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A personal note to my future patients...
In response to popular demand, I put together a
brief look behind the scenes of one doctor’s
education (mine). I hope that going a little
off-beat, lending a more personal perspective on
what is involved in becoming a psychiatrist
might be more interesting and enlightening than
the usual “Resume”.
Many people are unfamiliar with the differences
in education and practices of various
professionals with similarly sounding
professions. For example:
Psychiatrists, Physiatrists, and Psychologists.
Two of these groups are physicians (M.D's) who
study the sciences (math, physics, chemistry,
biology, etc) in college before entering medical
school. The psychologists and neuropsychologists
(PsyD or PhD) study a variety of (non-science)
subjects of their choice in college before
studying (in graduate school) those aspects of
psychology that do not require a science
background or medical training.
Physiatrists are medical doctors who pursue
special, formal postdoctoral education after
getting their M.D. for several years. They bear
no resemblance to psychiatrists or psychologists
other than the spelling of their specialty. They
are specialists who focus on the whole patient
as they help them overcome and recover from any
number of disabling injuries and illnesses. They
frequently work with physical therapists.
It surprises some people to learn that
all M.D.'s get the same education (that includes heart surgeons, psychiatrists, obstretritians, endocrinologists and brain surgeons) for the first eight years of their
formal education after high school. It is often
equally surprising for many people to learn that Psychologists and
Neuropsychologists (who are desevedly well-respected professionals) are not expected or required to take biology,
chemistry, physics, medical physiology,
higher mathematics, biostatistics, biochemistry, etc. -- all prerequisites of the
most preliminary medical school level courses,
particularly pharmacology.
I always knew that I would be a doctor, and was
fairly certain that I would be a psychiatrist.
When I was younger, I had the notion that there
was something special about a psychiatrist that
called for some life experience in addition to
the schoolbooks, technical training, and all
that the ivory towers of traditional education
could provide. Using that premise as my excuse?,
I proceeded to travel the world for a few years
before starting my premedical college training.
Anticipating being a "healer" in the future, I
had developed an early interest (from the 60"s
on) in natural , holistic, herbal, and other
"alternative" approaches. I had the good fortune
to have a very prominent expert in nutrition as
my professor in my medical school nutrition
course. One interesting occurrence in that
course was the frequent visiting talks given by
a Nobel Laureate who was very big on Vitamin C.
My very first lecture to other doctors as a
graduate doctor was about the effects of
antioxidants, and similar subjects (presented at
a SUNY Downstate program hospital's Internal
Medicine department in 1988). One advantage of
having such a longstanding interest preceding
scientific medical study is that it becomes far
easier to spot the “snake oil peddlers” once you
learn how things really work. My practice is to
follow the best standards and hold to proven
medical practices. Many alternatives are
considered, but are relegated to safe,
adjunctive roles when not contraindicated.
Later on, I worked as a paramedic, a physician and student physician in Emergency, Intensive Care, and Cardiac Care units. I felt extremely rewarded knowing without doubt that I helped save many lives in those critical care environments. It is my belief that the impact of a good psychiatrist on people's lives may appear to be less immediately obvious or dramatic, but I believe that it is certainly no less important to those people who are relieved from very significant suffering from illnesses treated by psychiatrists.
Medical school courses require a command of
certain basic sciences before one may even
register for the courses. It really isn’t
possible to understand beyond a very superficial
and sketchy level even the first, introductory
Medical School courses without having completed
comprehensive study in chemistry, biology,
physics, and math. The very first pharmacology
course requires a solid command of several years
of inorganic and organic chemistry, physiology,
biological systems, biochemistry and the
academic discipline to learn those difficult
subjects. Pharmacology is integrated into the
training on a regular, intensive basis for most
of the following eight years of a psychiatrists’
formal education after college.
During medical school I was lucky enough to
arrange to do a special psychiatry “rotation”. I
had the unique experience of being, at that time
the only student/doctor/trainee etc. to actually
live in the venerable Manhattan Psychiatric
Institute while undergoing training. MPI is one
of the oldest and largest institutions in the
U.S. It is located on its own, large island
offshore in Manhattan, NY. During the
approximately half year I was there, I lived
with, ate in the cafeteria with, strolled the
grounds, socialized, etc, with the many patients
who were in residence there. During the day I
was working in the wards under the supervision
of my teachers (professors of psychiatry and
psychology on the staff of MPI). Because I was
there “24/7” my time with the patients extended
well beyond the usual, expected 40-50 hours per
week of clinical training. I felt very
fortunate, indeed to have this early experience
well in advance of my psychiatry residency
training. That was an elective that I was able
to modify to maximize the experience, but all
medical students have additional requirements
for classroom courses in Behavioral Science
regardless of their intended future
specialization.
I had heard that the medical training in England
was somewhat different than in the U.S. in that
the students had much more individual didactic
contact with senior doctors, and more practice
with patients, (and less “scut” work). Having
learned this, I had the good fortune to arrange
to study Medicine and Surgery at the Royal
Hampshire Hospital in Winchester England. The
Royal Hants is a venerable old institutions with several medical school affiliations, and
was, during my time in training there, visited by Queen Elizabeth, who
came to meet us as part of the celebration of
the 275th birthday of the hospital.
Many people are unaware that Psychiatrists are
licensed to practice general medicine. We are
required to continue with general medical
training even after getting an M.D. Most
psychiatrists incorporate that training as part
of their psychiatry residency. I chose to do a
separate, Internal Medicine internship in a big
city hospital to challenge and enhance my skills
as a medical doctor. Many people find the
official work schedule of a medical intern to be
surprising. My schedule involved a 12-16 hour
day every day, except for every third day, when
I was required to work the entire day and night,
and the subsequent, regular (12 hour) shift the
next day. That is, for example: Monday 12 hours,
Tuesday 14 hours, Wednesday 24 hours, Thursday
12 hours, Friday 14 hours, Saturday 24 hours,
and Sunday 12 hours, and one Sunday off a month!
Yes, really! Yes, that does add up to 110 hours
per week (and doesn’t count all the studying).
The time in internship and residency is not all
patient care. There are classroom didactics,
independent study required, conferences, and
rounds. Doctors (M.D.’s) are required to take
national, standardized tests for the first two
years of medical school, the first four years of
medical school, and the first 5 years of medical
school/residency. We cannot be licensed without
passing those (one to two day long) exams.
I began my formal, postdoctoral study of
psychiatry at the University of Miami School of
Medicine. One special aspect of that residency
program is the vast and broad population served.
There are strong cross-cultural challenges, and
there is more exposure to more pathology and to
more rare pathology (being essentially a medical
destination for large numbers of foreign
visitors). While there, as my class
representative, I introduced a system whereby
the patients could be fully covered by the
residents without the residents having to stay
up all night every third night—making things
better and safer for all.
One area of interest that I was able to expand
upon was that of addictions. I was privileged to
be one of a small team helping get the new
addiction center going under the direction of
Dr. Barbara Mason. Our first scientific study
was a fascinating look at a brand new drug that
prevented the brain from reinforcing drinking
patterns by blocking endorphins…that is, we took
the “buzz” out of drinking. That approach
continues to be one avenue of approach to
addictions today. I followed my interest in
addiction further and undertook a number of
elective rotations at the excellent Veterans
Hospital there to learn more about addictions
and traumatic stress. I've been working with
people facing difficulties with substances
throughout my psychiatric career.
I transferred to the Chapel Hill School of
Medicine, Department of Psychiatry to finish my
four years of postdoctoral training in
psychiatry. It was there that I discovered
during fairly extensive training in forensics
during my residency that there were some very
prominent Forensic Psychiatrists on the faculty.
I had the good fortune to become the First
Fellow in Forensic Psychiatry at Chapel Hill in
my fifth postdoctoral year of training. The
significance of formal forensic training, as it
relates to clinical patients, is the emphasis on
diagnostics. Formally trained forensic
psychiatrists are actually diagnostic
sub-specialists.
A common misperception has been emerging lately:
the idea that psychiatrists are prescription
writers and aren’t involved with psychotherapy
or extensive diagnostics. The reality is that
psychiatrists have far more supervised clinical
training in psychotherapy than any other
profession. A psychiatrist is required if a
diagnosis is complex and requires the
integration of diverse diagnostic modalities or
more serious mental disorders. Sadly, this trend
has devolved in part due to financial
considerations, a shortage of qualified
psychiatrists, and insurance pressures, hence
limiting patients' access to optimal psychiatric
services.
My forensic work has taken me down some unusual
and interesting roads. I’ve been enlisted to
evaluate mass and multiple murderers, and an
alleged American “Terrorist”, I’ve interviewed
more than a hundred murderers and hundreds of
violent felons. I’ve been on a number of
committees involved with management of the
criminally insane, public safety issues related
to the mentally ill, advisory committees, a
national congressional advisory committee, etc.
Despite all the drama associated with forensic
cases, my first professional interest is, and
will remain, working with individual
patients—which is the center and focus of my
practice.
My patients tell me that many considering seeing
a psychiatrist like to have a better idea of who
and what a psychiatrist is when making that very
tough decision to find help. I hope that I have
anticipated and addressed some of your
questions.