Going underground

by | Jun 16, 2022 | Curbside Consults

Q: I wanted to ask about integrating the things you teach into my learning and practice as an upcoming resident. Lots of what you say is in conflict with what is traditionally taught, and I feel that I will just end up getting confused and my preceptors will perceive a lack of knowledge if I used some of the principles taught by you on the website/podcast (ex. Giving Lithium for a patient with MDD who has suicidal ideation with plan). My preceptors will probably just think I am dumb and reject a suggestion like this one, despite the evidence.

Do you think I should save what you teach for after my residency training? I just don’t want to be learning one set of rules from my residency and then another set that are different. I’m having a hard time reconciling these thoughts.

PL: Leston Havens was the director of the psychiatry residency program at Cambridge Hospital in the Harvard system for many decades. In his first meeting with a new group of residents, he would say: “You have to learn to lie to your supervisors.”

He was acknowledging that psychiatry training almost always involves supervisors with different opinions or attitudes or philosophies. They would teach you what they think, but then another supervisor would teach something different. That’s actually good. As a resident, you want to be exposed to different ways of thinking, partly because it helps you get the tools to come to your own judgment, but also because it reflects the reality of the profession, where there is no one single correct approach for all aspects of psychiatry.

So Les would say, lie to your supervisors, tell them what they want to hear; that doesn’t mean you have to believe it.

The problem doesn’t end with residency. I’ve faced it with many residents who I’ve trained over the decades at Tufts and Harvard. For those who get more supervision with me, and who agree with much of what I teach, they run into problems when they graduate and go into the real world. A former resident joined a group practice in San Francisco; the other psychiatrists disapproved of her approach of being conservative in diagnosing ADD in adults and not using amphetamines. She had to leave. Another former resident began a forensic psychiatry fellowship, and found that many of the patients there had misdiagnosed bipolar illness, but his faculty teachers didn’t realize it.

I faced the same problem in my career. Once I worked at the Emory University psychiatry department’s clinic at Grady Hospital, in inner-city Atlanta. I found that many patients diagnosed with “depression” had bipolar illness, and failed to benefit from antidepressants. I took them off, and switched them to mood stabilizers, as proven in the research and as I routinely did in my bipolar clinic on the Emory main campus. The staff (not the patients) raised a howl about all my medication changes, and even though was a professor, not a resident, they complained enough so that I was transferred out of the clinic.

I don’t know the solution, but among the options, one approach is to go underground. This approach means that you don’t advertise or announce what you’re doing, and you don’t try to convert the unconverted. You just do it, quietly. You just go about your business with your patients.

I take this approach somewhat today. Not everyone in the departments where I work agree with me; most probably don’t on many topics. But I don’t try to convert them, and they don’t try to convert me. We just go about our business.

As a resident, the matter is especially sensitive since others have some control over you. I would suggest to keep a low profile with these ideas, use them when you can, drop them when you need to, and come back to them in your mind over time, testing how much they seem to work in your experience. Even after residency, you’ll have the same dilemma.

That said, sometimes you’ll find an open-minded supervisor or a flexible setting where you can do things the way you want. And, in the big picture, if your approach is better than others, patients will know and they’ll come to you. And maybe even clinicians will come to you too.

Nassir Ghaemi MD
The Psychiatry Letter