August 2008, Volume 58, Issue 8

Opinion and Debate

Quest for a 'Universal Psychiatrist': How long is the journey?

Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, St. John's, NL A1B 3V6, Canada )

Psychiatrists are the medically qualified specialists who deal with human behaviour and psyche. In the current global scenario of chaos, violence and political disturbances they have assumed an important position in the light of high prevalence and incidence of mental illnesses.1 This speciality has a role in almost every medical subspeciality as many physical illnesses have a psychological background. There are a number of psychiatrists all over the globe catering for the mental health needs of people in their respective countries but we still do not have adequate data about how satisfactory their input is in terms of psychiatric services. A psychiatrist should be unique from other specialists as he/she deals with the emotions, psychodynamics and at times spirit of human beings. Should anybody opt for this field? Or can anyone become a perfect psychiatrist? Do special qualifications in psychiatry confer academic and clinical omnipotence? These are the questions that come to the mind but the issue is not that simple. To be a good rather 'perfect' psychiatrist one should possess a balanced personality which should be free from a nasty trait or disorder. The early childhood development and the environment in which an individual has been brought up is an essential factor that determines and shapes behaviour and personality apart from genetic influence. The qualities of a good human being should be visible. The traits of being oversensitive, narcissistic, paranoia, hostile, anger, cyclothymiacs, obsession, histrionic should not be in evidence. The strong superego may add to the flavour of the personality. The moral bindings and ethical thought process are features of importance. Psychological mindedness is a feature of high merit during the medical school years. There should be criteria for selecting the potential psychiatrists and here the selection committees can play their effective role.2 Weightage should not be given only to academic merit but also on personality record and aptitude. Ideally, a personality test should be performed in order to screen those candidates who by virtue of their faulty personality traits may cause more harm to the discipline rather than benefit. Before taking up the specialty, it is important that the candidate undergoes an extensive tuition in the subjects of philosophy, spirituality, psychology, anthropology, ethics, epidemiology and statistics. The knowledge of cultures, religions and languages are additional qualities. Computer literacy is essential as it has wider applications throughout the career. During training, electives in different cultural settings should provide adequate exposure to patients from a variety of backgrounds and emphasize on developing cultural competence. During training, stress reducing exercises and guidance services should be available. It is important that the trainee should have refrained from substance abuse and excessive alcohol intake and has not developed any mental disorder. With multiple evaluations during training, the behaviour with patient and colleagues should have shown consistency and maturity. As a new psychiatrist, the general expectations are: competency in treating the patients, able to follow the protocol of service in terms of attending inpatients and outpatients, attend emergencies, able to provide opinions and function effectively as a leader of a multidisciplinary team. Among the characteristics of good psychiatrist is open mindedness to fundamental issues of the subject and has not allowed himself or herself to one exclusive sort of explanation.3 During the training and until certification, the essential features as per CanMED4 model through which a psychiatrist grooms are viewed in a broader perspective. "As a Medical Expert-application of knowledge, clinical skills and professional attitudes in their provision of patient-centered care. As a Communicator- can effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. As a Collaborator- effectively work within a healthcare team to achieve optimal patient care. As a Health Advocate- responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations. As a Scholar- demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge. As a Professional- are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour". The physician/Psychiatrist competency is measured by numerous ways including periodic reviews, mock orals, OSCEs and class tests. in order to be sure that the end product matches the model.5 Apart from some objective assessments, a psychiatrist is well regarded if he/she can act as an effective team leader who is open to suggestions from the other team members and be able to form decisions based on thorough consultations. The approach adopted in such a role should be flexible, democratic and free from personal biases. This role should be replicable in any given cultural setting. When it comes to psychotherapeutic intervention, the 'psychiatrist' should be able to handle the issues of 'transference' and 'counter transference' as this can put the therapist in a very vulnerable position and can be a good parameter to check the strength of personality in the said perspective. The 'psychiatrist' should be acutely aware of boundary issues in dealing with the patients and be able to demonstrate the understanding of its dynamics and complexities. As mentioned earlier, understanding of religious connotations and ability to apply effectively the components of spirituality and faith in the management plan can go a long way in addressing the mental health issues in the face of complexities. As a professional, a 'psychiatrist' comes under stress and strain related to the profession itself and may result in some emotional 'wear and tear' that can have undesirable effect on the psyche. It is therefore necessary that the 'psychiatrist' is able to and for that matter agreeable to subject one self to periodic psychological evaluation and if necessary should take 'time out'. Where can one find this 'universal psychiatrist'? For sure, this 'model psychiatrist' is not exclusive to a particular country or region. Credit could be given to those regions that endeavor to produce such professionals who are good for anywhere and everywhere. Can we find somebody like a 'universal psychiatrist' in Pakistan? If we make our efforts more vigorous, we may come across some individuals who might come nearer to the 'model' and if not then it is not too late to start working with our future generation of doctors and identify the ones who can successfully assume the qualities of the model universal psychiatrist. This can give a new boost to the fragile mental health system of the country and will help improving the mental health of a large population of the country in need for attention in this respect. The ultimate patient satisfaction can then be measured by application of scales. To reach this goal, we need to judge the length of this journey while keeping our fingers crossed.

References

1. Ustun, TB, Ayuso-Mates, JL, Chatterji, S, Murray, CJC Global burden of disease 2000 Study: World deaths related to neuropsychiatric conditions by gender and cause for year 2000. Brit J Psychiatry, 2004; 184: 386. 
2. Gadit, AM Cultural competence is not optional; Clinical Psychiatry News, 2007, 35; 10; p: 13.
3. Hill D. The Qualities of a Good Psychiatrist; Brit J Psychiatry; 1978; 133; 97-105.
4. Frank JR. (eds). The CanMEDS 2005 Physician Competency Framework; better standards, better physicians, better care. Royal College of Physicians and Surgeons, Canada and Associated Medical Services Inc 2005; p: 1-27.
5. Memorial University of Newfoundland (MUN). 'Evaluation of residents' available at: http://webeval.med.mun.ca/mun/admin/pages/viewformprint. php date accessed: 7th February, 2008.

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