COMMENTARY

How to 'Brand' Psychiatry Today

Stephen M. Strakowski, MD

Disclosures

September 11, 2018

Hello. I am Stephen Strakowski. I am associate vice president for Regional Mental Health and the chair of the Department of Psychiatry at Dell Medical School at the University of Texas in Austin.

I want to continue our discussion about rebranding psychiatry. I very much appreciated the thoughtful and fairly lengthy discussion that the previous video elicited. I valued everyone's comments, and I was pleased to see that people were interested and that the video stimulated such a conversation.

Today I want to build on that and talk further about how we can brand our discipline more effectively. In the last video, I proposed a five-step process toward that end. The first step was to recognize that we are responsible for psychiatry's branding problem and for better defining our specialty. The comments many of you made supported the assertion that we own it and agreed with my supposition that we need to do something about it.

I proposed this definition: Psychiatry is a medical specialty that studies and treats disturbances in brain function that predominantly affect behavior—behavioral brain disorders. We frame those treatments within biopsychosocial models and then use our medical expertise to guide diagnosis and treatment. In general, comments about the definition were positive. I believe that we can continue to move forward, with the goal that, as a discipline, we are clear with others about what we do, to defeat stigma and to make it easier for our patients to get care.

Today I want to focus on step two: placing ourselves and psychiatry within the larger context of medicine. We talked a bit about this last time as we were defining psychiatry, and I apologize about being repetitive, but I hope we can use this discussion to embellish and expand the previous discussion.

What Differentiates Psychiatry From Other Medical Specialties?

Our definition states that psychiatry is a medical specialty. It is important that we not forget that. Within this context, let's think about what differentiates us from other medical specialties. I will be interested in your opinions about this. I believe that two features differentiate us from the rest of medicine.

First, we develop expertise in the diagnosis and treatment of brain diseases that are expressed almost entirely through behavior. Other branches of medicine also do this, including behavioral pediatricians and behavioral neurologists. Thus, our specialty is not completely unique, although I believe that we psychiatrists typically work with patients who have conditions that are not yet associated with well-defined brain lesions. I am the neurology chair here, and I joke all the time about how, as soon as we psychiatrists figure out where or what in the brain is causing a behavioral disorder, the neurologists swoop in and take it away from us, although I do remind them that psychiatry is actually the older specialty. Regardless, psychiatrists treat brain-behavioral conditions such as schizophrenia, bipolar disorder, depression, obsessive-compulsive disorder, and all of the others for which lesions are not yet defined but that clearly need to be managed.

The second feature that differentiates us is that we develop expertise in human behavior that is beyond what other physicians typically learn. And from that expertise, we develop approaches aimed at changing behaviors that cause our patients distress.

With those two things in mind, I believe that it is our responsibility, within the context of medicine more broadly, to bring this expertise forward within a medical model, which I will talk about later.

What Distinguishes Psychiatrists Within the Mental Health Care Team?

We also need to differentiate ourselves from other mental health care providers. Our medical school training is part of what differentiates us from these other mental health care providers. We need to bring that training to the table when we are working in teams to manage patients with mental illness. Our responsibility is to perform medical assessments and to lead the medical model.

There have been discussions contending that the medical model is flawed and that other cognitive or psychological or social models are better. These are often academic arguments. In the real world of treating people who struggle with these diseases, we need to borrow the best from all of these models. In fact, we often claim to use a biopsychosocial model, but we frequently exclude two of the three components. As the medically trained professionals, it is our job to bring the medical model to the table and also to have a strong understanding and ability to incorporate the broader context of what impacts human behavior and experience.

The differential diagnosis is a significant part of the medical model and it is something that we are specifically trained to develop. We often jump to a diagnosis much too quickly, in my opinion, and do not challenge ourselves and our colleagues to take more time and learn more about people before we decide what we are treating. It is also our job to understand how the diagnostic structure drives the evidence base that drives our treatment decisions.

Within that context, most people who suffer from psychiatric disorders struggle with multiple conditions. Our training as physicians prepares us to consider both medical and psychiatric conditions so that we can provide the broad management necessary to help people most effectively and also to prioritize among the conditions in order to tackle the most important first.

Finally, all of that can be used to drive the evidence base. Often, when people talk about the medical model, there is an assumption that it means we only care about medications. But that is inaccurate. In other branches of medicine, a variety of therapies are part of the treatment protocol. It is true that we have to be great pharmacologists, but we also have to understand and be able to deliver complex therapies to people whose illnesses are so complex that we are in the best position to manage them.

We need to be careful not to confuse the medical model with using only medication for treatment. Rather, the medical model uses the medical approach to define the treatment evidence base and decide on the treatment.

As we work within teams, both mental health care teams and medical teams, we are the people who can bring that expertise. In my view, it is our responsibility to be able to be vocal and clear about that. We are medical doctors, and thus, we should not apologize for using the medical model. On the other hand, we need to recognize that this is not the only way to think about people. The more broadly we understand this, the better the care we can provide.

Because of our position in the care teams, part of our job is to enable everyone to work at the top of their area of expertise—to allow those who are the best therapists to be the therapy providers, for example. We don't have to do everything. In part, this assertion is related to concerns of mine that there is and will be an ongoing shortage of psychiatrists. If we tie ourselves up and provide care that other people can provide, then we become unavailable to deliver the complex care that society and our patients most desperately need. It is important for us to understand our role, the medical role, as psychiatrists, to make that our primary responsibility in the care teams, and to support others as they provide their care.

I believe that our priority is to assess patients, define the evidence-based treatment, and manage complex patients while we work with the team to handle the issues we don't have to be doing directly ourselves. We need to build partnerships and understand the team skills that will best use what is available to improve the lives of our patients.

Psychiatrists Must Lead

We also must continue to step up and be leaders within the medical community. It is one thing to bring our expertise within the medical teams, but it is another to be part of the medical leadership so that we are thought of as physicians who are driving the care of patients. We have to stand up and meet other physicians, in medical schools, on medical executive committees, in hospitals, in multispecialty practice groups, and in the community. I believe that it's important for us to commit some time to take on leadership roles to make our specialty visible and make it clear that we are part of the continuum of healthcare.

We can't all do everything. We have to choose. But I would encourage every psychiatrist who is watching this to think about where he or she can pitch in at the community level, and into leadership to help establish psychiatry as part of the medical care continuum. In the end, this is the best and only way that we can defeat stigma and open ourselves up, so that patients can get the care that they need from us. We are too scarce a resource to continue to be unavailable. I hope we can think about our roles in providing the medical model, being part of the medical leadership, and taking an active role in the healthcare continuum to continue to improve the lives of our patients. Frankly, as we become clearer about what we do, we will enjoy our practices even more.

I appreciated many of the comments that you sent in about being proud of being a doctor and being a psychiatrist. I completely share that with you. I went to med school to be a neurosurgeon and, for a variety of reasons, shifted to psychiatry. I have never questioned that as a choice. It is a truly rewarding field.

I hope that this discussion of step two has been useful. Up next in part three: As we deliver our medical model and take responsibility with the evidence base, we must also take responsibility for our understanding of the treatment evidence. With that, I say thank you.

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