Wednesday, 11 June 2008


Oliver Smith asked here for comment on the view, "Why would you want to go into psychiatry? It is a dying bread. They've lost a lot of credibility"

I quite like the typo. There's something very pastoral about bread, what with priests and vicars gifting it as the Host, restaurants benevolently tossing it out for free whilst you await your starters, families sharing it around a table.
But anyway, why would anyone opt for psychiatry?

A post in two parts. To answer the question, it's easiest for me to be shamelessly self indulgent and share some of why I am a psychiatrist. This at least gives a context and one account of why one person chose psychiatry. Thoughts on why others have opted for psychiatry are the musings of another post since it's more contentious.

Since the question's about psychiatry, I'll not wax lyrical about medicine, as a profession. Motives for being a medic usually are laudable and enduring. Friends who didn't do medicine earn more than I do, starting to do so whilst I was still a student; money's better gained elsewhere. You're part of a huge system with the Department of Health, numerous Institutes and Colleges and "expert bodies" having influence over how you can work. Specifically, commissioners and the hospital management structure can influence details of how you work, who you work with, when you work and what you do at work. You don't go in to medicine to be your own boss.
Suffice to say, most medics I know are in it to do good, which is why they stay on evenings and work extra hours and do work that's outside their contract, because they're keen to do what's best for their patients.

So from this viewpoint, why opt in to psychiatry?

Every individual will have their own motivations and ideas and desires, but I think a few themes emerge.

For me, I knew it was something I was interested in. I finished medical school and was fortunate, passing all exams throughout university clearly, never needing a viva or resits or anything stressful. I believe this was because I was simply lucky, I saw peers who studied as hard and were cleverer failing bits. But the process of endless exams that had to be passed left me weary, so on starting out as a doctor I didn't want more arduous exams right now, thank you kindly. This left me General Practice, a career choice that (at that time) didn't need Membership examination. So I trained as a GP. I loved the medicine. The scope of what came through, the continuity of care as you see someone over time, the exploring of issues together (that shift from issues to symptoms to resolution or to problems or to diagnosis) was great - little was straightforward, it was all challenging and engaging and immersive work. People generated symptom lists, medical knowledge was applied to sift through the significance of these, cluster relevant information together, consider pathological processes and illness that can generate such symptoms, formulate diagnosis, generate and effect management, supporting physical and occupational and relationship and social and practical dimensions of peoples' lives.
And it really was broad, with stuff to do on whether folk could have a shotgun, or drive, or had capacity to get married, or was fit to stand trial, or could fly on one last holiday to Australia, or had disability and couldn't work. Not just physical medicine, General Practice was a vibrant and stimulating and diverse environment that lived and breathed biopsychosocial medicine (rather than pure medical models of health/illness).

Through this I knew GP land was great medicine, but wasn't for me. I loved the work. I found the time constraints unacceptable. So, being pragmatic, this constraint was unacceptable so I chose not to accept it and left GP land.
I got in at 8.00am, started surgey at 8.30am, over ran 'til 11.30am. I then spent half and hour sorting all referrals and paper work and letters to the hospital or whoever and all Item of Service fee stuff and went through all the letters I'd get from the hospital. From there we're up to midday, when I'd do my home visits. Usually 3 or 4, with 10 minutes to drive there, 15 minutes with the patient and family to do the history/examination/diagnosis/treatment/safety netting, document it and on to the next. Often I'd go to nursing homes too since I loved reviewing elderly folks in care (so much is found that can be improved upon when it's looked for). So we're up to about 1.30pm and I'm back in the surgery to do my Child Health Surveillance clinic or minor ops clinic or Diabetes clinic or Asthma clinic or whatever. Two and a half hours on, 4.00pm to 6.30pm and it's evening surgey. Say someone comes in with something easy that I'm really, really shit hot at and well trained in like chest pain; I take a history to see if the pain's likely to arise from stomach, oesophagus, bone/costochondritis, lung/pleura, nerves, heart, mediastinum or is referred from elsewhere then I'd examine then I'd discuss formulation/diagnosis then we'd plan investigations and treatment (and detail risks and benefits and side effects) then safety net in case there were serious cardiac events then plan follow up then document all this, all in 10 minutes. I just couldn't do it. If someone came in with something complex there are times you could just weep. Usually over ran, usually had paper work, investigation requests, referalls and Item of Service stuff to do for half an hour after the last person was seen. 7.00pm now.

Hmmm, I've been working from 8.00am to 7.00pm and, heck, I've not had any lunch yet, have I? Oh, or had any 'phone calls from a District Nurse to sort, or Health Visitor, or Midwife, or Community Psychiatric Nurse, or any of the patient problems that crop up that others bring to a GPs attention. Eeek, I've not yet fitted in any urgent calls or visits either. Thus, days often over ran beyond 7.00pm and were very very stressful.

This left me with a problem. I loved the medicine, I loved the work, I loved the patient consultations, I just couldn't do consultations in 10 minutes and have no latitude in the day to do what needed to be done in a way that was "good enough" so General Practice wasn't for me. Liked the job, couldn't live with the system. But being fair on entering GP training I knew I wasn't wholly wrapped up in it and just wanted to do something that didn't need lots of hard exams at the time. Yes, at that time junior doctors were that frazzled.

I've nothing but respect for GPs, they do an incredibly diverse and difficult job and, as evidenced, they're better men and women than me, being able to stick it out and work in such a system.

So I swapped over in to hospital medicine and trained in psychiatry, which I knew when doing GP training that it was where I'd want to be. Patients I saw were not just similar to patients I'd see as a GP. They were identical.
"I'm tired all the time, doctor."
"I feel run down."
"I think I may have something serious, I ache a lot more and can't do as much."
"I've headaches all the time which won't go away."
Instead of 10 minute consultations, I had an hour. Time to explore the issues in detail and then work through things as I'd wish. I was home. I got to do a lot of medical stuff and in training worked with physicians. I had to revisit exams, but was lucky, getting through membership exams at the first attempt. This let me continue in to higher specialist training, specialising in old age psychiatry but also continuing to work in a subspeciality as a physician. I passed all my exams and training and was appointed as a Consultant Psychiatrist and as a Consultant in a medical subspeciality seeing folk of all ages. This leaves me being more medical than many psychiatrists.

It's noteworthy that this career path, with the valuable experience I gained through each and every post I did, is no longer an option for todays junior doctors. They have to decide promptly on one career path, have to start on it straight away and have to choose a career that has vacancies (so may have no choice at all, ending up being a pathologist or GP when they wanted to be a cardiologist or orthopaedic hand surgeon).

In old age psychiatry I get to work with older adults, which I prefer. They're often a disadvantaged group with few folk improving their lot. There's an affable and courteous nature to consultations that's very agreeable. There's a stoicism that arises from having coped with everything life's thrown at you for 60, 70, 80 years or whatever, so dealing with the problems of the here and now can be childs play compared to some of the past adversity that folk have had to manage. Almost always, there's a lot that can be done to improve things. There's usually physical comorbidity to improve upon. There's usually a drug regimen that can be rationalised and improved. Sometimes mental health problems can be improved upon, invariably even if we can't change/fix the condition we can help folk cope with them better. Usually their world (the environment, their relationships, their wealth, the richness of their social contact) can be improved significantly. I work in well resourced teams (a rare privilege in old age psychiatry) with sensible managers who've always given me what I've asked for (a very rare privilege in old age psychiatry) so have a service that I think is great. Community services have enough staff to see everyone as often as needed (daily, sometimes), in-patient wards are new and bright and spacious and everyone's got their own room. It's the service I'd want for my parents or my wife or myself.

For me, I get to work in an area of medicine that I thrive within, working with older adults over the long haul improving their mental wellbeing through addressing their psychiatric conditions as well as looking at medical and psychosocial interventions. The service has been shaped so that delivery's exactly how I'd wish it to be. I work with great teams. I'm working long hours but thoroughly enjoying it, I'm not frazzled any more, I choose to do so rather than need to do so.
At the end of the day, for my patients and the lives I touch, and follow through on, I see the difference that I make.

Much goodness.


Milk & Two Sugars said...

Much much goodness.

Elaine said...

That was a most interesting post; psychiatry is often seen as a cinderellla service, but in your little corner it appears to be almost heaven. Long may it continue that way.

Seratonin said...

Thank you for the insight.I find your blog so incredibly interesting & enjoyable to read.Also gives me a bit of faith in Shrinks !!!


Anonymous said...

oops, I never noticed my typo!

That was a very interesting insight. Thank you.

Dragonfly said...

That was a great post! Thanks! I would have thought that the need for psychiatrists would be on the increase.

Petronius said...

More generally, you get to help some of the most marginalised and disadvantaged people in our society.

ditzydoctor said...

much goodness indeed :D i once thought of doing pyschiatry (it's still an option!) and your piece has convinced me that pyschiatrists indeed are happy people :)

on a side note: i'm back to bother you once more! :D

Midwife with a Knife said...

It's interesting, your reasons for leaving primary care are very similar to many in the USA (either for leaving or for not going into it). High work load, diminishing autonomy, diminishing respect from the people who pay you.

Also medicine is full of interesting fields that can be very rewarding with fewer hassels.

E said...

Well resourced team, non interfering managers, can I come and work for you?

The Girl said...

That was a great post. You touched on a lot of the reasons why psychiatry is my number one choice of specialty of interest. Thanks. :)

Pseudo_Doctor said...

very interesting post thanks for sharing...