You or me?

Evidence-based practice matters, and rigorous research is not only a thing of beauty but also necessary to find and validate further and better treatments, especially in psychiatry. But real people exist in a less ordered world, where things are often unclear. Diagnosis, treatment, prognosis, outcome – these are all islands, navigated by many, in boats that are seldom going in similar directions and often reaching different destinations.

I am a patient and also a psychiatrist – sometimes both in the same day. I would rather this was not the case, and usually I am pretty well when this happens. At times when I have been more ill, I have had weeks or months as a patient, followed by a tortuous return to being a doctor. The two are separate. But sometimes, when well, I will lead a ward round, see patients and then have a routine appointment with my own psychiatrist, before heading to a multidisciplinary team meeting and an afternoon clinic. That routine appointment pulls me back to being a patient – exposed, raw and unsure – and to memories that I would rather leave undisturbed. It is a stark comparison of the roles of patient and doctor.

As a doctor, I have, occasionally, felt quite despairing when seeing a patient – I know that there is little that I can do for them, little in my bag of remedies that can change things in their troubled lives. But I am a psychiatrist, and I try to offer anything with evidence, albeit often limited by resources. There is, for example, little doubt that it is easier and quicker to try drug treatments than talking therapies – faced with distress, no-one wants to impose another wait. (But that is another story, one of cuts and austerity). I am there, in the room, with my patient, and I don’t know what to do. Sometimes I think – someone else would – even though I know, realistically, that this is probably not the case. Sometimes I may even be doing something that my patient resents, like withdrawing medication on which they have become dependent, or not prescribing something they would like. My interventions are rarely the panacea that the patient needs or desires; and even when there are benefits, their onset is often delayed. 

It is very different being a patient – you dread and yearn for that meeting when your doctor will help you, will smooth and mend your distress and thoughts. It can assume great importance, and then is quickly over and little has changed. Your friends and relatives may have told you – wait until you see the psychiatrist, they will help, things will be better then. You cannot even recall what you said, or what your doctor said. The truth is that your expectations are far too high, often raised further by excessive waiting times and lack of staff. 

I, the patient, know all this, and more so than many. So why are my expectations so unrealistic? I have an evidence-based knowledge of psychiatry that seems to fly out the window when I am on the other side. As a patient, I think there is still something magical about psychiatry; I still wonder if psychiatrists can read minds, and know things that others don’t. There is an inevitable power imbalance, which will be present in every branch of medicine, but is perhaps a little different in psychiatry. Is this bad? Well, I would hate to be the one holding all the cards when seeing my psychiatrist, as he would hardly then be in a position to practise much evidence-based medicine. He would have to do what I wanted, which might well be very bad for me. But nor do I want to feel helpless and unheard in our relationship.

And therein lies the fundamental issue, that of the relationship. It is a funny old word, that can be misconstrued, but should never be underestimated. We all have relationships with all kinds of people; the one between patient and doctor is vital to consider and to try to understand, especially for the doctor. This may be the fifth patient in your overbooked clinic, you may be tired and hungry, and have quarrelled with your partner. But this matters to them and you need to listen, and they need to know that you’ve listened.

My psychiatrist copies his letters to me after each appointment. When he asked me, some years ago, if I would like him to do this, I said no; but he did it anyway – confirmation, I thought, that he wasn’t listening. But over the years he has continued to do so, and what I most like is that he usually gets the facts right. He remembers something I said about my mother’s brother, he describes, mostly accurately, what I have told him. Many years ago I remember seeing a letter about me, written by some unremembered psychiatrist. The only thing that I recall from it was that they said I had an older brother. That my brother is younger was largely irrelevant, but what mattered was that I felt that I had not been heard. They weren’t interested enough to get it right. I know I am being unfair, and that I myself will have got things wrong, but it made me think about the importance of the relationship, of listening to your patients, and to the things that they say. That hearing them does matter, even if you have no easy cure, and that the relationship is important, even though it is, of necessity, somewhat one sided.

So I (or you) will – probably – try out your (or my) evidence-based treatments if I know you’ve heard me, that you’ve taken time to explain, even to chat a little. They may not work, or I may decide that the side effects are too much. I may just hate taking pills, or I may love it too much. I may not always take your advice, but at least I might ask for it again. 

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