The good enough psychiatrist

As patients, we often ponder whether our doctors, nurses, and other health care professionals are caring enough. As a psychiatrist myself, I assume that I am caring. But how do you measure caringness, what exactly is it? How do we know if we have it, and how can we train others to acquire it? Even more importantly, is it a good thing? Does coming across as caring actually make us provide better care?

I have recently been the recipient of what was probably a relatively minor bout of abuse on Twitter, and I must admit – reluctantly – that it made me feel rather sorry for myself. I couldn’t understand what I had done to deserve this. But it was very much centred around me being a doctor, not a patient, and I am starting to realise that combining these roles is quite difficult on social media, where opinions can be rather black or white.

Much of the criticism of psychiatrists seems to centre around prescribing, and there is often a suggestion that some doctors are trying to hurt people by prescribing medication, and even enjoying it. As doctors we are trained in the use of medication, and there is no denying that it is one of our primary tools. We learn the advantages, and (hopefully) disadvantages of prescribing, and we try to do it as well as we can, and according to guidelines. 

There is also the threat of Big Pharma, and the belief that doctors receive financial rewards for the many drugs they prescribe. It’s impossible to know how much this influences doctors. I don’t prescribe many medications in my job, so I tend to think it doesn’t affect me, but this may well be wrong. Even if one only prescribed one drug, ever, it would be very difficult to appreciate the subtle effects of pharmaceutical companies, which may often not be noticed.

The problem is that psychiatric medication is unpleasant, often even at its best. It is sedating, it makes you fat, and it doesn’t always work. I am on three different drugs, two added in (again) fairly recently, and am already putting on weight. I am angry and upset about this, and, were I not a psychiatrist myself, this would most likely be directed at my psychiatrist – he knows I’ll put on weight, he doesn’t care, it’s deliberate. I don’t think this (much) as I do understand his logic, but it’s taken a while to do so, and I still want to stop them.

Most of us – perhaps not all – respond well to kindness. If we go to see a doctor, there are certain things that make a difference. These may include being on time, looking at us, having read any referral, explaining things, perhaps giving us some degree of choice as regards treatment. It really helps if we go away feeling that we have been listened to, and even more importantly, heard. It matters when the doctor does what they said they would do, and remembers to send a copy of the clinic letter, showing that they remembered things.

I see some patients where there is very little one can actually offer. I used to feel quite uncomfortable in these appointments; and it was only quite recently that I realised that things were much better if I spent time listening to the patient, hearing what they said, and that not being able to prescribe anything was not always a problem. In fact, with some of these patients it would have been more of a disaster to prescribe, and would have amounted to treating myself rather than them.

But it’s difficult to be binary about these approaches. If someone said to me – Would you rather see a psychiatrist who is caring but somewhat limited on the knowledge front, or one who has a vast knowledge of interventions (for the purpose of the argument, let’s say psychiatric drugs) but not much of a bedside manner? – which would I decide to see? I think it’s almost impossible to decide – as a psychiatrist myself, I’d probably go for the latter, but, even as a doctor, I want to be heard and to be cared for.

Obviously, the ideal psychiatrist is the caring super brain, with plenty of time for patients. Realistically, all of us will tend to have different skills than others, and this may change with time and circumstance. Perhaps we should just aim to be the ‘good enough psychiatrist’, who will do their best, care about their patients, and try to keep up with treatments, both pharmacological and psychological. But sometimes we will not be perfect – we may be unwell, we may experience personal difficulties, we may just be trying to juggle complicated lives. I think I’d be happy to see a ‘good enough psychiatrist’.

What would trouble me would be seeing a psychiatrist who was too caring, particularly if this was not matched by their knowledge. There are a few doctors who seem to have a need to be liked by patients, and may actually prescribe, or offer other interventions to achieve this end, rather than in line with evidence. In my own specialty of addiction psychiatry this would be very easy to do, as patients will often ask for what we would view as inappropriate or harmful prescriptions, and can become angry if these are denied. 

I am well aware that there are people who have been prescribed psychotropic drugs who consider that they have been damaged by them, or are having major problems coming off them. I feel great sympathy for them; it is impossible for me to know the rights and wrongs of individual cases, but we do have a considerable amount of power in prescribing these drugs. It is our duty to maintain and enhance our knowledge about them, and about the disorders they treat. Above all we must take responsibility, and prescribe according to up-to-date research and guidelines, but I don’t believe that we should withhold them, for exactly the same reasons. 

Finally, I suspect that our characteristics are difficult to elicit on Twitter – we all tweet what we believe about ourselves. But, in the end, psychiatrists are many different people, just like everyone else.