Stimulus-Response

Dr. Rob, whose blog I have recently discovered and started to enjoy, asked me this question:

All of my non-psychiatrist doctors tell me that psychiatrists are a joke.  They say it’s the easiest residency to get, by far, and that they are the bottom-of-the-barrel of physicians, a pseudo-science.  Is there any truth to this?
Why yes, Dr. Rob, unfortunately there is. Quite a bit; in fact, I have made many a similar comment in my days. In medical school the joke goes: there are two kinds of people who go into psychiatry: the bottom of the class, and the top of the class who are themselves mentally ill.

In this one-liner, the “mentally ill” isn’t meant as derogatory, as in “they have to be crazy to do that, but rather describes a real phenomenon of how mental illness is hidden in the world of medicine – if someone like me (top of the class, full of energy, didn’t “have” to go into psychiatry because of lack of better opportunities),  chooses psychiatry (as I might have considered doing, for both obvious and less obvious reasons), the diagnoses start flying.

As to the other type, I’m not sure I’m so derogatory. Family docs are just one rung on the ladder above psychiatrists for “touchy-feely” soft medicine and I admire them. A lot of people go into psychiatry because they really really hate medicine, or aren’t very good at it. Others can’t take clinical medicine – don’t like blood, the smells, illness, the general grossness dealt with day to day by most docs. Or they really wanted to help people and just don’t see how medicine does that, which is fair enough. So I do share a lot of their viewpoints about medicine in general. Unfortunately, I don’t see a career in psychiatry as being the solution – more on this in a minute.

This view of psychiatry makes it harder for a doc to actually go to one. There’s always that learned contempt under the surface. There’s probably a lot of truth to the idea that a psychologist is more likely to be the type who excelled and worked hard in school and be brighter and better at what they do than the bottom rung of medical school.

But the problem is, when a lot of them aren’t too bright, they get educated mainly by the drug companies, the only ones funding ANYTHING in their departments. They hated medicine, and forgot as much of it as possible after going into psych, therefore they aren’t really familiar with medicine even in the minimal way they need to be. This means other docs get patients who had, say, seizures, from an electrolyte imbalance due to a psych med…and the shrink just doesn’t get it. “But Pfizer said it has no side effects.” This gets them a bad name. Using psych meds is pretty much a crapshoot, but made so even more by the types of people practicing psychiatry. Very few of them understand much nuance.

As to my friends in med school who went into psych, I like them a lot. They liked the humanities, the human side of medicine, had interests outside of medicine, and saw the ridiculousness that is so prevalent in hospital medicine. The problem is they burn out hard, lose any idealism that they started with. Some of that is understandable – think of a counselor or psychologist who only dealt with the severely psychotic all day. I assume that some of their patients do get better, are grateful, make changes one can see, and allow their therapist to have meaningful interactions with them. Imagine a psychologist’s job without that.

The brighter psychiatrists end up in research, but most of them are the ones who went into psych because they were grossed out on medicine, but also hate patients, or because they just burn out on patient care. It is also the only place there is any money or prestige, which attracts those seeking ego strokes. Research psychiatrists and drug company ones are usually jerks.

This line of thought has made me think I would probably be better off with a good counselor of another discipline. I just needed this guy to manage meds (which he also doesn’t do very well, but nobody does). And then it was sort of nice, despite all that, to be with someone who had been through medical training and understands how horrific it is. But I’m thinking now that maybe I might be better off with someone who can see it from the outside as sort of sadistic and ridiculous, not someone equally indoctrinated. Give me some reality testing about how crazy it all is.

And this guy is very therapy-analysis oriented. I’m still reeling from the bipolar diagnosis, from how crazy I was, how this will affect my life and coming to terms with being “second-rate” or “damaged” on some level…but he doesn’t get that – he thinks that now if I’m balanced out medicinally, it should just fade away, I shouldn’t even be thinking about it.

Also – more and more, family docs are receiving further training in psych, and in some countries, Canada and South Africa at least, there are also advanced counseling trainings for family docs. I think there was one South African family doc I met who was doing a lot of family counseling. I’ve thought of one of those kind of training programs.

Thanks for your thought-provoking question. I guess somehow this blog is getting more and more mental health-oriented with every post.

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5 Comments

  1. Here there all all sorts of CME’s that fam MD’s can take for psychotherapy. Problem is that it doesn’t pay very well at all. nothing does anymore.

  2. My psychiatrist writes my prescriptions, but it is my Social Psychiatric Nurse who gives me all the wonderful counseling and feedback and makes me feel less crazy than I am supposed to be. As to the medicines, I have a very good idea of what i need to control what is wrong and very often take the lead in this. Assertiveness is important. You can’t be a passive patient, and you can also not be the label that has been put upon you. I have characteristics of certain disorders. I am not those disorders. I have those tendencies. Most of the time, I live a totally normal life, with medication, I must emphasize. It does have a place in my life, but my psychiatrist has no clue as to what makes me tick and never will have, soi will not goto him for an enlightening conversation. My SPN or almost anybody else does a much better job.

  3. yeah the discrimination towards psychiatrists is rampant in medicine isnt it? they aren’t seen as real docs, and are mentioned almost with a smear
    But i suppose, the touchy feely stuff is just as important because people arent just made up of cells and tissues. Alot of what we feel translates into symptoms and vice versa.
    Although i totally agree with your reasons that its just not for me.

  4. i can’t stand the way Psychiatrists are treated so second (or third) rate by other physicans….i admire an MD that would actually go in to Psych/therapy, which is v e r y rare these days (thanks insurance…they must think Psychiatrists aren’t r e a l physcians either). Because of the excellent therapeutic relations i have had with two Psychiatrists and one Resident i was actually in therapy with, i guess i am very biased in this area (and yes, they were all men…wouldn’t have it any other way!). But as for non-MD’s, my luck has been crappy…i have never found a good psycholgist or orther mental health worker…my first therapy experience was with a female psychologist and it was a trip through utter hell…i was obviously extremely depressed and anxious, yet she NEVER even gave me a choice of a Psychiatric consult. Guess it’s obvious where my bias comes from. i finally wisened up and went to a Psychiatrist (“back in the day,” when the majority actually did therapy). i am sooo desperate, i would come up with the 200.00+ or wharever an MD might charge for therapy if the relationship was a “good fit”..it would be worth it. (and we do not have “extra” money). If he were to take my insurance, it would be a blessing.

    Anyhow, sorry for the rave…..thanks for letting me ramble.

    love to you, Sara and all
    PS Inpatient, it used to drive me crazi(er) whrn the staff would call the Internest the “Medical Doctor”….ALL the doctors were “Medical Doctors”!!

  5. This got a lot of responses.

    Irene: my psychiatrist has no clue as to what makes me tick and never will have, soi will not goto him for an enlightening conversation

    I think that might be something I need to hear and accept for myself.

    Tracy, I have only found good fits with women counselors who are definitely NOT from a medical viewpoint. Part of the problem is psychiatrists (and all doctors really) are trained to pick out the pathological, not build on strengths. And I also admire one who goes into that. But…only if they do it for the right reasons.

    I think “Medical doctor” means “internal medicine” – it’s not a slight to the psychiatrists, surgeons say stuff like that too…depending on your region “medicine” can mean specifically “internal medicine.”


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