I Chose the Wrong Profession

Oh, actually, I love my work.  I love seeing patients for therapy and I've seen over and over how helpful medications can be, so I'm glad I can prescribe them, and I love that most people feel better (or they quietly move on and I don't know).  

So far, I chose the right profession.  Hoping that holds for a while.

I entered college with plans to become a psychologist.  I didn't really get the differences between a research psychologist and a clinical psychologist.  My university also offered a major called The Biological Basis of Behavior, and there was a strong graduate program in experimental psychology but not clinical psychology.  I thought I wanted to be a researcher, and I majored in both Psychology and "BBB" (as it was called).  At the end of my second year, I had the thought that I would like to do research but I'd like to see patients as well.  There was no one to tell me that Clinical Psychologists can do both, and so I figured that going to medical school and becoming a psychiatrist would give me more options down the road.  So I went to medical school -- in New York City, where psychiatrists back then were often psychoanalysts and I'd never even heard the terms "med management" or "split treatment" -- and I became a doctor, then moved to Maryland and became a psychiatrist.  I liked that there were so many options, and I realized I really liked seeing patients and that research was more about writing grants (and praying you got them) and concerns with data in a way that I'm not primed for.  

Back then, I had no idea that social workers did psychotherapy.  As a medical student, and even as a psychiatry resident, I saw social workers do family therapy on the inpatient unit and arrange for discharge planning, help patients obtain benefits, and arrange for aftercare programs.  I was well into residency training before I realized that psychotherapy was mostly done by social workers.  

I had no idea that there would ever be any expectation that I would see 3-4 patients an hour and confine my work to asking about symptoms and side effects, much less the time consumption that filling out paperwork (soon to be computer work) would become in clinic settings.  

I brought this up because we've been talking about capitated care versus fee-for-service care on an earlier post.  I think the capitated care folks are winning so far, they seem to like their system.  But in 2012, in capitated care systems, psychiatrists do management, they don't do psychotherapy.  Where would that leave me?  Am I worried?  No, there seems to be a demand for what I do, and neither presidential candidate has come knocking at my door for suggestions, so I'm just hanging out to wait and see.  I am feeling a bit obsolete and like somehow, I ended up on the wrong train. What do you think?

To Shrink or Not To Shrink?

Here at Shrink Rap, we often talk about the stigma of having a psychiatric disorder. It's funny, but society has it almost ranked, so that certain illnesses are very stigmatized--schizophrenia and schizoaffective disorder, and borderline personality disorder, to name a few, and others are pretty much socially acceptable: Attention Deficit Disorder, for example, especially among the high school/college crowd where the patient often gets identified (or self-identifies) as the source for those late-night stimulants that so many kids cop.

It's not just the patients. Psychiatrists are also stigmatized, and that doesn't help much when our society talks about the shrink shortage.

Exalya writes:

I'm a first (almost second) year medical student with a strong passion for psychiatry. I love listening to your podcasts; you give me hope for my future when the drudgery of first year classes is getting me down, and I feel like I always learn something useful.

That aside, I am writing to you seeking some advice. At my school, we are required to follow doctors in family practice clinics periodically during years 1 and 2. Frequently I am asked, "What field are you interested in?" to which I reply, of course, "Psychiatry." It seems like every time an attending finds out that I'm into psych, I get eye rolls and flippant remarks. The most common ones are "Psychiatrists just push drugs," "Talk therapy is garbage," and "You'll talk to patients more in family practice." Do you have any advice on how to deal with attendings who do this? Is this the kind of attitude I'll be facing during 3rd year rotations outside psych?

Appreciate anything you have to offer!

----
From Dinah:

Dear Exalya,

I am so glad you enjoy our podcast! I also got the same nonsense, one of my preceptors told me that I would be more use to society as a plastic surgeon. Great.

The three of us wrote a post sometime back called Who Wants to be a Shrink?...please check it out.

Psychiatry has a lot of options: it is what you make it. You can have a low volume practice and focus on psychotherapy, you can have a high volume practice and madly write prescriptions, or you can mix it up. You can teach, do basic research and never see a patient, be a chairperson or administrator, focus on public health or private health. I do promise you, if you want to, you will talk so much more to your patients than in family practice. I also promise you won't make the money that you would in a surgical subspecialty. There is always the advise the financial aid adviser gave me when I graduated from medical school heavily in debt and insisting I was going in to psychiatry: "Marry rich."

What should you do? Ignore these turkeys. Do what you love and have a career where you enjoy your days. We took a survey recently: 90% of the shrinks in our state said they would do it again (at least of those who answered the survey).

---

From Roy:
I agree with Dinah. You will have lots of flexibility in what you can do. And you do not need to marry Rich or any other guy. As for the flip remarks, you Will get them. Shrug them off as uninformed comments, or as just trash talk to get you to go to their specialty. Just smile and tell them that you hear all the smart people go into psychiatry ;-)

__________________________________________________________________

From Clink:
Yes, I heard comments like that when I was a medical student too: if you become a psychiatrist you'll lose your medical skills, why bother being a doctor if you're just going into psychiatry, psychiatric disorders mean there's nothing "really" wrong with the patient, etc. Twenty years later, I still occasionally hear comments like that---even from friends and family. It's a hazard of the biz. You'll eventually have the last laugh though, the first time you get called to consult on a delirious patient and you can lecture the "real" doctors about forgetting their basic psychiatry skills. You'll also see how the karma plays out during residency: all the surgery and internal medicine docs will be miserable while the psych residents love their work and their patients. And really, psychiatry IS a lot more fun than any other specialty. Don't be too hard on the docs making ignorant comments. They're jealous.

What Makes A Good Therapist?

This is for Dr. D.

We were having lunch when Dr. D mentioned she wanted to write a book aimed at teaching residents how to do psychotherapy. It would start with a section on What Makes a Good Therapist? What does she thinks makes a good therapist? Real life experiences which impart an ability to empathize. Do we grow from our own difficulties? More specifically, do we grow in to better therapists? I asked another shrink this, and he said that people like to believe there is some meaning to their suffering, and perhaps it's nice to believe that if you've been stuck suffering, then it makes you a better therapist, but he wasn't so convinced it was true. Me? I don't know, maybe. Or maybe not. Personally, I'm fine with the idea of not suffering, at all, ever again, so long as I live.

In residency, I was taught that warmth and empathy are important to being a good therapist. Empathy would speak to Dr. D's theory. These are hard things to teach--- I don't know how you make someone feel what they don't feel and empathy is there or it isn't. I do think people can learn responses that get perceived as empathic, and that this is important. When a patient talks about sadness around an issue and the shrink does not feel empathy, it's still important to have a modulated response that acknowledges the patient's feelings-- this sounds terribly difficult....tell me more about how you are feeling...or kind, gentle, silence, but not, "Yeah, yeah, well I'm glad your old hag of a cousin died, she was never nice to you anyway."

So what do I think makes a good therapist? The ability to listen and hear what the patient is saying, even if the shrink doesn't agree. A non-judgmental stance, and this can be harder than it appears. It seems obvious, but it can be hard when a patient talks about hard-to-hear things, such as a pro-racism viewpoint, or disliking people of the doctor's religion or political party, or feeling happy that another person is person is suffering.

Non-dismissive is even better. No one wants to hear that their feelings are stupid or unjustified.

Kind. That's important.
Probing in a way that brings up new information and insights.

Mostly, I think therapy is about pointing out to people their patterns of behaving and responding in a way that is not so painful that the patient becomes defensive, and lets the patient choose to make changes in these patterns. Some patterns are harder to break than others, and the really entrenched one are often components of one's personality.

I'm not doing so well here. I Googled What Makes A Good Therapist, so you can check out these links:
http://www.therapist4me.com/what_makes_a_good_therapist.htm
http://www.therapists411.com/therapist-information/what-makes-a-good-therapist.html
http://askdrrobert.dr-robert.com/goodtherapist.html
http://www.goodtherapy.org/what-is-good-therapy.html

From here, I'll leave it to you. What makes a good therapist?

Unhinged-- The Trouble With Psychiatry by Daniel Carlat, my Review

Unhinged. The Trouble with Psychiatry--A Doctor's Revelations about a Profession in Crisis by Daniel Carlat.


Disclaimer: I wrote this book review while I was working on the final draft of our own book, so it's hard not to compare our book and style to those of Dr. Carlat. Ours is better (just so you know). This is not the result of a controlled study and there was no pharmaceutical agency support. It's simply my biased opinion.

So, I started out poised to hate this book. Dr. Carlat is a shrink/writer who has both a blog and an e-newsletter. He has a good reputation in the medical blogosphere, at least I think that's the case. So why was I poised to hate the book? I was offered a review copy by the publisher -- an inquiry email came with hype: "Carlat exposes deeply disturbing problems plaguing his profession." “The shocking truth is that psychiatry has yet to develop a convincing explanation for the pathophysiology of any illness at all.” "This has to stop—and it can. Throughout the book, Dr. Carlat provides empowering advice for prospective patients, describing the kinds of treatments that work, and those that should be avoided. In the final chapter, he provides a powerful prescription for how to get psychiatry back on track."

Yup, it's true, we don't know the actual pathophysiology of most of the psychiatric disorders. Is this shocking? Deeply disturbing? We've got a long way to go and we've got issues in our field. . Does it help to use language that sensationalizes these problems? It's kind of shocking that we haven't cured cancer, dementia, or obesity . I started reading. Carlat presents the fact that we don't know the actual causes of psychiatric disorders as though it's some big secret, something we purposefully withhold from our patients. He doesn't say that exactly, but he implies it with statements about how doctors don't like to admit what they don't know.

Okay, so the book is full of Carlat's epiphanies and revelations: he starts with the realization that it is limiting to see patients for a 50 minute evaluation, write a prescription, and then have the patient come back in a month for a 15-minute visit and refer them to a social worker or psychologist for therapy. Maybe this isn't the type of practice Dr. Carlat was meant to have! It's the way some psychiatrists practice, but it is not the way all psychiatrists practice. He writes as though this is the standard in the field and what we're "taught" to do. It's what some docs do and are comfortable with, but we aren't told that this is how you must practice, and no one packages this version of care as the best, highest standard of treatment. I personally don't like that he peddles the notion that a large volume/brief contact practice is the only thing psychiatrists do.

Later in the book, he talks about the use of therapy by psychiatrists, and discusses one psychiatrist who sees patients for psychotherapy -- she lives in a rural area and she makes half the income of the average US psychiatrist. She is the only psychiatrist he talks about who sees patients for psychotherapy--the others are a now-retired, lost generation of older docs who had it right. I know psychiatrists with psychotherapy practices who make reasonable livings. He doesn't even touch on this possibility, and in a single sentence he dismisses the idea of a fee-for-service, non-insurance based practice. It's not reasonable to present the field in the light that all psychiatrists do is write prescriptions....quickly and badly at that...and that there's no time for thoughtfulness. It got me thinking that -- at least among Shrink Rap readers -- and our informal, non-scientific polling reveals that 44% of readers who responded see their shrink for 45-60 minutes per session (the most frequent answer by far) and that less than 20% of readers see their psychiatrists for 15 minutes or less. Granted, we may have a skewed readership of those who are thinking a lot about their care and perhaps more apt to seek out something more fulfilling. A quarter of our readers see their psychiatrist weekly (also the most common answer but not by much), about the same number who see their psychiatrists every three months. At least among Shrink Rap readers, we can conclude that psychiatrists practice in a variety of ways and it's not uncommon for people to see psychiatrists for 50 minute sessions, or to see them weekly. I'm sure this varies depending on the region of the country, the availability of psychiatrists, the financial needs of those psychiatrists, the setting in which treatment takes place, and the role insurance has in determining care, and the age of the practice-- with the idea that patients may start out with weekly treatment and move to every one-to-three months after they get better. But Carlat glances over those issues. Dr. Carlat notes that fewer docs offer all their patients psychotherapy. One of the figures he quotes is that only 11% of psychiatrists offer psychotherapy to all patients at every visit. Hmm... All patients. Every visit. Some of this might depend on how we each define psychotherapy -- and there is no standard to that -- but if I was asked this same question, I'd say No. I work a half day a week in a clinic and there I see patients who also see a social worker/therapist. I see two patients an hour there, and sometimes they talk and I listen and sometimes it feels a lot like psychotherapy, and sometimes it doesn't feel anything like psychotherapy, but I would say that No, the therapy is done by the social workers and I don't "offer" psychotherapy to "every patient" I see in every capacity of my practice of psychiatry. And I would ask, "how exactly are you defining psychotherapy?" Read the Shrink Rap book (Spring, 2011) and we'll talk more about this. Interestingly, by the end of the book, Carlat talks about doing psychotherapy in 20 minute sessions.

Okay, so he says psychiatrists are taught to write prescriptions and aren't taught how to do therapy. Only he talks in some detail about his therapy supervisors, their thoughtful insights, how he was supervised in a psychodynamic style, and later he talks about how his training program educated residents in Cognitive Behavioral Therapy. Are we taught therapy or not? This all sounds quite reasonable-- what's he complaining about? For the record, I think I finished training at the same time Carlat started (so, 3 years earlier than he) at an institution with a strong biological focus, so I don't think our differences in opinion on how docs practice is about orientation or timing .At the end of the book, Carlat proposes some solutions: Psychiatrists should NOT go to medical school, it's a waste, and they should have more stream-lined training. All psychologists should be taught to prescribe medications. He had no problems with the DOD program in Louisiana, where 7 years of the program taught a total of 10 psychologists to prescribe. He says this type of program is safe and works well. He fails to note that it cost the military over $600,000 per psychologist (why? no idea?) and that's why they stopped it. Or that it did not decrease the mental health treatment shortage in Louisiana. I'll spare you my rants, you can read about psychologist prescribing here, in a piece by Ron Pies and the article does reference Dr. Carlat. He talks about his own revelations that Cognitive Behavioral Therapy works well, that it's good to ask a patient with a recurrence of depression if anything is going on in their lives (funny how that works), and how he he now does a brand of therapy that he calls "therapy lite." I found the examples to be a bit condescending -- his description of therapy sounds a bit like common sense.

Carlat's book may make him enemies. I'm wondering who his audience is:

-- it might appeal to the anti-psychiatry audience, at least from the cover hype, only much of the book is a fairly reasonable discussion of our work, and so it's not really anti-psychiatry.

-- I don't think many psychiatrists will agree that medical school should be done away with for us, or that other professionals can do what we do as well and as safely.

-- The alarmist tone just didn't go over well with me.

-- Sometimes it felt like he quoted studies when they fit his agenda. There were several mentions of how psychiatrists feel inferior to other doctors, and I'm not sure what to make of that one. Is this a universal phenomena?

-- His bash on how pharmaceutical companies interface with psychiatry include some of our major psychiatrist players here. But if you want to hate the drug companies, this is the book to read.

So what was good about it, why did I read it to the end, and why would I ever put this review on Shrink Rap? After the beginning, Carlat presents a reasonable view of how the DSM is crafted, including the controversies about disclosure in the process of writing the new DSM-V. The most interesting part of the book, however, is his discussion of how the drug companies have influenced research, publications, and practice. Some of this I had read in the New York Times. Some was news to me. I've never seen this side of the pharmaceutical hard-sell -- it was interesting, a bit shocking, and definitely eye-opening. His insider's view of this world is revealing.

So is Daniel Carlat the emissary of truth and ethics while the rest of us remain busy trying to get the big bucks by seeing too many patients too quickly or by getting money unjustly from the pharmaceutical industry? Read the book and see what you think.

Shrunken Shrinks?

Midwife with a Knife writes:

"Hm... so I'm not sure it's fair to make psychiatry residents have psychotherapy. After all, nobody made me have a gyn exam or give birth as part of my ob-gyn residency!"

It's been a common theme in our comments, this idea that one needs to walk in the shoes of the patient to truly empathize. One commenter even wanted all med students to have a couple of electroconvulsive therapy (ECT) treatments!

So let me talk for a moment about the whole concept of psychiatric residents having their own personal psychotherapies. It started as part of psychoanalytic training (and remains a requirement in order to become a psychoanalyst). The idea isn't to empathize, or to experience what the patient feels, the idea is that the analyst must understand and work through his own unconscious conflicts in order to effectively work with the patients. He must be able to recognize his own counter-transference, know which issues are his so he isn't projecting them on to the patients, and be aware of his own unconscious motivations and conflicts. It sounds good, I have no idea if it works. I'm also not a psychoanalyst and I've never been in psychoanalysis, so my knowledge is limited, and this whole last paragraph may be a bit off or misstated.

Some residency training programs encourage residents to have their own therapeutic experiences. Where I went to medical school, residents would openly post that they were off to therapy or analysis, and it was both expected and encouraged, and trainees would leave the hospital four and five times a week to lie on the couch. Where I trained as a resident, I was aware that some residents were in therapy, but it was never openly announced in public-- it was something that was either done quietly or on the residents' time-- I believe if a resident working on an inpatient unit announced they had to leave for therapy, it would have been frowned upon during working hours. The residents were expected to be doctoring and leaving th for the hospital for treatment in the middle of the work day was not encouraged.

It's hard to learn therapy. It's a process over time and there's not a great mechanism to watch it unwind. Having it oneself probably provides at least one example, and that can't be bad. Most supervision occurs based on notes or the resident's report and so it is skewed, the supervisor can't always be sure the reporting is accurate or necessarily get a great feel for an unseen patient. Yes, there is "mirror" supervision (where the supervisor watches the resident with a live patient), and this is a terrific learning experience, but there isn't really a way for a trainee to be a fly on the wall of an older, more experience psychotherapist over time. Being your own experiment may help with the learning curve, but I'm not aware of any programs that require it. Is therapy required (as opposed to encouraged) to become a social worker or a psychologist? If so, does the program pay for it, does health insurance, are there discounted ways of getting treatment, or does the trainee pay for it? And for how long and how often?

Does one need to have therapy to be a sympathetic human being? Absolutely not. In fact, one can have years of therapy and still be a creep, while another person can be a wonderful therapist even without having been a patient. Nor does one need to have chemotherapy to understand that cancer sucks, or have AIDS to treat it with kindness. As MWAK has pointed out, many child-free people have delivered wonderful healthy babies and rendered terrific care to their pregnant and delivering mothers without ever having had the experience themselves. And if one has never psychotic, can one truly appreciate the pain it causes: I doubt it. Is it necessary to feel that pain in order to render good care? Of course not.

Sometimes it brings people comfort to know their doc has been there. Substance abuse counselors are often open about their own past histories with drugs. A friend with cancer is now seeing a therapist who is a survivor, and she feels very comfortable with this. I have always been comforted by the idea that my children's pediatrician is himself a father.

But you don't have to have panic disorder to treat it. You don't have to have suffered with depression or schizophrenia or obsessive compulsive disorder to treat it or to appreciate that someone else is suffering.

Should psychiatrists undergo their own psychotherapy?
Oh, everyone knows what I'll say: yes, if they want to.
I believe that most people who are drawn to being psychotherapists have a somewhat analytic nature. They like to look at patterns and relationships (maybe they even like to blog about them). They are curious about what makes humans act the way they do, and by extension, they are probably interested in what makes their own psyches tick. Furthermore, people who practice psychotherapy tend to believe in it's power, they feel there is value in articulating emotional life and in examining the internal world. Given this, a personal therapy may have some appeal, with or without the presence of a psychiatric disorder. (I'm not going to even touch the question of who should pay for it if the psychiatrist doesn't actually have an illness...). If the psychiatry resident wants to have a personal psychotherapy, he should. If he has a psychiatric illness, he should get treatment. But a psychiatry resident who is not ill, who is not suffering emotionally, and who is able to work and to love and who doesn't want to have psychotherapy should not feel compelled to do so for it's own sake. And, by the way, if he later decides it might be helpful, there's no time limit on when, it's not just for trainees.

Are there studies? I don't know of any that randomly divide shrinks who've been shrunken from shrinks who are unshrunken and then looked at their treatment successes with patients....

Should Psychiatrists See Patients for Psychotherapy?

The trend is for psychiatrists to see patients for psychiatric evaluation, treatment with medications, and a medicalized version of psychiatric care, while parceling out psychotherapy to non-MD psychotherapists-- social workers, psychologists, licensed clinical counselors, nurse therapists, pastoral counselors (and anyone else who wants to listen...a bartender or two, perhaps the hair stylist).

Those readers who've been following Shrink Rap for a while know that I work in two types of outpatient settings: a community mental health center where I see people to treat their mental illnesses with medications, and a private psychotherapy practice where I use medications but I also provide psychotherapy to patients who want and need it. ClinkShrink sees patients in forensic settings (name your jail) and she sees a remarkably high volume of patients. She deals exclusively with medical issues-- patients may say or hear things that impact them positively, but the formal setting of therapy to talk, as a process over time, to resolve specific issues, to deal with past events, and to alter patterns of behavior, is not what she does. Roy has worked in many settings, but his current hat is as a Consultation-Liason psychiatrist in a large community hospital-- he mostly evaluates patients and makes treatment recommendations, but he doesn't see outpatients over long periods of time. He used to do that.

Psychiatrists (in the old days) used to see people for psychotherapy routinely, especially before medications were available. I think I was finished with medical school before I even knew that social workers saw clients for psychotherapy. I thought they met with families, worked for agencies, helped with disposition and obtaining benefits, and had a lot to do with foster children and protective services. I believed psychotherapy was the exclusive domain of psychiatrists and clinical psychologists. I simply didn't know.

I've talked here before about why I think, in a totally ideal world, that it's best for patients to see one person for psychotherapy and medications: one stop shopping is more convenient, psychiatric illnesses aren't 'explained' away without the offer of medications, the doc really gets to know the patient and learns to differentiate better what is, and what is not, a symptom of illness or medication side effects, and there isn't a set-up for patients who are prone to dividing their care-takers into good guys and bad guys.

The reality of the world is that psychiatrists are the most expensive mental health professionals, and in the shortest demand. They are more expensive to train, they often finish school heavily in debt, and there aren't enough to go around. And psychiatric residency programs, for the most part, don't emphasize psychotherapy training-- the resident has to pursue it. A psychiatry resident was recently telling me about a patient who wanted insight-oriented psychotherapy and the resident said, "We just don't have time in residency to do that." For those who know they want to pursue a career in research, spending a lot of time learning to do psychotherapy may not be a wise use of limited time. Some people might go as far to say that it's wrong to have psychiatrists doing psychotherapy, especially in shortage regions where there aren't enough shrinks to go around--- a lot more patients can be seen for quick med checks than for 4 times/week psychoanalysis (-- I'm not a psychoanalyst, by the way).

I believe that people should do what suits them, given the realistic constraints of their environment. I'm even okay with the psychiatrist beauty queen. With regard to psychiatrists doing psychotherapy: I like the work and there seems to be a demand for it. I also work in a clinic where the option does not exist to do this kind of work, but it does afford me the opportunity to see a different population of patients and to work as part of a team.

(Roy made me proof read this; my first draft was a disaster.)

I'm Proud of My 'Kids'

I have a nice little cadre of students these days. They are young, bright, enthusiastic and at times a little anxious and intimidated. They are a wonderful group, and it's my job to figure out the best way to teach them what they need to know. They have a lot to learn and a limited amount of time to learn it in. Information is being thrown at them fast and furiously from several faculty sources. It's their job to catch it, retain it and somehow organize it for future use.

Eesh, I'm glad I'm not in their position anymore. It's tough.

People learn differently, and from year to year each group of students has their own preferences about teaching methods. Some want lectures, some want case conferences, and some just want to be left alone to read on their own. I find that we tend to cycle through these preferences on a regular basis, responding each year to the preferences of the previous years' students while hoping that some day the two years' preferences will match and all will be happy.

That's never going to happen, but I don't mind trying. I like the idea that some day years down the road I will have a group of folks whom I've helped propel along the professional path and whom someday I'll be pleased to call my colleague. It's the next best thing to having kids, without the driving lessons and diaper changes.