Friday, July 22, 2011

Is Psychiatry Different From Other Specialties?

In the Clinical Encounters case featured here two days ago, I presented the story of a psychiatrist who goes for a urological procedure and discovers that one of his former patients is the nurse assisting.  People wrote in to suggest ways he should handle this awkward situation and I was struck by the idea that some suggested he tell the urologist that he knows the nurse in a social setting (because he can't tell the other doc that the nurse was his psychiatric patient) and the assumption that the urologist would be understanding, and that perhaps the urologist should have policies in place in case of such events.

Do surgeons think this way?  I assumed the urologist would be angry--his time had been allotted for the procedure, and it's a surgical procedure with professional staff, what's the big deal?  To a surgeon, I think you see the best, and if the best is your friend, then so be it, a body's a body.  It's not unusual for clergymen to be treated by their parishioners, for medical staff to be treated at their own hospital and by members of their own department, and for surgeons to operate on colleagues.  In small towns, there is often very little choice as to who delivers your baby or shrinks your head.

Traditionally, psychiatry is a bit different, and we maintain some distance.  In the program where I trained, this view was not felt to make sense: if you're sick, you go to the best, and we are the best.  Psychiatrists would have their family members come in for care, and there were times that people in the department were admitted to the inpatient unit (and yes, I mean psychiatrists as well as nurses, staff,  residents, and med students).  For those who insist that the stigma of a label or a treatment necessarily destroys you-- it ain't so. 

It all makes me, personally, a little uneasy-- I like my privacy, even for the most mundane of medical things, though I do think that if I had some unusual, or difficult-to-treat condition and the 'best' was someone close to home, I'd get over it very quickly.


rob lindeman said...

If psychiatry is like other specialties, how come I get letters from EVERY OTHER specialist I refer my kids to EXCEPT psychiatrists?

If you want to be like other specialists, please extend us the courtesies that other specialists extend.

wv = remon. Moron, sideways

Anonymous said...

No matter how much you like your privacy (who doesn't?) you wouldn't have an awful lot of it if you got admitted to the psych ward, whether or not your colleague or some stranger treated you. Do you mean you like your anonymity when it comes to these things? That is a different story. And the doctors ,nurses and med students on the ward--they have their psych histories laid bare and pretty often, their butts, too.

Shrink2B said...

Psychiatry is the same in an emergency - When someone REALLY needs help, they come and ask and they don't care how they know you.
BUT until it is emergent - the stigma of mental illness is often too great, and it changes peoples perception and treatment of the entire mental health field.
At my high school 10 year reunion last year I asked my friends - "If you needed to see a shrink - would you want to go to someone you know, or a complete stranger?"
Almost every single one said a complete stranger.
HOWEVER - now that I'm a resident, I get people at church asking me for psychiatric help and advice all the time because their kid is in the psych hospital, or their mother tried to commit suicide, etc...
Psychiatry is still perceived least until we're REALLY needed.

Sunny CA said...

Surgeries I have had expose a lot less of my body than the scenario you described at the urologist and in the case of surgery I would not object if I were the psychiatrist being treated by a former patient (unless something revealed during treatment led me to believe the former patient could not be trusted).

A prolonged crotch view is different, I think than surgery on the hand, inside the throat, even in the abdomen.

Gynecologists get used to seeing women's private parts, but the woman on the table would still want control over who is down there looking. I feel more exposed when both my feet are in stirrups and I am scooched to the end of the examining table than when I was draped and ready for abdominal surgery.

I wonder with a former patient as nurse on an in-patient ward with her psychiatrist who is now the patient whether the attitude of "teaching the inpatient a lesson" would still prevail? Would the former-patient-now-nurse of the inpatient-psychiatrist try to "teach him a lesson" by intentionally inflicting physical pain? Would she then ever seek help from him in the future? How would physical cruelty to your former psychiatrist while the psychiatrist is in-patient affect a future therapeutic relationship between the nurse and her psychiatrist should she seek help from him? Since I was a recipient of the "teach-the-inpatient-a-lesson" school of nursing as an inpatient, it is the first thing that comes to mind.

Anonymous said...

It comes down to stigma. Years and years of stigma.

And shrink2B -- please note that the ppl asking your assistance are asking for assistance dealing with psychiatric matters concerning those close to them, not themselves. It's a world of difference.

jesse said...

As usual, several issues here. One relates to privacy and another to the way in which the relationship itself between the psychiatrist and patient is used for therapeutic advantage in psychodynamic therapy.

As to privacy, psychiatric treatment involves not merely symptoms (anxiety, depression, etc) but to information about the patient’s life. Anxiety, for instance may come from a sexual affair, the loss of prestige or position, humiliation, and so on. If you would not normally tell a social acquaintance these things, you certainly would not want to have them revealed to him in a psychiatric context. So a person might readily choose to go to a social acquaintance for chest pain, but not for various physical or emotional issues that would be considered, well, personal.

As to psychodynamic therapy, if one does not work in an analytic manner, or was not trained in it, one cannot truly understand the issue. One can understand, however, that psychodynamic work involves intense feelings that lead both the psychiatrist and the patient to understand the need for clear boundaries.

Obviously, an emergency, such as a suicide attempt, that would get a patient admitted to an inpatient ward, creates other needs and solutions must be more flexible. Still, to the extent possible, privacy and boundaries are best observed.

jesse said...

P.S. A surgeon would not operate on a member of his family. Psychotherapy can create feelings very like those in a family. The same considerations apply.

moviedoc said...

Rob is right, but I often get the sense that referring docs don't necessarily want a letter, or that the patient doesn't want me to write it.

I believe the association of psychiatry with psychoanalytic precepts has fed the unrealistic fantasy that this intense dyadic relationship can and must be isolated from the rest of the world in the name of boundaries. The film Prime perhaps best gives the lie to this notion.

Part of the problem is that still haven't figured out whether we really believe psychiatrists treat illness or something else.

jesse said...

A further thought on the idea of "going to the best." We are lucky in Baltimore to live in a city which boast a very high number of excellent physicians. There is no single "best" in virtually anything, much less in psychiatry. How psychiatry differs, however, is that the patient is part of the equation in a manner very different from that of surgery. In our practices a patient does not simply present to be treated, but rather is an integral part of the treatment. So one patient may work well with me who has trouble getting anywhere with someone else, and vice versa.

If a patient, or a psychiatrist, unnecessarily wants to ignore the most prudent boundary issues, it is immediately a subject to be considered and addressed. For instance, I have at times been approached by friends who trust me and want me to treat one of their family members. I know that this is different from surgery, and that there are many psychiatrists I respect who would have none of the difficulties that would inevitably arise for both me and the respective patient.

rob lindeman said...


BINGO. If psychiatry were a medical specialty, you'd be OBLIGED to send me (the primary) a letter!!! But since psychiatry is NOT a medical specialty, but rather is "something else" psychiatrists believe the primary does not deserve a letter. The primary's lack of desire to read the letter is irrelevant. The patient's request for no letter should be explicit. m

moviedoc said...

Another thought though, Rob. Do you call the psychiatrist before making the referral to make sure the case is a good fit? I always appreciate that. And if you asked for the letter then I would provide it, with the patient's consent of course.

Anonymous said...

"I like my privacy" ??? You're a media psychiatrist?!

Anonymous said...

You say "BINGO", then proceed to put words into moviedoc's mouth, (that she or he did not say), in order to support your own dogmatic theory. I am pretty certain that a psychiatrist not being "OBLIGED to send me (the primary) a letter" does not logically negate the whole specialty of psychiatry. Also MD never said anything about "psychiatrists believ[ing] the primary does not deserve a letter", rather s/he was concerned about the patient's right to privacy, a right that is intensely important for therapy and the patient/psychiatrist relationship to work.
Here in Canada letters are sent to Primary physicians, (I guess we have "real" psychiatric specialists up here;>), but as a patient I would rather they were not sent. Knowing my family dr will read about my work with my psychiatrist stops me from talking about some things as openly as I would like to.

I never really understand why people who are so opposed to psychiatry come to these sites that are about psychiatry, psychiatrists and psychiatric patient's and try to bully their anti-psychiatry stance onto all the readers.

Do they think we will change our minds about the medical help we provide or receive? I know for me all it does is annoy me and increase the already huge level of stigma I already feel about having a psychiatric Illness.

moviedoc said...

Anon: I also have the sense that many PCP's are not interested in what I might write, which sort of proves your point about stigma, like they are uncomfortable and would just like someone else to handle that stuff they don't really understand anyway.

I like hearing what people don't like about the practice of psychiatry.

Dinah said...

Anon: I like my privacy about what I like my privacy about. What's on the blog isn't the stuff I care about privacy about. And since I'm a human being (most days), none of it has to make sense.

Rob-- Psychiatry is a medical specialty. Just because you've decided it isn't, doesn't make it so.

Sometimes I write a note to the primary care docs. On my intake form, I ask the primary care doctor's name and address, and there is a place the patient can check off consent for communication. I try to write a note if the patient was specifically referred by the primary care doc to me. Many of my patients are self-referred, or got my name from another source. In theory, I'd write a note to all the primary care docs, but I'm either lazy or too busy blogging.

To those who worry about what I say about them: if there is anything that seems particularly personal and not something a primary care doc needs to know, I leave it out.

rob lindeman said...

Moviedoc, when I'm actually asked to make a referral, I speak to the MH myself. On the phone. (Dad, what's a 'phone'?)

Wv - surin. Nerve gas. 100% effective

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Anonymous said...

It is funny, b.c as a doctor, i think you would think about body parts and exams in different ways. You get to know very private things about people. Getting urological exam is not that private. Your former patient would care more to do his job as a nurse assistant.. nothing else. Psychiatrists think about themselves as kings!

Anonymous said...

Is psychiatry different from other specialties? Of course. While all physicians hold a special form of power in terms of their knowledge (of medicine and an individual's particular medical history/issues) and capacity to make life-altering decisions. While we turn to all professionals (CPAs, plumbers, lawyers, etc.) for their professional expertise, nowhere are we quite as vulnerable as with a physician. And I would argue that, among physicians, nowhere are we as vulnerable as we are among psychiatrists. For not only are they (er, you folks) all privy to our medical histories, but you also have access to our deepest, darkest, most sacred, and often most shameful parts of ourselves. To run into your PC at the kids' soccer practice as I often did could be disconcerting (especially just after the annual physical and pap smear), but to run into your psychiatrist in day to day life when they have (or it at least feels at least if they do have) access to some part of your innermost thoughts can be provocative. Given the power of transference and countertransference, presumably it works both ways.

And yet, Rob, I disagree with your premise that psychiatry is not a medical specialty. I've read many of your critiques here and elsewhere of psychiatry, and I'm not sure why you (clearly) feel so strongly about this issue, but clearly you do. I hope I'm still maintaining an appropriate living room style, but I do get defensive (as the child of a shrink) when people claim that psychiatry is not really part of the practice of medicine. As described above, it certainly delves into psychological and emotional realms that urology or neurosurgery or orthopedics doesn't address, but it nonetheless is built soundly on medicine. And, as I think we are learning increasingly given the % of folks with depression in this country, other fields might benefit from increased attention to mental health issues as well.

As the child of a child psychiatrist, I certainly recognized early on in life that it was something different to be a shrink's kid rather than any other kind of doc's kid. I didn't know who my dad's patients were, but they sometimes knew who I was and it sometimes led to some difficult bullying situations in which they were clearly acting out issues not related to me on me. I, in fact, remember being beat up from time to time (not the usual thing for girls in my elementary school!). I didn't see that happening to my childhood friend whose father was the neighborhood pediatrician or the allergist or the orthopedist . . .

It seems to me that the crux of this issue comes down to boundaries. Boundaries are profound, sacred, yet invisible and perpetually in need of negotiation. What's comfortable AND APPROPRIATE for BOTH the psychiatrist AND the patient. I think that part of the power of therapy can be the act and art of negotiation and learning for some how to tolerate looser boundaries while for others to learn how to set and maintain tighter boundaries. No, I'm not talking about relative boundaries or boundary violations, but that boundary crossings can actually build a patient's capacity.

An interesting question! And while I assume that as a urology nurse you get used to seeing folks' business, I think I might need to go back to therapy if faced with Dinah's situation!


Anonymous said...


I appreciate the way you seamlessly weave your personal history into your articulate (may I call it?) defense of psychiatry or at least it's place in medicine as a specialty. However, I think that when Rob, framed the conversation this way (as he was trying to come to grips with defining "moron") set up a straw argument. There is no movement to demedicalize psychiatry and make it an allied health profession. It was an insult designed to provoke better people to spend time defending their right to their
Obstetrics is different from orthopedics which are each different from primary care. One of the most amazing differences that we get to experience in psychiatry is the experience of witnessing someone else not only healing, and articulating the humaness of that healing, articulating
it, or, if not we sometimes see them behave differently as humans.
It is like one you Shrink Raps said on the podcast about
"nervous breakdowns". Patients use that term sometimes because it makes sense to them. Being bipolar will never be like having chronic severe asthma: "psychiatric"
illnesses are experiences people have to make sense of for
themselves. Without shrinks to help them with the experience: control the symptoms and immediately frame the experience as illness and, therefore, essentially human the illness continues and the stigma worsens for that
When an OB catches a baby, everybody in the room holds their breath until the baby breathes. In psychiatry, we have
to (mostly) keep breathing until someone has an "Aha!"

Steven Reidbord MD said...

I also liked Meb's comment... thoughtful and very human.

I believe the urological scenario is awkward for two reasons, only one of which is unique to psychiatry.

The unique aspect is our use of dynamic psychotherapy, a doctor-patient relationship notably different from those in other specialties of medicine.

The nurse in this urological encounter acted quite atypically for an ex-therapy patient... so maybe she wasn't one. Such patients usually avoid even the most casual social encounters involving their therapists. Many feel acutely uncomfortable and choose to leave a social gathering if their therapist is spotted there. The safety of the therapeutic frame is lost outside the consulting room, and anxiety often results. If the nurse HAD been in therapy with Dr Mind, I would be concerned that she is hiding her discomfort, or (as another commenter wrote) has sadistic or hostile intent.

The other consideration doesn't especially distinguish psychiatrists. This is the matter of dual roles. Medical (and psychiatric) encounters are fraught with safety and vulnerability issues. Interpersonal boundaries allow comfort in such situations, and one such boundary is avoiding mixed or dual roles with the other participants.

Dinah is right: Surgeons operate on colleagues, and in small towns you may socialize with the doc who delivered your baby. But it isn't ideal or, if truth be told, particularly comfortable. Maybe necessity requires it, or everyone puts on a brave face and makes the best of it. Even so, I'd wager male gynecologists rarely socialize closely with patients, even with their spouses included. The urological example is similar: Dr Mind prefers to avoid a dual role with his ex-patient, with whom he had a close relationship of a different sort. If she fails to anticipate this discomfort in her patient, he should speak up himself, as diplomatically as possible.