Can a psychiatrist be a real doctor?

This is a question that is asked seriously by some, and tongue in cheek by others (usually other doctors). Yet we too go through the slog of medical school, followed by two years as foundation doctors in a variety of specialties, including those in acute hospital settings. At this point, some embark on the long training to become surgeons, or physicians, or GPs, but others choose psychiatry. We work then for six years under supervision, while taking expensive exams, learning to assess and manage people with depression, anxiety, schizophrenia, eating disorders and many more. We work with children with ADHD, and with older people with dementia. We work with people with intellectual disabilities, and those who use drugs or alcohol. 

There is no doubt that we lay our hands on rather less than other doctors, and much of what we do relates to the relationship with the patient and with others. We listen, and we talk – hopefully less of the latter – and, over the years, we become more skilled. We see patterns, we recognise risks. There are probably those who would query whether a medical degree is necessary; could a psychologist or a psychiatric nurse not do this at least as well? I wouldn’t deny this; but they, too, come from different backgrounds that inform the way they do things. I am a doctor before I am a psychiatrist, and this is present in every way that I practise. 

Psychiatric patients often carry a heavy burden of physical illness, and may find it hard to access help. Smoking is more common, as are use of alcohol and drugs, and many of the medications used can cause metabolic effects, such as weight gain. In my own specialty of addictions, patients’ health is unsurprisingly poor. There’s no point in focusing only on the symptoms of mental illness, as these will inevitably merge with those of physical illness. While I may not be the one to treat their heart attack, or remove their appendix, I need to know the symptoms and signs of many such illnesses before it’s too late. I also need to understand the array of drugs that people are on for their physical conditions before I engage in some prescribing some of my own for their mental illness.

The big question as to whether mental illness is caused by nature or nurture continues to trouble us. And, once established, is it a biological or a psychological disorder? I’ll throw my hat in the ring and say that I believe that many of the more severe mental illnesses, such as schizophrenia, are biological. I think few would argue that dementia, or intellectual disability, could be purely psychological; it gets harder with some other conditions, especially when there appears to be a clear link with previous adversity or trauma. Then someone’s symptoms can almost make sense, as a result of what has happened to them. Trauma may worsen any mental illness; but then smoking worsens lung disease (and much more). It is also true that many physical illness cannot be explained by biology alone.

In view of all this, I would argue that psychiatry is not a refuge for doctors who don’t want to do real medicine. My wide knowledge of illness and drugs differentiates me from my psychologist colleagues, and they in turn provide sophisticated assessment and therapies learnt from their years in a very different type of training. My patient may be depressed as a result of many illnesses – hypothyroidism, heart disease, arthritis, just to name a few. Many tumours can cause psychiatric symptoms, directly and indirectly. They won’t thank me for treating their depression and missing their underlying illness – although their depression may still require treatment.

The pandemic has rather brought this home to me. During the first wave, my ward was converted to a covid ward for the psychiatric hospital, at least partly because, working in addictions, we come up against a lot of physical illness, so might manage better than others. Most of the patients we cared for were not severely ill, but still required a lot of skilful nursing care. I arrived at work, bemused, changed into peach-coloured scrubs and donned PPE before we met as a team to discuss the patients’ needs – very different from our usual fare. I found this hard – largely because I needed to recognise my own limitations, and, sometimes harder, convey them to others. I knew that I would never be a respiratory physician; my job was to ensure basic care, and to spot when patients became more ill, so that they could be transferred to a more suitable ward.

You can imagine my relief when we reverted to our usual diet of detox, far more within my comfort zone. And the hospital was able to plan for this wave, such that we have not, on this occasion, been designated the covid ward. The uneasiness remains, though. It is possible that junior doctors may be redeployed to help out in other hospitals, given that they have worked in these settings far more recently. This could result in senior psychiatrists needing to provide more of the day-to-day physical care for our own in-patients. I pride myself on keeping up with the basics, including bloodletting and the odd cannula, but I am realistic enough to know that I would need to have a low threshold to ask for help.

Having had my covid vaccination, however, I feel very fortunate, and have volunteered at some vaccine clinics, which feels like the least I can do. Despite being a true face-to-face worker, I feel a degree of survivor’s guilt – my daughter, working in a care home, waited more than a month longer than me for her vaccine, as did the residents she cares for.

Covid has decimated peoples’ health, both physical and mental. I’m a psychiatrist, and I want to continue to work with people with addictions and other mental health disorders. But first and foremost, I’m a doctor. Many of us specialise, and I certainly wouldn’t want a surgeon to treat my diabetes, or a dermatologist to take out my appendix. All specialists need some general knowledge.