Defining the competent psychiatrist

psychwclientWhat defines a competent psychiatrist?  To staunch critics of the field, perhaps nothing.  Some believe psychiatry has done far more harm than good, or has never helped anyone, rendering moot the question of competency.  What defines a competent buffoon?  A skillful brute?  An adroit half-wit?  Having just finished Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown, 2010), a reader might easily conclude that psychiatric competency is a fool’s errand.  From directing dank 19th Century asylums, to psychoanalyzing everyone for nearly anything during much of the 20th Century, to doling out truckloads of questionably effective, often hazardous drugs for the past 35 years, perhaps psychiatry is beyond redemption.

Of course, I don’t think so.  For one thing, critics often disagree about what is wrong with the field.  For every charge of over-diagnosis and overmedicating, another holds that debilitating disorders are under-recognized and under-treated.  A charge that psychiatry has become too “cookbook” and commodified is answered by the complaint that it is too anecdotal and not sufficiently “evidence-based.”  Claims that the field stumbles because it is subtle, complex, and understaffed by well-compensated specialists, are met with counter-claims that checklists in primary care clinics can do most of the heavy lifting at less expense.  Contradictory criticisms offer no evidence that the field is faultless.  But the confusion does suggest that psychiatry’s limitations reside at a different level of analysis than that engaged by its critics.

For another thing, the undeniable shortcomings of psychiatry don’t make the patients disappear.  Whether the field teems with genius humanitarians or raving witchdoctors, there are still families watching their teenage daughters starving themselves to death; beloved aunts and uncles living unwashed and mumbling to themselves on the street; people ending their lives out of temporary tunnel-vision; tormented souls imprisoned in their homes by irrational fears.  And our society still harbors a nagging ethical sense that a crime is committed only when a person knows what he’s doing — and that when he doesn’t, he deserves help not punishment.

We can admit that psychiatrists are (at times meddlesome) do-gooders who take on misery and heartache and uncontrolled destructive behavior despite deep controversies over how best to help.  It’s the same role filled, in different times and places, by clergy, by family, by shamans, by the village as a whole.  Every society fills it by someone.  This is the modest starting point that bootstraps a meaningful definition of psychiatric competency.

Lists of “core competencies” are issued by the Accreditation Council for Graduate Medical Education (ACGME) for psychiatry residents, and by the American Board of Psychiatry and Neurology (ABPN) for board-certified psychiatrists.  Both organizations categorize psychiatric competency under the six headings established by the ACGME for all medical specialties: Patient Care, Medical Knowledge, Interpersonal and Communications Skills, Practice-Based Learning and Improvement, Professionalism, and Systems Based Practice.  (These categories are also used by the Accreditation Council for Continuing Medical Education [ACCME], so that continuing education required to maintain one’s medical license addresses one or more of these competency areas.)  A review of either of these detailed lists reveals two important truths.  First, a committee can make any aspirational standard byzantine and lifeless.  And second, in the eyes of  ACGME and ABPN at least, it’s not so easy to be a competent psychiatrist.

However, these official competencies are unlikely to satisfy skeptics, nor do they get to the heart of the matter.  No such list can be exhaustive: the ABPN includes knowledge of transcranial magnetic stimulation, presumably a recent addition, but fails to require knowledge of specific pharmaceuticals.  Focus areas such as addiction, forensic, and geriatric psychiatry are mentioned, but not administrative or community psychiatry.  The linguistic philosopher Ludwig Wittgenstein argues that our inability to precisely define natural categories, even simple nouns like “chair,” is a feature of language itself, not of psychiatric competence specifically.  Accordingly, any catalog of psychiatric competencies, whether intended to be comprehensive or a “top ten” list, captures some, but not all, of what constitutes a competent psychiatrist.

As implied above, the starting point, although not the end point, for defining the competent psychiatrist is intent.  A psychiatrist aims to relieve suffering in an uncertain human domain.  Brought to bear are skills, knowledge, and personality factors (“professionalism” etc) which bring this goal closer.  These cannot be listed exhaustively: virtually the whole of human knowledge and experience can inform one’s understanding of a patient’s emotional turmoil.  The best we can say, I believe, is that a competent psychiatrist is curious, has a wide fund of knowledge and life experience, and aims to keep an open mind.  Some of this knowledge certainly should be biomedical.  But knowing about the psychology of aging, common stressors such as job loss and divorce, gender differences, and many other areas are hardly less important. The practitioner’s proclivity to observe the human condition both scientifically and humanistically is ultimately a better gauge of competence than whether a specific treatment modality such as TMS has been added to a long list, or whether the practitioner is able to cough up a specific fact.

Given the controversy and uncertainty in the field, another essential of competent practice is humility.  In most cases we don’t know the etiology of what we’re treating.  Any treatment we offer helps some patients but not others, and nearly always carries risk.  Whitaker makes many good points along these lines.  A competent psychiatrist tempers his or her urge to intervene with the realization that the road to hell is often paved with good intentions.  Psychiatrists virtually always mean well, and (contrary to some critics) help our patients far more often than not.  Nonetheless, a competent psychiatrist is always ready to admit misjudgment or miscalculation.  Self-correction is a feature of competence in psychiatry as well as in many, perhaps all, other domains of human expertise.

For another take on the competent psychiatrist, arriving at a similar endpoint using different reasoning, see this 2011 post by Dr. Raina.

I wrote above that psychiatry’s limitations may reside at a different level of analysis than that engaged by its critics.  Psychiatry is a hard job because the brain is the most complex organ, because normality is so hard to define, because human development is a subtle interplay of nature and nurture, and because we don’t understand the root causes of many forms of mental distress.  But even if we did know and understand these far better than we do now, the field would still be fraught with controversy and uncertainty.  Our attitudes regarding responsibility, free will, conformity versus deviance, and how we treat each other reflect our politics and deeply held values.  Psychiatry serves as a lightning rod for strong feelings around these matters.  By its very nature, it always will.  Psychiatrists must accept that many will view us skeptically, some with hatred — and others with undeserved adoration — and not let this dissuade us.  A competent psychiatrist hears criticism from individual patients and the public, neither dismissing it unthinkingly, nor allowing it to lead to demoralization and defeat.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net.

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