Choosing a Specialty: A Letter to a Medical Student

Nassir Ghaemi, MD, MPH


January 04, 2017

Part 2

Let me give you a few anecdotes that will give some personal background for my thoughts.

When I was in medical school, I had an oncology fellow who took a liking to me. When he found out I planned to go into psychiatry, he became very upset. You're wasting your talents, he said. He was disgusted. I just assumed he was wrong, thinking that I could do even more good in a backward field such as psychiatry than I could in a more advanced field such as oncology.

Twenty-five years later, I think he may have been right. I thought I could just get into psychiatry, do good work, and join many others who wanted to push the field forward, and we would all progress together. I didn't realize that so many people work at cross-purposes—that much of the work I did would be resisted and negated by other colleagues working equally hard against me. We weren't working together; we worked against each other. So the field stagnated, and my own efforts produced much less fruit than I anticipated.

Another anecdote: I went to see a faculty member in my residency, a well-regarded researcher, who would later become a leader in a department, an endowed chair at Harvard. He was a success by all conventional standards. I remember asking him about his work. I realized that although he had published a great deal, nothing much was coming of his research in terms of any breakthrough or truly important outcome. He replied that his work still mattered because it was part of the larger efforts of many other people. Perhaps their results weren't major, but they added up in the larger process of science. In retrospect, I was thinking of Kuhn's revolutionary science, and he was referring to what Kuhn called "normal science," when small advances are made bit by bit. One spends a lifetime in research and achieves very little in fact, and yet is rewarded handsomely.

Awards and rewards aren't given for great achievements, as society claims, but for small ones. I've come to the conclusion that conventional success isn't real success, even on conventional grounds.

A final anecdote: In residency, my closest friend was devoted to research. He had a wife and small child, and worked long hours. He spent many hours in the library, in the old pre-Internet days, photocopying page after page of hundreds of journal articles, drawn from large heavy books on dusty stacks. He worked while he was on call, in between appointments during the day, and at night. He produced an incredible scientific article, a meta-analysis on outcomes in schizophrenia, that was on the cover of the American Journal of Psychiatry, our most prestigious journal. He was poised to continue such excellent work in a long career. He tried for about two decades, rising to become a department chair. But then he got brain cancer and passed away in his 40s, with three children. In the meantime, his research hadn't progressed much farther than when he had started.

I often wondered why progress was so slow. It took me two decades to realize that besides the conflicting ideologies of our field, there was the current ideology of the DSM, which is inherently unscientific. The DSM was and is a social construction, as I said, created by the profession for its own social purposes. When we make up our phenotypes for social, economic, and professional purposes, why should genetics, biology, neuroimaging, pharmacology, and even psychotherapies correlate with it?

I realized that the efforts of my friend and of the Harvard mentor, and my own efforts, all were doomed from the start because we were using DSM definitions that didn't correlate with reality. I thought I had made an important discovery, and that others would agree with me as soon as they understood it. To my surprise, my critique was resisted strongly and harshly by the leaders of our profession. I was saddened to come to the conclusion that most of our psychiatric leaders, including prominent researchers, didn't care. They would rather maintain the status quo than make changes that are needed if we really want to live up to our proclaimed ideals of scientific progress.

That's when I realized that maybe the oncology fellow was right. I hadn't realized that my efforts wouldn't combine smoothly with those of others to push our field forward, but rather that my work would be like flowing water, dispersed by large boulders of resistance, into small rivulets that turn sideways and end weakly in infertile soil.

Things look different in middle age than they do in earlier years and, I understand, than they look in later years. When you are starting out, around age 30, twenty years seems like a long time. And you expect to get important things done by age 50. A decade moves quickly, and then another, and then you are 50, with 20 years behind you reminding you of your goals of yesterday, and 20 years ahead of you reminding you that time will run out. At age 50, you will have mastered your work, you will know what is right and what is wrong in your profession, and you will have ideas about how to fix things. You just won't have much time.


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