Wednesday, June 23, 2010

On Being a Psychiatrist

Here is a little story I wrote, depicting some musings on being a psychiatrist. I wrote it a couple years ago, for a Minnesota Medical Association little writing contest. They did not see it as a winner and therefore not fit to print. If you still wear Birkenstocks, raise Llamas, vote a certain way, and present a certain, non-disquieting view of medical practice, well that may make for a better and potential printable winner, so that rules me out. We do like our realities to be in a certain way up here. The stuff we know:  we know The stuff we don't know: does not exist. Its mostly the stuff we don't want to know: does that exist?


Joseph J. Sivak MD

            "The shiny brown leather couch glistens in the late afternoon sunlight. The couch envelops the supine patient. A bespectacled gray-bearded man in a brown herringbone tweed three-piece suit sits in a cherry-spooled rocking chair a few feet behind the patient, frantically taking notes. The psychiatrist directs the patient, “Tell me how you feel about that.”
            The patient a perpetually shy woman of about forty years shifts on the couch and obsessively twirls her pearl necklace and chews on the white beads, as a grandfather clock on the other side of the room seems to tick more loudly than ever. The patient struggles with her analysis. The psychiatrist pulls out a gold-chained pocket watch from his vest. “Hmm…times up for today. See you tomorrow at four.”
            The patient hastily rises from the couch, walks out of the room and pays her bill to the receptionist, handing her cash from her purse. It is a bill for services to have ones head shrunk, to become actualized.
This archetypal image has little resemblance to the modern day twenty first century practice of psychiatry. Hollywood holds dearly to this quintessential image, as does a vast portion of society. It is a romantic, classic, yet profoundly irrelevant image. In fact I don’t even have a couch in my office, let alone a grandfather clock. I do own a three-piece suit somewhere, but have not worn it since the eighties.
The patient scowls across the room at the harried doctor. The doctor has fifteen minutes with the patient and unfortunately has three people waiting in the crowded waiting room and he is already 45 minutes behind. The patient barks, “You better give me some klonopin or adderall dude, cause if you don’t, I don’t know what’s gonna happen. I might violate my probation and I’m not going back to prison. I’m gonna hurt somebody if you don’t give it to me dude.” The patient is agitated and twirls the chain on his wallet in one hand and beats a cell phone against his leg with the other.  The psychiatrist hears someone in the waiting room loudly swearing at the receptionist for having to wait so long.
This scene may be somewhat more realistic for many modern day psychiatrists, but not as classically romantic as Hollywood wishes for.  When I was in medical school and I chose a residency in psychiatry, I still held on to a bit of the classic archetypal image. The image implied that the patient actually wanted to be there, and happily paid their bill. I liked the idea where the patient developed new insights into their unconscious and became healthier. The idea that almost everything had a meaning and was precisely interpreted was most appealing.
Many myths and misnomers abound in regard to the modern day practice of psychiatry. Many people believe that psychiatrists are extremely wealthy. They stare in disbelief during conversation, when I advise them that psychiatry is the second lowest paid specialty in medicine. They are shocked when I advise them that most medical students don’t choose a residency in psychiatry because there is relatively little pay compared to other specialties. They are dumbfounded when I advise them that 90% of my patients don’t pay in cash or check or credit card and that the vast majority of my patients don’t pay anything at all for their psychiatric care.  It seems that it is much simpler to hold on to the classic romantic view of psychiatry.
Another popularly held myth is that most psychiatrists are a bit crazy and simply go into psychiatry to figure themselves out.  Sometimes I ascribe to that view, but I can honestly say that the rate of craziness is probably not any higher in the field, than say surgery, or the legal world or carpentry or any other line of work. The psychiatrist just hangs around professed psychopathology all day. But you can’t really catch mental illness per say in the same way you catch a cold.  Most psychiatrists are actually rather humane, empathic individuals that chose the profession because they were interested in truly helping their fellow human being.
Ideally, in medical school, I felt psychiatry may have bridged the gap between the art and the science of medicine. It starts at an infinitely tiny point, namely the human brain and explodes into every scholarly domain. It touches philosophy, sociology, art, history, biology, chemistry, anthropology, linguistics and psychology to name a few. 
            After practicing for fifteen years, it is so very different from what I idealized back when three piece suits where still in style. The pressure like most areas of medicine nowadays can be ungodly. Idiosyncratic pressures in the field are abundant. For example psychiatry is the only field where one might be sued for malpractice, for failing to protect someone you never knew existed.  Depending on circumstance, the psychiatrist may be held liable if their patient harms someone else. The degree of violence in society is astounding and dictates the scope of many psychiatric practices in America today. Violence often stems directly from early abuse and neglect and a lack of human regard and connectedness.  A large percentage of my patients grew up around violence and abuse with very little familial nurturance. Simply having no other option, be it determined by nurture or nature, they continue to perpetuate the cycle and are often predisposed to anger and impulse problems. Unfortunately for some the psychiatrist often becomes the displaced object of that anger. Every year in this country a significant number of psychiatrists are assaulted and one or two actually murdered by their patients. The threat rivals that of a busy emergency department, but the psychiatrist’s office is usually not equipped with armed security, unlike a busy intercity ED.
            It is often common for a patient to visit a psychiatrist’s office for some reason other than coming to get treatment for an illness. This was something never taught much in training. Reasons range from: staying out of jail, to getting ones children back from social services, to getting disability income, to improving their divorce outcome, or to keep their job.  Often when there is some primary reason for being there other than getting treatment, the person may feel everyone else, including the psychiatrist has a problem.  Pulling the psychiatrist out of the role of physician and into a role of manipulating ones social environment can often have little to do with true patient advocacy or treating ones mental illness and making the patient healthier.
            Another strongly ascribed to fallacy is that psychiatrists are all just “pill-pushers”.  The truth of the matter is that most medications can and do eliminate psychiatric symptoms and alleviate suffering, but in 2008 most medications do not essentially cure or heal mental illness. There are fascinating breakthroughs in the understanding of the plasticity of the human brain and discoveries of such substances as brain derived neurotropic factor. The mapping of the human genome also has profound implications for psychiatry, but we are still hard pressed to prescribe a medication that heals psychological wounds and cures psychopathology. Yet in our fast–food, Madison Avenue Based society there is much pressure and unrealistic expectation to simply prescribe a “happy pill” or a “normal pill”.    
            At this point in time till proven otherwise, the healing component directly relates to and takes place in the relationship between the patient and the doctor. The psychiatrist often becomes the only safe and stabilizing figure in a patient’s otherwise chaotic, entropic life. The doctor often becomes a nonjudgmental empathic entity that the patient can depend upon. In this sense there is almost a re-parenting process that takes place, in the transformation towards psychological healing. Indeed some strictly biological psychiatrists would scoff at this idea, while at the other end of the spectrum non-physician psychotherapists often believe that the psychiatrist does not even talk to their patient in lieu of simply pulling out the prescription pad and begin scribbling on it. Most good psychiatrists, the ones that actually take care of patients all day know better. The medication prescription often takes on more than biological implications. It takes on metaphorical proportions as a symbol of the most ancient of archetypes the physician patient relationship and the healing that takes place.
            The ultimate loss of a patient comes in the form of suicide. When a patient walks out the door of the office, the doctor can never be 100% certain that a patient will be safe from harming themselves. Even when the psychiatrist does everything within their clinical capabilities, they can not always save a patient from themselves. This is in the context that depending on the practice, a psychiatrist may treat hundreds if not thousands of patients a year who are chronically suicidal.
            The academic challenge can be more elusive. It is true that there is little that surprises or necessarily intrigues me about human behavior anymore. Another Hollywood misnomer is that the average psychiatrist finds human psychological aberrations so very interesting. Indeed at a dinner party when the conversation turns to some strange behavior in someone’s uncle, all eyes turn to the psychiatrist for a response filled with alacrity to hear more. I suspect this is true for the psychiatrist that sees three patients a week. Most see many more. Many psychiatrists would rather discuss baseball or Beethoven or bookstores when away from work.
It is true that I have heard tens of thousands of narrative life stories filled with anguish, terror and pain, and after one or two pieces of information I can usually fill in the rest quite accurately in the narrative. This can lead to a cynical attitude in the psychiatrist, or conversely it can be used as a gift to help patients feel cared about and understood. The understanding comes from a perception of an uncanny clairvoyance on the part of the doctor and empathy for the patient by making the patient feel that their story is unique. When they are sitting in the office, their life story is the only thing that matters to the doctor.
Over the years it has also become apparent to me that the mentally ill can not always speak for themselves or stand up for themselves. The current health care climate continues to perpetuate this phenomenon. There is a greater responsibility than ever for the psychiatrist to advocate and help fight the stigma of mental illness. This can only help each of our individual patients that struggle with these issues.
So from that ideal image I conjured up almost 20 years ago to today, my perceptions have changed a bit. I felt the job would be energizing if not invigorating. What I have learned is that the human psyche and spirit only has a certain amount of positive energy to give and so much negative energy it can absorb. The end result can sometimes be a daily mental and physical exhaustion.  It is a job in which one is obligated to give 100% of their spirit and psychological energy in treating their fellow human beings. The real joy comes from the fact that we have a gift in the responsibility to give and to care for our fellow human being. This joy touches not just psychiatry but all physicians. Despite the pragmatic realities of health care and our technological fast-paced world, and the continued reduction of human connectedness in society, the ancient archetype of healer will remain as long as human beings remain.
I know of nothing else that I could do now. It is in my blood and in my soul. Perhaps the joy also comes from the exhaustion of giving ones positive goodness and energy in the name of healing on a constant basis in the physician’s daily professional life. Anything short of that and we should not call ourselves a physician. Perhaps the joy of giving is actually invigorating. Perhaps that gray-bearded man in the tweed suit with the pocket watch felt that exhaustion or maybe that joy."
                                             ©2008 Joseph J. Sivak MD

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Talking about the book with the Lake Superior wind....... a calm day