2nd Anniversary!

August is a month that holds significant emotional valence. This past month marked the two year anniversary for two major relationships in my life: personal and professional. As August 2026 flew by, the self-reflections also surfaced rapidly. Particularly within my professional role as an early career attending, there is a lot that I’ve learned about myself and about clinical practice.

Every specialty and field of medicine has its own hurdles. Heck, medicine as a whole has garnered a list of very recognizable headaches that permeate throughout the healthcare industry. Throughout residency and fellowship, I had become sensitive to some of the common pitfalls and challenges within psychiatry. And through the training, I thought I had become resistant to to some of these difficulties. Yet, as my second year post-training comes to a close, I am seeing that there’s much to clinical practice that I am still learning to overcome.

I’ve often said (and still believe) that there are few things more gratifying than treating patients. It’s an honor to be privy to the deepest, most inner-workings of my patients. As a patient myself, I know that it takes significant vulnerability to engage in mental health services. I can only imagine it more so for patients who are navigating it for the first time and without comprehensive knowledge of the mental healthcare system. To sit with them in their times of need brings about much needed fulfillment required of an otherwise rigorous and demanding job.

A profession dedicated primarily to helping enrich the lives of others can be as demanding as it is gratifying. Though, much of the gratification ordinarily comes only after or during successful treatment—or at least semblance of such. Anybody who has been involved with mental health knows that some journeys are long and arduous. Sometimes, the treatment, no matter how intensive, can seem futile. This is the nature of the beast in medicine and healthcare: that some conditions remain refractory to improvement despite our best efforts. These are the moments that have been hardest for me, not the fact that healing can take longer than anticipated.

Moreover, psychiatry is a rapidly evolving field. And in my opinion, this evolution brings with it significant misunderstandings of what psychiatry is, which obfuscates its current limitations. These misunderstandings give rise to two very polarizing opinions, both of which have made clinical practice more challenging. The first is the assumption that any affective disturbance or subjective discrepancy, small or big, is suddenly abnormal. Many people can be soothed that some of the phenomena they experience are, in fact, contextually normative. Other times, such angst is not so easily reassured. Though often difficult, this type of education is something I actually really enjoy. Many of the issues we work with in psychiatry are as much psychological or social issues as they are biological and medical. Sometimes my patients’ anxieties can be quelled just by knowing that they’re not sick or need additional medications.

On the other hand, there is the ever-growing demonization of psychiatry as a field: a pendulum swing that is, admittedly, well-warranted by decades of (and ongoing) overprescribing and overmedicating patients. (There’s also much to say about psychiatry’s dark history with egregiously overstepping bodily autonomy). I’ve seen first-hand the laundry lists of psychotropic medications or inappropriately prescribed medications. As a prescriber myself, I understand it to a degree. It’s not uncommon that when patients report ongoing side effects or persistent symptoms, new or rapid medication adjustments are implemented. As we hold prescriptive authority, there is a natural discomfort in declining medication adjustments while addressing some of the issues non-pharmacologically.

Driven by a desire to help and simultaneously affected by a fear of potentially withholding care, it is easy to succumb to medication requests (especially if the demands continually escalate). After all, doctors often feel dismissed as not listening to their patient when scripts or perceived treatments and workup are withheld. Thankfully rare, there have indeed been days where I’ve felt that I am damned if I do, and damned if I don’t. Perhaps because my training was steeped in geriatrics, my focus is as much on de-prescribing as it is on appropriate prescribing practices. Taking the time to educate and provide rationale on my decisions has definitely alleviated this conundrum that so often arises.

It would probably be easier for healthcare providers to truly address and assuage a patient’s apprehension if only time were not a constant constraint. Between shortened appointment times to massive waitlists and far-out bookings, providers are seemingly set up to fail. The system feels very much suffocating as it pits healthcare providers and patients against each other. It is so commonplace now that healthcare providers work beyond their paid time to provide adequate and appropriate care. There have been countless days during which I’ve experienced that same pressure, telling myself that I’ll just endure another hour or two after work to ensure my patients get the care they deserve. I feel badly only in that Peter has to deal with my depleted emotional reserves on those difficult days.

As providers, we also are held highly accountable for bad and sometimes catastrophic outcomes. However, there seems to be a disconnect in how we perceive fault. Cardiologists are not blamed if their patient has a heart attack, especially if the patient has an established history of poor diet, genetics, or even medication adherence. After all, the patient is seeing a cardiologist precisely for that reason: that they are at an elevated risk of cardiac complications. Further, cardiologists do not pride themselves on “preventing” heart attacks, but rather helping reduce the risk of one. It’d be ludicrous to expect “prevention” altogether, right?

And yet, when bad outcomes arise within the arena of psychiatry, suddenly there is intense scrutiny over “preventable” outcomes. Just as heart attacks are often fatal sequelae of cardiac disease, suicide attempts are sequelae of severe psychiatric illness. There is a misconception that somehow, we have not only the power of clairvoyance but the ability to control our patients’ behaviors. This is one of the heaviest burdens that psychiatrists carry—not only that societal views us as failing our patients, but that we hold ourselves deeply accountable for such as well. There’s so much to be said on this topic, but it has definitely been a growing shadow that looms in my conscience.

Last but certainly not least comes the antagonization of the provider by the patient—often unknowingly. The humanistic and intimate facets of psychiatry that make it so gratifying unfortunately also make it extremely difficult. Disorders of personality, characterized by longstanding and pervasive dysfunction that underlies basic relational interactions, are much more prescient in a psychiatrist’s office than in other fields of medicine where rendered treatment can be much more concrete. Certain subsets of personality disorders or pathologic traits are much more difficult to work with. By the nature of these disorders, the psychiatrist often becomes the object of a person’s immature defenses (e.g. devaluation, projection, and so much more). Earnest attempts to help the patient can quickly be weaponized against the provider, which only fans the flames of burnout.

All of these grumblings only to say that the field of psychiatry desperately requires better solutions for problems both new and old. Clinical practice has not looked at all what I thought it would as a young and naive medical student. But despite this, I love the field of psychiatry. I find the science to be fascinating and the work to be deeply rewarding. Though some days can be very rough, I am always reminded by my patients who’ve done wonderfully well just why I entered this specialty. My current position has done a very good job in providing an environment where all I need to focus on is seeing the patient in front of me. I am grateful that, at the very least, the administrative burden is mostly cared for by my amazing team. Nevertheless, there are problems intrinsic to psychiatry and medicine that has left me feeling vapid some days, and I dislike that.

Some of these challenges will hopefully get easier to master with more clinical practice and experience. It also means that I’m actively thinking about ways in which I can continue contributing to the field and impacting the practice of psychiatry without burning out. Hopefully by my next anniversary, these woes will have been uplifted!