Choose Something You'll Love Doing at 3 in the Morning

Nassir Ghaemi, MD, MPH


July 26, 2017

Most of us would like to be sleeping at 3 in the morning. But if you have to pick a job that may keep you up in the middle of the night, it is important to like it.

In a recent Medscape commentary I offered advice to a medical student, Elizabeth, who was considering a career in psychiatry. Many commenters connected to the idea that our efforts and our passions and our intentions don't seem to translate into effects. We intend something, but it doesn't come to pass. The world seems to conspire against us.

The healthcare system cuts us into pieces and places us into holes: the hospitalist, the 24-hour walk-in clinic, the specialist. We work in hospital systems; we have bosses, staff, administrators. Sometimes we feel that we have to choose between serving all of them or serving the patient. The patient might be happy, but the patient can't promote you. There's something about the profession of medicine that touches the souls of many who live it. They know that it's something special, and they are hurt deeply when they can't live out what they know. In all of the debates about healthcare reform and health systems, in all of the euphemistic goal-setting of quality of care and access to resources, we lose this simple fact. Doctors feel that they aren't allowed to be their best.

Was my advice positive or negative for a medical student? Was I encouraging or discouraging? My assessment of reactions has been that there was a correlation with age. The younger the reader, the more encouraged they were. The older ones, if psychiatrists, seemed to be the most disturbed.

Some came to the defense of psychiatry. It's not so bad, they say. Things are much better than they used to be. In the long course of history, I would agree. Psychiatry today is better than it was in 1945, and 1955, and probably 1965, but I'm not sure beyond that date. My point was not that we've had no progress; it's that we've stalled, and the train petered out somewhere in the 1970s and 1980s.

The main correlation I see is to the DSM-III revolution of 1980. I won't revisit that debate here. I've written plenty about it in multiple blog posts and scientific articles. Critics should make an effort to read those discussions before commenting further. I'll just make one claim now: DSM-III and its follow-up revisions were mostly made up, invented, created out of thin air, with limited to no scientific evidence to support the majority of their claims. I back up this statement with studies, data, and historical evidence documented in the articles I've described above. The defenders of current psychiatry can't hear this fact, because it undermines their practice for decades. The young ones who enter the field have no past to defend and need not defend it. They should read the articles and discussions elsewhere, not in blogs, and come to their own determinations. At the very least, they should ask themselves why we have stalled since around 1980.

For what it's worth, Elizabeth decided to enter psychiatry. She just started her residency.


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