“Is there a doctor here?”
This is the alarming call to every health practitioner on board a plane flying above the clouds, its impact varies according to their different specializations and their readiness to deal with emergency situations. An emergency doctor will get up from his seat to deal with the case as if it were happening on the surface of the Earth, as will the internist and critical care doctor. While we find that the confidence of those in surgical specialties depends on the nature of the case itself: Is there bleeding? Is there a break? Is there anything that requires me to use my manual skills?
But what if a health practitioner who identified himself as a “psychiatrist” answered the call for help? How would the plane passengers react then?
This question can become a source of ridicule about the nature of the psychiatrist’s work, as well as the stereotypical perceptions that the majority of people adopt, but at the same time, it prompts us to ask why such perceptions were formed in the first place (1). We claim here that the issue revolves around “clinical knowledge and skill,” which people assume is present in every doctor according to his specialty. The psychiatrist possesses these knowledge and skills that make him closest to being named “the wise man,” which is what was used to call doctors in the past, or that is what people assume!
Someone might ask, isn’t this assumption correct? No one expects the hand of a heart surgeon to be unsteady, just as no one expects the character of a psychiatrist to be unforgiving. It is an expectation based on the institution of medical education and the long journey in its faculties. Those outside the health field believe that the seven years that a medical student spends studying are sufficient to hone his skills, which will enable him to meet the standards required to enter health specialty training programs.
But as soon as preconceived assumptions collide with reality within psychological clinics, and as soon as you discover that not every medical practitioner in this field is characterized by wisdom, tolerant traits, tactful manner, and graciousness, then a question comes to your mind: “How did this doctor come to specialize in the psychological field?”
The question of “access” presupposes the existence of “standards.” That is, the general perception among the majority of people is that all doctors wishing to enter the psychological specialty are subject to a standard filter based on the foundations of the skills, characteristics, and interests necessary to practice psychiatry. But the bitter truth is that there are no such standards! All you need to be a psychiatrist – according to the regulations and bodies of training centers – is a set of numbers that reflect your academic achievement and nothing more!
Here we can see the problem looming on the horizon, a problem in the form of a wide, wide-open gate that allows the passage of many who are not at the required level of psychological, behavioral and intellectual fitness to deal with the suffering of souls.
Who is a Psychiatrist?
Before discussing the specifics of our need for filtering criteria, let us first define who a “psychiatrist” is. Once the features – the features and the nature of the work – become clear to us, we will be able to agree on the standards we want to measure, in order to fulfill the sufficiency requirements of the pillars of this specialization.
So, let us begin by choosing the answer to the question: Is it correct for a psychiatrist to answer it? We don’t think so. Because his answer will be based on his vision of himself in the mirror (2), which leaves us with many different answers that will not serve our purpose here. Over the years, people in the field have not yet agreed on a specific definition of what it means to be a “psychiatrist.” The concept itself is characterized by a highly diverse dynamic like that which governs the entire psychological field.
In this case, diversity itself is the common point on the importance of which there can be consensus when we talk about the work of the psychiatrist and the nature of his practices. The American Psychiatric Association describes him as someone who is able to provide “talk psychotherapy” and “psychosocial interventions,” in addition to his knowledge of drug treatment, which is the basis of his education in medical colleges (3), and the Royal Australian and New Zealand College of Psychiatrists goes further in its definition, describing it as one who “sees the patient as a whole,” and is not limited to providing drug treatments (4).
If the definitions contain so much diversity in naming the skills, attributes, and therapeutic interventions that the doctor is supposed to practice, how can the criteria for accepting training programs be limited to the medical-pharmaceutical aspect only! Did we not say that the psychiatrist is the one who is able to provide more than just a medication prescription? So why, when we come to accept a new generation of doctors, do we treat them as if they were merely writers of these prescriptions? What about their personalities, curiosities, mindsets, and experiences? Are they marginalized factors? Is it reasonable to marginalize it despite our knowledge of its importance in light of the specificity of the practice of psychiatry?
In this regard, we find that studies have been conducted for many years that academic grades in medical school do not sufficiently guarantee good performance by a doctor in his medical training program (5). Several studies have also concluded that high scores on American medical admission tests are mostly associated with good performance on theoretical tests during residency training programs, and not with the trainee physician’s actual performance during his or her training (6,7,8). Many of those in charge of these medical programs give preference to a doctor with a distinguished personality and modest academic performance over his diligent counterpart but with weaker personal qualities (9). Sometimes, intelligence in human communication is the key factor in why trainee doctors remain in fellowship programs (10).
What About Students Who Dream of Specializing in Psychiatry?
Several years ago, a study was conducted on applicants to the psychiatry program at Johns Hopkins, the factors that most likely influenced their choice were non-medical, among them: the philosophical dimension of the nature of the field, experience in the different methods of schools of speech psychotherapy, and the prestige inspired by the department’s legacy and depth (11). In Canada, a questionnaire was administered to doctors trained in the field of psychiatry, and when asked about the reason for their choice of specialty, the largest percentage of answers agreed that practicing verbal psychotherapy is the fundamental reason for becoming psychiatrists (12). The same applies to other cultures that are relatively close to ours, as a study was conducted on Turkish psychiatry fellowship doctors, and their most prominent answers about why they chose the specialty tended to pay attention to the human dimension, in addition to the social and relational dimensions as well (13).
Objectification and Psychiatry
When we trace the origin of the problem related to the criteria for entering the field of psychiatry, we will find several reasons, the most important of which are: neutralizing the field from its different path due to the nature of the psychological illness, and forcing it, like the rest of the other specializations, on the organic path, and interpreting phenomena from a biological perspective. This compulsion dates back to the history of psychiatry, which moved between the chairs of organic and psychological interpretations and so on. But there are other reasons that are no less important, including that our field is too full of “objectification.” There is a tendency to objectify and frame human suffering by placing everything related to mental illness under specific standards and classifications. This is forcing the human experience – floating by nature – to make it something that we can forcefully grasp, and to believe that we have captured it with our diagnostic criteria and tables, and although most of us agree that elucidating the complexities of the human experience cannot be achieved through brain scans or blood tests alone, this forced objectification of human suffering has indirectly created a skeptical attitude toward the value of the individual human self of each one of us. This skeptical attitude towards subjective experience is a clear reflection of our unspoken rejection of who we are now, especially on the emotional/sentimental level in our relationship with our patients in general, and entering into a deeper area of our patients’ selves in the psychological field in particular. This whole scene created an emotional state among health workers, which some have termed “professional alexithymia,” where feelings within the relationship – between the health practitioner and the patient – are something that is not addressed or treated, but is often warned about (14).
The Impact of Objectification on Admission Criteria to Psychiatric Programs
Often, the objectification of things entails the objectification of everything attached to them, if human suffering is made objectified and unified within a purely medical framework, the medical establishment itself has been led to objectify those who enter and practice the fieldTherefore, if medical science, for the most part, does not easily accept conjectures and floating matters, and behind them are purely human matters that are more sticky and difficult to comprehend, then it is natural that the criteria for entering one of its fields will not have many of these speculative matters, even if this field is mostly based on presumptive matters, such as the field of psychiatry. This matter extends beyond entry into psychiatric training programs in mechanisms and practices. That is to say, if contemplating the human self of the trainee doctor before entering the field is something that does not deserve to be assigned significant criteria for acceptance into psychiatry training programs, then why is the human self of our patients one of the important matters that we must look at during the period of training and practice?
In a Polish study, diagnostic interviews were recorded for 16 different psychiatrists from different hospitals with new patients (with depressive symptoms) in their clinics. It was noted that the doctors’ questions had a kind of absence of delving into the patients’ selves and the social context of their behavior, which led to the absence of important information about the patient (human) from a functional standpoint (15).
So, What is the Solution?
I do not have a magic solution, but the entire article is an attempt to think about the necessity of these standards, and an attempt behind them to answer the question that is frequently asked: “How did this doctor come to specialize in the psychological field?”
The solution certainly does not lie in a complete overturn of the current scene, the current scene is something that was forced into logical and illogical contexts, and it is also something that must be modified and improved. This dilemma, by the way, is shared by all psychotherapists, whether they are doctors or psychologists. Perhaps the situation among specialists is more tragic in terms of the standards of those who enter their homes. There is hope that the training itself will be the solution to these humanitarian and philosophical aspects that are not measured during the criteria for accepting medical programs, that hope, that the training will be the solution, is a logical hope, as training corrects the major calamities and improves the great positives, but the crisis lies in the small mistakes in the personalities of those applying for training, which is difficult to measure or limit and ignore if it multiplies within the same person.
This article is a call to liberalize the criteria for accepting doctors into psychiatric training programs, which have been emphasized on purely medical grounds, as well as a call to give more space and weight to the standards that measure the non-medical and important aspects of the psychiatrist’s personality. For example – according to my personal experience working in medicine in Sweden and Australia – there is greater weight in the acceptance criteria for letters of recommendation found in the CV of the same doctor wishing to enter the training program – and here we are talking about letters of recommendation that are given to those who deserve it, as they have weight in the local medical community, not copy and paste letters – when this doctor submits for a psychiatric training program, there is a review and communication with the owners of these letters. In Canada, an evaluation of the admission criteria for psychiatry programs was conducted, and the heads of psychiatry training programs, as well as trainee doctors (16), participated in the evaluation. Both parties agreed that the personal interview before entering the psychiatry training program, as well as the letters of recommendation, are the two most important factors in ensuring that the inputs to the training programs are of good competence, not only from a medical standpoint.
What is the Connection Between Talal Maddah’s Song and the Article?
During the emergency on board the plane, the doctors expressed their concern about their lack of training and confidence in handling such cases. Psychiatrists, in particular, seemed to bear the brunt of this concern. It’s somewhat ironic that, despite the strict medical standards for selecting trainees for psychiatry programs, these standards may not significantly contribute to the psychiatrist’s knowledge or skills throughout their career. While they are undoubtedly useful in assessing the mental capabilities of the trainees themselves, their practical application in real-world situations may be limited. So, when I walk up the stairs on the plane, three things come to my mind: First, where is my plane ticket so I can remember where my seat is? The second is Talal Maddah’s wonderful song on the plane’s stairs when he cried against his will due to being separated from his loved ones. Third, I pray that there will be no medical emergency during the trip, and if it does happen, that I will not be the only doctor on board, so that the crying does not happen on the plane stairs or inside it as well.
References
- [Russell Peters]. (2020, December 10). Russell Peters | Doctor vs. Psychiatrist [Video]. Youtube. https://www.youtube.com/watch?v=K3Xo0Yu56Dc
- Felix, R. H. (1964). The image of the psychiatrist: past, present and future. American Journal of Psychiatry, 121(4), 318-322.
- https://www.psychiatry.org/patients-families/what-is-psychiatry
- https://www.ranzcp.org/pre-fellowship/become-a-psychiatrist/what-a-psychiatrist-does
- Wingard, J. R., & Williamson, J. W. (1973). Grades as predictors of physicians’ career performance: an evaluative literature review. Journal of medical education, 48(4), 311–322.
- Wood PS, Smith Wl, Altmaier EM, et al: A prospective study of cognitive and noncognitive selection criteria as predictors of resident performance. Invest Radiol 1990; 25:855–859
- McDonald JS: Performance of residents in anesthesiology as related to measures of personality and interests. Psychol Rep 1991; 68:979–994
- Smilen SW, Funai EF, Bianco AT: Residency selection: should interviewers be given applicants’ board scores? Am J ObstetGynecol 2001; 184:508–513
- McDonald JS, Lingam RP, Gupta B, et al: Psychologic testing as an aid to selection of residents in anesthesiology. Anesthesia & Analgesia 1994; 78:542–547
- Hojat M, Borenstein B, Veloski JJ: Cognitive and noncognitive factors in predicting the clinical performance of medical school graduates. J Med Educ 1988; 63:323–325
- Davydow, D., Bienvenu, O.J., Lipsey, J. et al. Factors Influencing the Choice of a Psychiatric Residency Program: A Survey of Applicants to the Johns Hopkins Residency Program in Psychiatry. Acad Psychiatry 32, 143–146 (2008).
- Hadjipavlou, G., & Ogrodniczuk, J. S. (2007). A national survey of Canadian psychiatry residents’ perceptions of psychotherapy training. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 52(11), 710–717. https://doi.org/10.1177/070674370705201105
- Ozer, U., Ceri, V., Carpar, E. et al. Factors Affecting the Choice of Psychiatry as a Specialty and Satisfaction among Turkish Psychiatry Residents. Acad Psychiatry 40, 299–303 (2016). https://doi.org/10.1007/s40596-015-0346-5
- Shapiro J. Does medical education promote professional alexithymia? A call for attending to the emotions of patient and self in medical training. Acad Med 2011; 86: 326–32
- Ziolkowska, Justyna. (2012). The objectifying discourse of doctors’ questions. Qualitative analysis of psychiatric interviews. Social Theory & Health. 10. 10.1057/sth.2012.8.
- Ross, C. A., & Leichner, P. (1984). Criteria for selecting residents: a reassessment. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 29(8), 681–686. https://doi.org/10.1177/070674378402900809
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