1 Boring Old Man

Half a century ago, I donned an Intern’s Uniform: white pants, white socks, rubber soled shoes, a short white coat with pockets filled with medical tools, a safety pin holding a tourniquet to my chest near the name-tag that said "doctor." It wasn’t just pride in finally achieving something, it was driven more by something else – fear. I didn’t feel like a doctor – more like a lethal imposter soon to be exposed. The uniform and the haggard sleepless look was at first a disguise – the way we interns swathed ourselves in "doctor" until some of it worked its way inside. Over the years in training, the uniform changes: coats get longer; pockets bulge less; the clothing under the coats gets more specific – green scrubs for surgeons, blue scrubs for OB, shirts and ties for Internists, etc. It’s the loud public marker for the gradual process of identity formation.

In my Internal Medicine days in Memphis, the psychiatry house officers wore white coats except in the mental hospitals ["white coats" had gotten a bad name in mental hospitals]. I didn’t know it then, but the psychiatry residents only wore white coats in the biological programs – radiating up and down the Mississippi River from St. Louis. Years later in Atlanta as a psychiatry resident, I never saw a white coat [except for the animal handlers in our rhesus monkey lab]. Then, in the mid-1980s, our new Chairman showed up wearing a white lab coat, and they began to appear on the faculty and younger residents. Psychiatry was "rejoining" medicine. When Dr. Nemeroff came to Emory several years later, white coats became more the standard. By that time, I was long gone.

Since wearing white coats didn’t have anything to do with protection from splatter, I guess it was more symbolic – a symbol of "doctor-ness" of some kind. I don’t know if it was about collegiality with other physicians or "medical-ness" with patients or both. But it didn’t suit me. It felt contrived. I had done the white coat progression as an Internist followed by three years in the Air Force with two layers of uniform, so I was uniformed out. To be slightly serious for a moment on this weighty topic, my understanding of the relationship between psychiatrist and patient did not include authority – symbolic or otherwise – so I was more than happy to shed the mantle and would’ve felt silly putting it back on – true to this day.

This late-summer day’s ramble has an origin, if not a known ending. I was musing about identity. Psychiatrists themselves and the field of psychiatry itself always have had the most ill-defined identity among the medical specialties – except in drama where a hypothesized split between the professional and personal identity makes for endless plot twists – Hannibal Lecter comes quickly to mind. I guess there’s a cartoon identity. One rarely sees a dermatologist in a New Yorker cartoon, but bearded psychiatrists are frequent flyers. We started life as Alienists working in Mental Hospitals and Sanatoriums, then the Victorians brought the consultation rooms into the mix. But the white coated psychopharmacologist hasn’t found a dramatic personae. And I’ve noticed that unlike physicians in other specialties, psychiatrists don’t show up in the direct-to-consumer television ads mumbling about side effects or giving advice, nor are they much the stuff of dramatic presentations. So in the television series In Treatment, it’s back to the old consulting room set [or maybe the group room on Celebrity Rehab]. The psychiatrist as expert psychopharmacologist seeing patients for brief medication checks hasn’t caught anyone’s literary fancy.

In fact, the thrust of many of the pharmaceutical initiatives have written psychiatrists out of the loop except as KOLs giving canned CME talks to groups of Primary Care Physicians. Who can forget Eli Lilly‘s campaign to eliminate psychiatrists altogether [from their sales seminars for detailing the Primary Care Physicians]?

But those are outside things. I know that from the inside, a psychiatric identity was much different from my medical identity in Internal Medicine. It was about a lot more than the progression of the length of my white coat. As the training years passed as an Internist, I had a lot more knowledge, sure enough, but it was more than that. It was a cognitive matrix of how all that information was woven together – an intuition that found the appropriate path through all the facts that was pertinent to the case I was dealing with, and an equally important intuition about when I didn’t know what I was doing and needed to turn off the autopilot and start over, or hit the library, or get help. In training, there was always someone behind me who was ahead and could help – someone with a longer coat. After training, you had to know when to call for back-up on your own. But my point is that the progression from idiot Intern to competent practitioner was something more linear, something you could feel happening slowly over the years – an internal identity.

Psychiatry wasn’t like that. Left alone in an empty room, I felt no more competent the year I finished than I had before I started, maybe less. It’s hard for graduating psychiatry residents who usually take some clinic job just to get some feedback that they know what they’re doing before venturing out into the great unknown. For me, even today I only really feel competent in psychiatry when I’m seeing a case, and the feeling only pertains to the case I’m seeing. I guess I don’t really feel I’m a psychiatrist until I’m being one. That is probably a slight exaggeration, but I bet that most practicing psychiatrists of my ilk know exactly what I’m talking about. And there’s no real "back-up." Of course, anyone will do in an emergency – suicidal behavior, psychosis, etc. But in a complex ongoing case, no one can step in and pick up the ball. In psychiatric training, there’s supervision – but it’s from a further distance than when the senior resident is literally standing at your side. So for me, my psychiatric identity is felt in action, in a case, not as a stand-alone like in Internal Medicine. My psychiatric identity is sure not tied up with intimately knowing the DSM-IV TR. That’s something I’ve learned more about in writing this blog than I ever knew when I was in practice. And it’s also not in knowing about those drugs I listed a few posts ago. Thirteen drugs just aren’t that hard to get down pat. In Internal Medicine, there were hundreds – a whole PDR full.

As a matter of fact, back in my Internist days, I learned about the psychoactive drugs that were available at the time. The reason was simple. I was practicing at an Air Force hospital in an era when seeing a psychiatrist or having a family member see a psychiatrist was at least perceived as a career black mark, so very few people who needed to go would accept referral. So I got proficient in pharmacotherapy, which rarely, if ever, got the job done. That’s what sent me back for training in the first place. The idea that mental health care can be delivered by Primary Care Physicians strikes me as absurd because I couldn’t bring it off myself even when I worked at it, independent of the thoughts of the Zyprexa drug reps. Likewise, it’s pretty hard for me to imagine a viable future for psychiatrists whose essential function is to tweak psychopharmacologic agents – the ones we have now or those at any future level of refinement.

Dr. Stahl’s blog post was titled Are future psychiatric treatments doomed? Be careful what you ask for…you just might get it. It’s clear how he meant that. He was chiding the people who are negative towards the Pharmaceutical Companies, implying that these critics are chasing them away and that they [the drug companies] will stop trying to discover new drugs for our future patients. Just about everyone I know or know about has let out a collective howl about the absurdity of what he had to say. But there’s another way to hear his title. Are future psychiatric treatments doomed? because Dr. Stahl and his Pharma-aligned colleagues have turned psychiatry into a myopic specialty focused in only one short-sighted direction, neuroscience and psychopharmacology, the former limited by our knowledge and the latter limited by …its limits. Were they banking on a future yet to be realized, or perhaps with intrinsically less to offer than they hoped? If either we or our patients are better off twenty-five years after the Brave New World of psychiatry as clinical neuroscience, I sure don’t see it or hear about it. So he and his colleagues need to respond themselves to his statement, Be careful what you ask for…you just might get it. They asked for it. And they got what they requested. Are they happy with where it lead us? Did putting on the white coats work? Frankly, Dr Stahl doesn’t sound very happy to me.