Speaking as a Physician

I recently covered on our inpatient psychiatry service at Tufts Medical Center. It is always valuable to see patients at the bedside and to spend time with wonderful psychiatric residents. As usual, the level of both medical psychiatric comorbidity and clinical complexity was challenging, as were the efforts to find the right clinical care and navigate a mental health system that is often fragmented and difficult at best. It was nevertheless greatly rewarding to see patients, to learn something about their life stories, and try to select care that was based on the best available science, and, when none was available, upon clinical experience and judgment.

In my response to the presidential address at APA’s annual meeting in New York in May, I highlighted four key tasks facing psychiatry. The first task is that we need to speak as the physician experts on mental health.

By this I meant that we must always remember, first and foremost, that we are physicians. It is thus incumbent upon us to be aware of the best scientific evidence available when we make clinical decisions, doing so in the context of the total needs—medical and otherwise—of our patients. It means to speak on their behalf even when it may bring us into conflict with others whose primary focus may be financial, legal, or ideological. It requires us to be deeply knowledgeable not only about the scientific literature and best practices, but also to have more than a passing familiarity with the limitations of that literature and to be prepared to speak when we must despite those limitations. And to do so on our patients’ behalf, not our own.

Implicit in these capacities is not just a comprehensive knowledge of psychiatry, but of clinical medicine as well. Whether on a consult service or in an emergency room, a state hospital, or a community mental health center, no one else can duplicate what we do, or do it with the years and depth of clinical experience that under the best of circumstances leave us seasoned practitioners.

It is critically important that policymakers and the general public understand that as physicians, the scope of our attention is to the totality of our patients’ historical, personal, and medical conditions. Our patients don’t come disconnected from the neck up, and neither does the way we practice. Regardless of the setting where we work, our ability to diagnose and treat patients from this broad perspective is an essential capability.

For decades our literature has been clear that psychiatric patients have substantial medical comorbidity and that this comorbidity is often not recognized, even by other physicians. In some cases it complicates the management of their psychiatric illness, as in patients with liver or renal disease who cannot metabolize their medications effectively. In others their medical illness or the medications needed to treat that illness affect the presentation of their psychiatric illness—or modify it substantially. Patients with fatigue due to their malignancy or whose depression is intermixed with a confusional or delirious episode secondary to metabolic abnormalities are among many possible examples. And there are yet others whose psychiatric presentation is directly due to a medical or neurologic illness, or a medication. Whether it is mania due to treatment with corticosteroids, or a young woman whose new-onset paranoid psychosis is due to an ovarian teratoma producing anti-NMDA antibodies, the role of psychiatrists in diagnosing, treating, and overseeing the totality of care is critical.

Indeed, there is an additional population of patients either having or thought to have psychiatric illness whose general medical illness is entirely undiagnosed until they are seen by psychiatrists. These patients, often seen previously by other physicians, are among our special responsibilities, especially in public-sector settings where we are often the only physicians. The unmatched breadth and intensity of our training in the full range of psychiatric illness make us the essential partners to both primary care and specialist physicians at, as our family practice colleague Dr. Frank DeGruy has so eloquently said, “the deep end of the pool.” 

Our scientific and research training makes it possible for us to not only create new knowledge but to speak authoritatively about psychiatric illness as well. While scientific training is not unique to us, the breadth of our training in neuroscience, medicine, and genetics, in addition to cognitive neuroscience and epidemiology, mean that our practice guidelines represent the most authoritative available guides to clinical care. And despite the legitimate conflicts about the etiology of and methodology for categorizing psychiatric disorders, there is no clinical substitute for DSM-5. And we are not the only ones who acknowledge this. The United States Supreme Court cited both our amicus brief and DSM-5 in the majority opinion in its Hall v. Florida decision rejecting a bright-line IQ determination in death penalty cases. As physicians, we have an obligation and an appropriate public expectation that we will provide dispassionate assessments of what we know—and what we don’t.

It is essential that we find a way to communicate to policymakers and the general public both the complexity of our patients and the distinctive expertise and experience we bring to the public discourse about mental health. Even more importantly, we must always be mindful that as physicians we have a special responsibility to speak from our rich clinical experience, and most importantly, from the best science available, wherever that may take us and regardless of opposition. These values and clinical and scientific expertise must be the primary touchstones of our policies and public statements about psychiatry. People may not always like what we have to say, and they may often disagree with it. But if we speak as physicians from our best understanding of what the science of our field is, and our honest view of the best interests of our patients, then they do listen. Ultimately, they will often trust, respect, and rely on our opinion.

I plan in future columns to expand upon this theme, as well as discuss other key tasks that confront us, both as a field and an organization. I welcome your thoughts at [email protected]. ■