Why go into Psychiatry?

By John Tennison, M.D. and Psychiatrist (A.K.A. Nonjohn)

To answer the question of "Why go into psychiatry?," it is helpful to first answer the question of "Why go to medical school?"  Of course, the easiest answer to this question is, "because medical school completion is required to gain admission to a psychiatric residency!"  In fact Solomon Snyder, a brilliant scientist, psychiatrist, and chairman of the Department of Neurosciences at Johns Hopkins wrote, "In college I was far better at writing and philosophy than at science, but like many of my friends, I chose to pursue a premedical major; philosophy is hardly a proper vocation for a nice Jewish boy.  Although I did not particularly look forward to medical school, I did see it as a vehicle to gain admission to psychiatric residency training, and that is where I had set my sights. In medical school, I eagerly absorbed everything my books and teachers could tell me about the brain, but I approached the rest of my courses perfunctorily at best. One other subject did catch my fancy, however, and that was pharmacology. I found it incredible that simple chemical molecules could bring about such profound changes in the human body, and I was intrigued by the disparity between how drugs were used and what was actually known about them: drugs have long been the primary means of treating most diseases, yet until recently physicians have had little understanding of how most pharmacological agents exerted their therapeutic effects. Needless to say, any drug that affected the brain struck me as being especially interesting."  (from Drugs and the Brain, Scientific American Library, 1986)  

In addition to Snyder's justification for attending medical school, it makes sense to consider what benefits medical school offers over and beyond being a necessary pathway to psychiatric training.  Depending on the values of who you ask, you will invariably get a multitude of answers to this question.  For example, if your passion is for general clinical medicine, you might very well find all of the traditional medical-school curriculum to be interesting.  However, if you are driven more by timeless philosophical questions regarding existential issues, mind-body relationships, ultimate truth, etc., you might see the required memorization and dehumanizing workload of medical school to be necessary evils on the way to getting at the people, places, things, or ideas that truly interest you.  For those with such broad interests, the most desirable medical schools will be those that have the most flexible curriculums, the fewest required courses, and that encourage you to think for yourself, rather than use you as a grunt to get work done.  Moreover, it is best to attend a medical school with as many classes AND clinical rotations graded on a pass/fail basis as possible.  In doing so, you will avoid putting yourself in a position of feeling pressured to OVER-memorize minutia that has virtually no value to you or your patients.  (Don't worry -- even medical schools with pass/fail grading are "standardized" enough to prepare you to pass the national USMLE boards required for licensure in the United States.)  Thus, anyone with an interest in psychiatry should first ask themselves if they are willing to enroll in medical school and complete a medical degree, the activities of which will not always be intimately related to the issues that typically fascinate psychiatrists.

Even if one did not go on to complete a psychiatry residency, a medical-school education by itself is among the best liberal-arts educations available from a single degree program within the United States.  However, if a physician did not apply his or her medical education in ways that improved the human condition, a medical education would be a waste of resources.  Moreover, a physician does not necessarily have to work within the traditional confines of clinical medicine or doctor-patient relationships to have a positive effect on humanity.  Particularly in the United States and other places where the content of medical education is highly regulated, a medical school graduate will have built a classical, liberal-arts foundation that is immensely useful, regardless of one’s chosen endeavor.  The perspective instilled by this educational background helps physicians to prioritize and see more clearly many of the most important challenges facing humanity, many of which are not within the realm of "disease" or "pathology."

The liberal arts value of a medical education can be further enhanced by attending a medical school that is part of a larger university that will let you take courses offered at the other non-medical schools that make up the university.  Being enrolled at a medical school at a university offering an on-campus training hospital, extensive undergraduate and graduate degrees, a law school, a business school, and, if possible, other graduate/professional programs is optimal. There are some universities that have these resources spread over several campuses.  However, the best arrangement is to have the time-saving convenience and inter-departmental collaboration that result from having all of these resources on a single campus.  My word for such a campus is “geccun” – my acronym for “GEographically Consolidated Complete UNiversity.”  There are several universities within the United States that are geccuns, including Stanford, UCLA, University of Chicago, and the University of Pennsylvania, to name a few.

To address the question of why one would choose a psychiatric residency over training in another medical specialty, it is helpful to examine the breadth of issues that define psychiatry.  It is also helpful to compare psychiatry to two closely-related fields:  neurology and psychology.  For example, both psychiatrists and neurologists are interested in neuronal processes.  Consequently, the same certifying board accredits both psychiatrists and neurologists.  However, psychiatrists more often focus their attention on neuronal processes that have a bearing on the quality of someone’s experience over a lifetime.  For example, a psychiatrist tends to be less interested than a neurologist in the behavior of a neuron in someone’s big toe, unless that neuron is doing something that impinges on experience, such as causing pain.  Thus, a psychiatrist can be thought of as a psychologically-minded neurologist, someone who is especially concerned with neuronal processes that have a strong bearing on how you feel, think, and behave.

            In addition to emphasizing neuronal processes that influence subjective experience, psychiatry residencies are distinguished from neurology residencies by requiring psychiatry residents to undergo training in five forms of psychotherapy.  It is in this area that psychiatry has overlap with psychology.  The emphasis on psychotherapy recognizes the fact that many things other than neuronal processes contribute to mental health.   A good psychiatrist eclectically seeks to learn all factors than impinge on a person’s mental health, including social, environmental, cultural, political, and religious influences.  Psychiatrists are legally empowered to use all treatment and assessment modalities available to psychologists, including psychological testing.  However, psychiatrists also have expertise in human physiology, pharmacology, and licensure to prescribe medication.  Thus, given their medical-school background, a psychiatrist could be thought of as a physiologically-trained psychologist.

            Whereas some medical specialties are only now beginning to emphasize spirituality and creativity in their practices, psychiatrists have been doing so for many years.  The work of psychiatrist Carl Jung exemplifies psychiatry’s strong historical emphasis on spirituality and creativity. 

            Ideas from psychiatry have considerably influenced our culture and the media, and provided subject matter for some of the greatest films, music, literature, and art ever produced.  Ron Howard’s Academy-Award-Winning Best Picture, “A Beautiful Mind,” demonstrates how fascinating, and yet tragic, mental illness can be.  HBO’s “The Sopranos” portrays an entertaining account of what psychotherapy for a Mafia boss might look like.  The word, “psychedelic,” was coined by psychiatrist, Humphrey Osmond, and has been used by many to describe musical, visual, cultural, and political movements that emerged in the 1960s and continue to this day.

            Psychiatrists are interested in far more than mental illness.  Consequently, psychiatrists do far more than treat mental illness alone.  There are currently seven board-certifiable subspecializations within psychiatry:  Psychosomatic (Mind-Body) Medicine, Clinical Neurophysiology, Pain Management, Forensic Psychiatry, Child and Adolescent Psychiatry, Addiction Psychiatry, and Geriatric Psychiatry.  Other subspecializations of psychiatry include Sports Psychiatry, Preventive Psychiatry, and Transpersonal Psychiatry.

Modern psychiatrists are well-grounded in science, as evidenced by psychiatrist Eric Kandell having won the Nobel Prize in 2001.  For example, the Research Imaging Center at the University of Texas Health Science Center in San Antonio is a world-class facility where psychiatry faculty image human brains in research that could revolutionize our understanding of the human mind.

For careers focusing on subjective human experiences or social interactions, completing a psychiatry residency builds further upon the liberal-arts foundation of a medical-school education.  For example, the ability to see through duplicitousness is a skill developed during psychiatry residency training.  This skill has been extremely useful for Jim McDermott, the psychiatrist in congress who contributed his astute commentary and insights to Michael Moore's "Fahrenheit 9/11," to date the highest grossing documentary of all time.  Other physicians apply the liberal-arts foundation of a medical education to the arts, as evidenced Michael Crichton’s numerous novels and screenplays for television programs and movies.  Still another example comes from psychiatrist Fred Goodwin's excellent radio program, "The Infinite Mind," as heard on National Public Radio.  Goodwin’s program provides fascinating insights that do not necessarily focus on “pathology,” yet always help us to better understand the human condition.

Psychiatry has more in common with the formal discipline of philosophy than any other medical specialty.  For example, Louis O. Kattsoff wrote that philosophy “examines the foundations of other studies.  It asks the social scientist what he believes to be the nature of man.  It asks the physical scientist why he uses the scientific method.  Philosophy seeks to organize the results of the various sciences to show the many ways in which they are related.”  In a similar vein, Henry Sidgwick has noted, “It is the primary aim of philosophy to unify completely all departments of rational thought.”  Consequently, because of its eclecticism, psychiatry is easily the most "philosophical" of all medical specialties.  Put another way, psychiatry exists where medicine and philosophy intersect.

Another strong connection that psychiatry has to philosophy is in determining what to label as “psychotic” or “delusional.”  Psychiatrists make daily practical application of philosophy by asking the timeless ontological questions of “what is real?,” “what is not real?,” “what exists?,” “what does not exist?,” and “what are our criteria for determining whether or not we regard something as ‘real’ or having ‘existence’?,” etc.  The way psychiatrists articulate answers to these questions has substantial affects on the attitudes and value judgments that society makes about patients who are having unusual experiences or who make unusual claims.  This ontological role of psychiatrists can potentially be harmful if psychiatrists are not extremely careful in what they label as “psychotic” or “delusional.”  For example, imagine if the Wright Brothers – after claiming they would achieve human flight – had been locked away in a psychiatric hospital as a result of a psychiatrist believing the Wright Brothers were a danger to themselves and/or others.  Clearly, psychiatrists have a great responsibility to exercise caution, sensitivity, precision, and empathy when dealing with ontological issues.

Having visited and spoken with residents and faculty across the nation from Harvard to Stanford, I have come to believe San Antonio has one of the best psychiatry residencies in the country.  Moreover, I regard San Antonio as one of the best places to live in the United States.  If you are a physician, I hope you will consider psychiatry as your medical specialty.  I encourage anyone considering psychiatry as a career to speak with residents at the University of Texas Health Science Center in San Antonio.  I invite you to email me any time at tennison@texaspsychiatry.net so that I may share my enthusiasm for psychiatry, the most fascinating and profound of all medical specialties.

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