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Psychiatrists, Physicians, and the Prescriptive Bond

Psychiatrists, Physicians, and the Prescriptive Bond

Almost the first memory I have of a physician is our family doctor at my bedside, leaning over to press his warm fingers against my neck and beneath my jaw. I’m 5, maybe 6 years old. I have a fever and a sore throat, and Dr Gerace is carefully palpating my cervical and submandibular lymph nodes. In my family, Dr Gerace’s opinion carried a lot of weight. It was the 1950s, and my mother did not quite trust those new-fangled antibiotics. She usually tried to haggle with the doctor over the dose—“Can’t the boy take just half that much?”—but even my mother would ultimately bow to Dr Gerace’s considered opinion.

Doctors counted for a lot in our family. I knew that if I wanted to stay up late to watch a television show, I first had to persuade my mother that it was a show “about a doctor.” Growing up with 2 MDs in the family—my Uncle Morris (the ENT specialist) and Uncle Elmer (the surgeon)—I could say that I was “scripted” to become a doctor. But I never felt pushed to enter the profession. Doctoring always felt like something, well—bred in the bone.

Twenty years later, I was a medical intern, bounding down the corridor at Upstate Medical Center, trying to keep up with my 2 testosterone-crazed medical residents, Frank and Dave. When “Code Red! Code Red!” sounded over the intercom—an indication that somebody, somewhere, had just keeled over—Frank and Dave always raced to be the first ones on the scene: the ones who would “run the code.” For Frank and Dave, a myocardial infarction (MI) was an invitation to adventure, mastery, and derring-do. Sure, they wanted to save the patient, and often did. But you also knew that these 2 young doctors were testing themselves against some unseen God of Chaos. They were hard to work with, and nearly impossible to please—but if you were the one keeling over with an MI, you wanted Frank and Dave running your code.

Thirty years later, I am in the harvest years of my trade and calling. And I find my profession—psychiatry—driven by competing ideologies, rival theories, and divided loyal-ties. Yes, we have many critics outside the profession. But it sometimes feels that the real threat to psychiatry—and much of the rancor directed at it—comes from within our own ranks. Our internecine squabbles often bring to mind Yeats’s line from The Second Coming: “The best lack all conviction, while the worst/Are full of passionate intensity.” How can we hold out hope for psychiatry, when it is regularly disparaged by some who continue to call themselves psychiatrists?

Sir Lancelot smiled and said, “Hard it is to take out of the flesh what is bred in the bone.”

John Heywood, Dialogue of Proverbs; ii, viii, K2 (1546)

To be clear: Psychiatry has many sincere and well-intentioned critics whose voices need to be heard and whose criticism is often justified. It is true, for example, that some psychiatrists have become too enamored of the biomedical model and the ubiquitous “pills for ills” that often promise more than they deliver. Some of us—ignoring our better angels—have allowed market forces to pull us far from our heritage of listening, understanding, and healing. At the same time—somewhat paradoxically—some psychiatrists have lost touch with their medical roots and allowed their skills as physicians to deteriorate.

We often hear the charge—false, to be sure—that “psychiatrists never do physical exams.” Unfortunately, many within the profession have played into the hands of these critics. I suspect that the number of psychiatrists who routinely check their patient’s blood pressure and pulse, or do a circumscribed neurological exam when the patient complains of “muscle twitches,” is much smaller than it should be. In many respects, we have actually widened the rift anthropologist Tanya Luhrmann1 described in her book, Of Two Minds: The Growing Disorder in American Psychiatry. There, Lurhmann describes 2 competing models of psychiatric illness and treatment: roughly, the biomedical and the psychodynamic. Luhrmann does not take sides—but she correctly observes that:

These two ideals embody different moral sensibilities, different fundamental commitments, different bottom lines. . . . The differences become part of the way the young psychiatrist imagines himself with patients, the way he comes to empathize with patients, and, ultimately, the way he comes to regard his patients as moral beings.1(p158)

In my view, the gap between these 2 models and cultures has widen-ed into a chasm—hastened, perhaps, by the economic stresses and professional competition faced by psychiatrists in the decade since Lurhmann’s book appeared. How can we bridge this formidable divide? Some see the solution in a kind of “doubling down” strategy: one that urges psychiatrists to become even more focused on neurobiology, neural circuits, and neurotransmitters, leaving “talk therapy” to the psychologists and social workers. Others have gone to the opposite extreme: belittling the real strides we have made in understanding the biology of mental illness, denouncing medication as nothing more than “covering up symptoms,” and even suggesting that psychiatry should no longer be a specialty within general medicine.

Indeed, the recent controversy over “prescribing privileges” for psychologists has revealed to me an even more fundamental dichotomy than the one Luhrmann describes. Having exchanged ideas with psychiatrists both for and against so-called prescribing privileges for psychologists, I have reluctantly concluded that psychiatrists (with exceptions, of course) fall into 2 main camps, divided by radically different self-identities. There are those who see themselves as psychiatrists first, and physicians second—if, indeed, they view themselves as physicians at all.

Conversely, there are those who see themselves as physicians first, and psychiatrists second—I sit squarely in this camp. Some in the first camp have spoken quite candidly of their basic discomfort, going back many years, with their identity as physicians—discomfort experienced almost from the day they were told to put on that heavily symbol-laden “white coat.” I respect colleagues who feel this way, and I have no reason to believe that they are not fine, decent, and effective clinicians. But I am also saddened by them, as I see them tugging our profession as far from our core values as those who think only in terms of neurotransmitters and brain circuitry.


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