Wednesday, September 25, 2013

On being a psychiatrist: Is an MD sufficient?

Sigmund Freud
Freud argued that a psychoanalyst did not necessarily need to have a background in medicine. Think about it: would the study of medicine or, alternatively, the study of psychology, anthropology, sociology, history and, of course, the proper way to think about things, i.e., philosophy ideally prepare one to understand the dynamics of the psyche?

At odds with this view, psychiatrists are physicians first. In the US system, following graduation from medical school, they enter a one-year internship, followed by a three-year residency in psychiatry. During internship, a psychiatrist typically splits his time between medicine and neurology (for six months) and six months of inpatient psychiatry. For the next three years, the future psychiatrist gains experience in treating a variety of patient populations (inpatient and outpatient, patients with major mental illness such as schizophrenia, bipolar, major depression or Alzheimer's dementia, illicit drug users, or severe personality disorders). As a trainee, a psychiatric resident learns how to use a variety of psychotropic medications and psychotherapeutic interventions.

It is a lot to master and that leaves little time for anything else.

At the same time, psychiatry is so much more than just making a diagnosis in accordance with the medical model and then prescribing an evidence-based intervention. In psychiatry, an evidence-based appraisal of data is only the beginning, of a psychiatric assessment, formulation, and plan.

By allowing itself to be reduced to an exclusive medical model perspective, psychiatry loses the ability to meaningfully understand the complexity of human experience. This is a complex discussion (HERE for a link) but the point is relatively straightforward.

As the medical model only partially informs a psychiatrist expertise, it follows that psychiatrists need to be more than just evidence-based physicians. A psychiatrist's expertise in describing pathology and offer evidence-based interventions should be comparable to the expertise of any other physician in any other medical specialty. But while the study of philosophy is irrelevant to the outcome of an appendectomy, philosophy plays an organic part in understanding and treating any form of mental illness.

Critical thinking, good humor, perspective, skepticism, and a dialectic understanding of complex facts are as essential to good psychiatric practice as the skills of carrying a psychiatric review of systems and mental status examination.

Thus, a good psychiatrist, while a physician first, also has a working knowledge of philosophy. Which should exude throughout a visit with a patient.

You are not sure where your psychiatrist stands on the above issues? Not a problem.

Email this post and ask for an opinion. If you get a response, please bring it back here.

Discussing, debating, trying to understand each other's perspective will make us all better patients, better doctors, better fellow beings.

© Copyright Adrian Preda, M.D.

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