You don’t really know how your life as a psychiatrist will work out of course, even if you think you do. In the UK, many of these career decisions will involve the National Health Service, which is in effect a monopoly employer. Much of the employee burn-out and job dissatisfaction relates to the dysfunctional nature of the NHS. In-patient resources are much less available now than when I started, adding significantly to the stress of the job. The reality is that General Practitioners are often too busy to offer modest interventions which can make a critical difference. In the UK it is indeed sometimes hard to get any treatment at all, and you will see evidence of this in the streets and Accident and Emergency.
But I’d like to put that to one side and reflect on the essential nature of the job.
Clinical work involves seeing patients and their families. You may be surprised that since I qualified (and for decades before) there has not been much change in the nature of clinical psychiatry. Others might disagree, but if you look at the core clinical interactions of interview, diagnosis, and treatment I’d argue it is unchanging. A key element of the consultation concerns the quality of the doctor and patient relationship. In my professional lifetime there have been tempting pathological and biochemical pointers to the cause of psychiatric illnesses, but for the most part the diagnosis remains descriptive. Treatment with medication has not changed in a profound way. Talking treatment, often referred to as psychotherapy, has become more acceptable.
Although rarely articulated, it seems to me that there are three reasons that put people off training to become a psychiatrist.
Just who would want to waste their professional life being associated with such losers as these psychiatric patients? They are all dead-beats, drug addicts or in some way have brought the condition upon themselves. Why don’t they stop whinging and just pull themselves together? All that is just so not true. In my experience the patients are just like the rest of us. Over the years, I have come to admire the strength of character and fortitude that so many show in managing their illness and its’ consequences.
Second, it is worth remembering that serious mental illnesses are indeed serious, and the outcome is not always good. Adverse outcomes are to be found in all areas of medicine of course, but suicide is a catastrophic, tragic situation that is profoundly distressing for the family. It also deeply affects all those involved in the care of the patient. Personally, I found that knowledge, training, and experience have helped me to manage. Sometimes the best you can do for a patient is to give them a few extra years. A colleague mentioned to me that you should always expect a few suicides otherwise you are not seeing the right patient group.
And so, to the last reason which is the perceived view held by some that you cannot help these patients. Many modest interventions such as the prescription of medication or short-term psychotherapy have a real impact to the benefit of the patient and their family. See the change yourself and I can guarantee that you too will be impressed.
I have been most fortunate in finding a career that suited me. Not everybody does. I hesitate to describe the personality attributes required, but I have seen many different styles make a great success of psychiatry. If you like the job, you can do it, whoever you are. You need to be able to tolerate uncertainty, and, in my view, appreciate that clinical work is hard to compartmentalise. Crises don’t just occur in working hours. Good colleagues are essential. Being kind to everybody usually works well.
In the future, personalised treatment underpinned by advances in epigenetics, computer-based AI, and a better understanding of the pathology of psychiatric disorders will change the nature of the job considerably, but the core values are likely to remain the same.
In life there is an arc of beginning, middle and end. Even though I enjoy the job after nearly 50 years, it is a good time to retire. I have enjoyed the teaching and research opportunities that came my way, but my career has been mainly clinically based. A fair number of patients and their families have written to me, and I have very much appreciated their kind comments. With the patients’ permission here are some from one that, in my mind, summarise what the job is truly about.
Thank you for helping me to live life in full colour.
You took me on as a patient when other doctors had given up. My parents were told I would not finish my teen years.
I’ve really appreciated that you have always treated me as an intelligent human being and not been afraid to prescribe medication. You allowed me time (years!) to get to trust you and talk about the difficult things.
Enjoy your retirement.
So, I think it fair to say that I have found it to be a wonderful career choice that offered the sort of job satisfaction few others have the chance to experience. You could too if you want.