Sunday, November 11, 2007

Psychiatry's Identity Crisis


Today, the Sunday New York Times has not been inspirational. I suppose I could blog about the pictures they have of the brains of the political candidates, but I just don't want to.

So I surfed around and from KevinMD, I landed on The Medfriendly Blog where neuropsychologist Dominic Carone is talking about how some physicians claim that others-- particularly psychiatrists and physiatrists-- aren't REAL doctors. Dr. Carone goes through the definition of doctor, and his theories on why some docs dis other docs. I added my thoughts to his comment section, specific to psychiatrists, that we may be seen as "less than" because we are less-hands on, our version of an exam is a of mental phenomena and not necessarily of the body, and that part of our treatment is the act of listening/interpreting. Also, many shrinks don't wear a white coat (I'm one of those). Plus we have the Woody Allen view of shrink as psychoanalyst, and pure psychoanalysis can be done by people with several different degrees.

You know, it's a complicated issue because even the term "shrink" is sometimes shared with psychologists, and I generally address anyone with a PhD (even if it's in history, social work, nursing) as "Doctor" and I'm completely comfortable with that, but really, is someone with a PhD in English a "doctor"? No, they have a doctorate degree, but the professional designation is reserved, I think, for those who've graduated from medical and osteopathic schools. Dentists, podiatrists, and vets (and others, for example, neuropsychologists) do the same stuff as "doctors" -- they diagnose and treat illnesses, they have training that's at least as extensive as a people doc, the same prerequisite education, they've dissected those cadavers, they write prescriptions and perform surgery -- in my brain they are certainly doctors, but I bet if you ask them what they do at a party, they say 'I'm a vet/dentist' not I'm a doctor (the podiatrist probably says 'I'm a foot doctor' but hey).

Even without a white coat and a complete physical exam (...ah, I do sometimes check vital signs, ask a patient to walk, hold out their hands to evaluate a tremor, check for cogwheeling, order labs, request that medication vials be brought to the session) ...here's my view of why shrinks ARE docs.

Psychiatrists must attend medical school. To even get into medical school, certain pre-med requirements must be met and back-in-the-day these included: 2 semesters each of calculus, chemistry, organic chemistry, biology (one semester was biochemisty), physics, and all the sciences included lab courses as well. I believe a year of English is now required, my university back then required it for graduation as well as 2 years of a foreign language and some history/social sciences as well.

Medical School entails a two year pre-clinical course of study. I'm not sure I can remember all the courses I took, but here's a smattering: gross anatomy with cadaver dissection, histology (the study of cells), physiology, pathology, pharmacology, biochemistry, neuroanatomy, embryology, microbiology, immunology. With all the talk around about psychologist prescribing legislation which allows psychologists to prescribe psychotropics after taking a 10-week pharmacology course, I want to point out that pharmacology for medical students is a second year course, begun only after years of science prerequisites are met. That's another rant for another day. In the second year, medical students begin learning to perform physical exams and take medical histories.

The two final clinical years of medical school include for everyone (even shrinks): 12 weeks of internal medicine, 12 weeks of surgery, rotations in pediatrics, OB-GYN, psychiatry, neurology, and I maybe missing some other stuff. Surgery for me included a few weeks of cardiothoracic surgery, and electives in neurosurgery and plastic surgery. The fourth year has lots of elective time and time to interview for internships/residencies. I spent some time doing psych research in California, primary care on a Navajo reservation, psych rotations in hospitals I thought I might want to go to, cardiology, a pain service month, and I can't recall what else.


Before psychiatry training formally begins as a specific residency, a year of internship, hands on, being-a-doc is done-- a transitional year may include 6 months of psychiatry, I did a year of pure medicine and did the whole CCU/ICU/renal transplant unit/AIDS units stuff, no psychiatry.

Okay, then there were 3 years of psychiatry: inpatient, outpatient, electives, mostly just psychiatry except for when inpatients got physically sick and needed work-ups begun before the medicine folks arrived.

Many days, I feel like I've forgotten everything that doesn't have anything to do with psychiatry. Actually, I'm pretty sure I have. I haven't heard of half the meds people are on anymore, I forget the details of how lots of stuff works. My father-in-law asked if you pee less if you have one kidney...? does the second kidney double it's filtration rate? And I need to go look up what a mild decrease in T3-uptake means if the TSH and T4 are both normal.

I titled this Psychiatry's Identity Crisis, and if some surgeon or radiologist wants to fight... but really, amongst ourselves, we don't have a "crisis".
--Dr. Dinah