Advice to Young Psychiatrists From a Very Old One

Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of Saving Normal and Essentials of Psychiatric Diagnosis. Twitter: @AllenFrancesMD.

I recently came across this compelling tweet: “An open question on mental health as a junior psychiatrist. What do you think I should learn and focus on to be a better doctor and advocate for my patients?”

Could there possibly be a better question for all people starting out in any field to ask themselves, and others, as they embark on their careers?

The 140-character limit imposed by Twitter forced me to offer only a brief reply containing five scant snippets of advice. This troubled me-his serious request deserves a more serious response.

Here it is-the 50 most important things I have learned in my 50 years studying psychiatry:

1. Your patients will be your best teachers.

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

3. Focus on establishing a strong therapeutic alliance and healing relationship-the most important goal of any first session is the patient's returning for a second.

4. Helping serious mental illness is very much harder, but also much more gratifying, than treating mild illness or the worried well.

5. Validate that your patients are currently trying to do their best, but also set a tone of future expectations they will find ways to change themselves, and their world, for the better.

6. Always inspire realistic hope and always reverse unrealistic demoralization.

7. Follow your patient, not your preconceived notions, a supervisor, or a manual.

8. There are no bad or boring patients; but there are some bad and boring doctors.

9. Be as empathic, as caring, as involved, and as alert for the tenth patient each day as for the first.

10.Never lose sight of the practical struggles the patient faces in the real world and try to help them find practical solutions.

11. Don't be shy about giving advice when advice is needed.

12. Don't give advice when the patient can find their own way.

13. Include family, friends, other informants, and potential co-therapists whenever possible.

14. Be open ended enough in your questions to let patients tell their life stories; structured enough in your questions to get the specific information you need.

15. Try to create rare magic moments-things you say to patients that they will remember always and use in changing their lives.

16. Take your time and be careful-small mistakes can have major consequences.

17. Know the patient, not just the diagnosis.

18. Diagnosis should almost always be written in pencil-especially in the young and the old. Always err on the side of underdiagnosis-it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don't worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

20. Educate patients about their symptoms, diagnosis, course, the risks and benefits of plausible treatments.

21. Negotiate, don't dictate, the treatment plan: allow the patient to pick whichever plausible treatment most suits them-with awareness that no one size fits all.

22. Do not join the bandwagon of diagnostic fads. Whenever everyone seems to suddenly have a diagnosis, it is surely being way overdone (eg ADHD, autism, bipolar disorder).

23. Watchful waiting is the best treatment whenever there is doubt or the symptoms are mild.

24. Placebo is best medicine ever invented and responsible for most of what appears to be “drug effect” when milder symptoms improve.

25. Severe illness is usually easy to diagnose reliably and always requires urgent intervention.

Next > #25 to #50

26. Always rule out the real possibility that symptoms are caused by medications, alcohol, street drugs, or medical illness.

27. Don't be a careless “pill-pusher,” but do understand the great value of medications used wisely for proper indications.

28.  Know the risks, not just the benefits, of medications

29. Educate your patients on adverse effects, complications, and withdrawal symptoms.

30. Be alert to, and try to avoid, drug-drug interactions and include in your consideration all the many non-psychiatric medications the patient is likely to be taking.

31. Start low and go slow especially with young and old patients.

32. De-prescribing requires much more skill than prescribing-learn it well and apply it often to reduce the harms caused by over-medication.

33. Avoid the current tendency toward irrational poly-polypharmacy

34. Learn and use three treatments that are very effective, but relatively harder to use and thus very underutilized: lithium, clozapine, and ECT.

35. Never meet with drug sales people; ignore all drug company marketing; do not believe any study that was funded by a drug company; and educate patients to be skeptical of direct-to-consumer drug ads that misleadingly promote disease mongering.

36. Read the scientific literature with great skepticism and awareness that most studies do not replicate, positive results are always exaggerated, and negative results are usually buried. Do not be wowed by genetic findings-so far, they have flopped in finding causes and have no place in planning treatments.

37. Uncertainty sure beats false certainty. Accept its inevitability;’ dont jump to conclusions; and help your patients deal with the anxiety it provokes.

38. Learn statistics, especially as it applies to medical decision making, and think probabalistically, not in rigid yes/no categories.

39. Have a rich, varied, and satisfying personal life.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

41. Learn from your supervisors, but don't follow them slavishly.

42. Read widely, especially the great classic novels, and see psychologically astute movies and plays.

43. Read history and try to deduce its recurring patterns.

44. Travel the world to understand the wide diversity of human experience.

45. Do not impose your cultural biases, your religious beliefs (or non-beliefs., or your personal values on your patients).

46. For every complex question, there is a simple, reductionistic answer-and it's wrong. Don't expect or believe simple answers to complex questions, such as “What causes mental illness and how best to treat it?”

47. Instead, do have a well-rounded, four-dimensional bio/psycho/social/spiritual approach to understanding mental disorders and selecting treatments for them.

48. Be a vocal advocate for our patients. We must do all in our power to reverse the shameless neglect of the severely ill that has relegated 600,000 of them to jail or homelessness.

49. Be yourself-and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.

50. FIRST, DO NO HARM!