Done with psychiatry and onto 4th year

I just finished my clerkship in psychiatry. It was pretty fun. It was very interesting. But I'm not sure if I want to be a psychiatrist. Psychiatrists seem to be a pretty happy, low-strung group of people. Psychiatry is really different from the other medical specialities. Only in psychiatry can you treat any illness with the same medication, and the same illness with any medication.

The field is somewhat maligned by the rest of the medical profession. Doctors view psychiatry as a medical field like physicists view sociology as a scientific field. It is soft in terms of method and subjective in terms of evidence. The large majority of doctors dislike mental illnesses, exemplified by diseases like schizophrenia and bipolar disorder. They dislike the diseases because they are poorly explained by modern biomedical paradigms (e.g. molecular and cell biology). They remain resistant to the kinds of physical explanations given to other diseases. We know a whole lot about how the heart works and why heart attacks happen. With our knowledge of that organ we've been able to develop a very accurate mechanical model of physiology and disease. We are far from that stage when it comes to diseases of the mind, although there is no doubt that these diseases are ultimately based on dysfunctional biology too. Psychiatry is a good 200 years behind cardiology. This is not a failing of the field but proof of how extraordinarily complex the brain is.

My attending likes to poke fun of neurologists, the other kind of doctors who study the brain. Actually, neurologists diagnose and treat nerve abnormalities, and to the extent that this involves the brain, that organ too. Neurologists have the same prejudice towards mental illness that is widely found in medicine: they hate it. This must sound odd to someone who does not make a clear distinction between the mind and the brain. Indeed this duality - formalized by Rene Descartes - is largely rejected by neuroscientists, who view the mind has a manifestation of a whole bunch of ultra complicated neuronal connections (synapses). The above-mentioned attending likes to say that neurologists and indeed most of the medical community think of the brain as the motor and sensory strips, the visual cortex, Broca's area (language control) and the basal ganglia, thus excluding most of the brain that constitutes the essence of being human: executive cognition.

Perhaps more than mental illness, most doctors dislike the mentally ill patient. The reasons for this is varied. Many doctors went into medicine because they like the application of biology to making people's bodies work better. To be honest, many doctors (and especially surgeons) are not much different than car mechanics, except the car is very sophisticated and the stakes for success and failure are very different. Sure, a lot of doctors (and especially internists) do like the fact that their patients have personalities, quirks, desires, flaws, and so forth. This guarantees variety and unpredictability to the profession. Personality, however, often becomes an impediment to the doc doing her job. For example, the patient with chronic low back pain who wants an easy fix with a pain killer instead of loosing weight. Or the individual who fails to control his diabetes with proper diet and exercise because he suffers from depression. People find all kinds of excuses to not do what their doctors tell them. To some extent this is normal, we all do it, but for those who are mentally ill, it is more than a matter of making excuses. The reasoning machinery we take for granted is skewed or even grossly flawed in these people. You can't just tell a schizophrenic that he has to take his medicines or he'll go crazy, just like you can't tell a depressed person to cheer up and get on with their life.