleading as it misrepresents the literature. The only intervention it describes that has actually been show to reduce suicides is restriction of access to lethal means. This is a population based approach.

The third paper is again a population-based approach not a clinical one, and the study is actually pretty good. However the approach included critical incident stress management, an approach that is highly controversial, and has been shown to increase the risk of developing PTSD. In addition, suicides in the airforce have skyrocketed since this study was published. This reflects trends in the military overall and there are a number of reasons for this.


That said there are 4 interventions that do have a modest effect on suicide:
1. brief intervention and contact in the emergency room following a suicide attempt has been shown to reduce deaths from suicide
2. writing caring letters to patient has been shown to reduce suicides in a military population
3. lithium has a small, but clinically important effect at reducing suicide independent of its moodstabilizing properties.
4. clozapine has a small but clinically important effect at reducing suicide in patients with "schizophrenia"

In the Big Picture, there's very little an individual doctor in any specialty can do or has done. Our interventions are nothing compared to the introduction of hand hygiene, public sewage systems, vaccine programs, smoking cessation, gun control etc. Even in ID, the big changes haven't been new antibiotics but checklists and protocols to stop iatrogenic infections. Doctors can be useful disseminating public health, although the system is setup against that (with brief encounters, billing incentives and so forth). In the studies on lithium, the absolute number of suicides prevented is at most double digits (which is significant because of the relatively small number of suicides). The more telling statistic is 38%: the percentage of people who saw their PMD 1 month before completed suicide. What (if anything) can be done in those encounters?

Medicine is one of the few advanced degrees that actually narrows your impact - we interact with individuals one at a time, in brief windows of time, and we have to accept those limitations. I derive a lot of meaning by being intellectually engaged and challenged, but the reality is that there are times when the work becomes a monotonous, Sisyphean task -- in those moments, I just try to appreciate the fact that I get paid to listen to people tell me their life stories. And occasionally they get better.

With that in mind -- nancy, maybe we can agree on a few points

1. Sharing a story about your mother, her 85 lbs laberdoodle and her "psychic woes" on a board crawling with humorless, wannabe Freuds was questionable (although I appreciate it)
2. I stand by the fact that I'm interested (and I'm guessing several other people are) to learn the details of your training and experience in psychiatry, and where you're moving to
3. While I think all of medicine has cringe-inducing moments (see Dr. Oz), when psychiatrists make messes, they tend to be spectacular and public. MAYBE that's fed by the expectation of the public, who see us either as magicians or con artists.

 

[tr]

@splik:
Suicide is a rare event, so if you want to study it prospectively you need a large sample, hence a large-scale, 'public health' or population-based intervention. These interventions are also planned and implemented by psychiatrists and mental health workers, just like the smaller-scale ones.

The four examples you gave are also good ones, and the overall point, which is that psychiatrists and mental health workers do indeed have significant, well-documented positive effects in the prevention of suicide, stands.

 

[SeniorWrangler]

But in my experience both in medical school and residency is that in relation to other specialties, psychiatry brings it upon itself. We tend to recruit more passive/pushover people who lack confidence and thus appear "weak" on off service rotations. In reality, most interns suck in the beginning, and if any decent 'tern (psych or otherwise) makes a concerted effort to learn they can perform just as well as anyone else for most things. After a few months I would routinely manage and make (appropriate) changes on my very sick patients (electrolytes all out of whack, volume issues, sepsis, etc) without telling my senior residents, which did irritate them, but whatever. Also, on neurology (where psych 'terns are mostly treated like medical students) I aggressively took more challenging cases because I love neuro and almost went into it. I also corrected the senior resident in front of the attending about something, much to her annoyance, but again, whatever.

As a psych resident, when interacting with other services (ie, on consults, in the ED), I'm blunt, assertive, and direct. I will give pushback and tell people directly that they are wrong. I think it's my athletic background (long time competitive swimmer and runner, now triathlete and marathon runner- Chicago in a little over a week!), but I definitely come to work with a chip on my shoulder and am not afraid to get in other people's faces when they try to denigrate psychiatry. Has it increased respect for psych as a whole? probably not. But do people know what they're getting when I have the consult phone? Yes.

Our chair (who is a National Academy/IOM member and internationally regarded) was an NCAA champion soccer player and played on the US national team and preaches "tough-mindedness", which has been the philosophy of our Department for quite some time. A tough minded psychiatrist will look at the stigma and fight for his or her cause in spite of it.

So we're going to change the stereotype of psychiatry to "pushy jocks who aren't Ortho?"

 

[Dr. Harambe]

So here I am, in a very lucky place, really. I've found a specialty I really love. I feel compelled to help the patients in this field and I'm fascinated by the science behind it. It gives me a sense of motivation unlike anything else. In addition to this, it happens to be a field that offers a great lifestyle, huge demand, and awesome pay. I love psychiatry. No matter how many times I try to lie to myself, I love it. I should feel very fortunate that I've found something that I really want to pursue, but I feel like something is wrong with me.

... I was just wondering if anyone here has felt the same way. If so, how did you get over it? ...

I'm a 4th year applying to psychiatry residencies this year and I can relate so much to what you wrote in this post.

I love psychiatry. But, it has taken me a year to be able to confidently say those words.

I was completely caught off guard as a 3rd year when I first realized that I liked psychiatry while on my rotation. I was confused by the feeling of being "happy" at work each day and felt that perhaps I was being tricked. Maybe this was just a particularly good rotation, maybe it's just the hospital I'm at or these particular psychiatrists that I'm working with. Maybe I'm wrong and I don't actually like this. I too worried about the stigma (both from colleagues and the public).

It didn't help that on subsequent rotations revealing my newfound interest in psychiatry was sometimes met with less than favorable remarks. One resident scoffed "why!? only crazy people do that." Another resident asked me if I did drugs (because I expressed interest in patients with substance use disorders).

I carried this with me for a while, but returning to rotations where I am seeing psych patients again has helped tremendously. I've met even more psychiatrists who I admire and value as mentors. I've seen fascinating pathology, and I've been able to help patients acknowledge and talk about traumas previously untold (these especially are such powerful moments). I continue to find myself smiling when our patients say and do things you can't make up. And every time I see a physician in another speciality at the hospital looking miserable and burned out (including some of the same residents mentioned above), I feel an incredible since of relief knowing I will never be them!

It has also helped to talk to my fellow classmates who are going into psychiatry and to think about how much respect I have for them.

There are certainly still moments where I feel insecure and judged by others, but for the most part I could care less what anyone else thinks.

 

[Dharma]

Watching your IM buddies putting in 80-100hrs. That should clear any worries of stigma.

 

[psych]

I didn't read anything but the original post therefore please read my response with that in mind :/
My job is so incredibly meaningful (please take into account I've gone through phases of dismay/disillusionment) that to me, I couldn't care less about the ignorant stigma externally. Granted I work in a high acuity setting and see the entire spectrum of psychiatry on an every day basis, but I wouldn't trade it for the world.

 

[GH253]

Psychiatrists aren't real doctors, sorry

 

[dl2dp2]

I've had very similar thoughts a med student.

However, now that I'm an attending (of some sort), echoing a few posters above, I think the best argument against stigma is cold, hard cash.

If I say there is a specialty that's half as competitive as derm, twice as interesting, and nearly as good in terms of money and life style, but you just have to endure a little "stigma", what would you say to that? 'Tis what psych is.

Life is all relative.

 

[Shikima]

Psychiatrists aren't real doctors, sorry