Astonished by How Much There Still Is to Learn and Do

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COMMENTARY

Mark Twain fully grasped the folly of youth. He contrasted it with the humility that comes with experience in this memorable observation: “When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much he had learned in 7 years.” Tongue firmly in cheek, Twain is commenting that the aging process teaches us how little we really know.

Since I started medical school in 1977, we have witnessed dramatic advances in our understanding of neuroscience, psychopathology, and numerous psychiatric and psychotherapeutic treatment modalities. As the knowledge base of biological psychiatry has become more robust, a growing body of psychotherapy outcomes research has had a dramatic impact on the work lives of most American psychiatrists. Time-limited therapies were shown to be as effective as open-ended, longer-term psychotherapies. We also learned that mental health professionals who had not attended medical school were able to assist emotionally distressed patients as effectively as, and sometimes more effectively than, psychiatrists. As we became more biological in our orientation, episodes of care got shorter and shorter. At times, the assembly line moves too quickly and the flames and smoke of burnout may singe and choke us if we do not effectively balance caring for ourselves with caring for others.

With 1 eye on the patients and another on ourselves, we are also paying more attention, as we must, to the larger social picture. As I watched addiction psychiatry come together as a central psychiatric subspecialty that exemplifies the wisdom and intellectual vigor of our biopsychosocial orientation, we have all witnessed the limitations of a 1 patient at a time approach that ignores the socioeconomic determinants of mental health. Alas, the opioid epidemic rages on. Mental health parity is incomplete. Universal access to adequate care is not a reality. Far too many Americans with chronic psychiatric conditions are receiving care in the criminal justice system.

As section editor-at-large here at Psychiatric Times™, I hope to partner with you—psychiatrists and psychiatric nurse practitioners in different practice settings—to move the field forward. How do we leverage our knowledge and skills to optimize the biopsychosocial well-being of our patients and their families? How do we partner most effectively with our colleagues in other medical and mental health specialties? As stakeholders in a needlessly complex patchwork quilt of orthogonal health plans and reimbursement systems, what can we do about the vexing administrative complexities that interfere with patient outcomes and effective care coordination?

Although our field is atomized into many subspecialty areas, most of our patients experience challenges that cut across our categorical approach to psychopathology. Personally, I like nothing more than leaning into the complexity of patients with complicated presentations. I am currently treating 2 individuals with significant cooccurring anxiety, substance use, and personality disorders. In 1 case, I function as an integrative psychiatrist delivering all necessary care. In the other case, I am one of 3 mental health professionals working with the patient on a weekly basis, but the only psychiatrist. It is not simple figuring out how and when to flex ourselves—sometimes as a 1-person band, other times as a member, or conductor, of a small interdisciplinary collaborative group.

Thankfully, my career experiences have been rich and varied. I invite you to reach out to me through Psychiatric Times™ with questions or concerns regarding the following subject areas:

Burnout: What are the best protective strategies for us and our colleagues? How can we sort out the overlap between burnout and depressive disorders?

Career development: What are the pros and cons of (1) different institutional practice settings, (2) subspecialty training and practice, and (3) private practice? What is the role of mentorship in developing your career?

Coaching and coaching psychiatry: Is coaching the new psychotherapy? Should psychiatry embrace coaching or shun this nonspecific discipline that has been defined as “partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential (International Coaching Federation)?”

Health professional health and well-being: How does the psychiatric treatment of independently licensed health care providers and other safety-sensitive professionals (eg, aviation, transportation) differ from the usual and customary care we provide to other patients? How do we respect patient confidentiality while ensuring the safety of the public?

Integrating medical and mental health care: What practice settings are most amenable to integrated and colocated mental health care? What are our options when patients constrain us from communicating with clinicians from other specialties?

Integrating pharmacotherapy with psychotherapy: What are the pros and cons of integrated care versus split treatment—from the perspective of the patient, the organization, the bottom line, and the job satisfaction of different professional disciplines?

Leadership in medicine and psychiatry: How can frontline mental health professionals develop their leadership skills and gain experience in mid-level and high-level leadership roles? How can we best leverage our understanding of human behavior as emerging leaders?

Motivational interviewing: How can we use motivational interviewing to assist chronically mentally ill individuals who struggle with acceptance and compliance? What are the limitations of motivational interviewing in working with some communities and populations?

Problematic workplace behavior in medical and mental health settings: What is the role of psychiatry in assessing and treating health professionals who show up at work with “rough edges”? How can we effectively address a colleague’s problematic behavior in a mental health setting?

Psychiatric supervision of nonphysicians, residents, and colleagues: When it comes to supervision, what best practices and pitfalls should we keep in mind?

Spirituality and psychiatry: What do spirituality-informed psychiatric assessment and treatment look like? How do our own spiritual/religious histories and practices enhance or interfere with our care of patients?

Substance use in psychiatric patients; addiction medicine; and addiction psychiatry: What advice should we be giving patients without substance use disorders about their use of legal and illicit psychoactive substances? As the general subspecialty of addiction medicine grows, what is happening to the American Board of Psychiatry and Neurology subspecialty of addiction psychiatry, and where do we go from here?

Traditional psychotherapy and psychiatry: Should all psychiatrists possess knowledge, skills, and experience in psychodynamic psychotherapy? What training and skills in nonpsychodynamic psychotherapies are essential for the practicing psychiatrist?

I look forward to contributing pieces on these and other matters in forthcoming issues of Psychiatric Times™. Just as I endeavor to be patient centered and client centered as a physician and coach, my goal here at Psychiatric Times™ is to be reader centered and learner centered. I look forward to hearing from you.

Steve Adelman, MD

Dr Adelman is a coaching and consulting psychiatrist, and is board-certified in psychiatry, addiction medicine, and coaching (BCC). He launched www.AdelMED.com after 8 years directing Physician Health Services, Inc. Dr Adelman is on the faculty of the University of Massachusetts Medical School and serves a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School. He serves as Psychiatric Times™ section editor-at-large. ❒