Thursday, January 30, 2014

William Hay, Psychiatrist

I am thankful for my name. Wiliam has served me well.  I use the formal, long version, though have been nicknamed Bill or Will throughout my life. The name Hay is a name I acquired from my parents.  My grandfather was a Reeve and my father a man admired as a leader.  The problem for me was ‘psychiatrist’.
I had no problem being, William Hay, Physician.  Today I still commonly introduce myself as such.  The stigma against the mental ill which is so prevalent in this country also applies to their caregivers.
I’m proud to tell people that I was accepted into surgery and did a year of the three or four required to be a surgeon.  Mine was a surgical internship and my electives had been in plastic and orthopaedic surgery as a student.  I had concluded in my training that I wanted to be a missionary doctor and that best equipped missionaries were surgeons.  I was reading a lot of turn of century history at the time.  The problem was my wife, another doctor, by the time I was an intern, didn’t want to be a missionary. She wasn’t even a Christian per se.  She wanted to work in the university and stay in the city.  She wasn't adventurous and certainly didn't like camping when I introduced her to the wilderness.  Our marriage never did work out.
In those days, and the tendency remains, I thought if something was ‘good’ , like obviously being a missionary to me was, others would see it as such.  Today I know a whole group of people think missionaries are idiots.  My wife hated the idea of my becoming a psychiatrist.  She loved the idea of being married to a surgical resident.  She didn't like psychiatrists, possibly because she'd grown up surrounded by severe mental illness and wanted a life as far away from that as possible.
When I announced I wasn’t going to return to surgery and wasn’t going to stay a family practitioner, but rather I was going into psychiatry, my wife was ashamed.  My medical colleagues collectively expressed their astonishment.  The jist of their concerns were summed up in these repeated exclamations,
“You’re such a good doctor, you don’t have to be a psychiatrist’.  When I entered psychiatry it was thought to be a place where only the lowest level of doctors worked.  Often immigrants entered the country by agreeing to work in asylums because even psychiatrists didn't want to work in asylums in those years.
“You can be a surgeon, you don’t have to be a psychiatrist”.  The hierarchy in medicine was from the ‘seen’ (surgery is so obvious) to the ‘unseen’ - the work of psychiatry is by far the ‘subtlest”.
“You’re a real physician, you’re not going to get along in that quackery’.   As a ‘real physician’ this meant, that I was a scientist.  I’d come into medicine with a mixed arts and science background.  My arts background made me ‘suspect’ to those students whose only interest had been science or technology.  I felt I had to ‘prove’ myself as a ‘scientist’ and that having done theatre and arts and english, liking music and writing, well, I was suspect.  I ‘proved’ myself with outstanding performance and knowledge in biochemistry and a gift for surgery.  So having ‘proved’ myself, here I was’ forfeiting’ my ‘membership’ in the ‘elite’ medical group of the ‘scientist doctors’ or ‘surgeon doctor’ to become somehow ‘less than.'  This 'elite' group has made an ironic comeback with in recent years as the respect for medicine declines and everyone is turning to superstition versus science in the true quackery of so many 'alternative medicines' and 'health food stores'.  People don't want 'scientists' or 'technicians' as much as they want 'physicians' but I never could explain my decision to be a psychiatrist because that was what was most "needed" back then and I can't explain this to them now.
The real ‘money’ in medicine was in surgery and internal medicine.  The psychiatric patients were predominantly poor in comparison.  The richest doctors were surgeons and internists and the poorest were often psychiatrists. The billing schedules from the start were always against the psychiatrist.
We were often mixed up with ‘psychologists’ and psychologists were considered collectively as ‘flakes’.  Mostly the psychologists were girls and the counsellors were usually people who couldn’t do the heavy lifting, like radiology technicians so ‘just talked to people’.  They were likened to ‘high school teachers’.  Doctors were university men.
As a family physician and a flyin doctor in the north I’d seen that the ‘greatest need’ was in psychiatry and addiction. I’d become interested in ‘non compliance and ‘non adherence to medical regimen.  This was only addressed at my university by psychiatrists.  It was called ‘resistance’.
Alternatively I considered ‘immunology’, a fledgling speciality pre HIV, because it too discussed the idea of the organisms' ‘rejection’ of transplants, and ‘immunological vulnerability’ to disease.  
In surgery and infectious disease, the emphasis was on the terrible external environment.  Bad things like bulletts entered good bodies and good surgeons took out the bullets and returned people to wellness.  Bad bugs entered good bodies and good doctors made good drugs to kill bad bugs and restore people to healthiness.  I consider 'regular' medicine like playing chess (I played chess at university) whereas psychiatry was like three dimensional chess. In psychiatry I was juggling a lot of ideas whereas in medicine I was usually just following protocols.
My first patient who died that upset me so much had been given excellent care. His doctors had all given him good drugs and he had good education and all should have been well but he and his family rejected the ‘education’ and he didn’t take his medication and therefore died.  Nothing all the kings soldiers could do would put humpty together again.  I felt a personal failure despite having done above and beyond the call of duty.  I 'd pulled out all stops to save this man and in the end it changed my interest from surgery to understanding 'noncompliance' and 'resistance' and a renewed interest in 'spirituality'.
That’s when in research  I learned first that 30% of all patients are ‘non compliant’ and another ’30% of patients spontaneous remit.  I'd always been interested in 'placebo' effect and became even more interested in 'psychosomatic medicine' when it was a fledgling idea. Further in a lot of populations 50% of patients didn’t follow their treatment and in psychiatric patients the number was as high as 80% of patients. 80% of patients didn’t take their medications.
My  colleague, rich, and loved by drug companies always saw a patients lack of progress directly a consequence of the medication so he prescribed a newer more expensive medication. I went to the patients homes and found that their drug cabinets were full of unused medications.  I asked why they didn’t take their medications and learned a wonder of information about how humans behave which was wholly overlooked in the pharmacy training at the university.   I remained poor and eventually didn't even teach whereas my colleague because the richest and most admired and favoured physician and psychiatrist because he was the principal representative of the pharmaceutical industry. Their greatest promoter and richest retainer.  I continue to look in drug cabinets and do home visits and believe thats where the real money of medicine is.
I also saw that the most difficult patients to treat in my family practice were the ones with mental illness. They were the challenge and the businessmen doctors didn’t like these patients because they didn’t get better like ‘good’ patients did.
There was a fine line between ‘bad’ and ‘mad’ and everyone, despite their expressed ‘liberal’ and ‘politically correct sentiments’ about the ‘mad’ ultimately treated them as ‘bad’.  They were ‘non compliant’ and ‘resistant’ and ‘difficult’ and as doctors became family men and businessmen and pharmacists vied to prescribe, all people wanted to make money and have a good job and go home to their families with patients who came sick, got better quick and went home themselves. No one wanted psychiatric patients. And no one wanted addicts. These groups were complainers and angry and didn't get better.  This was the time before 'lifestyle disease' became a fashionable word.
Most mental illness is life long.  The ‘chronic’ diseases are a waxing and waning sort. They have relapses and recurrences and there is a ‘vulnerability’ that causes patients with psychiatric illness to often slowly deteriorate overtime or not quite get back to where they were. Or, even if they do succeed very well, whose to say they won’t have an episode a decade or so down the road.
Whereas we never looked at people who had recurrent respiratory infections as having ‘weak’ lungs because of the ‘bad bug’ idea of infectious disease, we tended to look at people who had recurrent depression as ‘weak’ because psychiatry focused on the ‘vulnerable’.  Indeed psychiatrists who focused on 'trauma' or 'stress' or 'toxic workplaces' were no more welcome than were jail doctors who faced with treating bones broken by guards questioned the breaking rather than just setting the fractures. There's 'preventative' medicine and 'preventative medicine'.
Psychiatric patients were therefore called them ‘weak’ and especially those  with addiction, a part of psychiatry.  They were told  ‘buck up’, “man up’, ‘quit your crying’, ‘toughen up’.  Don’t be silly.
It’s 25 years later and I’m still calling myself, William Hay, Physician, without any concern but when I say, I’m William Hay, Psychiatrist, I’m hesitant.  When I am an ‘advocate’ for a patient who has heart disease or is in a wheelchair or has infection, I’m seen as ‘doing my job’.  A physician is supposed to be an advocate for his patient.  It’s part of the code of ethics for physicians.
I am an advocate for my patients.  As a Christian I am a healer and know that Jesus was a healer and he was also a teacher and advocate.  Part of my becoming a physician, when I could as easily have been anything else, I was a straight A student in Arts and Science at the university, the golden boy, a very large part was that I was a Christian. The finest doctors I’d known were Christian to that time in my life.  When I studied the history of medicine I saw that the truly religious, not just of Christianity but of every religion were the ones who made the greatest contribution to the healing sciences.  Religions in general took care of the sick.   My hero was Albert Schwietzer.
But to be an advocate of a psychiatric patients, worse, an advocate of an addict, or even a former addict, was to be akin to the "despicable."  Even St. Peter denied his association with Jesus when Jesus was condemned by the courts.  I saw that psychiatric patients and especially the addicted were condemned by society at large.  I was condemned by ‘association’ from the time I said I wanted to be a psychiatrist.  25 years later I am still condemned by association. I’m the modern equivalent of the ‘leper’ doctor.
Advocating for the addicted and mentally ill makes one ‘bad’ and as everyone knows psychiatrists are ‘mad’ already.
So William Hay, Psychiatrist is still a thing I hesitate saying despite years of experience, years of healing, years of amazing restoration of health of thousands of individuals and the overwhelming evidence that what I’ve done as a psychiatrist is deeply ‘good’, I’m still afraid to be associated with the ‘fallen’ .  Just like Peter, I fear ‘association’ with Jesus. I fear association with the mentally ill and especially those in recovery because they, and we are punished.  
This is today, when all surgeons and all internists know that they are working in the area of 'chronic illness' and that their patients all suffer mostly from 'psychosomatic' illness. As psychiatry has learned it's somatic aspects with MRI and beneficial somatic treatments like surgery and medicine, the rest of medicine and surgery has had to come to grips with it's psychiatric aspects and especially address the issues of non compliance and non adherence to medical regimen.  
William Hay, Psychiatrist.
William Hay, Advocate of the Mentally Ill and Addicted.
It still doesn't sit as well as William Hay, Physician.
Some days William Hay, Psychiatrist is a truly frightening thing to call myself.   It's like putting a target on.  It's like wearing general’s stripes on a helmut in a war zone. It's  like painting a red cross on an ambulance in a war with people who see illness as weakness and weakness as something to be exploited. That’s like saying to the rich, I’m poor, and waiting for the condemnation and laughter.  That’s not something one says openly in a world of ‘survival of the fittest’.
William Hay, Physician. That’s something societies at large have grown to accept and live with. Physical illness isn’t viewed superstitiously or as ‘malingering’.  But mental illness is.
Mental illness and those who treat mental illness and the advocates of the mentally ill are actually ‘threatening’ to those who are the most mentally ill themselves but conceal this as people who have secrets and lies do.
People who are hiding mental illness, especially those with alcoholism or doing cocaine,  for instance, or pedophilia, or sex addiction, or sadism, like to ‘punish’ the mentally ill to distance themselves from themselves.  But that’s something psychiatrists know.
William Hay, Physician. I can live with that.  William Hay, Psychiatrist, most days I’m too cowardly to say that.  Just like William Hay, Christian, is hard for me to say.  Christians are the most persecuted group in the world.  So what’s worse in a secular insane society, William Hay, Psychiatrist and William Hay, Psychiatrist and Christian.  Might as well, lock oneself up in the asylum.  When I worked there and lived there I knew as we all did that the bars on the wall were to protect us from the outside.  We didn't want patients to escape, not because they were so much a risk to society but because society was so harsh on them.  Jails were where people were locked up to keep them from escaping by comparison.  Jails protected society from criminals.  It's a subtle difference but then psychiatry is 'subtle'.  
Anyone who ‘advocates’ for the mentally ill and the addicted has painted a bull’s eye cross on their forehead for enemies to take aim at.
Much easier to be William Hay, Physician.
William Hay, Psychiatrist.  I don't know.  It takes a better man to wear that title.  I think I'll wait for the cock to crow a few more times.

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