Wednesday, August 07, 2019

Advice to a young doctor considering a career in psychiatry

Dear trainee

Psychiatry needs doctors who are prepared to think critically. Unfortunately, it does not always make it easy for them to do so. Professor Sir Robin Murray, one of the most eminent UK psychiatrists over recent years, confessed to mistakes in an end of career mea culpa, wishing he had not adhered so “excessively to the prevailing orthodoxy" (see previous post) . As he says, there is an orthodoxy in psychiatry. You should, therefore, be prepared to be indoctrinated in your training (see previous post). This can be a confusing experience, and these comments are written to try and help you with that confusion.

Modern UK postgraduate psychiatry was developed at the Maudsley Hospital Medical School after Aubrey Lewis was appointed Professor of Psychiatry in 1948. He promoted the recruitment of high quality psychiatrists with "ardent, critical, lively, disputatious and reflective, eager minds" (see previous post). He encouraged a sceptical approach to psychiatry and had little patience for imprecision or poorly thought-out ideas. Building on these roots, it is still the case that doctors with open minds, who are sceptical of psychiatric quackery, need to be attracted into psychiatry.

The trouble is that you may have been encouraged to come into psychiatry because of clinical neuroscience (see previous post). There have been many exciting developments in basic neuroscience but what you may not have been told is that it is questionable whether these have any bearing on most of clinical psychiatry (see another previous post). The history of biological research in psychiatry is of speculations that have failed to be confirmed. Inconsistencies and confounders plague research studies, so that essentially it’s not been possible to say anything definitive about the neuroscientific basis of functional mental illness.

This may seem disappointing. But I wouldn’t want to encourage you to come into psychiatry if your only motivation is to uncover the biological basis of mental illness. You are bound to become disillusioned (see previous post). You may well have a successful career, like Robin Murray, but that may not be sufficient compensation for your personal scientific integrity (see another previous post).

However, maybe, after all, your primary attraction to psychiatry was more for philosophical and cultural reasons. You have trained as a doctor, so can appreciate how medical training is not always patient-centred (see previous post). However difficult it may be to have a whole-person approach to medical practice, this may well have been your initial motivation for choosing medicine. And, psychiatry, at least theoretically, should give you the opportunity to develop these interests further, although psychotherapy training is perhaps not always as readily available as part of psychiatric training as it used to be. Not that I am necessarily encouraging you to become a psychotherapist. Psychiatry itself has wider social concerns.

And, if you think about it, maybe you should not be so surprised that functional mental illness cannot be reduced to brain abnormalities. Biology itself raises philosophical issues about whether life can be understood as a machine. The fundamental issue of the relation of mind and body creates the context for stimulating conceptual debate and conflict in psychiatry. Despite Descartes, the soul and body are not separate but integrated in the organism. Psychiatry should take an organismic, processual, rather than mechanistic, perspective in the life and human sciences.

I would encourage you to take up the challenges of psychiatric practice. Clinical work is a privilege to share the traumas and sufferings of patients and help them understand and do something about their situation. Intellectual and academic rewards and fascinations are there for those that accept the limitations and uncertainty of practice. I wish you well in your application.

Let me know if I can do any more to help.