Choosing a Specialty: A Letter to a Medical Student

Nassir Ghaemi, MD, MPH

January 04, 2017

Dear Elizabeth,

You asked whether you should consider psychiatry as a specialty, as opposed to another discipline of medicine. As I write to you, I think about my own children, and how I would answer a similar question from them, knowing that in just a few years, I will have to do so.

So, I have reflected on your question carefully.

When you ask me whether you should enter psychiatry, your question also becomes whether I would go into psychiatry once again, knowing what I know now. Most people will tell you to enter their profession for that reason. They are justifying their own decisions. Their reply to you is a means of reassuring themselves.

I'm not going to answer your question that way. I'm going to try give you the truth as I see it now, realizing that it isn't how I saw it 20 years ago when I entered this profession, and it may not be how I'll see it in 20 years when I leave.

Let's begin with a practical matter; let's be honest about it. Deciding on a profession, even medicine, isn't all about the ethics and ideals that we write in our medical school applications. A key factor is that the profession provides money: It allows you to make a living. There's nothing wrong with that motivation. The question to think about is how much that motivation matters.

Making a living is not a dishonorable reason to decide to go into a line of work. Most everyone has to make a living. Most everyone has to find a way to pay bills. There are two ways to pay bills: increase your income, or reduce your expenses. There is much to commend the latter approach. Emerson said of Thoreau: He made himself rich by making his wants few.

The problem with this Thoreauvian solution is that modern society will impose itself upon you at some point. It may be through a tax bill, or a nasty next-door denizen, or a lawsuit, or an illness. At some point, you will need to respond to an unfriendly world, and if you have money available to you, you will respond more effectively than if you don't.

So there is something to be said for making an income, and as much as you can make while still laying your head to sleep at night without massive worry.

You should ask yourself: Is your main purpose in choosing this line of work to make a living? If it is, then you should know it is, and don't put too much effort or care into worrying about the work. It isn't your main purpose in life. Your main purpose in life could be your marriage, or your children, or your larger family. Or it could be another activity other than your main paid work, such as writing, or art, or music, or faith.

I used to criticize the average psychiatrist for just making a living—I didn't see them motivated deeply in their work—until one of my friends pointed out that it doesn't make sense to criticize the average person for being average. I wanted the typical psychiatrist to practice above the standard, but then that average psychiatrist would be at a new standard. I realized that I was asking more of the typical human being than a typical human being can be.

But it's true that everyone needs a main purpose in life. Otherwise, it's hard for our lives—brief as they are, and with a definite beginning and end—to have any meaning. This purpose need not be a "great" thing; it isn't minor to have a good marriage relationship or a happy family. Those "simple" things in life aren't simply attained, nor are they even common.

This question of meaning is very important, and something to consider deeply. It matters perhaps more than any other consideration.

The other approach would be to make your work your main meaning in life—to unite your avocation and your vocation. This is where, in the case of medicine, Osler said that it's a "calling." The other major callings have always been law, the ministry, and teaching. Some are called to heal, some to teach, others to preach, or to implement just laws.

Many claim it, but few are called. You can tell the difference in two ways. When you are called, you don't choose. You just know. You don't have an option. Every fiber in your body tells you that you must do this work; you can't do any other. And when you're called, you don't change your mind; you don't compromise; in fact, you sacrifice. Many people claim to have a passion for a line of work—they want to contribute to scientific research, they want to publish, they want to teach—but at the first (or second or third) sign of the world's inevitable resistance, they give in, and return to the safer path of making a living.

Look deep inside yourself; meditate on it; interrogate your deepest yearnings. Are you deeply called to do this line of work? If you are, you'll know it. If you doubt it, either you aren't called, or you haven't gotten in touch with your deepest feelings.

You ask about psychiatry as opposed to another branch of medicine. Let me tell you a few things about psychiatry, which you may already know, or perhaps sense.

Psychiatry is the least medical of medical branches. Some celebrate this fact, others rue it; some deny it; many refuse to come to terms with it. It's acceptable in a way, if by "medicine" we mean biological aspects of physical diagnosis and treatment, because psychiatry deals sometimes with the mostly physical and sometimes with the mostly psychological.

But psychiatry is medical, in the sense of dealing with diseases (whether mental health professionals want to admit this reality or not). The problem with that medical aspect of psychiatry is that the field is ambivalent about it. The diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) are created as social constructions, as preferences of the profession—not solely, or even primarily, as scientifically based definitions. For two decades, our profession has bound itself to these social constructions and pretended that they were scientific facts. This has been proven a lie, but we are unwilling to admit our self-deception.

This is nothing new. Before DSM's hegemony began in 1980, psychiatry had self-deceived itself with psychoanalytic orthodoxy for about half a century.

Do you want to enter a field that engages in such deep self-deception, and doesn't mind? Not just my career, but those of at least four prior generations, have passed this way. This process could easily continue for another generation or two at least. Are you willing to let your entire career pass under its sway?

You can fight it. You can make it your passion to try to raise psychiatry up and move it forward when all the influence of the status quo holds it back. Are you willing to spend your entire career fighting the powers that be? You may become a hero for future generations, if you succeed in the process of change in the long run, but that posthumous adulation will do nothing for your personal happiness in this life.

You may not care; perhaps you will ignore the larger profession's delusions, and practice well in your little corner of the world. Perhaps you'll do psychotherapy and enjoy helping people dealing with the basic struggles and stages of life. That's good work, and important. And if it's your calling, it's worth doing. But know that you'll be doing it in a larger context that's inimical to your purposes.

Society punishes those who improve it. Emerson observed this fact when he gave up a promising Christian ministry career to instead minister to all of mankind. Don't expect awards and accolades from the psychiatric profession for bettering it. The awards go to those who maintain the status quo, not to those who change it. Freud never won a Nobel prize; they gave it to the fellow who introduced frontal lobotomy.

The above dilemmas don't apply to the rest of medicine. There are no DSMs as diagnostic straightjackets in any medical specialty except psychiatry. There is no other discipline that has mostly thrown out what it believed for most of the past century. In other specialties, you can work with the mainstream, rather than constantly swim against it.

If you want to make a living, the other specialties will provide an easier life than psychiatry. If you have a calling, you may help psychiatry, but it still will make your life difficult.

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.

Part 3

By the time you've mastered your profession and completed your lifelong education, you may find that your time has run out. So said the depressed Henry Adams. Maybe it's not as bad as he thought, but he had an insight.

That's how it all looks at middle age, but the optimism of youth has a twin in the optimism of old age, because once you get into the latter years of your career, you'll find that some of your younger colleagues will value you more. Your old enemies will have withered away, and the world will listen to what you have to say. You won't be able to storm the barricades yourself, but you'll direct the younger ones on where to go and what to do. The only final blow: You won't be there to see the victory. Like Moses, you may not make it to the Promised Land; only Joshua will.

This is what change in psychiatry feels like. It's glacially slow, if it happens at all.

All these comments are based on one assumption—that the past predicts the future, that the next 20 years will be like the last 20, and the next 50 years will be like the last 50. I think this is a fair assumption, because human nature doesn't change. But it is possible that other social or economic factors may drive changes in the psychiatric profession that are unpredictable. It may be that smartphones and new technology will speed up change, promoting new ways of thinking and an end to the old. But maybe not.

So there is psychiatry for you, riddled with ideologies for two centuries, stultified by the conservative instincts of human nature. People prefer the status quo to change. Our ideals are mouthed and empty. We don't really want scientific progress, or to discover the causes of mental illnesses, much less cure them. What we really want is for things to stay the same.

I realize that these criticisms apply outside of psychiatry; I'm sure they apply in obstetrics to some extent, and in cardiology, and in dermatology as well. I know they apply in other professions, and in society at large, certainly in our political life. Some will say that all professions are corrupt; this may be correct. I'm not singling out psychiatry as uniquely different in this regard, but there is a matter of more and less. Psychiatry is plagued deeply by its self-deception.

To put it another way, relevant to all professions and all of life, but especially to psychiatry:

It's an unjust world. How will you live in it?

You have three options. The first is passive acquiescence; this is what a normal, mentally healthy person does. Most of us conform to the world as we find it. Go along to get along. Join the mainstream. Accept the status quo. Kiss up, kick down. This is normal, because conformism is the virtue most rewarded by society. The world will leave you alone at worst, and applaud you at best. But you'll leave it as unjust as you found it.

The second option is violent resistance; by "violent," I don't mean just physical acts, but verbal and mental ones. You resist the world's unfairness, but you are angry and bitter. You defend the weak by hurting the strong, but you create enemies all around. You may do some good, but you'll die by the sword, and after you, your enemies' children will fight your children.

The third approach is nonviolent resistance; by "nonviolent," I mean that you fight your enemies, but you don't hate them. You're not angry, you're a "happy warrior;" you seek not to defeat, but to persuade; and if you can't persuade, to simply stop evil without harming the evildoer. You may not persuade your enemies, but their children and grandchildren will come around to your view. You'll leave the world a better place.

If you seek to take the hard road, I advise you to be careful, and learn the methods of nonviolent resistance. Study Martin Luther King and Mahatma Gandhi, not because their lives were happy (they weren't), but because they left a legacy of progress which millennia of history failed to provide. It's the same in the profession as in larger society: We've been fighting each other for centuries, without meaningful progress, because we've either been violent in mind and word, or we've been passively acquiescent. The third road is the hardest for the person, but the best for the world.

As for you, look into your soul. Don't be shy. Be honest. Be brutal.

I have thought that Nietzsche got it right: One way of understanding these matters is think of our task in life as becoming who we are. You are someone; it may take your life for that someone to unfold. You do well to become who you are, rather than to deny yourself, or distort yourself, or never to get to know yourself. You don't really know who you are right now, but you have an inkling. And over time, that inkling can grow until you are more and more confident in yourself.

Freud had another insight into it. He said that in decisions of great importance—such as choosing a career, or whom to marry—he found that it was best to go with one's inner instinct, with a sense of what's right that might be difficult to explain or defend. This intuitive approach is more accurate, he thought, than purely rational calculations, because it puts you in touch with your deepest needs. So as you look into your soul, pay closest attention to your intuitive feelings, even if you can't explain them.

It isn't a fault to want to live a quiet life. You don't need to be a hero. If you want to make a living, make a living in that field which will provide you the least daily hassle. Then follow your dreams outside of your profession. Make a living however you find most profitable, but find the passion of life elsewhere. Look into what gives you meaning, what you think will give your life its deepest meaning. Put your efforts there.

If you feel a deeper calling within the profession, follow it, but prepare yourself for the resistance of the world. Find your solace inside yourself, not outside. And know then that you are like the saints of old, but in a different era, doing God's work in a world where gods no longer are recognized.