Many of us psychiatrists are struggling with where we are as a profession and field. Our burnout rate is off the charts. Suicide is common; 400 doctors in the U.S. kill themselves yearly, and 5% of U.S. physicians have considered suicide in the last 12 months. Isolation and hopelessness abound for us. And 40% of us will not seek help of any sort, out of fear for our licenses. This is surely a serious problem!
We psychiatrists were once “soul teachers,” which is the true meaning of the word psychiatrist. Not that long ago, our work involved stepping into the deepest recesses of our patients’ worlds, and partnering with them to find healing and transformation. Many of us were drawn to the field of psychiatry specifically because it afforded us the best opportunity to get to know, and help, others in need of healing. The therapeutic relationship was broadly understood to be paramount to that process.
We psychiatrists spent a lot of time with our patients, and were deeply mindful of the power of our words to harm or heal. While we may have prescribed some medications, we were not dealing with a universe of ever-expanding, questionable diagnoses and unsubstantiated medication recommendations. We did not feel betrayed by the professional organizations and societies we counted on to provide us the best tools for success. And we were largely happy and fulfilled in our work. That universe has been totally transformed.
The changes I have seen in the field of psychiatry over the course of my 35 years in medicine are stunning! Things once unthinkable are now common. On October 15, 2017, an article appeared on Doximity’s Op-(med) feed written by Jeffrey Alan Vernon, DO, titled: “Why Psychotherapy Training Shouldn’t Be Part of Psychiatry Residency”! For those of you unaware, Doximity is an online social networking service for U.S. clinicians. Launched in March of 2011, Doximity has over 800,000 verified members as of February 2017. Since the publication of Dr. Vernon’s article, 214 physicians, mostly psychiatrists, have commented on it. Most have been deeply troubled by the suggestion that psychotherapy should be relegated elsewhere, and the psychiatrist “freed up” to do more of the “Medical Management.” But 32 have expressed their thumbs up, or like, for the article.
A notion this article reflects, that the psychiatrist is predominantly a medical expert whose job is disease and medical management, has taken over our culture. We psychiatrists are now “providers” rather than healers. This growing movement of questioning the importance of the psychiatrist engaging deeply with our patients, to best address the challenges they experience, is quite disheartening. And I believe it is a driver of our distress as psychiatrists.
Many of us have become disillusioned with our profession. We have experienced a loss of meaning, purpose, connection, and hope. As the field has moved away from the wonder and pathos of human existence, and taken on a model that reduces life to tick boxes and pill dispensing, we have lost touch with what makes us human. The psychoanalytically oriented field I was raised in, psychodynamic psychiatry, told of complex human beings who suffered and struggled. As psychiatrists, we had the opportunity to meet with such people and hear their stories in an intimate way.
“Modern psychiatry gives us all such an impoverished sense of what it means to be human,” Robert Whitaker said to me, “and has led to disaster wherever we look.” The drivers for that cataclysmic change, from sharing stories to taking pills, include the very institutions we most hoped would be there to protect us and prevent it.
Much has been written and shared on this website about the great betrayal by the APA, the pharmaceutical industry, the FDA, and guild interests in building and perpetuating this house of cards. I need not review that here. But what I do need to call out is that many of us psychiatrists are struggling with questions about whether we have helped or harmed our patients by some of our interventions, with confusion about who we can trust, and with a tremendous amount of worry about what we ought and need to do next.
Like many of you, I have been a doctor for my whole adult life. I love that I have had the opportunity to help those in pain, and learn from them in return. I have always felt privileged to be welcomed into the deepest recesses of another’s heart and soul, and be given the opportunity to partner with them for a better outcome. I have felt blessed to be a healer and teacher. I thought I would practice psychiatry forever.
I never expected to have to worry that the tool bag I was being given to do my job would be full of rusty implements and ineffective potions. I never thought I would be pushed to do things that had the potential to harm, or even kill people. But today I know that our drugs can do that. As the curtain has been pulled back, and the ghoulish nature of the pharmaceutical universe revealed, I have felt completely overwhelmed and personally challenged.
During my career, I have seen doctors become “treatment providers.” I have seen the capacity of a doctor to care for their own patients from office to hospital and back again disappear. I used to be the psychiatrist for my patients in and out of hospital. Now we have doctors who only see patients in the hospital. They are called “hospitalists.” And we can’t see our own patients in the hospital, because their insurance carriers control where they go, and who they can see.
We psychiatrists no longer treat patients, we “manage medicines.” Almost all of us use an electronic health record (EHR), in which we need to document the clinical notes and prescriptions. This activity takes precious time away from the few face-to-face moments we have with our patients. All the work of the visit, which is frequently less than 20 minutes long, must be documented in a cumbersome, time-consuming EHR.
In 1997, in the early years of my career, the United States became the first country in the world to allow the pharmaceutical industry to market its products directly to the consumer. Until then, they could only market to us doctors. We physicians could at least be a buffer back then. Now, the marketing budget of the pharmaceutical industry dwarfs its new drug development budget massively, and drug companies bombard the public with messages about everything that is wrong with them, needing another wonderful pill to fix it. Our patients come in demanding specific medications, and a recently published study has shown that we are apt to get bad reviews as doctors if we do not prescribe and order what the patient wants! Unfortunately, many organizations expect us to get consistently good reviews, irrespective of the challenges involved in doing so.
As I write these words, a deep sadness wells up in me for what we have all lost. We have all lost the soul of caring for those in deep pain, and the optimism and faith that we can recover from the bumps, bruises and setbacks that are the stuff of life. We have been herded into pill dispensaries, blindly, and without logic or justification. We have not been respected or heard. We have been given few choices. And we have come to rely on, and believe we need, things that may be interfering with our good lives. We have all been done a horrible disservice. We deserve much more!
I believe, and perhaps you do too, that medical care should be about helping people. It should not be primarily profit driven. The patient should be the center of the model, and the priority. One’s professional organization should be the bulwark against which we can all stand for support of our best efforts. But the whole field has gone mad. And we psychiatrists, and our patients, have been the victims. This is truly tragic. Understanding this is enough to make us all want to curl into a ball and give up. But we are resilient and capable. So, we will pick ourselves up, dust off, and begin looking at where to go from here.
I decided to write this blog, instead of the one I originally thought I would be writing on this site, because I believe we disillusioned psychiatrists need a forum to connect, be heard, supported, and helped. It is hard to speak up and out against the prevailing model. And it is hard to know where to go, or what to do, when all the jobs open to you — and there are thousands of them — are fundamentally the same.
Today’s senior residents in psychiatry get an average of 100 job offers to do medication management. And there are no other options out there. Many graduating residents have huge medical school loans to pay back, and may not even have much knowledge of the risks inherent in the prevailing models. Psychotherapy training in psychiatric residency programs is quite minimal today, so many newly minted psychiatrists may not even be able to employ therapy options to address distress and promote transformation in their patients.
Many of us psychiatrists can’t abide by the prevailing paradigm, and are struggling with what to do instead. I myself tried to work within the new model for about 10 years. And it made me quite unwell. I was seeing patients non-stop, lost a lot of weight, was anxious and unsettled, and had trouble sleeping. I tried working for a series of different organizations, thinking that it might be different elsewhere. But I learned that the model, and challenges, were basically the same in all of them. In my last employed position, I had as many patient visits in three years as I had once had in my full-time private practice in 10 years. And I wrote more prescriptions in the three years I was in my last job than I had written for the previous 20 years!
Ultimately, I found myself unable to keep working in the universe of med management, that tick box place where many of us now reside. But leaving was hard to do! I had no idea what I would do next. And I love being a doctor, and didn’t really want to give it up. Yet, what I was doing, and being asked to do, ran counter to my deepest beliefs about what it meant to participate in healing. I struggled a lot. And there really weren’t many safe places to talk about it. I couldn’t raise it with my supervisors at work, where it would challenge the financially driven model of the organization. I couldn’t write about it in a broad manner, for fear of losing credibility as a psychiatrist. I saw no way to make it better, and I kept feeling more and more isolated and distressed. So, I finally did leave, in March of 2017.
Since then, I have been learning a lot about what ails us all, and what keeps us from getting help. I have been able to speak more openly about where I am, and what I believe. And, I have decided that I need to provide help and support as a coach to my colleagues who may be experiencing similar difficulties and have nowhere to go with them. Our distress is literally killing us.
I recently had the opportunity to attend the first ever American Conference on Physician Health in San Francisco, co-sponsored by the AMA and Stanford University. There were 375 places, but given extraordinary demand, they accepted 425 participants, and had a waiting list of 100 more! We are clearly struggling for support and guidance.
Former U.S. Surgeon General Murthy spoke to us about the growing dehumanization and depersonalization in medicine. He discussed our need to be valued, understood, wanted, and appreciated. He said, “Workplaces don’t prioritize social connections with our colleagues” and that “Doctors are in pain, and their pain matters.” He spoke of the lack of self-efficacy many of us feel, and the extreme personal cost involved in doing great work for our patients. The 2shoes app was used for questions, so attendees could vote on questions pending for each speaker, to let the moderator know which ones they most wanted answered. The first and most voted on question for Dr. Murthy was: “How do we destigmatize physicians seeking help?” I applaud Stanford University, the AMA, the conference speakers and Dr. Murthy for validating this crucial problem.