John M. Talmadge, M.D.

My Philosophy of Professional Practice

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UPDATE: In the April 2015 issue of The Carlat Psychiatry Report, Dr. Scott Miller discussed the importance of the therapeutic relationship. “The best predictor of treatment outcome in mental health services is not the specific technique, but rather the provider of those services. In psychotherapy, for example, who provides the treatment is between five and nine times more important than what particular treatment approach is provided.” The discussion is amplified in: Wampold BE, Imel ZE. The Great Psychotherapy Debate, second edition. (New York: Routledge; 2015).

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This essay on my philosophy began as a statement, but gradually the essay morphed into a series of questions. As I began to write, I started to feel as though I should have written this many years ago. I began to experience a deep sense of gratitude toward the many individuals who have taught me with such patience, kindness, and wisdom for so many years. I realized that my philosophy should reflect my desire to be a good psychiatrist.

Practicing medicine is a privilege granted to very few individuals, and I am indeed fortunate. Within the field of medicine, working in psychiatry requires more than an understanding of anatomy and organ systems, because psychiatry is about the mind, the brain, the self, and human experience.
Like any other professional, I believe in high ethical standards, sound knowledge of my field, and the importance of practicing wisely and compassionately. Beyond the obvious nostrums and philosophical cliches, however, I want to be one of the good psychiatrists. As I thought about this lately, I began to wonder: how does one identify and recognize a really good psychiatrist? What makes a good psychiatrist? If I made a list of the most important aspects of a psychiatrist’s professional philosophy, what would that look like?

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In 2006 an article was published in the Journal of Affective Disorders showing that good psychiatrists prescribing placebos (sugar pills) had better results than poor psychiatrists prescribing actual medication. Over 120 patients were divided into two groups, one group that received sugar pills and another group that received full strength psychiatric medication for depression. At the same time, each psychiatrist was rated on a number personal qualities: verbal fluency, interpersonal perception, expressiveness, warmth, acceptance, empathy, and the ability to focus on the other person. When results were analyzed, the psychiatrists strong in these personal qualities had the best results, even when the “medication” they prescribed was not medication at all.

The effective psychiatrists were fluent, clear, and expressive in speaking, and they had an accurate feel for their patients. Rather than being distant and aloof, the good psychiatrists were warm, friendly, and accepting. The good psychiatrists empathized well, spent more time with their patients, were more thoughtful in their strategies, and formed strong therapeutic partnerships. The point of the study was that having a good psychiatrist makes a difference in recovery.

Although medication can be extremely helpful in psychiatric care, treatment is not all about medication. The combination of the right medication, the right psychotherapy, and the right psychiatrist is the key to success.

Research has shown for generations that some clinicians consistently produce better results than others, regardless of the type of psychotherapy or theoretical orientation of the practitioner. Hundreds of studies have shown that the differences between types of psychotherapy is very small, but the psychiatrist providing the psychotherapy is critically important.

Over the past fifteen years, extensive research has given us a solid body of evidence about the qualities and actions of effective psychiatrists. Based on the psychotherapy research of Dr. Bruce Wampold of The University of Wisconsin, I have formulated here an inventory that provides the basis for judging whether a psychiatrist is likely to be effective.

  • Effective psychiatrists demonstrate a sophisticated set of interpersonal skills, including verbal fluency, perceptiveness of others, emotional intelligence, expressiveness, warmth, and acceptance. Given these gifts, the most effective psychiatrists are those who are first excellent physicians, well trained in medicine, competent to practice at the highest levels.

  • Effective psychiatrists are inquisitive, questioning, and seeking new knowledge constantly. They embrace science while at the same time possessing the humility to know how little we really know.

  • Patients of effective psychiatrists feel understood, trust the psychiatrist, and believe the psychiatrist can help. The psychiatrist creates these conditions in the first moments in both speech and action. In the initial contacts, patients are very sensitive to cues of acceptance, understanding, and expertise. Although these conditions are necessary throughout therapy, they are most critical in the initial interaction to ensure engagement in the therapeutic process.

  • Effective psychiatrists are able to form a working alliance with a broad range of patients. The working alliance involves the therapeutic bond, but also importantly agreement about the task of goals of therapy. The working alliance is described as collaborative, purposeful work on the part of the patient and the psychiatrist. The effective psychiatrist builds on the patient’s initial trust and belief to form this alliance and the alliance becomes solidly established early in therapy.

  • Effective psychiatrists provide an acceptable and practical explanation for the patient’s distress. The patient wants an explanation for his or her symptoms or problems. There are several considerations involved in providing the explanation. First, the explanation must be consistent with the healing practice. On the medical side, the explanation is biological, and in psychotherapy the explanation is psychological. Second, the explanation must be acceptable and compatible with the patient’s attitudes, values, culture, and worldview. Third, the explanation must provide a strategy by which the patient can overcome difficulties and solve life’s problems. These three factors together make for a strong therapeutic alliance.

  • The effective psychiatrist provides a treatment plan that is consistent with the explanation provided to the patient. Once the patient accepts the explanation, the treatment plan will make sense and patient compliance will be increased. The treatment plan must involve healthy actions—the effective psychiatrist promotes healing by replacing failed strategies with effective strategies. At the same time, strong defenses will replace weak defenses, and healthy practices will replace self-defeating behaviors.

  • The effective psychiatrist is influential, persuasive, and convincing. The psychiatrist presents the explanation and the treatment plan in a way that convinces the patient that the explanation is correct and that following through with the treatment will benefit the patient. This process leads to patient hopefulness, increased expectancy for mastery, and healthy actions. These characteristics are essential for forming a strong working alliance.

  • The effective psychiatrist is honest and authentic. Authenticity refers to communication to the patient that the psychiatrist truly wants to know how the patient is doing. The best psychiatrists tend not to use checklists, scales, and paper measures. Instead, they talk and listen openly and honestly.

  • The effective psychiatrist is flexible and will be patient if resistance to the treatment is apparent or the patient is slow to make progress. Although the effective psychiatrist is persuasive, persuasion can be a process that takes time. The good psychiatrist pays attention, takes in new information, test hypotheses about the patient, and is willing to be wrong. A good psychiatrist will seek second opinions, refer to other specialists, and even take calculated risks such as trying a new approach or a newly released medication.

  • The effective psychiatrist does not avoid difficult material in therapy. Doctor and patient must use such difficulties therapeutically. We all tend to avoid material that is difficult. The effective psychiatrist senses avoidance is taking place and does not collude to avoid the material. Instead, the psychiatrist will discuss the difficult material and address difficult problems. Sometimes conversations can be difficult, and at times the relationship between doctor and patient can be strained, but this is part of the work of therapy. The good psychiatrist can use skill, experience, and compassion to overcome these barriers to recovery.

  • The effective psychiatrist communicates hope and optimism. Sometimes this is easy to do, and sometimes it’s difficult. The working partnership must maintain hope and optimism in the face of chronic illness, relapses, lack of consistent progress, and many other difficulties. Effective psychiatrists acknowledge these issues and still communicate hope that the patient will achieve realistic goals in the long run. This communication is not blind faith or Pollyanna optimism, but rather a firm belief that together the psychiatrist and patient will work successfully. At the same time, effective psychiatrists mobilize patient strengths and resources to facilitate the patient’s ability to solve his or her own problems. The best doctors know that the patient, through his or her work, is responsible for therapeutic progress, creating a sense of mastery.

  • Effective psychiatrists are aware of the patient’s characteristics and context. This is a tall order with many categories: culture, race, ethnicity, spirituality, sexual orientation, age, physical health, motivation for change, and beyond. Furthermore, the effective psychiatrist is aware of how his own background, personality, and beliefs figure into the relationship.

  • The effective psychiatrist is aware of his or her own psychological process and does not inject his or her own material into the therapy process unless such actions are deliberate and therapeutic.

  • The effective psychiatrist is aware of the best research evidence related to the particular patient, in terms of treatment, problems, and social context. It is very important to understand the biological, social, and psychological basis of the patient’s problem.

  • The effective psychiatrist seeks always to improve, always to be a student. Hippocrates said, “The life so short, the craft so long to learn,” and truer words were never spoken.

  • Finally, the good psychiatrist must possess both humility and a sense of humor. We will never know enough, or be wise enough, to have all the answers. We cannot take ourselves too seriously, lest we become arrogant, prideful, and set ourselves apart from those who have graced us with the privilege of being socially sanctioned healers.

Development of skill in psychiatry involves intensive practice and unceasing professional growth. Patients are sometimes our best and most effective teachers. A few years ago I taught a seminar for third year students at the University of Texas Southwestern Medical School, “Psychiatric Nightmares, Disasters, and Catastrophes.” The entire content of the seminar consisted of mistakes I’d made, errors I had committed, and pitfalls that these students likely would encounter, sooner or later, in their medical careers.

I told the story of a patient with whom I’d had a terrible, angry argument, and how guilty I felt for years about my lack of composure—only to have the patient return, two years later, to ask me for a job at the hospital and tell me that she had been shaken into reality by our confrontation. I told them the story of the patient who overdosed and came to the ICU, and how I was baffled by the case—until I realized that the patient had diabetes, and was actually in a diabetic coma, not a drug-induced state.

I told them about the patient who came to the doorstep of my home on a Sunday afternoon, bearing in her arms her injured pet cat, hoping that I could help. I told them about an elderly man from New Orleans who was my patient in the middle of the night as Hurricane Katrina washed away his home.

And I told them about the time when I was called to the ER to examine a beautiful young woman, a Duke University cheerleader, who had bruised her shoulder. When I approached her to examine the injury, and she undid her gown and dropped it with a smile, I calmly reached into the pocket of my white coat for my stethoscope, only to realize that I then stuck my reflex hammer in my ear.

These encounters are the building blocks of the effective psychiatrist’s life. I’ve come to realize that most of the learning happens after we graduate. As Dr. Stead used to say at Duke, “Medical school is where you stay for four years until you’re old enough to become a doctor.”