COMMENTARY

Psychiatry Is Seeing Life From the Inside Out

Tracey I. Marks, MD

Disclosures

August 24, 2011

I have been practicing psychiatry for a little over a decade now, but I was a relative latecomer in choosing this profession. When I started medical school, in fact, psychiatry wasn't even on my specialty radar. I didn't know anyone who had seen a psychiatrist, and I simply never thought of psychiatry as a meaningful branch of medical science.

During my third-year rotations, I managed to side-step the psychiatry clerkship. When it came time to choose a specialty, I landed in the field of internal medicine (IM). It seemed the most logical choice for me at the time: I had majored in engineering in college, and I viewed IM as the ultimate problem-solving specialty.

During my fourth year of medical school, I finally rotated through psychiatry, simply because it was required for graduation. By then, I was in the midst of completing applications to IM residency programs.

I soon discovered, however, that psychiatry was nothing like I expected. I found the patients and their disorders extremely interesting, and I saw first-hand how a person can be completely debilitated by emotional pain. I came to appreciate how the physical body is simply a vessel that eventually deteriorates, whereas the human mind plays a critical role in how the body functions and how a person responds to life experiences. For example, research shows a strong link between depression and mortality in some cancers.[1] During my psych rotation, I saw time and again how the "mind over matter" principal actually works. The mind, in a very real sense, defines the quality of human experiences.

My engineering background led me to view the mind as the body's central processor. As an analogy, in the computing world you need peripherals to have an optimally functioning system. But if your "CPU" fails, your high-end color printer is rendered useless. Likewise, a dysfunctional mind can affect a person's physical health as well as quality of life.

Despite my growing interest in psychiatry, the reality was that my applications for internal medicine residencies had already been submitted. So I shook off any doubts and moved forward with that decision. When I received news that I was accepted into an IM residency program, I was excited; at the same time, I was concerned that I might have made the wrong choice. Fortunately, I was given the option to switch to a psychiatry program at the same institution, and I happily decided to make that switch.

Psychiatry training includes general medicine training. Typically the internship year involves spending 6 months or more on an IM unit, focusing exclusively on medical problems. This prepares you to evaluate patients in a psychiatric setting while taking into account any medical problems that may be contributing to their symptoms. Psychiatry residents also spend time on a neurology unit, learning about and attending to patients' neurologic disorders. Because of this multifaceted training, I see myself as a physician who is able to understand and appreciate the nexus between the mind and body.

The range of work within this discipline is enormous. As a psychiatrist you can choose to specialize in treating acute problems, such as mania resulting from Hashimoto thyroiditis, or intermittent psychosis due to temporal lobe epilepsy. Or you can help the overworked professional manage stress and anxiety and stave off the destruction of his marriage. Psychiatrists work in various settings such as outpatient multidisciplinary clinics, solo or group private practice, inpatient hospitals, academic institutions, emergency departments, jails, or military bases. Some psychiatrists work as consultants in occupational health settings.

As a psychotherapist (which I believe to be an integral feature of practicing in this field), I feel privileged to be invited into someone's inner world, to talk with him about his most vulnerable thoughts and feelings. Psychotherapy is a required part of your residency training and typically begins in the second or third year.

The best parts of psychiatry are forming relationships with people and helping someone rise from the depths of darkness and into light of hope. Even patients who don't have a severe disorder still have pain on some level. A person may lack desire for his spouse, feel fed up with his place in life, or feel trapped in a "dead-end" job. As a psychiatrist, you are able to recognize the problem and help the patient see the blind spots holding him back. You are in a crucial position to potentially change the course of someone's life for the better. I don't take that lightly and am thankful for the opportunity to help people accomplish their objectives.

As much as I love what I do, psychiatry isn't for everyone. For instance, those wanting to perform procedures would not be satisfied with this specialty; the closest we get to procedures is performing electroconvulsive therapy or transcranial magnetic stimulation.

One negative aspect of practicing psychiatry is income. Most insurance plans reimburse for mental health care at lower rates than that for medical care. As a result, compared with doctors who perform procedures, psychiatrists' salaries are lower, especially if you evaluate this based on time spent with a patient. For example, an insurer may reimburse a doctor $1000 or more for a surgical procedure that takes 1 hour of the doctor's time; that same company may pay only $100 for 1 hour of psychotherapy.

But if you love critical analysis and forming relationships with people, it just doesn't get any better than practicing psychiatry. If you are considering psychiatry as a specialty, talk to some of the psychiatrists on the faculty of your school. They can give you their personal insights and maybe even connect you with psychiatrists in the community who can expose you to different working environments.

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