Now that I’m getting ready to turn 70, I thought I’d summarize what I’ve learned since I finished my residency, when I was 28. Of course, I didn’t learn all this only by being a psychiatrist, since I would hope that most folks have also learned lots in the last 41 years.
1. Psychotherapy is important, particularly if the patient is on the right medication. I won’t do “med checks,” since I would not want them if I was a patient. I figure if it’s simple enough to do in a few minutes, my family doctor can probably handle it or learn how to do it. If it’s complicated, it’s going to take me more than a few minutes. If you have a severe psychiatric disorder like schizophrenia or bipolar disorder, and you are not on the right medicines, you’re in a lot of trouble.
2. Splitting the treatment is serious. Do it only when both treaters know and trust each other and are able to communicate easily. It puts a psychiatrist at great risk of a suit, with little reward.
3. Try to get along with colleagues. Never fight with secretaries; learn from their observations.
4. Try to have as few bosses as possible: Never have more than one at a time. All people — not just patients — have transferences, and these usually complicate relationships with bosses.
5. If you’re always agreeing with the general wisdom, particularly if money is involved, you will eventually be dead wrong. Beware of fads. Don’t trust ads. Don’t take professors or studies too seriously.
6. The more we know, the less magic is associated with us and the less respect we receive. It’s part of our attempt to climb out of the Middle Ages.
7. Psychotherapy is more about healing, which usually occurs in between sessions, than about insight. Patients who don’t do the homework probably will not learn new ways of handling problems.
8. You can’t tell who is going to be a good patient. People who have addiction problems are the hardest to predict. You probably should give them a chance.
9. People will pay for good medical care, particularly for their children. It is not an accident most psychiatrists are now practicing outside the managed-care system. Don’t allow managed care companies to tell you how to practice. Do what is right, even if it costs you in the short run. At least, be kind, if you can’t do any more than that.
10. If you’re willing to ask for a consultation, you are almost certainly not negligent. Set them up with someone whose advice you’ll almost automatically take. Don’t criticize colleagues to others, including to patients.
11. Don’t steal patients. Ask potential patients if they have ever seen a psychiatrist, when they first call. If it’s in the recent past, ask to have their psychiatrist refer them to you and say you’ll get back to them if that happens. Clarify beforehand if it’s for a one-time consultation or for ongoing treatment. If patients don’t show up for the first visit for any reason, or give you a hard time on the phone, you will eventually regret taking them into your practice.
12. Be available. Return calls. Have a call hour. Answer letters. Encourage patients to call you if they need you. Find someone to substitute for you whom you can trust when you’re away from the office for any significant time. Be very careful about prescribing for the patients of others when you cover for colleagues. Don’t charge for phone time; most people won’t abuse it. If patients call too much, you probably need to see them more often. Don’t let patients go for more than 90 days without seeing them.
13. Document. Too much is better than too little. Follow up on lab tests. Write legibly. Your reputation may depend on the quality of your notes.
14. Be cheerful. You can’t expect depressed patients to be optimistic, and someone has to be. If you are a psychiatrist, chances are that most people, and virtually all of your patients, have it worse than you do. Don’t complain.
15. Keep learning. I’ve heard that almost everything we know we’ve learned since 1950. Accept that what you know will probably turn out to be wrong or useless. They call that “progress.”
16. Patients are probably right about side effects. Be suspicious about claims made by drug companies, including maximum recommended doses. Ask patients about drinking and about caffeine, not just about illegal drugs. Check with families.
17. Be suspicious if patients forbid you to contact their families or the professionals who used to treat them. Get to know families. It’s crucial if something like a suicide occurs. Get a family history.
18. Don’t treat members of the same family, or close friends, if you can help it. Don’t write prescriptions for your friends or coworkers.
19. You can’t successfully treat everybody. Somebody else may be a better match.
20. You work for the patient, not the other way around. Dress accordingly, use honorifics like Ms. or Mr., and ask what the patient wants. Set up a valid treatment contract, early on. Be wary of double agentry, like working for the patient and the hospital, or for the patient and the managed care company.
21. Use “we” interpretations. People expect to be treated as equals, and they aren’t as tied to their traditions and their families as in other places. Sometimes a story or a fairy tale can illustrate a point. Be careful about using your own life as the example. Patients can sometimes change if they are laughing, but be careful. If you offend someone, apologize. Patients don’t expect their psychiatrists to be perfect, but they do expect them to display good manners, like holding the door for them or offering them a tissue when they cry. Psychiatric disorders are common, and chances are that someone you know, or even you, will get one.
22. If you’re going to work for yourself, you have to stay healthy. Take frequent vacations. Learn how many patients you can safely see in a row and what your personal clock tells you. If you are sleepy, excuse yourself and get some coffee. If you bring it into the session, offer the patient a cup.
23. Make sure you get paid. Don’t pursue it too hard; there are too many ways that disgruntled ex-patients can make you miserable.
24. When patients miss an appointment the first time, don’t charge. Make sure you call to find out what happened. If they can come later that day, let them. Patients tend to resent paying for missed appointments.
25. Be on time, or at least apologize if you’re not. Try to give extra time to people who need it. They rarely abuse it and often appreciate it. Give plenty of warning before you raise your fees.
26. You will like some patients more than others. Some patients will like you more than others. You are neither as good or as bad as your admirers or detractors say you are.
27. Things go wrong. Admit it when you make a mistake. The universe is always disorganizing.
28. Diagnoses can be important. Hand the patient the DSM-V if you think that a personality disorder is present. You may not want to make a diagnosis of a personality disorder, but it may be present anyhow. Completely ignoring it may complicate or destroy the treatment.
I hope I haven’t finished learning. It is upsetting to realize how little we still know about what causes psychiatric problems. Our patients live better lives now than they did 41 years ago and I’m optimistic that we can help them live still better lives in the future. I used to think that I would retire when I turned 70, but I decided not to do that. There’s too much going on for me to quit now.
Bruce Hershfield is a psychiatrist. A version of this article appeared in the Maryland Psychiatrist and at Shrink Rap.
Image credit: Shutterstock.com
