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Brain Matters

Spanning Psychiatry’s Mind–Body Divide

The New Physician April 2007
Most in the medical field found it hard to take Tom Cruise seriously as he faced off against the “Today” show’s Matt Lauer last year, railing against the evils of psychiatry. But there are doubtless many in the patient community who do.


The field of psychiatry has come under much criticism and debate, Cruise’s public antics notwithstanding. The increasing use of psychiatric medications and fewer psychiatrists doing traditional psychotherapy have created a stereotypic image of a medical specialty in the pockets of Big Pharm, diagnosing new disorders as fast as potential treatments for them become available.


Disparagement of the profession is nothing new. Abuses of early psychiatry—from the imprisoning of the poor and mentally ill in asylums to its use as a tool of political control—in Nazi Germany, the Soviet Union and apartheid South Africa—have not been forgotten. “Shrink” jokes still abound, and virulent anti-psychiatry movements are gaining media attention.


HAZING


On a much more subtle scale, medical students considering a career in the field often face bias from their own peers, hearing such comments as: “It’s not real medicine.” “Patients are difficult and incurable.” “All you will do is prescribe.” “There is no biology involved—it’s a pseudoscience.”


When Dr. Christopher Stanley was a fourth-year at the Medical University of South Carolina (MUSC), pondering his future, psychiatry was at the top of the list. In an article for The New Physician, he reported “mental hazing that comes with the stigma that is attached to psychiatry as a career choice.” He continued: “Attendings in other specialties are just part of the problem. I faced much more relentless attacks from family, friends and even classmates.” On every rotation, it seemed, “I was hit with pleas from classmates and other residents to stop considering psychiatry so that I would not ‘waste my medical degree.’”


Three years on, Stanley is a third-year psychiatry resident at the University of Kentucky Medical Center (UK) who teaches students daily and is involved in residency recruiting. He still sees the stigma to some extent, “but it’s different,” he says. Right now, the school is revamping its rotation requirements, and psychiatry may be compressed from two months to one, “because it’s seen as a less significant rotation. Now I am fighting to make sure students have access to us.”


That said, Stanley doesn’t sense the same negativity from students and physicians in other specialties that he felt in medical school. One reason, he believes, is that at UK, psychiatry residents are active and accessible in the emergency room, compared to MUSC, where they had no required call. “Students see us working just as hard and staying awake just as long as everyone else, and they gain a better understanding of what we do.”


Sunny Aslam, a fourth-year at Saba University School of Medicine, saw some of this stigma on his own rotations. He thinks the main issue for those unfamiliar with psychiatry “is that they think they don’t have the patience to sit and listen to patients whining on.”


Brian Hurley, a fourth-year at the Keck School of Medicine of the University of Southern California, says that while he has not heard any overt disparagement of his chosen profession, “there is an honest recognition by other students that you are going into something different—that you are not ‘in the fold.’” He and his peers who plan to enter the specialty often talk about the need to be “willing to give up the white coat” that is the symbol of a practitioner of physical medicine.


Psychiatry isn’t seen to have the same physiological underpinnings as other specialties, Hurley continues. Part of the disconnect for uninitiated students, he thinks, is a “hidden curriculum” transmitted through medical education that separates biological from psychiatric medicine.


Dr. Chris Ballas, a practicing psychiatrist for the University of Pennsylvania Health System, works with medical students and residents on the wards, and also blogs as “The Last Psychiatrist,” offering his sometimes controversial views on his profession. In six years as an attending, he’s seen his share of students “forced into the required psychiatry rotation” who demonstrate a definite skepticism about the field.


“Their attitudes are: ‘I don’t like it’; ‘It’s a silly specialty’; ‘Why do I have to learn this?’ These are typically students who are planning careers in surgery or other technical fields like radiology or cardiology, with more procedures.”


And while they don’t dismiss the instruction outright—they typically act professionally, he says—“you see it when they present their cases; when they say a patient has a ‘major depressive disorder,’ you can tell they are regurgitating what they have read and don’t really believe in the diagnosis.”


It is particularly telling, he says, when students go further “and use the word ‘disease’ rather than ‘disorder,’ thinking it is the psychiatry ‘party line,’” he says. “They don’t know me, and they assume I am just the attending psychiatrist and have no skepticism, even though I don’t believe [every mental illness] is a ‘disease’ either.”


Many are intimidated by the inpatients. “They don’t know if someone is going to assault [them], so there is a lot of tension and worry” about patient encounters, says Aslam. But in his experience, “Some of my patients are very, very ill, yet they are some of the sweetest patients you would ever meet. Sure, they have episodes of mania and can be noncompliant,” he says, but he tells of patients who have made handmade gifts for his daughter, whose picture he wears on the back of his ID badge. “One woman would ask about my daughter often.” From her questions and comments, he says, “I could tell how she was doing that day.” Attachments develop on both sides of the physician–patient relationship, he explains.


Hurley agrees wholeheartedly. In psychiatry, you come to know the patient on a deeper level, he explains. “While a family practitioner gets to know your whole body—even those of your entire family—a psychiatrist gets to know your hopes, dreams and fears,” which is very satisfying, he says.


BODY OR SOUL?


Despite the vocal anti-psychiatry movement—promulgated primarily by the Church of Scientology in various disguises—Ballas hasn’t seen a significant rise in student skepticism in the years he has been teaching. “It’s just that the language is different. When I was a resident, the key question was whether psychiatry was biology or psychodynamics; now they see it as either biology or bunk. The rhetoric is a lot sharper now.”


In fact, preconceptions about a career in psychiatry can be found at two extremes: among the most skeptical and the most committed, Ballas says. “A good 70 percent” of the third- and fourth-year medical students in his rotations have dismissed any notion of going into the field. The remainder are divided; half are interested in the specialty and really want to learn the basics, and the other half are already committed to this career. But paradoxically, it’s the mildly interested group “who are most able to learn,” he believes. “Many who have made up their minds are already biased. They think they know exactly what [psychiatry] is.”


The others—those who discover psychiatry after a particularly satisfying exposure in medical school—often dream of having a practice that allows them to holistically balance pharmacotherapy and psychotherapy. Ballas has to break it to them: Practicing both medication management and therapy is difficult, because insurers don’t want to pay for hour-long talk sessions with an expensive M.D. or D.O. “Students start out wanting to be able to do whatever modality they wish,” but by the fourth year of residency, he says, “they are looking at community mental health or hospital consulting. Reality sets in—they can’t do therapy at $250 an hour.”


And one can’t blame the payers for not wanting to reimburse board-certified physicians for work that can be done as effectively at lower rates by psychologists, clinical social workers and other health professionals with intensive training in cognitive and behavioral therapy.


NP "PRINCE OF TIDES"


Ballas himself says he has “a therapy bias” and “always wanted to be an analyst,” which is why he so enjoys his work with seriously ill inpatients. “But so many students don’t want to work with the inpatient population; they have images of the homeless and schizophrenics. But these are the same people they will see in a clinic; it’s just that [inpatients] have committed some act—setting a trash can on fire or something—so they ended up hospitalized.” Many students and residents “think the hospital experience is not realistic—they expect their practice to look more like ‘The Prince of Tides,’ but as psychiatrists, [the very ill] are the people they will see most.”


And almost all of the patients new psychiatrists will encounter—inpatient and outpatient—will be treated with psychiatric medications. This reality particularly agitates the anti-psychiatry crowd, and even much of the lay public, who often see new diagnoses like social anxiety disorder as lifestyle, rather than psychiatric, concerns. But the first question one should ask, says Ballas, “is, do these medications work? Many times, yes. But the second question is, just because the pills work, does that make it a disease worthy of treatment? Are insurance companies obligated to pay for it?”


As for the strong emphasis on drugs today, he says, “Everyone blames Big Pharm, but the unfortunate reality is that psychiatry has structured itself to define everything as disease [needing treatment by a physician] so it can justify itself as a medical specialty. It’s not that these medications don’t work, but do we need an M.D. to prescribe them? Do you really need four years of medical school to write a prescription?”


Increasingly, the answer is no, as nurse practitioners and Ph.D.s have won the right to prescribe medicine in many states. The American Medical Association and the American Psychiatric Association (APA) continue to fight this trend, but their efforts may be futile, since non-physician practitioners “are defining psychiatric medicine for the coming years,” says Ballas.


MORE THAN MED-CHECKS


James Knowles Rustad, a fourth-year at the University of Vermont College of Medicine (UVM), plans to enter psychiatry because he is passionate about the work, the patients and the professionals in the field.


“I love working with psychiatrists—they are a wonderful group. The profession is full of intelligent, nice people.” In addition, he finds the field “intellectually interesting, with a huge amount of research in high-growth areas like Alzheimer’s, schizophrenia and neurobiology.” He adds that he also finds gratification in the way patients “rapidly improve” with appropriate treatment, which often includes medication.


Rustad says he has long been interested in human behavior, and developed an interest in the biological sciences as a zoology major at the University of Florida. Before medical school, he frequently worked with psychiatric patients as a nurse’s aide in a local hospital, and was hooked. “I really like the mix of social and biological sciences in the field of psychiatry.”


When asked about the biological aspects of the specialty—something that many medical students aiming for other specialties cite as lacking in psychiatry—Rustad says this: “Just like any other field of medicine, patients come in with signs or symptoms. You take a thorough history and physical in order to tease out what’s going on. You start broadly, with a wide differential and just narrow it down.”


In clinical settings, Rustad has frequently observed the biological basis of psychiatric symptoms. “I recently did a rotation in neurosurgery, where I saw that patients with brain tumors and metastatic cancers can present with behavioral alterations. And I can’t begin to tell you how often depression turns out to be caused by an underactive thyroid.”


The physician’s role, he believes, “is to make the patient as comfortable as possible and alleviate symptoms. It’s not to be a magician who can instantly get rid of a chronic disease process, and in that way, [psychiatry] is no different from neurology or internal medicine.”


In medical school, he notes, the psychiatric curriculum trains the students to look at the body of scientific research like in any other field of medicine. “At UVM, we have excellent lectures with psychiatrists such as Dr. G. Scott Waterman that emphasize the biological underpinnings and clinical manifestations of bipolar affective disorder and other disorders. We learn about the effectiveness of medications in specific situations. We are always encouraged to do our own evidence-based medicine and keep the perspective of a scientist. You can’t let what’s emanating from pop culture affect your pursuit of knowledge—that would be foolish.”


And while it is too early for Rustad to decide on an area of practice or a subspecialty, he says he welcomes “the opportunity to work with patients whose lives are coming off the tracks, and get them back on the tracks—that’s the goal of any physician.”


In addition, he says the ability to practice in a variety of areas concurrently is one of the most compelling aspects of the specialty. “I know a lot of people who do everything. My adviser, Dr. Paul Newhouse, runs the Clinical Neuroscience Research Center at UVM, has a geriatric practice, and works with students and residents.”


Aslam agrees, and says that he “can’t see how any other type of training prepares you to treat people in so many different systems, and also the most seriously ill.” The field, he explains, delves into neurological testing, brain imaging, working in the court system, studying the pathology of the body, and exploring organic disease, genetics and pharmacology. “The explosion in the biological aspect of mental health is huge,” he asserts. “The future is in DNA, and targeting drugs so specifically to patients that we can look at how their genetic makeup allows them to break down chemicals.”


THE COMING CRISIS


Aslam, who will become the 17th generation of physicians in his family, first thought he wanted to be a surgeon like his father in Maine, but on his second rotation in January 2006—pediatrics—he had his first experiences with children with behavioral problems. “Primary care physicians treat these patients a lot because there are so few child psychiatrists out there.” The pediatrician he worked with, who cared for a number of very disturbed children, “made it very clear he felt he could deal with these problems as best he could, but when he was out of his depth, he would turn to psychiatrists and the community mental health system.”


After Aslam’s next rotation—six weeks of inpatient and adolescent psychiatry—he began seriously considering the field of child psychiatry. “It was a well-rounded program, and I enjoyed learning the stories of [patients’] lives.” Plus, he found the psychopharmacology fascinating.


And even with the legacy of surgeons in his filial history, he says his family has been very supportive. “They see how much I want to do this and how invested I am. I am talking about it all the time.”


As for the dichotomy between medication management and therapy, Aslam wants to do both, but understands it will be a financial tradeoff. During his recent interview at SUNY Upstate Medical University, where he hopes to do his residency, he brought the issue up with the department chair. He came away with the realization that “I can get paid to do therapy, but not as much as only doing med checks. But I want to do what’s best for the whole patient. I want to combine both, so I can follow patients over time.” Whether that will prove a reality, he doesn’t yet know.


Is Aslam worried about the encroachment of non-physicians into the areas of therapy and pharmacology? Not at all, he says. “I see a lot of resentment among physicians about the involvement of mid-level practitioners, and them causing salaries to drop,
but I am fairly supportive.” There
are not nearly enough mental health practitioners out there, he believes. “Everywhere I’ve gone to interview, I’ve seen a huge shortage. I see kids having to wait six to eight weeks to get help at a community mental health center.”


He points out that “there are only about 7,000 child psychiatrists in the whole country. With so many foster children in the United States—so many moving stories of deprivation—there really is a need. All [students] want to feel like we are making a difference.”


Rustad, too, is concerned about patient needs going unmet. “The World Health Organization is forecasting that by 2020, depression will be the second-most frequent cause of disability and death in the world,” he notes. “It is important to recruit as many people as possible to go into mental health, especially psychiatry.”


To this end, he serves as a regional coordinator for PsychSIGN, the Psychiatry Student Interest Group Network, a new organization that works to foster the involvement, organization and implementation of student psychiatry interest groups at individual medical schools. The group functions as a central hub for the exchange of ideas, information and resources for student coalitions in psychiatry. It also promotes discussion of psychiatric education in the medical school community, and for advocacy and justice in mental health as an integral part of health overall.


The group meets annually alongside the APA’s national meeting, and also holds regional conferences and speaker series around the country with a goal to eliminate misconceptions and promote the positive aspects of the profession.


“I really don’t know why there aren’t more of us,” ponders Rustad. “I have found the training extremely fascinating. The field represents a wide range of opportunities—a lot of directions you can take your career. The future is wide open and poised for high growth. And there is a great deal of satisfaction involved in helping these patients.”


Aslam agrees: “To me, psychiatry [training] is the gold standard. I wouldn’t change my choice for anything. I feel prepared to jump right in and get involved right away.”
Martha Frase-Blunt is editor of The New Physician.