Psychiatry is the branch of medicine focusing on the diagnosis, treatment and management of mental, emotional and behavioural disorders, providing tertiary care to those in need. There are three main branches under psychiatry, including child and adolescent psychiatry (with patients under 18), adult psychiatry (with patients aged 18-65 years), and psychogeriatrics (with patients aged 65 or above). Community psychiatry is under the umbrella of adult psychiatry, in which doctors treat and help patients with mental disorders such as anxiety, depression, schizophrenia, bipolar affective disorder, etc.
Introduction to the psychiatrist
We were very lucky to be able to interview an experienced psychiatrist, Dr L, who would prefer to remain anonymous. Dr L has worked at Prince of Wales Hospital and Shatin Hospital for almost 20 years and counting, leading a community psychiatrist team which consists of doctors, nurses, occupational therapists and social workers. The community psychiatric team provides support to patients who live in the community. Their needs and risks are regularly reviewed through regular home visits and contacts with patients and their relatives. The team holds regular meetings to review cases for clinical advice and decisions. In some acute situations, such as deterioration in mental condition with escalating risk, the team will get involved and call the police, to take the patient to the hospital for further treatment.
Dr L made up her mind to be a psychiatrist mainly due to her interest in the field. Fine motor skills, while essential in conducting surgeries, are not her strength, but she also developed a passion in listening and understanding others. She pointed out that “the goal you set may not be the same as your destiny”. She said that she was lucky enough to have the chance to be a houseman in psychiatry, which made her determined to be a psychiatrist.
In psychiatry, an emphasis is placed on the interactions with patients. Unlike other divisions of medicine, the diagnosis in psychiatry is made based on clinical interviews, rather than laboratory tests.
Life as a psychiatrist working in public hospitals
On a typical day, Dr L has more than 30 patients in a half-day clinic session. “Although I can’t control the patient load, I can make adaptations to prioritize patients who are more in need,” said Dr L. For patients whose symptoms are more serious, the doctor spends more time talking to them to provide appropriate management and interventions.
As a psychiatrist working in public hospitals, she generally comes across more patients with lower social class and severe mental illnesses, such as schizophrenia and bipolar affective disorder. These patients are already socially disadvantaged. Apart from the fact that their illness will lead to deterioration in functioning, some have suffered from their disease for over 30 years. Patients from the lower class usually lack support and are more socially deprived. They are more likely to be isolated from the community, while some are abandoned by their families. One of the psychiatrist’s roles is to help patients integrate back into society by providing relevant services.
Even though severe mental illnesses are more common among the lower class, middle-class patients may also develop similar disorders. “There are no exemptions for mental disorders. No matter how wealthy you are, you may still develop such symptoms,” said the psychiatrist. “The only difference is the patient’s needs.” Patients from the middle class have other issues such as stress from work, coping issues, interpersonal issues including peer, marital, and parent-child relationships, etc. For example, some individuals were affected by the COVID-19 pandemic, facing the problem of bankruptcy, unemployment, increased financial stress and family conflicts.
Types of patients a psychiatrist faces
Most people have the impression that patients with mental issues tend to be more violent. However, those are only the most extreme cases. Working under community psychiatry, they are constantly in contact with patients who have a history of violence. Having worked for all those years, Dr L said she is lucky enough not to be hit by a single patient. With a safe working environment, proper risk assessment, and early intervention through identifying unstable cases early, violence at work is not a threat.
She often comes across cases with mood problems, whose lives are tragic. For the first few years, she felt miserable for the patients. With time, she learned that there may be misfortunes or setbacks, but they are a part of life. As a psychiatrist, what they can do is to give comfort and support to patients, to alleviate pain, and to let them see their hopes in life in the midst of hardships. After all those experiences with patients, she has learnt to be more grateful for what she had in life.
There are cases where the patient’s recovery isn’t as ideal as they expect. “Doctors are not almighty. They face many limitations,” said the psychiatrist. There are situations where the patient commits suicide, but it may be out of the doctor’s control. The role of psychiatrists is to give patients the most appropriate treatment options, services, and support. Despite all these efforts, their illnesses or stressors may still take their lives. Life and death are something that every Doctor has to face in their daily practice.
Qualities of a good psychiatrist
It is important for a psychiatrist to be empathetic, observant and good at listening. But at the same time, they need to be self-aware of their own emotions and not affect the patients.
Observation is also vital in providing clinical information. One must pay attention to the patient’s clothing, accessories, eye contact, etc. For example, if the patient is an alcoholic, they can smell the alcohol, with disorientation in time or place. A manic patient could have fast-paced speech, exaggerated facial expressions, and over friendliness, as well as wearing bright colour clothes and excessive jewellery like dozens of rings and necklaces.
In psychiatry, a clinical impression may change over time. A psychiatrist has to look at the longitudinal picture of patients and review their diagnosis and treatment with time. Moreover, it is important to collect collateral information for a more comprehensive assessment, instead of the one sided story from the patient. During the diagnosis process, the doctor needs to pay attention to their social, financial, and relationship issues.
“Psychiatry cannot purely rely on medication or psychological intervention. It is always an integrated approach, striking a balance between medication and psychological intervention,” said Dr L.
Comparison of the medical system in HK and overseas
The medical system in HK is quite different from the one overseas. In foreign countries, patients with mental problems are mainly taken care of by the primary care system i.e. the general practitioner (GP) or family doctor. Those with severe and enduring mental illness are usually referred to specialist care. As for HK, many patients are directly referred to a psychiatrist.
In terms of patient load, HK is higher than overseas. This is mainly due to three factors, namely the high population density, the low doctor-to-patient ratio and the fact that many with mental problems are directly referred to specialist care. As such, each doctor in HK has to take care of more patients when compared with overseas doctors.
Advice for students who dream of becoming a doctor
Firstly, one has to ask themselves whether they meet the qualities of a doctor. They are expected to be diligent, ready for life-long learning and to be competent to cope with stress and exhaustion.
Secondly, a doctor needs to help others out of the goodness of their heart, but not merely for the monetary return. A doctor may also not have enough rest time, since they sacrifice their time for patients.
But for this psychiatrist, “The return of being a doctor is the joy of witnessing the patient’s recovery. Personally, this is very meaningful.”
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