Why Psychiatry Is the Hardest Specialty

Part of being a psychiatrist is dealing with a “black sheep” image that our specialty still encounters. At times we may feel looked down on by other physicians, as if somehow (despite having survived the same educational obstacle course) we weren’t as clever as they. However, time in the field has begun to help me appreciate just how intelligent you have to be to be a good psychiatrist. It’s an open question whether the human brain, with its ineffable complexity, is capable of understanding itself. We have to try and make sense of someone else’s brain in about an hour.

Being a psychiatrist means dealing with ambiguity all the time. Most people reflexively assign meanings to their perceptions all day. If I sniffle, my mother says, “Do you have a cold? Or is it sinus?” (After 11 years in medicine, I still don’t know what she means by “sinus.”) The truth is I don’t know. I can pick one and that will satisfy her, but assigning this name to the condition doesn’t make it true. I go to work and listen to someone describe a vague uneasiness felt for a lifetime. Then after about 45 minutes I’m asked to assign it a name. I can call it “depression” or “demon possession” or “sinus,” but that doesn’t make it true. How I choose to conceptualize this person’s complaint is not merely a matter of my own intellectual satisfaction; in addition to the implications for what treatment is applied, what I say will probably become an integral part of this person’s life story.

In such situations I may reflect that I’ve previously met people who described their life in a similar way, and when I wrote a prescription for Prozac, they sometimes came back and said they felt better. I have to have some sort of model for what I’m doing. So sometimes I think, “She needs her serotonin levels tweaked, that’s why she feels this way.”

The truth is I don’t really know why she feels this way. If I asked the right questions, I’d probably find something that happened in her childhood that could be considered traumatic. If not, I could probably find something in her current life that is a “stressor.” I could develop a sense that this problem is more “psychological” than “biological” (as if thoughts and feelings weren’t biological events and there were really two organs inside her cranium).

The one thing I can’t think, that I really can’t tolerate at all, is that I don’t know what’s wrong and I don’t know what I’m doing that is helping. Furthermore, thanks to placebo-controlled trials, I don’t know if what I’m doing is “really” helping or if she and I are just imagining that it is helping.

In medical school we learned about the pathophysiology of cancer. On a surgery rotation I looked inside someone’s thoracic cavity and saw cancer. We learned about the treatment of infection. This was a little harder to visualize: very small organisms, unable to complete their cell wall formation because of antibiotic therapy. I couldn’t see this happening, but I could imagine it, I could see the patient’s temperature going down on the bedside chart, and I could believe it. When it came time to learn about depression, they told us, “Depression is when a person says he has been unhappy for at least 2 weeks.” Why has he been unhappy? “According to our book, it doesn’t really matter.”

As a psychiatrist, I’ve learned to imagine various things “causing” an illness. Some of them are relatively easy to conceptualize. A child being beaten or raped. A man watching a plane sail into a skyscraper. Cultural icons telling a young girl she should be thin. Some are a little harder to visualize. Neuronal pathways “kindling” and driving their owner into madness. A sluggish cell failing to emit enough neurotransmitter. A “G” in place of an “A,” resulting in a molecule that is shaped wrong. A depressed parent failing to respond to a toddler, not once but a million times over several years. Harder still is to imagine all of the causes happening together, responding to each other, making each other worse, compensating for each other, benefiting the person, harming the person, comforting the person, killing the person.

The hardest cause of all to imagine is the one that you don’t know and you will probably never know. And that’s what I have to think about all day to be an honest psychiatrist. That’s why psychiatry is the hardest specialty.