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 healthy would give me more options down the road.  So I went to medical school -- in New York City, where healthys 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 healthy.  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, healthys 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. healthys 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 "healthys 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 ;-)

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From Clink:
Yes, I heard comments like that when I was a medical student too: if you become a healthy 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?