Dare to be wise

INVITED COMMENTARY ON... WHAT EVERY PSYCHIATRIST SHOULD KNOW

Mike Shooter Retired Consultant in Child and Adolescent Psychiatry and a past President of the Royal College of Psychiatrists. Correspondence c/o The Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG, London, UK

	Abstract

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It is remarkable that any of the advice given to medical students 70 years ago should still be relevant today. But none of it now makes sense without reference to the two-way relationship we share with our patients. We should be asking not what the doctor should be blessed with by the world, but what the patient should require of the doctor. This would include humanity, humility, honesty and especially wisdom.

‘A psychiatrist needs youthfulness, sanctity, a well-judged sense of humour... and the wisdom of the ages would be helpful, but I don’t want to seem greedy.’

I used this quote from the specialist adviser to one of our national charities a decade ago, in an exploration of what a patient could expect from a consultant psychiatrist (Shooter, 1997). I was reminded of it again, reading the account by Kelly & Feeney (2006, this issue) of the seven gifts Hutchison bestowed on the medical students of the 1930s.

Some things, of course, remain as true today as when Hutchison delivered his speech. His sense of justice seems to have been an exercise of clinical faculties and the responsibility to keep abreast with medical knowledge and skills. Kelly & Feeney see this as the antecedent to modern, evidence-based practice. I suspect that Hutchison’s art of diagnosis meant much more – the laying on of hands, which has almost disappeared in these days of technology and the randomised controlled trial.

I think Hutchison would turn in his grave to see justice reduced to evidence, but in other senses the doctor’s battle for justice is now much wider than he might have anticipated. We owe it to our patients to fight for equality of services across geography, age and culture or, at least, for an equal right to the principles of service that might be differently realised in different groups. The psychiatrist practising on windswept housing estates with families torn apart by unemployment, violence, alcoholism and drug misuse may feel more akin to Osler’s 19th-century philanthropy and the political passion that fired it.

It is certainly arguable that the greatest skill a medical training confers (apart from the ability to stay awake for several days at a time) is Hutchison’s equanimity – the nerve to assimilate everything in a crisis, weigh up the options and decide when and when not to act, holding everyone’s anxieties in the process. It might also be the greatest contribution the doctor can make to the multidisciplinary team of professionals who have been taught either to procrastinate indefinitely or to shoot from the hip. But I’m prepared to be shot at myself for saying so!

In all this, it is still difficult to imagine how any doctor could cope with the suffering of their patients, and the unresolved issues this might evoke within themselves, without a sense of humour. Far from seeing this as ghoulish, the way TV comedy is flooded with gore would suggest that the public shares the same defence against the horrors of illness and its treatment. And in an imperfect science, when the General Medical Council is ready to gobble us up for our every mistake, ‘luckiness’ seems increasingly important. I’m tempted to ask my specialist registrar the same question Napoleon asked of his generals: ‘Yes, I know you have skills and experience, but do you have luck?’

For the rest, brains, beauty and good health would need qualification at least in the ways that Kelly & Feeney have suggested. However, even this would be too kind to Hutchison’s list. It is inconceivable now that anyone could talk of ‘gifts’ to ‘bestow’ on doctors without reference to the context in which they work. Gone are the days when the consultant strode the wards in a three-piece suit and a personality to match. Gone even are the days of the lone general practitioner, ministering to his communal flock in ways he thought best (Berger, 1981). The role of modern doctors is a contract between what they have to offer and what is expected of them by many surrounding agencies.

The triangular dynamics between medicine, the public and government have been well studied (Salter, 2001); yet the situation is more complicated still. The doctor may feel pulled apart at the centre of an eight-pointed star of competing interests– patients and their carers, public opinion, the press that feeds off it, politicians that react to it, professional bodies and their regulations, the training requirements of the Postgraduate Medical Education and Training Board and Modernising Medical Careers, primary care trusts and other management, and the pharmaceutical industry. Lest they disintegrate in mind, body and spirit, doctors would do well to align themselves with their most natural allies – patients and carers.

In which case, far from showering his doctors with qualities that might best suit them, the modern Hutchison should ask what the patient might require of the doctor in the therapeutic relationship. This would certainly include humanity – the ability to see the patient as an individual rather than a bundle of symptoms. It would include humility – the willingness to share power in the relationship, helping patients to decide for themselves what feels best for their life. And it would also include honesty – the readiness to give patients all the information necessary to make such decisions.

Humanity, humility and honesty: all of which together make up that mysterious quality of wisdom that is so hard to define but which is part of medicine’s current search for a more spiritual professionalism – the ‘care of souls’ (Williams, 2005). I have no idea what wisdom is. It certainly does not come with experience, since we have all met consultants who have never acquired it in a lifetime of practice and junior doctors who are already wise beyond their years. It may well include that self-awareness that Kelly & Feeney point out is so conspicuously missing from Hutchison’s list.

What I am sure about is that wisdom is an essential part of what the good-enough psychiatrist needs to know. And that specialist adviser who wrote to me a decade ago should not have been so coy in asking for it.

	Declaration of interest

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None.

	References

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Berger, J. (1981 reprint) A Fortunate Man. London: Writers and Readers Publishing Cooperative Society.

Kelly, B. D. & Feeney, L. (2006) What every psychiatrist should know. Advances in Psychiatric Treatment, 12, 462–468.[Abstract/Free Full Text]

Salter, B. (2001) Who rules? The new politics of medical regulation. Social Science and Medicine, 52, 871–883.

Shooter, M. (1997) What a patient can expect from a consultant psychiatrist. Advances in Psychiatric Treatment, 3, 119–125.

Williams, R. (2005) Editorial: The care of souls. Advances in Psychiatric Treatment, 11, 4–5.[Free Full Text]

Related articles in APT:

What every psychiatrist should know

Brendan D. Kelly and Larkin Feeney
APT 2006 12: 462-468. [Abstract] [Full Text]  

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