Bridging a cultural divide within medicine: a role for psychiatrists?

Abstract

In wealthier countries there are currently more psychiatrists than surgeons, and the gap is increasing. A recent President of the UK Royal College of Surgeons has commented that there will be little need for most types of surgeon in ten years, as much of their work will be done less invasively and more effectively by interventional radiologists. There is no prospect of such an outcome with respect to psychiatry for the foreseeable future. As a profession our ultimate aim should be for our expertise and that of our colleagues in other disciplines to evolve to deliver or support interventions that are both less invasive and more effective than those currently in use. One of the criticisms levied at psychiatry by other doctors is that our evidence base is weak and the prognosis of severe mental illness is poor. But surely this is a case of the “pot calling the kettle black”. The science underpinning much of medical practice is weak. The difference may be in the false confidence other doctors have in the utility of their treatments, and the false modesty we psychiatrists have in the effectiveness of our own 1. Take the treatment of cardiac arrhythmias for example, for which ablation of an aberrant pathway in cardiac muscle may be offered, which whilst highly effective for most, carries a risk of serious complications including stroke, heart attack or death in a small percentage. Or consider the fact that prognosis for first diagnosis of diabetes in an adult is worse than the prognosis for first diagnosis of schizophrenia. Does this information help to put our diagnoses more in perspective? I agree with Katschnig that as a profession we must embrace a biopsychosocial approach, but it is a challenge to psychiatric teachers, managers and purchasers of psychiatric services to protect this necessary holistic approach. Attempts by neuropsychiatrists or psychopharma-cologists to claim superiority over social psychiatrists or psychotherapists, and vice versa, are ultimately damaging to our profession and our patients. But some psychiatrists who are focusing on highly specialist aspects of brain research, or some tertiary specialists providing evidence-based technical interventions, may need to leave broader biopsychosocial practice to other colleagues. In my view Katschnig’s conclusion didn’t go far enough. I would like to see psychiatry strengthen its alliances within medicine, and at the same time, strengthen its alliances with patient and advocacy organizations and its understanding and support of the recovery paradigm. Within medicine this means fostering a greater awareness of the link between mental and physical health and the recognition that all of our bodily systems are affected to some extent by dysfunction in another part. There are some fascinating and unexpected challenges to our understanding of cause and effect. For example, it is well known that heart attacks are more common in people who are depressed, but why is it that recovery from depression does not appear to reduce the risk of myocardial infarction 2? These examples explain why I believe that psychiatry should be reintegrated into medicine. This in itself would do much to destigmatize mental illness and psychiatry within the medical profession. At the same time, however, we would be failing in our responsibility if we did not retain and develop our partnerships in the community. This would also enhance our contribution to the wider medical field, where there remains a limited understanding of the importance of personal relationships and environment to good health. A failure to develop ourselves as social psychiatrists would distance us from service users, carers and colleagues in related disciplines. It is imperative that we are able to work in the context of people’s lives and alongside colleagues with more focused skills. And whilst some of our knowledge and skills are shared by other disciplines, none have our medical background and understanding of the link between mental and physical illness. Several years ago C.P. Snow 3 wrote about the “two cultures”, drawing attention to the gulf between the sciences and the humanities. What he argued for was an infusion across the barriers. This would help counter the ignorance of the arts-educated elite, but also the simplistic belief that everything could be explained through natural science. An example is the discredited argument that poor people have poverty in their genes, which was widely believed at the time of the eugenics movement in the early 20th century. As psychiatrists we must resist all such attempts at biological reductionism and do everything we can to bridge the two cultures. Psychiatry needs to continue to attract talented young doctors who bring scientific understanding to the medical profession, but who also bring an understanding of the humanities and of life itself.