Challenges in Psychiatry

Psychiatry is often viewed as a soft specialty; it's touchy-feely and its vital signs include such things as mood and whether someone is feeling suicidal. Our bread-and-butter is someone's family support or occupation or marital status or education. We ask where our patients grew up, how they got to San Francisco. We don't physically examine the patient. Our trade involves things the public knows (or thinks they know): depression, psychosis, paranoia.

But after two weeks of this rotation, I realize this is not an easy specialty at all. We deal with the hardest patients: the manipulative, the uncooperative, the narcissistic. We deal with the hardest people: victims of abuse, murderers, schizophrenics. We have few diagnostic tools; there's no brain scan or lab test that can diagnose bipolar disease. We have to carefully evaluate someone's history, behavior, speech, and thought process to decide whether to label someone with a potential stigma. We can't even count on our patients communicating coherently. We run the risk of asking a sensitive question that turns the patient against us. We are often emotionally drained by those we see. Our patients have chronic, progressive, debilitating diseases.

Watching a good psychiatric interview done by one of the attendings is an amazing experience. I really see the remarkable finesse, the careful wording, and the planned organization of the interview to ally the patient and convince him to share deeply personal aspects of his life such as history of trauma or the delusions no one else will believe. It takes as much skill as conducting a good physical exam to conduct a good interview with an uncooperative, psychotic, or suicidal patient. It's often very difficult to "put oneself in the patient's shoes" when they are threatening to hurt others or hallucinating or delirious.