Sunday, June 05, 2011

Attracting people into psychiatry

Thomas Insel, in his NIMH Director's blog, views clinical neuroscience as the answer to psychiatry's recruitment problem. The dean of the Royal College of Psychiatrists, Rob Howard, has also said that recruitment into psychiatry is at a crisis point (see his May 2009 newsletter). Solutions were discussed at a London division academic day (see Frontier Psychiatrist blog).

The problem with Insel's remedy  is that too many young psychiatrists, if they believe him, will become disillusioned. He makes reference to an NIMH Neuroscience and Psychiatry module Translating neural circuits into novel therapeutics, which suggests that impaired GABA neurotransmission in chandelier neurons in the dorsolateral prefrontal cortex contributes to cognitive impairments in schizophrenia, which may be corrected by an agonist for GABAA alpha 2 subunit receptors. The module mentions a small RCT using such a drug, MK-0777, which seemed to find evidence of improved performance on memory tasks, but doesn't mention a larger scale study which failed to show any improvement in cognition.

Putting on one side that cognitive impairment in schizophrenia may well be functional, the complexity of speculation is supposed to excite people into understanding the pathological basis of psychiatry so that they can develop so-called rational treatments that then undergo rigorous testing. But are hypothetical, wishfulling phantasies really going to attract a new batch of recruits?

Personally, I suspect we need to remind ourselves of the interest in psychiatry which Aubrey Lewis stimulated at the Maudsley Hospital Medical School after he was appointed Professor of Psychiatry in 1948. For him, postgraduate psychiatry should be for "ardent, critical, lively, disputatious and reflective, eager minds" (Lewis, 1947). He encouraged a sceptical approach to psychiatry. He had little patience for imprecision or poorly thought-out ideas.

As Michael Shepherd pointed out in a BJPsych article, "Throughout his professional life Sir Aubrey was at all times an educator who was much concerned with the problems of recruitment into psychiatry, more especially with quality rather than quantity." Doctors with open minds, who are sceptical of psychiatric quackery, need to be attracted into psychiatry.


Marian said...

What usually drives people to study modern western medicine is an interest in the human body, combined of course with an interest in helping others. Thus, at our home medical doctors were referred to as workmen specialized in the human body. With very few exceptions, I find it unfortunately to hold true, also for psychiatrists, that the interest rarely is other than what you might call "mechanical". So, if you have a group of med students, of young people whose main interest is a rather mechanical one in the human body, how likely is it that these people will choose a certain speciality within the field, if you tell them the speciality in fact isn't that much about the body, but mostly about sociology, philosophy, psychology, etc. etc.? How likely is it that they will choose this speciality if you tell them that they will have very little, if any, use for their medical training, working within it?

If you ask me, med students aren't the people we should look for at all when looking for people to help and guide others in emotional distress. Psychiatry, in representing -- or wanting to represent... -- a medical speciality, isn't what is needed at all. You don't need to be specialized in psychiatry to write a prescription for a tranquilizer. Any physician can do that. Especially when the role this tranquilizer plays in the help on the whole is a temporary and secondary one, as it ought to be.

Marian said...

P.S.: The -- sad -- truth is, as long as we keep thinking of emotional distress as a phenomenon that needs to be taken care of by medical professionals -- and, btw, I know the following is highly provocative -- you get mostly med students attracted who a) would have chosen neurology, or some other speciality in the realm of somatic medicine, if their grades had allowed for it, and/or b) people who have somewhat greater narcissistic needs to satisfy than the average helper, since psychiatry, as it is practised today, and like no other profession, allows for virtually unrestrained acting out of these narcissistic needs (cf. Wolfgang Schmidbauer, "the helpless helpers").

Alistair Stewart said...

I certainly agree that clinical neuroscience, as described by Thomas Insel, is not THE answer to recruitment into psychiatry, although it may be part of the answer. I also strongly agree that psychiatry needs doctors with enquiring and curious minds who want to help people. Particularly important to attract medical students who have a nose for nonsense rather than a taste for it, to use Bede Rundle's image. Students who might also speculate as to what is meant by "cognitive impairment in schizophrenia may well be functional"!