Letter to a Medical Student

On Choosing to Become a Psychiatrist — To A Subscriber

Dear Almost-MS4,

I’m happy to hear from your last email that you’ve completed your third-year psychiatry clerkship, and that psychiatry is still your top choice for residency. Congratulations on your honors grade. I have no doubt you earned it. Based on our talk a while ago, I think you will make a fine physician whether you ultimately decide on psychiatry or not. Since I already addressed most of your practical questions in our conversation, I thought I’d follow up with a few additional scattered thoughts that have been percolating since.

I’m sure you’ve heard the third year of medical school likened to speed dating. In the course of the year, you go through your core clinical rotations: internal medicine, pediatrics, surgery, OBGYN, psychiatry, each for a few weeks, with a few specialty rotations thrown in, and then decide which one you’re going to marry. Some, like me, go into medical school with a pre-arranged marriage, but tolerate flirting with others on the side as a price that must be paid for getting through the process. Others are more undifferentiated and pluripotent in their interests, and don’t mind the promiscuity.

The year goes fast as you well know, and it can be difficult to find time to think things through. My general advice for choosing a specialty—any specialty—is rather prosaic. Choose a field that: (1) has patients with whom you enjoy working; (2) has medicine you find interesting in itself; and (3) is compatible with whatever personal and family life you desire. There are other subsidiary considerations, but I think these are the essential three. These are also the three that are at least somewhat knowable to you at this point in your training and don’t rely on you making fantastical guesses about the future (will AI replace my field in ten years?!). A note of caution: take care not to let a single bad experience on a rotation decide your whole fate. If you love a particular field but, say, your attending is an insufferably pompous ass or your senior resident has an IQ three points lower than fungus, don’t let that necessarily spoil you to the whole field. The opposite is also true: don’t let a particularly charismatic superior lure you into something you know in your heart isn’t for you.

So, what about psychiatry in particular? I won’t try to sway you one way or another in your decision (not that you need my help making decisions) but I can tell you some of what makes it appealing to me. I can also tell you what I think makes for a good psychiatrist, and perhaps point out some salient features that would make someone inclined, or not, to pursue the field. Needless to say, this is all my own personal take on the subject. I certainly don’t speak for anyone else or with any other authority beyond my own experience and some common sense.

All physicians deal with the human condition, often in various cases of extremis. We encounter suffering and do the best we can to mitigate it. Human suffering is almost infinite in its variety and forms, and different physicians see it in various guises. Psychiatrists deal with the human condition in a way that’s a little bit different than the rest, at least as I see it. A big part of our job is helping people whose troubles have robbed them of some portion of their very humanity, or identity, or life-as-they-know-it. We try to help those whose basic psycho-physiological mechanisms for perceiving the world, interacting with others, and communing with their own selves have to some extent broken down (few feelings are more terrifying than feeling like you’re losing your mind). Our patients tend not to have clearly defined lesions amenable to excision. We have comparatively few objective tests to diagnose the illnesses we treat; the diagnosing being left mostly to the psychiatrist’s clinical acumen.

My mom (she’s also a psychiatrist, total coincidence of course) used to say that psychiatry is the only truly interesting field of medicine. Already I hear cries of protest, but in a way she’s right. Psychiatry is different. Most of the rest of medicine, she’d say half-jokingly, isn’t all that different from plumbing, or carpentry, or pest control, or waste management. Balance the fluids, set the bones, quash the infection, make sure the bowels are moving. It’s wonderful to have these doctors around. They save lives every day and we’re very grateful for the work they do. But as interesting as studying hypovolemic shock, or osteosarcoma, or Pseudomonas, or constipation may be, it just isn’t as interesting as studying the human mind. At least for people like her, and me. Psychiatry can attract a certain type, as you may have noticed by now.

As for the job itself, I have a few thoughts. First, you should be able to be around people all day. Ideally you’ll find them interesting enough to talk to and, more importantly, listen to. Some of us are naturally good listeners; most, like me, are not. Being able to listen well isn’t just a natural gift, it is also a skill: it can be learned, although many choose not to. You know that whole “you only use 10% of your brain, so imagine how powerful you’d be if you could harness the rest of it” stuff? Replace “brain” with “ears”, and it might be closer to the truth. We shouldn’t forget that one of the most common complaints doctors get is “he didn’t listen to me”.

Listening is not merely a passive, receptive capacity. The best listeners have a way of making others feel heard and truly understood that is therapeutic in itself. This mode of listening is a kind of existential acknowledgement of another human being. The deep listener gives something of himself to the speaker. The value of deep listening only increases as its practice becomes rarer—just consider how uncommon it is for someone to just listen to you attentively without interrupting for five whole minutes.

A good psychiatrist follows both the content and the process of a conversation. As the superficial listener appreciates only the basic tune of a song, so in conversation he attends only to the words that are spoken. The silences, rhythm, tone, anticipations, unconscious conflicts, hidden intentions, wishes, and the feel of the whole thing, are neglected. Overall, an eye for nonverbal cues and an overall sensitivity to the emotional temperature of the room are assets. We should learn, as Theodor Reik said, to listen with the third ear¹.

It sounds cliche, but listening really is a gift you can give other people, one which often repays with interest. I’m still working on it myself.

Two significant hindrances to good listening are: first, not actually being interested in what your interlocutor has to say and, second, being too caught up in your own issues to be able to attend to anything else. Psychiatric patients are some of the most genuinely interesting people you’ll ever meet, so I trust the first hindrance will not be a problem. If you do find yourself uninterested in your patients for an extended period of time, I recommend seeking out consultation from a trusted colleague. The second hindrance is one of the chief reasons psychoanalysts are required to undergo their own analysis as part of training: it is difficult to listen carefully while maintaining therapeutic distance if your own mind is incessantly tossed about in a whirlwind of unchecked neuroses. This isn’t to say you need to go into therapy, but it’s worth putting in the effort to cultivate and maintain a gratifying personal life. It will be a refuge and safe harbor when you feel like the whole world has gone crazy. Few physicians can practice top quality medicine for very long when their home life is in shambles.

The depth and range of human dysfunction will always find ways to surprise and shock us, and we each have our own varying tolerances for other people’s problems. You should therefore have an interest in, or at the very least be able to stomach, the strange, bizarre, wild, and scary in both yourself and your patients. You must be able to empathize with it, listen to it without judgment, talk to it, relate to it, work with it. Sometimes you’ll feel like you’re marinating in it.

Get comfortable with adversarial relationships. Although they can occur in any field of medicine, psychiatry happens to have—at least potentially and depending on the practice setting—more than average. The clearest examples are cases of involuntary treatment, but there are more subtle and common forms. After all, a good chunk of our job is dealing with people whose chief complaint is some version of “patient’s behavior has become intolerable to other people”. Managing these adversarial relationships turns out to be one of my strong suits. The process is helped by having a variety of tactics and approaches in your toolbelt, ranging from the most receptive, validating listening all the way to showing confident authority while laying down the law with an aggressive or violent patient. I can’t stress the confidence point enough, and while it’s true that many legitimate criticisms of our profession rest on our tendency to overconfidence, I’ve noticed I have decent results getting psychotically ill patients to take medication when I look them square in the eyes and tell them frankly, “Look, I’m pretty good at what I do, and if you’re willing to trust me, I bet I can get you feeling better.”

Many people have absolutely no understanding of psychiatry nor any appreciation of what it can offer, which is perfectly fine until someone gets sick. In training I was surprised by how many people really do believe mental illness is more akin to either some kind of magic, or merely the result of needing to “buck up and get your priorities straight”. Sometimes these people will be your patients or their families. This can be a source of great frustration for some psychiatrists. I suggest, for the sake of your sanity if nothing else, that you respond with interested curiosity. Work to remedy the situation within reason and when appropriate, but most importantly learn to work with people, of all types and as weird as they come. Use the affordances people give you as best you can, and work with what you have. With the right attitude, the whole thing is quite interesting and more than occasionally amusing.

Every psychiatrist should have some competence for psychotherapy. It is one of the foundational skills that can and should continue to distinguish us as effective clinicians (and is all the more important given the recent proliferation of questionably trained therapists). Not all psychiatry residencies emphasize serious psychotherapy training as they should, so you may need to make something of a curriculum for yourself. A good psychotherapy supervisor can help you with this. Remember that your psychotherapy training is not limited to 45-minute therapy sessions: every evaluation, follow up, “med check”, or phone call with a family member has potential psychotherapeutic value. As a medical student, you’re already talking with patients all day, so in a sense your training has already started.

(Oh, and about that 45-minute therapy session thing: psychiatry is still one of the few specialties in which you can actually spend time with your patients. Unless they’re running a concierge practice, many doctors don’t get more than around 15 minutes per appointment. In my opinion, and I’d venture a guess the majority of primary care docs agree with me, that simply isn’t enough time to practice medicine at the standard to which we were trained. But as a psychiatrist, even if you aren’t a psychotherapist doing 45-minute sessions, it is relatively easy to construct your practice such that you have ample time for each patient.)

During and after residency I dove into psychotherapy intensely. I still love it, study and read about it, and practice a form of it in my hospital work, but I found that doing it all day was impossible for me. One mundane contribution to the impossibility: the sitting. Sitting hour after hour, day after day, listening to others with intense focus, even with breaks in between, is taxing. Freud was somehow able to see up to ten analysands a day, six days a week, but us mere mortals usually can’t keep up that pace². It can also get lonely if every day is spent just one-on-one with patients. Hospital work allows me the physical activity and socialization that keeps me alive and, well, on my toes, while still affording me the opportunity to work just as closely with my patients. I’ll probably re-focus on a psychotherapy practice someday, likely once I’m tired of being on my feet all day.

Psychotherapy aside, you’re in medical school, so I don’t need to tell you that we’re physicians first. But once you’re far enough out from training it doesn’t hurt to be reminded once in a while. One thing that distinguishes us from PsyD’s and other graduate-level colleagues is our connection to medicine—we spent years in medical school and residency dealing with people who are really sick in all kinds of horrible ways for a good reason. This means doing doctorly things like performing physical and (especially) neurologic exams regularly. Know your pharmacology like the back of your hand. Never hesitate to go back to basic sciences: if you need to brush up on your lithium pharmacology, you can squeeze in a pretty decent review of renal physiology in about fifteen minutes. Same for beta-blockers and cardiac physiology, and so on. Keep current in the neurosciences and the basic and translational research that interests you. Importantly, you should become versed in critically appraising the medical literature so you can intelligently evaluate it yourself without lazily falling back on appeals to authority or group consensus. More importantly, develop a method for continuing your learning—learn how to learn. Create systems for regularly reviewing your clinical work, spotting your errors, and correcting them. Start a running log right now of every interesting patient you see—medically interesting, personally interesting, whatever you like—and keep it going through residency and after. Whatever crazy case you just saw with all those great teaching points, which you’re convinced you’ll never forget, will get wiped from the memory banks sooner than you think.

I know you have an interest in internal medicine and emergency medicine. Should you become a psychiatrist, there is no law mandating that you sequester yourself from other specialties and forget the rest of your medical training. Depending on your practice, you could continue to work closely with IM and ER docs, or even work on the medical and emergency floors in a med-psych capacity if you find the right hospitals. The opportunities are there if you look for them. Psychiatry is a flexible specialty and if the job you want isn’t already out there waiting for you, then you can probably make it yourself with a little initiative and creativity.

Re: opportunity and flexibility, you have a good deal of that to look forward to in your career. Psychiatry is not without its benefits, and this is one of them. Most of this you won’t have to think about for a few years, but it doesn’t hurt to have some ideas percolating in the meantime. You have a range of choices for fellowship³ training in addition to your general adult psychiatry residency, including: child/adolescent, geriatric, consultation-liaison/psychosomatic medicine, addictions, forensics, sleep medicine, hospice/palliative care, neuropsychiatry, and even a few emergency psychiatry programs. The flip side of all this is that unless you want to do academic medicine or some other niche work where credentials matter, psychiatry fellowships are not necessary for a career. More and more specialties these days require fellowships, and sometimes fellowship upon fellowship, to be competitive in your practice. Psychiatry has thankfully avoided this pitfall thus far. Also—and some credential-minded people won’t like this—I think that if you finish your psychiatry residency and then work for a year or two with geriatric patients, or addictions, or in ERs, or whatever, that you’ll get just as good an education as you would in most fellowships all while making attending salary (as long as you’re putting in some time to study and find a good mentor or two).

One of the most rewarding ways to advance in your own training is to teach your junior colleagues. In medical school I worked as a teaching assistant for almost every course that had a TA position. I did it because I love teaching, but the ancillary payoff for my medical education was extraordinary. A good test of how well you know something is how well you can explain it to a layman. Teaching forces you to remember first principles. It forces you to make what is familiar new again, seeing it as if for the first time, with the eagerness and receptivity of a novice; in Zen this is called beginner’s mind. The very best teachers are characterized by their ability to maintain beginner’s mind even after decades of experience.

Being a psychiatrist is a really fun job. The people are great. Hardly a day goes by when I don’t hear or witness something unexpected. And you can truly get to know your patients. Our patients have some of the best senses of humor, and I laugh a lot more at work than I thought I would. They will tell you things they’ve never told anyone else. You will hear and witness amazing things, and also heartbreaking things and courageous things and violent things and hilarious things and all very human things. You will come to appreciate human weakness in a new and profound way. You will have the chance to save people’s lives. How cool is that?

There’s a lot we don’t understand about psychiatry. We deal in illness that are mysterious and will remain so until our scientific understanding is less primitive. Sometimes I sense psychiatry has an inferiority complex because in many ways we know less about how our organ works than other fields do about theirs (although to be fair, one of my big takeaways from medical school was that those other fields have a bad habit of pretending they know much more than they in fact do). But the mysteries and uncertainties and unknowns can be sources of unending excitement if you let them. Every day I see something new. Every day I’m learning.

What is important to you? How do you actually want to spend your time? What do you have to do such that when you lie down at night you can say to yourself honestly, “I’ve done something worthwhile with my time on Earth today”?

A couple weeks ago, my daughter and I were at Chick-fil-A getting takeout for dinner. The cashier had just handed me our order and as I was grabbing some extra napkins someone called out from behind me with a “Hey, Dr. Greenwald, is that you? It is you! Hello, it’s good to see you!”. It was a young man with bipolar disorder whom I had treated on the inpatient unit and recently discharged. He thanked me again for helping him out of his unusually violent psychotic episode and working with his parents to get him back in his home safely. We exchanged pleasantries and he wished us good evening, mentioning that since discharge he had already found a new job and, for the first time in months, was getting together with friends to celebrate with a Settlers of Catan game night and some Chick-fil-A. As my daughter held my hand on the way out to the car she asked if he had been sick in the hospital and if I had made him better. I said I’d helped out, at which point she looked up at me with that look toddlers get when they’re trying to be super serious and said, “Good job, daddy, I’m proud of you.”

I could go on with the feel-good stories—in psychiatry there turns out to be quite a few of them. I try not to romanticize the medical profession, but the reality is there are a lot of people suffering terribly whom we can and do actually help. Most people are happier when they’re helping others, and I’m convinced one of the reasons so many people are so unhappy today is that we have at some level forgotten this fact. I am unbelievably fortunate to have a job that affords me the opportunity to make philosophical inquiries into the nature of perception, or the self, or free will, or indulge whatever other heady ideas I’m tossing around, while also knowing at the end of that day I’ve helped people and done something that mattered.

One last parting thought. As you progress in your training you will find people placing incredible amounts of trust in you, granting you authority to influence their lives in profound ways. But as you progress you also become familiar with your work. Things become more routine. Eventually, someone’s life-destroying medical crisis is just your Wednesday morning. It is easy to forget that for many patients, their brief visit with you may be the most important conversation they have that day, or week. It is easy to forget the rigor with which you applied yourself in medical school, sliding into convenient and lazy habits that are just “good enough”. It is easy to become resentful of every stupid, annoying obstacle the system puts between you and effective medical practice. It is easy to get jaded when it feels like none of your patients have listened to a single thing you’ve said for the past five years. Sometimes it feels easier to skirt the truth and sacrifice a principle here and there to get by. You will be faced with choices: do I do what’s profitable, what is expected of me, what the administration tells me to do? Or, do I remember the oath I took, and do the right thing? Therefore, and above all: preserve your integrity. Guard it like a precious jewel that is easily tarnished, and when tarnished takes a lifetime of work to re-polish. Because it is not knowledge, but integrity, that is the ultimate coin of our profession, our reserve currency and gold standard, and that when all is said and done it is by far the most valuable currency you’ll ever have. Living with integrity while maintaining a healthy flexibility to circumstance is the art of living. If I make any progress on that, I’ll be sure to let you know. In the meantime, I wish you nothing but continued happiness and success.

1. “The analyst hears not only what is in the words; he also hears what the words do not say. He listens with the “third ear,” hearing not only what the patient speaks but also his own inner voices, what emerges from his own unconscious depths.”

—Theodor Reik, 1952, pp. 125-126

2. I think this was at least a decade after he stopped using cocaine, in case anyone was wondering.

3. For the non-medical people: in the US the general scheme is 4 years medical school, where every medical student learns basically the same stuff, followed by residency training lasting 3-7 years depending on the specialty. Residency is where newly minted MDs train to become urologists, internists, ophthalmologists, psychiatrists, or whatever other specialty they applied for. Fellowship is an additional level of training done after residency for further subspecialization, e.g. a cardiac electrophysiologist has to complete 4 years of medical school, 3 years of internal medicine residency, 3 years of cardiology fellowship, and then two more years in a cardiac electrophysiology fellowship (at least last time I checked). An attending physician has completed formal training and practices without supervision; the buck stops with him or her.