I recently received an e-mail from someone who stumbled here through Google. He reported that he had looked up something like “first time seeing a psychiatrist” and that search landed him here. After reading through a few entries, he sent me a complimentary e-mail.

It’s stuff like that that makes me want to resume writing on a regular basis. After April 5th.

On April 4th and 5th, a whole bunch of psychiatrists will be in Boston. The American Board of Neurology and Psychiatry (it’s a dot com! not a dot org! or dot net! dot com!) will be testing psychiatrists for board certification. This part of the certification is a series of oral exams. The candidate will interview a real patient for 30 minutes (with at least two examiners watching), followed by 30 minutes of grilling inquisition questioning from the examiners. There are also a series of written or videotaped vignettes and examiners will ask the candidates questions about the clinical material.

The reported pass rate for this exam is around 50%. The residency program from which I graduated has a pass rate closer to 90%.

The cost of the exam is $1300. This does not include travel and hotel fees. No one wants to pay another $1300 to take this exam again.

Did you know that the Diagnostic and Statistical Manual of Mental Disorders is dedicated to “Melvin Sabshin, a man for all seasons”?

There have been a lot of, frankly, disgusting stories about the mixing of mental health, medications, and money in the media recently. Philip over at Furious Seasons has written a number of posts about the latest developments. I look forward to the day where I read something related to psychiatry in the media that doesn’t make me cringe.

One of the ideas that I want to expand at some point for my own reflection (and clarity) is just who we are treating in psychiatry. Sometimes, family members and friends bring people in and comment on how their function has declined or how something has changed. Sometimes, patients themselves opine that they don’t seem to fit in, that “everyone else” seems so happy, satisfied with life, etc.

Dissatisfaction is okay. This is an emotional experience that most of us have at various points in our lives. At what point does this emotional experience become more than just an emotional experience?

A good friend of mine is a psychologist in Boston. He and I were discussing the seeming ease with which some docs prescribe meds to alleviate psychic discomfort.

(Why do I feel compelled to explicitly write that not all psychiatrists seek to medicate all people they see? Maybe because I myself am often questioned by superiors and colleagues as to why I don’t prescribe more often? “If you have the power to prescribe something that can help people, aren’t you just withholding something helpful, then?”)

“People somehow believe that dissatisfaction or sadness or depression is a problem,” my friend remarked, “instead of considering that it may simply be a signal.”

Yes.

I’ve written in the past that context immensely matters. I am grateful for my training in the libertarian-influenced state of Washington. People are much more easily involuntarily hospitalized here in New York. While I have not witnessed gross abuse of this law, I am often surprised with how easily people are detained… and how long they stay in the hospital. Their symptoms don’t improve and their behaviors don’t change.

Don’t we have obligations as physicians to try something different if things are not progressing towards realistic goals?

And whose goals are we pursuing? And how realistic are they? (See section 5 above.)

Job satisfaction should not be dependent on your peers. Who you work with, though, can affect how fulfilled you feel while working.

Dissatisfaction often arises when your actions and your values are not in alignment.

The setting will influence your actions (because, as above, context matters). Upon closer examination of your actions, you may realize that these actions are contributing to your dissatisfaction. And dissatisfaction in of itself may not be the problem: it may simply be the signal. You have the option to acknowledge and recognize the signal, consider what it indicates, and thoughtfully make choices once informed.

Do you like how this is all tied together?

And do you like how I keep using the second person pronoun when I really should be using the first person pronoun?

I’ve lived in New York for eight months now and have eaten a variety of cookies from different shops. My favorite cookie is the chocolate chip cookie at Jacque Torres. That’s a fine cookie. Go try one.

Dancing is still good for the soul. I should do more of it, even if only in the confines of my apartment (which, at one time, I thought was remarkably tiny… and, now, I think it’s just fine).