What the hell is a psychiatrist anyway?

So here’s my first blog post. After months of threatening my Twitter followers with a literary crime, I’ve finally done it. I warned you I would.

I want to write about things that are relevant to patients and the public, so I’d love to hear from you if you have any ideas.

For my first post, I’ve chosen to write about something that seems simple, but that in my experience seems not to be obvious to the people that matter; patients. I want to explain what a psychiatrist actually is. What we actually do all day, what the titles on our name badges mean and what our training involves.

So here we go.

Firstly, and to the astonished bafflement of many people, psychiatrists are doctors. In very simple terms, we are doctors that specialise in treating mental illnesses. It’s actually a bit more complex than that, because we sometimes treat “brain diseases” like dementia, but basically, that’s as good a definition as I’ve ever come up with. We tend to see things in a “you’re ill, you need treatment” kind of way, though what “illness” and  “treatment” mean is misunderstood a lot of the time. For me and for most psychiatrists, “illness” is just a byword for mental suffering, and “treatment” involves psychotherapy and social support just as much as medications. A mental illness has to take place as least partly in our brains, because that’s where our minds live, and prescribing medication is what we’re best at (because of our medical training) but a good psychiatrist will see social and psychological treatments as equally important parts of helping someone heal.

A psychologist, on the other hand, is trained in psychology, which is the scientific study of human thought and behaviour. They sat through lectures on topics like “memory”, “personality” and “language” at university. Many go into research in these areas, and many teach. But many are interested in what happens when unhelpful thoughts and behaviours become a source of stress for a person, and how we can help. These are called clinical psychologists and they work with patients to investigate and change the way they think and act, usually by forms of therapy like CBT. Beware: psychologists can get PhDs or other similar qualifications, and then they can be called doctor too, which can be confusing.

All psychiatrists went to medical school for around 5 years, just like all surgeons did, all GPs did and all cardiologists did. We sat through infinite lectures on genetics, embryology, physiology, anatomy, and histology. We lurked on hospital wards practising our cardiovascular and abdominal examination techniques on unsuspecting old ladies, vacantly watched operations with no idea what any of the yellow bits of flesh were, and crammed round the clock for brutal exams. We honed our pub crawl skills to near perfection (I have the mental and physical scars to prove it) and worked up overdrafts so big you’d need an oxygen supply to climb them.

After qualifying as doctors, we all spent at least 2 years working in hospitals, rotating round a series of 4-month-long jobs in medical specialities like surgery, ENT or gynaecology. The first year is called “F1” (Foundation Year 1) and the second year is called “F2” (Foundation Year 2). My dad, a man of fewer words and a different trade, called this my “apprenticeship”.

The purpose of the Foundation years is to push you to the brink of mental breakdown and keep you there. Your job, whether you’re working on a surgical ward, a medical ward, A+E, or somewhere else, is to do all the legwork for the more senior doctors. Blood tests, ordering scans, rewriting drug charts, clerking in new patients, seeing emergencies and writing discharge letters are the bulk of your work. You get in early, you stay late, and you get very few days off. Using the toilet becomes your break time, lunch becomes a myth and sleeping is a decadent sin. But you learn how to cope under pressure, how to make decisions, and how to organise yourself.

If you survive your Foundation years, you’re asked to choose which single speciality you’d like to train in further. Some (the strange, twisted few) choose psychiatry.

The first three years of psychiatry training are called CT1, CT2 and CT3 (CT stands for Core Training). These years used to be referred to as the SHO (Senior House Officer) years, until the terminology changed in 2007 to make things “easier”. Some people still use the term SHO (like my Twitter name). The table below should make things clearer.

Years after qualifying Old terminology New terminology
1 House Officer (HO) Foundation Year 1 (F1)
2 Senior House Officer (SHO) Foundation Year 2 (F2)
3 Core Training Year 1 (CT1)
4 Core Training Year 2 (CT2)
5 Core Training Year 3 (CT3)
6 Registrar Speciality Training Year 4 (ST4)
7 Speciality Training Year 5 (ST5)
8 Speciality Training Year 6 (ST6)
9 Consultant Consultant

The 3 Core Training years involve rotating around at least 2 adult psychiatry jobs, and at least one child and one old age psychiatry job. Each job lasts 6 months. The idea is to build up a solid base of knowledge in all forms of psychiatry. As a CT1 I’ve worked on an inpatient adult ward and in an old age community team. I’m still the most junior doctor on my team, which is frustrating. It means I still have to do all the menial jobs like doing ECGs, taking blood tests, rewriting drug charts and sorting out any minor problems the nurses might ring me about. I also type notes about what’s being said during the ward rounds; a job I find difficult and annoying because it distracts me from really listening to what’s said. However, we do get to spend a fair bit of time either on the ward talking to our patients, or teaching students.

We’re also on a big rota for on-call shifts. These are changeable in the severity of the workload, but are usually somewhere between difficult and dangerously impossible. Either in the evening, at night or at the weekend, when every other doctor is at home, you’re given a phone and you’re the first port of call if the nurses have any problems anywhere in the hospital. Anything from dealing with a physical health problem, to clerking in a new admission, to getting a taxi to A+E to see a referral there, it’s the job of the CT doctor.

I spend about 80% of my time on call running from ward to ward and 20% of the time laughing ironically because I know I just can’t do the job as well as I want to, because I’m so busy. I’m really sorry if any patients or ex-patients are reading this and have had bad experiences waiting for the on-call doctor to arrive. Trust me, it’s not that we’ve got our feet up somewhere watching the football; we’re probably drowning in jobs on another ward somewhere.

As part of our CT jobs, we get taught a lot. We don’t just learn about medications, the Mental Health Act and classifications of illnesses, but about psychology, psychotherapy, the history of psychiatry, sociology and research techniques. It surprises a lot of people to find this out; I really wish it didn’t. We tend to be pretty holistic, well rounded people most of the time, not the drug pushing robots people take us for.

During our CT years, we have to take exams to prove we’re good enough to progress to our next stage of training. Currently we have to do 3 written exams and a practical exam (which is mostly communication skills), and if we pass them all first time, in total they’ll cost £1660. When you add that to the £400 a year it costs us just to stay registered with the GMC, it’s quite a bit of money for a young person to be shelling out.

If we make it through the CT years, we get to become a registrar (or “SpR”)  and do our Specialty Training (ST), becoming even more specialised in one of a choice of 6 types of psychiatry:

  • General Adult
  • Old Age
  • Child and Adolescent
  • Psychotherapy
  • Forensic
  • Learning Disability

SpRs have a bit more clout. They don’t have to cope with so many of the little jobs from the ward anymore, so they’re free to deal with bigger problems, like running clinics and ward rounds (either with or without the consultant). They’re also senior enough to section people, and spend a lot of their on-calls either driving around doing this or being phoned by me whining about how busy I am.

And if you make it through all that, without deciding that you’d rather work in the city, become a GP, open a café in Brighton or emigrate to New Zealand, you can be a consultant. If you can find a job.

I really hope that makes the water a little bit less muddy for anyone who has been wondering what the hell psychiatrists actually are. If anything remains hazy, let me know.  

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About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

One Response to What the hell is a psychiatrist anyway?

  1. Ian Reid says:

    Very good.

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