Object-Level
Could you give me a run-down of the components of a normal day in your field?
“Sure, I’ll give you a day in my life of psychiatry, although depending on where you practice, a psychiatrist's day can look different. For me as an out-patient psychiatrist, I spend most, if not all, of my time in an office in a private practice setting. My day consists of seeing patients from 9-5, though some days run a little bit longer. I have two nurse practitioners who also work with me. We see a lot of patients for different types of things. Some of us manage medications, some people in the group do most of the counseling, but for me as a psychiatrist, I do medication monitoring, some therapy work, and I do that the entire day. As a side, I do some speaking and lecturing to educate people about mental health issues.”
How does this differ from the average practitioner?
“Most practitioners probably do something very similar. I believe there are two differences. The first is that when I sit down to talk with someone, my focus is their emotional health and well-being, whereas primary care doctors may need to talk about diabetes management or blood pressure issues. The second difference is that while a primary care physician may have an appointment of five minutes, my appointments are typically twenty to forty minutes. New patient appointments certainly are longer – about an hour and twenty minutes. And everyone differs in how they do this in psychiatry.”
Can you give me a more detailed outline?
“Sure. So I go to my office in the morning, and we usually have messages or prescription requests that have come in overnight, and we try to get caught up on that before our first patient of the day. Then at 9:00 I start with my first patient, and continue until lunch. Sometimes I eat lunch while working, because I have things to deal with. Then from 2:00 to 5:00, I’m back to talking to patients. At 5:00, my day of seeing patients ends, but then usually I have a stack of patients to call and prescriptions to write.”
What does a bad day in your field look like, and how does your definition differ from the average psychiatrist’s?
“A bad day for me means that on that given day more patients need me for longer periods of time – and I always want to give people the time that they need, but everyone has an appointment slot. If there’s a lot of patients who are having a difficult day, then that can sometimes feel like a lot. The other thing about a bad day is that I really am grateful to be a part of people’s lives, and help where I can, but it’s hard to see people at a really tough time in their lives. As much as I have a doctor hat on, I’m also saddened when someone is really struggling.”
What is your physical environment like?
“The goal with my practice was to create a place that feels less clinical and more homelike, because I really wanted people to feel as comfortable as they can when they come in. I do have a desk in the office to help me write my notes and so forth, but I have lots of options for places people can sit. There’s a sofa, there’s a recliner, and even smaller chairs for the children that come in. I grew up as a comic book fan, so I have a wall filled with superhero memorabilia as a way of letting patients know they can embrace their own interests and whatever makes them the way they are. It started with a single Superman statue, but kind people over the years kept bringing in things.”
Sometimes medical students intent on becoming surgeons find out they can’t take the sight of blood. They may shift towards a less sanguine specialty or abandon medicine altogether for that reason. What “deal-breaker” stressors are unique to psychiatry?
“I would say that one of the most challenging aspects of psychiatry is when people are really struggling, you’re talking about issues of life and death. There are times when, unfortunately, people feel so low it’s hard for them to imagine moving on to the next day. That can be really hard. We usually go into this field because we have empathy, and yet if we don’t have boundaries around our empathies, it’s easy to have all of that absorb and take over. I think that when people go into this field, they want to be really clear on their boundaries, so that they don’t have their own emotional health affected by their patients.”
If someone has too much empathy, and lacks the ability to compartmentalize, might psychiatry not be the right choice for them?
“My thing is that empathy in any form is a gift. I think that those of us that have empathy should not hold back on our level of being able to relate to people and understand how they feel. But every gift can become a burden if you don’t have boundaries. At the end of my day, after I’ve said bye to everyone, I look at my list of patients of that day. For each of them, I spend two minutes thinking about what else I could have done for them. If I don’t come up with anything, I move on to the next patient. If I do, I call that patient and tell them what I came up with. When I get to the bottom of the list, I turn that page over, and say a prayer or declaration of gratitude. Then, when I leave the office, I don’t think more about it. That doesn’t mean I stop caring for my patients, but I set an intention to do my best, and now that I’ve done my best, I need to let the rest of it go. It’s important whatever an individual practitioner uses for a boundary, but it doesn’t mean that you shouldn’t go into psychiatry if you have too much empathy. In fact, I’d say we need people with more empathy. But we also need to be very aware of how to keep our boundary in place so it can be something we can do in the long run.”
Can you paint a picture of your psychiatric training and residency? What was the average day like during this period of your life?
“After medical school, I started a four-year psychiatry residency at a university, combined with a fellowship in child analysis – which took five-years total. The residency/fellowship process varies in form depending on where you are in the course of the residency. The first year is called an internship, and you do a balance of psychiatry and other fields of medicine, because at the end of the day you are a trained physician. Part of my time in my first year was spent in pediatrics, and the other part was in psychiatry. For psychiatry in my first year, I was in an in-patient hospital setting, taking calls in the emergency room. If I was on-call, that meant coming to the hospital early in the morning and having what amounted to a typical day, but staying for the evening with my pager ready. That could have been an all-night experience, or it could have meant I got some sleep in between. The next morning, I got back up after having slept in one of the hospital rooms. As you go further into your fellowship, schedules get better. In the later years, we had clinical work, and fewer unplanned cases.”
During your residency, was there an event or collection of events that changed the way you practiced medicine, the way you interact with patients, or your general relationship with psychiatry?
“There are two situations that come to mind. One was a very young child – one of the first children I had seen. This was when I was still in medical school, on a rotation in child psychiatry. The child would have been about three years old, and she was in the hospital because of what was called a ‘failure to thrive’, meaning that she wasn’t growing and developing the way she was supposed to. After many different work-ups, we realized there may be something more going on emotionally with this child. That’s when I really started to appreciate the deep relationship between our emotional and physical health. And then I would say that some of the toughest patients you have to treat are the ones you learn from the most. It’s easy to get frustrated when you have a difficult case – we’re all human – but I think the lesson to be learned is in why the patient is resistant to treatment or difficult to work with. Then you realize that it all stems from pain, and so we still have to be persistent to help them describe what their pain is.”
Meta-Level
Do you find your work meaningful? Is meaningness contingent on specific things, or is it intrinsic to the work?
“I think it’s incredibly satisfying to be a part of someone’s journey, as they’re learning about they’re own self-worth and how to balance their lives. It’s incredibly rewarding to see people grow as a result of what was really challenging, and find out that there was purpose even in the most difficult times. I think it is intrinsic to the work. People come to see a health-care provider because they’re hurting or suffering in some way. To be a part of fixing that is what I find satisfying. There is something incredibly rewarding about being part of that.”
If you were trying to dissuade someone from becoming a psychiatrist – or test their will to become a psychiatrist – what would you tell them?
“I would really want to hear what they’re motivation is to be a psychiatrist. There are a lot of ways to make a difference in people’s lives, but I would want to hear that they have a specific interest in helping people with their emotional health. If it was something other than the empathetic approach to helping someone who's suffering, then I think there may be other things they should do than psychiatry.”
On the other hand, if you were trying to persuade someone to become a psychiatrist, what would you say?
“The best thing that I can say is that there is a growing need for more people in the mental health field. The great news is that the stigma around mental health is very quickly being chipped away at, and as that happens more and more people are going to understand the importance of getting help for whatever they may be going through. We’ll need more practitioners to meet that rising demand. While the satisfaction of the field is something that’s a privilege on its own, there will certainly be more job security for people entering the field.”
What is the rate of change of information, important paradigms, and established thought in the field? How often do earth shaking things get introduced?
“The part of psychiatry that has to do with pharmacology, and the science behind mood disorders, thought disorders, and anxiety disorders both are in flux. It’s astounding how medications have become so specific in where they work in the brain, and what type of neurotransmitters they have an effect on – all of that has gotten better. I’d also say the different ways in which we can screen people to better understand what’s going on with them has improved. You’re less likely to perceive any innovations as ground-breaking if you’re really tapped into the field, but there are some pretty cutting-edge things that are happening.”
Do recent innovations in the field change the way you look upon your psychiatric education? Did your years in school prepare you for how the field changes?
“I have to say I think I had a really excellent training in terms of my residency and my fellowship. My university’s program was well-rounded, so not only were we mentored in ways of approaching a patient pharmacologically – meaning through medications – but we were also given a lot of the training on different therapeutic approaches to individuals and to families as well. I felt very satisfied with the training that I got. Having said that, everything is constantly evolving, and so I think that you have to have ways in which you’re continually updating and educating yourself on new ways of thinking about things, new ways of approaching treatment, and the requirements for continuing education are meant to be a way to do that, but I would say I got a really good foundation.”
If you had to distill the process of acquiring skill, how would you do that? What’s the eat/sleep/repeat loop that you go through to get better?
“You know, to me, psychiatry is great part science, a little bit of art, a little bit of hunch. What I mean by that is the more you do it, the better you get at feeding your intuitive sense of what needs to be done. The rest of it comes with educating yourself, but nothing is going to match the hands-on, day-to-day training you get just by seeing people.”
Domain
To what extent does talent matter for succeeding in psychiatry? This could be a very vague question, but it’s known that journalism and athletics require a high amount of initial talent, and something like dog walking does not. (I could be wrong about that.) Where does your field fall in between those two extremes?
“I think that there is talent in the form of your personal gifts. Empathy is a gift that comes into play every single day as a psychiatrist. Your ability to be compassionate is another gift that comes into play for sure. The whole process of getting to this point, getting through the rigorous years of medical school and residency also require the gifts of perseverance, and it requires being organized in the way that you go about things. In terms of the skills of the practice, like conversational skills, intuition, your ability to listen – you just get better at those things with training and with time. Listening is a major skill. In this field, it's really important to be able to listen as much as it is to speak.”
How could someone find out if they have talent or potential in psychiatry?
“Mentorships, and talking to someone in the field. Once you’re in the process of becoming a physician, your rotations are really important. My problem with the psychiatry rotation is that they only show one part of what it’s like to practice psychiatry. For example, your rotation could be in inpatient care, but what I do now is nothing like that. If you talk to more psychiatrists, keep in mind that two practitioner’s day-to-day lives may not resemble each other at all. The more people you talk to, the more you’ll have a hunch as to whether you want to do this or not.”
What factors – besides the obvious ones like engaging in lots of deliberate practice, being disciplined, being intelligent, being talented, etc. – can enable someone to become a top performer in your field? We could start with personality traits, but it would also be interesting to expand the scope of this question.
“Personality traits make a difference in your ability to make other people feel comfortable, and to create an environment where they feel safe enough to talk about difficult things, which are both important in psychiatry. Beyond that – for private practices, there’s a couple different skills that you need, like hiring the right people, and maintaining a schedule.”
What kinds of interests or hobbies usually indicate someone will be good at or enjoy working in psychiatry?
“Well, again – I hate to harp on this, but if you have a high degree of empathy, it probably means that you've got certain interests that make the most of that. When people volunteer at an animal shelter or spend time talking to their grandparents, it indicates that there is some level of interest in connecting with people, and that the connection is mutually beneficial. I would say activities that involve being around people and listening would definitely indicate that you'd be good for this field.”
What prevents talented people with a good fit to the field from becoming top performers?
“The process of becoming a psychiatrist involves years of medical school training and difficult college courses before that. There are people who really want to go into this field, but don’t have a knack for organic chemistry, or find some other hurdle down the road prohibitive. If that’s the case, there’s other ways to help people in the mental health field besides psychiatry. You can become a counselor, or a psychologist, and still provide for people emotionally.”
Relatedly, what traps do people fall into in psychiatry? Why do people fall into them?
“Practitioners can get too involved with the running of the business, and that takes away from the ultimate goal, which is to provide care to the person sitting there in front of you. If you’re too preoccupied by scheduling or billing, that can block a therapeutic bond from forming. I make sure I have people who can take care of those things when I’m in my office with a patient.”
What are the specialties of psychiatry?
“Sometimes the specialties are related to the setting in which you practice. A person might be an outpatient psychiatrist the way I am, or a person might be in the hospital, and only see patients who are requiring inpatient care. Specialties can also be related to your area of interest. I am specialized in child and adolescent psychiatry, but there are some people who specialize in addiction psychiatry, or forensic
psychiatry. It depends on your area of interest, and of course there are psychiatrists who are researchers as well. I'd say that the scope is pretty great. That's why trying to get some understanding of psychiatry means talking to more than one person. My experience is going to be very different to someone who does research. It’s also exciting because it means there's something for a lot of people.”
What traits do different subfields favor?
“That’s hard to say, partly because I haven’t worked in all the subfields. I was drawn to adolescent psychiatry because I’m fascinated with periods of transition in people’s lives, and there’s something to nudging someone away from going down the wrong path. If you’re interested in a subfield, that will probably be the best determinant of how you’ll do. There’s also the lifestyle differences between specialties to consider.”
If you were talking to a new psychiatrist, and they were wondering how to become great at psychiatry, what would be the one thing you would tell them to focus on out of all the different things they could hone themselves at?
“I think the most important thing about psychiatry is forming a good therapeutic bond with your patient, and that's an umbrella goal because it involves a lot of things, but at the end of the day if your patient doesn't feel bonded to you in some way then they're not going to be able to share with you what you need. Forming that therapeutic alliance is the key to being a good psychiatrist.”
Contrarianism
What is something you believe about psychiatry that other practitioners don’t?
“That it’s okay to be vulnerable with your patients. Sometimes people who are on one side of the desk don’t convey that they themselves have ever been anxious, or found parenting challenging, or whatever the situation is at the moment. I think it’s okay to have some more two-way information flow.”
How does public perception of what it’s like to be a psychiatrist align with reality? What do people not in the field definitely get right, and what do they get wrong?
“There’s a lot of people who perhaps think that psychiatry is the way it’s depicted on some TV show, but there are many different ways to practice psychiatry, and boxing us into a particular look or setup is unfair.”
What is the most common useful fiction that practitioners in your field have, and why do you think they have it?
“To get through anything that is challenging you have to try to find some sense of hope. Hope to me is the possibility of something being good even in a really dark moment where it's hard to imagine that anything could ever get better. Sometimes we have to convince ourselves that that the hope is real until it actually manifests itself.”
What is one reason people go into your field that they don’t talk about?
“Sometimes people go into psychiatry because of their own experiences and their own struggles with mental health.”
Related to an earlier question, what will stay the same about your field? Are there universal constants or paradigms that you just don’t see budging?
“Psychiatry is a balance between medication management and counseling support, and I don't think that'll ever change.”
How will psychiatry change in the near future, and what longer term trends will become important?
“In the future our treatments will get even better in terms of the kind of relief that they provide but also in how well tolerated they are. I also think that we are going to continue to have a demand for mental health services. My real optimism is that this next generation is going to recognize that, and we are going to have more people going into this field enthusiastically.”
How do you disagree with everyone about the future of psychiatry?
“People think that the current shortage in care is going to last forever, but I think it’s temporary.”
Conclusion
What parts of the job do you find make up for all the dark, bad, evil things you need to go through? Is there an element of romance or thrill or existential importance to it that you find? What about your job captures the heart?
“What captures my heart in psychiatry is the bond that I have with a patient. Being able to really sit with someone, listen, and offer support or education or some type of treatment is just the best part of being a psychiatrist. I don't know about the negative aspects because I honestly just love what I do.”