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Special | May 01, 2006

The Problem of the Psychopharmacologist

Nicholas Kontos; John Querques; Oliver Freudenreich

Academic Psychiatry 2006;30:218-226.

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Received July 4, 2005; revised October 6, 2005; accepted October 10, 2005. Dr. Kontos is Associate Director of Consultation-Liaison Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts, and Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts. Dr. Querques is Assistant in Psychiatry, Massachusetts General Hospital, and Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts. Dr. Freudenreich is Director, Massachusetts General Hospital First Break and Early Psychosis Program, and Assistant Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts. Address correspondence to Dr. Kontos, Cambridge Hospital, 1493 Cambridge Street, Macht Building, Cambridge, MA 02139; nkontos@challiance.org (E-mail). Copyright © 2006 Academic Psychiatry.

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Abstract

Objective: The psychopharmacologist designation currently pervades and heavily influences the practice, perception, and teaching of clinical psychiatry. The authors hope to make a case and provide the raw material for informed discussion of this role during psychiatric residency training. Method: A definition for the psychopharmacologist is sought. Historical trends in psychiatry which contributed most to its evolution are explored. Problems of the psychopharmacologist role are delineated. Extant solutions to psychiatry’s problematic adaptation to an increasingly biological clinical role are critiqued, and a more effective one is pursued. Results: The term psychopharmacologist seems linked to presumed scientific and medical approaches, a goal of symptom relief through medication, and often other providers who are considered patients’ "primary" treaters. The role derives largely from economic and remedicalization trends. Aspects of disengagement are determined to form the core problem of the psychopharmacologist. The authors propose that psychiatry is defined by its practice of the medical model and call attention to three areas where the psychopharmacologist role and the medical model collide. Conclusions: Engaging psychiatric residents in a new dialogue about their role as physician will challenge the previously unquestioned psychopharmacologist categorization, begin to address its problems, and bring a vital element to trainees’ professional identity development.

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Definition

Nothing quite excites my ire so much as being pigeonholed in a strictly biological slot just because I am medically minded.

—Thomas P. Hackett (¹)

The potential effectiveness of every physician has increased dramatically in the past 50 years due to advances in biomedical science. In clinical psychiatry, however, an interesting phenomenon has occurred in which many of those affected by these advances have come to identify themselves with the science itself and call themselves psychopharmacologists. The term psychopharmacologist is now common parlance among physicians, nonphysician mental health professionals, and patients (², ³), but has been subjected to surprisingly little academic scrutiny.

Many departments of psychiatry now have clinical divisions of psychopharmacology; patients are referred to as "psychopharm patients" and are seen in "psychopharm clinics;" psychiatric residents are trained in these clinics and may also have "psychopharm supervisors." These experiences contribute to the formation of residents’ professional identities, and the authors of this article submit that they do so at the expense of trainees’ physicianhood and of thoughtful, medically minded patient care. Our position stems from a bias that the most vital and potentially effective role identification for the psychiatrist is that of a doctor utilizing a medical model, and that the psychopharmacologist categorization is erroneously co-opting this possibility.

In this article, we set out to explore definitions, origins, and problems of the psychopharmacologist role, and then to identify solutions to those problems. At various points we offer specific ideas on discussing these usually neglected topics with residents. The authors recognize that the very title of this piece may offend some psychiatrists and that what follows cannot capture the practice philosophies of all self-identified psychopharmacologists. Any controversy caused is not only welcome, but desirable, as our goal is not to put forth truisms, but rather to stimulate informed discussion about an important issue that has somehow eluded such discussion to date.

Though the term psychopharmacologist has been institutionalized, it lacks a consensus definition. Clinicians and patients often apply the term casually to psychiatrists who prescribe medications for patients without also providing formal psychotherapy. (Note: For the purposes of this paper, the term formal psychotherapy indicates interpersonally-based mental health treatments informed by models of human psychology and taking place within prescribed frames.) Whether patients assume that the appellation ‘psychopharmacologist’ connotes special expertise in prescribing psychiatric medications is unknown, but it seems an important possibility since psychiatry has embraced the term. Yet with no formally acknowledged subspecialty of psychopharmacology, there is no universally accepted set of training requirements and skills expected of those who go on to call themselves psychopharmacologists.

Very few authors specifically define the term. Investigators within an HMO state that "a psychopharmacologist is a psychiatric subspecialist with a high degree of expertise … in the diagnosis and treatment of drug-responsive psychiatric disorders" (⁴). Additional nonindustry input is desirable here. Stahl begs the question in defining psychopharmacologists as "clinical psychiatrists who practice psychopharmacology" (⁵). Obvious as the meaning of any "-ology" may seem, there is a critical ambiguity, as noted by Healy (⁶), between the clinical and research implications of this one. Ever since its inception in the 1950s, psychopharmacology has had a dual meaning, both therapeutic and experimental. To what extent each of these meanings informs the identity of a given psychopharmacologist seems idiosyncratic. We see this blurring of the boundary between clinician and scientist roles as an unresolved, but important element of the definition of the psychopharmacologist.

Some view the psychopharmacologist as a steward of the medical model in psychiatry, presumably by the use of medicines. In a case discussion titled "Psychopharmacologist as Family Doctor," a resident meets difficulties while acting as psychopharmacologist for a husband and wife and remarks that "psychopharmacologists [are] often supported explicitly by a ‘medical’ rather than a ‘psychotherapeutic’ model" (⁷). Noordsy et al. (⁸) seek to integrate "our role as psychopharmacologists in the medical model" with a "recovery model" and propose that psychopharmacologists learn to foster patients’ hopes and strengths within an "environment of mutual respect." In these examples, we note at both trainee and staff levels the impression of a medically informed psychopharmacologist role that must be supplemented by a nonmedical approach in order to address issues outside of prescription and symptom relief.

Ghaemi (⁹) evokes a medical image in describing the psychopharmacologist as someone who "might tend to be evidence based … diagnosis focused." He also warns that the role is associated with the idea of "performing med checks, a pejorative term" that suggests that a simple "checking" of medication doses and effects is all that is necessary in these clinical interactions. Many similar phrases crop up in the literature: "medication management" (¹⁰, ¹¹), "only doing medications" (¹⁰), "medication clinics" (¹²), "medication coverage" (¹³), and "medical consultation" (¹⁴). More thought-provoking are references to the psychiatrist as a "medical backup" or "backup physician." In this role, the psychiatrist manages biological aspects of cases, may carry ultimate responsibility for patient care, and is defined in the "backup" role with reference to a nonmedical "primary" treater (¹⁵, ¹⁶, ¹⁷).

Based on the above overview and the clinical experience of the authors, the term psychopharmacologist may apply to psychiatrists who utilize a presumed scientific and medical approach to treat patients, often in conjunction with a nonmedical provider who is considered the patient’s "primary" treater. Ultimately, the goal of the psychopharmacologist is to prescribe medication to treat psychopathology; prescription here implies a medical approach. The psychopharmacologist may possess exceptional knowledge of pharmaceuticals, but currently has no mandate to prescribe them. Practical aspects of the role often include the 15—20-minute "med check" and the sharing or ceding of other clinical duties in a "split treatment" where the psychopharmacologist’s direct responsibilities to the patient are easily hemmed in.

A review of a limited literature is, necessarily, limited. However, an explicit starting point for defining the psychopharmacologist is sorely needed by academic psychiatry. Any element of the above definition can be easily discussed and debated in an educational context. We recommend specific attention to residents’ ideas regarding scientific and medical approaches to the prescribing act in particular and psychiatric practice in general. These themes will recur throughout this article.

Origins

The historical and intellectual heritages of a concept can be critical to teaching and understanding it. Here we attempt to apply this idea to the psychopharmacologist.

Economics

When it comes to the "med check" aspect of the psychopharmacologist role, it is well-trod ground to point out that managed care saturation of the medical marketplace created an "economically driven practice of automatically dividing treatment" (¹⁸). Formal psychotherapy is preferentially administered by cheaper nonphysician mental health professionals, while physician time, expense, and often scope of attention are minimized during short "medication visits." All physicians have endured a decrease in subsidized visit length over the years, but psychiatry was uniquely vulnerable to a role crisis. Doctor-patient relationships in psychiatry historically have been understood in terms of transference and countertransference within the frame of dynamic psychotherapy. Shunted by managed care from the practice of formal psychotherapy toward "medication visits," psychiatry may have lacked sufficient conceptual flexibility to bring much more to the latter modality than what it most literally demanded.

Victimization by managed care is a valid and stirring rallying cry for social change, but not reason to assume that financial and political motivators within psychiatry did not also contribute to the psychopharmacologist phenomenon. Deinstitutionalization, the community mental health movement, and increasing practice rights for nonphysician psychotherapists created a turf war within the mental health field starting in the 1960s. While undoubtedly there was clinical concern behind the angst this generated among psychiatrists, there was also a sense of almost military threat. Authors wrote of "territorial conflicts" (¹⁹), "territorial claims" and an "assault on preeminence" (²⁰) under which psychiatrists worried that their "power base is being eroded" (²¹). Even a recent thought-provoking proposal to redefine psychiatry and its training "on the basis of its scientific foundations" (and which suggests a "pharmacopsychiatry" subspecialty) leads by validating itself as a defense against "political and economic forces … that could threaten the field" (²²). By the 1990s, it was clear (as it was to Freud long before) that medical training conferred no added psychotherapeutic aptitude (²³). Hence, some have endorsed replacing psychotherapy training in psychiatric residencies with enhanced training in assessment and treatment selection with greater focus on biology (²⁴, ²⁵). No one has argued for a restrictive view of the patient, but as Eisenberg wrote in 1985, "Increasing competition … has prompted us to run our medical credentials up the flagpole … to emphasize our medical skills for differential diagnosis and somatic treatment" (²⁶).

Remedicalization

It is possible to conclude that money and politics were all it took to nurture the somatic-treatment-focused medical model of the psychopharmacologist (²⁷), but this seems rather cynical and naïve. The discovery of the antipsychotic drugs allowed for deinstitutionalization and the subsequent revolution of the mental health field. It is no wonder that this scientific advance fueled new enthusiasm and hope in many psychiatrists. As elegantly chronicled by Wilson (²⁸), simultaneous blows to the status quo from the Rosenhan study (²⁹), the depathologizing of homosexuality, the unfulfilled promises of psychoanalysis, and the antipsychiatry movement created a further impetus for a major change in psychiatry’s course. The dominant result in the psychiatry of the 1960s and 1970s was a movement toward a medical model, the culmination of which was the publishing of DSM—III in 1980 (²⁸). Indeed, most proponents of the remedicalization of psychiatry saw the concept of diagnosis as central (³⁰—³⁴). Many argued further that psychiatry’s domain be limited to those diagnoses with a "known, suggestive, or presumed biological" (³³) etiology (³¹, ³⁵, ³⁶).

Though the case for greater attention to biology in a remedicalized psychiatry was a necessary corrective, overvalued biological explanations in psychiatry are of continuing concern (³⁷). The bottom line is that psychiatrists still have very little to go on biologically when it comes to "ruling in" most major psychopathology. This lack of diagnostic precision in a specialty where "we have been for so long pilloried by our medical and surgical colleagues as witchdoctors and woolly minded thinkers" (²⁶) may make the investment of identity in medication too tempting to pass up.

Wilson also points out that the remedicalization phenomenon was associated with a shift in academic psychiatry whereby the prominence of psychodynamic clinicians was overtaken by that of biologically-oriented researchers (²⁸). Luhrmann (³⁸), in her anthropologic study of American psychiatry, Of Two Minds, identifies the "psychoanalyst" and the "psychiatric scientist" as "epitomes of excellence" in the field. She initially uses the "psychiatric scientist" term to refer to researchers who feel that "neither the personhood of the psychiatrist nor the patient is relevant to the efficacy of psychiatric treatment," distinguishing them from even "psychopharmacological" clinicians for whom patient individuality matters. Later, though, her distinction between researcher and clinician blurs, with a "new kind of psychiatrist … [who] saw themselves as scientists … determined to create a psychiatry that looked more like the rest of medicine." These observations regarding the role model for the so-called medical psychiatrist offer historical and philosophical context to the physician-scientist element of our earlier psychopharmacologist definition.

Before leaving the subject of the impact of remedicalization on American psychiatry, it should be noted that psychiatrists who knew something about the use of medications may once have needed differentiation by a title (³⁹). For much of the 20th century, the word "psychiatrist" was essentially synonymous with psychotherapist. For much of that same time, many considered biology and diagnosis irrelevant or even anathema to the goals of psychotherapy (²⁸, ⁴⁰). Such division may have rendered "psychopharmacologist" a term of convenience. Seen in this light, the term now survives as an artifact despite long-standing evidence for noninterference between the modalities (⁴⁰) and the existence of standards from the Accreditation Council for Graduate Medical Education (ACGME), which require that all psychiatry residents receive training in biological and psychological interventions.

Problems

Logistics

Division of treatment between a psychopharmacologist and a psychotherapist is common (⁴¹, ⁴²). The challenges it presents have been noted on definitional (¹⁵), medicolegal (⁴³), psychodynamic (¹⁰, ¹⁴), and even ethical (¹³, ⁴²) levels. Some feel that the split treatment arrangement is misguided economically and see the real challenge as advocacy for coadministration of both medication and psychotherapy by a single psychiatrist (¹⁸, ⁴⁴). There is concern that these challenges are not being sufficiently addressed during psychiatric training (¹³, ⁴⁵).

Many patients would benefit from longer appointments and/or a single physician provider of both major therapeutic modalities and should have this opportunity, but others do not need both treatments. Realistic and thoughtful psychiatric patient care entails a significant proportion of short appointments in both single-provider and split treatments. This is true for all clinical medical specialties. Yet there exist no explicitly identified subspecialty pharmacologists other than psychopharmacologists. Perhaps this is because nonpsychiatrists are not shackled in their training to either/or ideas of "medicating" versus "doing therapy." Instead, they may implicitly be taught to accept the narrow pharmacologist role as synonymous with that of physician. We would argue that only the first possibility represents good doctoring. The psychopharmacologist role does not, and the logistic problems noted above are epiphenomena of a multifaceted disengagement in the service of a misguided medical approach.

Disengagement

By imparting legitimacy, and sometimes prestige, upon the psychopharmacologist, psychiatry corrals part of itself off from all but a limited interventionist-centered identity which is then available for propagation and consumption in its training programs. The result is disengagement from the patient’s experience; though most psychiatrists would eschew such disengagement, it seems nonetheless rampant. One must take many patients’ assessments of former psychiatrists with a grain of salt, but the sheer volume of reports the authors have heard of psychiatrists who "just saw me for 5 minutes," "tried something different every time we met," "did not even talk to me," "just kept adding drugs," and the like suggests a disturbing trend.

In the previously cited HMO study, when patients were to be seen by their psychopharmacologists, "it was explained that all subsequent follow-up visits would be for medication-response assessments only" (⁴). Others express concern over this sort of practice. Powell (⁴⁶) and Lurie (⁴⁷) voice alarm at a tendency to see patients as "static" recipients of a drug’s action. Adelman (⁴⁸) warns against viewing the patient as a "diseased organ." Most indicting are Luhrmann’s anthropologic observations that, in the practice of psychopharmacology, medications can take precedence over all else to the extent that they "increasingly took the place of relationships with patients" (³⁸). Further, she links this tendency to problems of overmedication and compromised healing potency in the doctor-patient relationship.

The ignoring or complete delegation to others of nonmedication considerations often reflects a presumption in psychopharmacology not only that matching criteria with drugs is necessary, but also that it is clinically sufficient. With such a permit in hand, psychopharmacologists can be at liberty to divorce themselves from patients’ personhoods "so they themselves [can] focus on the more ‘medical’ aspects of care" (²⁰). More than psychotherapeutic considerations are sacrificed here. Empathic and incisive scrutiny of a patient’s experience is needed to match phenomenology to the DSM diagnostic scheme effectively (⁴⁹). Exquisite skill is needed to handle resistance, impart realistic expectations, and simultaneously optimize the healing effect of the physician’s personal qualities (⁵⁰). Courage, sympathy, and resourcefulness are needed to provide education and be helpful when a person is in distress, but not mentally ill (⁵¹).

Selective disengagement can occur on both sides of the psychopharmacologist-patient relationship. The mentally ill and uncomfortable are bombarded with advertisements suggesting pharmacologic utopia and are quite aware of the psychopharmacologist designation. Those inclined to present themselves may expect a prescription, relief, and nothing more. For some, this may be an effective and appropriate treatment. For others, the idea of a "chemical imbalance," valid or not, becomes a defensive externalization or somatization, "an intolerable state that must be corrected or removed by the psychiatrist" with medication (⁴⁷). This defense can be facilitated easily by the psychopharmacologist, and particularly by the novice assuming this mantle. This collusion backfires when protracted lack of relief necessitates previously ignored and now jarring inquiries and advice that do not end with the scratch of a pen across a prescription pad.

Summary

Accepted and disseminated without attention to its potential implications, the psychopharmacologist role ferments irrationally narrow practice strategies in physicians, unreasonably concrete expectations in patients, and, by extension, an inaccurately pat representation of the stuff of psychiatry to the rest of medicine. Together, these products of logistics and disengagement form the central problem of the psychopharmacologist.

Looking for Solutions

Two solutions addressing aspects of the problem of the psychopharmacologist have been proffered to date: 1) attention to the psychodynamics of prescribing; and 2) application of the biopsychosocial model.

Over 20 years ago, Gutheil (⁵²) identified a "mind-brain barrier" that affects a psychiatrist’s ability to think seamlessly about medications in the context of psychotherapy. He proposed that a focus on the doctor-patient relationship could break this barrier and discussed this relationship in terms of transference and countertransference phenomena surrounding the use of medications. Since then, others have elaborated upon the importance of such psychodynamic considerations (⁷, ¹⁰, ¹⁴, ⁴⁶, ⁴⁷). Thoughtfulness of this sort clearly enhances effectiveness in prescribing, but by itself is a compromise, not a solution, to the disengagement problem. The psychodynamics of prescribing presumes psychopharmacology and by definition places psychodynamics in the service of a predetermined goal of prescribing. Additionally, it perpetuates the idea that only two ways exist to think about psychiatric patient care: psychodynamic and psychotropic.

In 1977, Engel offered up his biopsychosocial model as a scientific and holistic solution to the problem of biomedical reductionism in medicine as a whole (⁵³). Many see it as the necessary solution to such problems in psychiatry (², ¹⁸, ⁴⁴, ⁵⁴). Yet the psychopharmacologist evolved and now thrives under its watch. Engel ably identified a problem in medicine and domains of neglect contributing to it. However, as many note (⁹, ⁵⁵—⁵⁸), his model provides little room or rationale for prioritization in a given case. As perhaps most famously and cogently stated by McHugh and Slavney (⁵⁶), the complexity of psychopathology and the rich conceptual heritage and knowledge base that psychiatry can bring to bear on a case demand rigorous selection of data and interventions. With all good intentions, the biopsychosocial model preaches a practice approach comparable to carrying a Swiss army knife with all of the implements unsheathed: attentive to all things at all times but too unwieldy to use effectively. The psychopharmacologist role might counterintuitively prosper as an alternative by offering a comforting and pseudosimple do-it-all tool.

These candidate solutions are essential, yet insufficient to remedy the psychopharmacologist problem. For the individual psychiatrist at any career stage, a fuller solution should provide a sense of professional identity and responsibility that is rigorous, yet fulfilling. For patients, it should balance the experience of being empowered with that of being advised by an expert. For the field of psychiatry, it should provide a framework that can be seen as medical and humane by colleagues and society. In short, psychiatry must reassess its use of the medical model.

The Medical Model as Solution

The Medical Model

Here we strive to assert the medical model in contradistinction to the imposter "medication model" now found in clinical psychiatry. This is not a paper on the history of medicine or the medical model. Simplifications are made. Our goal is to craft a practical and teachable solution to the psychopharmacologist role problem. We also hope to lay the groundwork for reidentification of psychiatrists as physicians rather than as specialized technologists.

Many point out that there is no agreed-upon medical model at all, let alone in psychiatry (³², ⁵⁹—⁶²). While these writers present a multitude of historical and proposed models, they agree that the concept of diagnosis is the center around which all of them revolve. The core nature of diagnosis supersedes debates over etiology and therapeutic modality and defines the proper purview of psychiatry. For that matter, one can argue that with few exceptions (e.g., interventional radiology), diagnosis defines the domain of all of the clinical specialties. The identification of a current or to-be-prevented diagnosis imparts patient status upon a person, forms a major privilege of the physician role (⁶²), and justifies the physician’s presence in the patient’s life.

The next important issue is the context in which the physician deals with these diagnoses. We contend that the proper reference point for the medical model is the provision of clinical care. This ideal is in agreement with Whybrow (⁶³), who sees "caring for the diseased individual" as the overarching task of the physician. The task of caring introduces the greatest challenge to the job of the physician, as it demands knowledge, rigor, and humanity in order to design an optimal treatment for a given illness in a given person. It stands in contrast to overemphasis on concepts of mechanical, chemical, and molecular etiologies and psychodynamic, behavioral, and sociological formulations. These ideas inform much of medical practice, but are not equivalent to it.

Nonetheless, etiology is a critical part of the medical model in psychiatry. The formal object of inquiry in medicine is the human body, and thus "psychiatry is a branch of medicine because the biological aspect of it is very important" (⁶¹). However, the importance and mastery of biology in medical-model-based psychiatry are overstated by proponents (⁶⁴) and opponents (²⁷) alike. No branch of medicine has everything figured out biologically. Nor would any branch of medicine be completely served by the perfection of such knowledge.

Disease Model versus Medical Model

Classical ideas about the medical model invoke the elucidation of disease etiology and the subsequent targeting of etiology with ameliorative or curative agents. If medicine is a clinical endeavor, then this scheme is not the medical model. Rather, it represents the scientific endeavor that makes medical practice possible (⁵³, ⁵⁹). We feel it is better distinguished as the disease model, since its goal is to isolate the causes of and remedies for disease processes. Human individuality is an obstacle to this goal. When mistaken for the medical model, the disease model leads physicians to see only disease etiology and corresponding "magic bullets" as germane to effective patient care. It casts physicians in the role of scientists, when actually they are users of science. This error is a major flaw of the psychopharmacologist role. Even when psychotherapeutic, rehabilitative, or other such concerns are addressed by additional providers, remaining patient variables are not isolated for the psychopharmacologist to manipulate.

Drawing a distinction between the disease model and the medical model creates a teaching tool for examination of the psychopharmacologist role: Is an assumption being made about the sufficiency of biological aspects of disease inpatient care? Is this assumption consistent with one’s ideals for the practice of psychiatry and of medicine in general? Does one consider oneself to be a clinical physician or a scientist? Residents and faculty might be encouraged to challenge one another as to the compatibility of their answers with the implications of the psychopharmacologist.

"Real Doctors" versus Good Doctors

Many psychiatrists feel that they are conducting themselves as "real doctors" only when in psychopharmacologist mode. It has been suggested that those who accept such a premise on a personal level might be motivated by desire for acceptance (²⁶, ⁶⁵—⁶⁷) by the broader medical community. An overidentification with the medical role has also been blamed (²⁷, ⁶⁸). Psychiatric residents may be more vulnerable to such attitudes given their proximity to medical school and internship experiences. True or not, these analyses are more productively interpreted based on a view of the medical model that casts psychiatry against the backdrop of the rest of medicine.

However, if the medical model begins with diagnosis, is executed by way of thoughtfully-designed patient care, and is informed scientifically by biology, then this contrast is effaced. Put simply by Leigh (⁶⁹), "psychiatry is medicine" because of shared basic goals, assumptions, and approaches. Psychiatry is defined by the diagnoses it treats rather than by a specific treatment modality (⁶⁹), whether that modality is psychotherapeutic or psychopharmacologic. Likewise, psychiatry enjoys no monopoly on humanism (³³), psychosocial considerations (⁶³), the doctor-patient relationship, or patient empowerment (⁶⁹). It clearly is no longer differentiated by disinterest in biology. A skilled physician dedicates attention to these areas based on the diagnosis and individual needs of the patient. Hence, good psychiatry looks much like any other good doctoring and vice versa. There is nothing "real" about the "real doctor."

Caring in the medical model is a specialized type of human interaction. Under the influence of the disease model, the psychopharmacologist risks forgetting the human aspect of medical care: that every patient is a person. The good doctor takes neither this risk nor that of holism, which forgets the specialized aspect of patient care: that not every person is a patient and that not every aspect of someone’s humanity is relevant to their patienthood. Awareness of these risks allows an open and rigorous attitude toward what needs to happen even during brief appointments. The psychopharmacologist is expected to prescribe at each visit. The psychiatrist informed by the medical model need not. Rather, he or she chooses what patients most need and do not need in their treatment as a whole and at each visit. The options are not confined to medication, to being implemented in a single appointment, or to being formally acted upon by the physician who selects them. Referral to skilled specialists or technicians is the rule in medicine, so long as it is not seen as a free pass on future neglect of the reason for the referral.

In making these decisions based on thoughtful scrutiny of diagnoses, available science, and patient individuality, one utilizes a pluralistic approach to clinical psychiatry. In his argument for pluralism, The Concepts of Psychiatry, Ghaemi (⁹) asks psychiatrists "to forget about trying to justify what they do. I am asking them to think about what they do." If this is a challenge for the psychopharmacologist, is it really any more challenging than having a restricted role in the care of patients suffering from mental illness?

Humility

The complexity of psychiatry demands an appreciation of limitations. The ability to step back and reassess when a mode of understanding or means of intervention is not working requires comfort with fallibility. Most psychopharmacologists likely have a degree of personal humility that is easily adapted to a pluralistic method. More difficult and equally necessary to adopt is scientific humility. In the training arena scientific humility deserves special attention and modeling for novice psychiatrists whose insecurities may prevent them from experiencing comfort with it.

The psychopharmacologist role can encourage overconfidence in the validity of the current diagnostic scheme, in the potency of medications, and in the direct translation from evidence base to clinical practice. Holding a single weapon in the presence of a powerful foe is conducive to such an attitude. Gutheil (⁵²) warns of the allure of medication potency and calls its manifestation "the delusion of precision." Even when the day comes that such precision is no longer a delusion, however, this will not trump the need for other considerations in medical model psychiatry. Physicians will always need respect and enthusiasm for "education for uncertainty" (⁶³). The medical model implies medical authority and the patient is best served by an expert. That same expert must also be humble and humane in an alliance with the patient. The clinical indispensability of this is best captured by Seymour Kety (⁷⁰):

…[T]he average patient is sensitive enough to recognize what the psychiatrist can be expected to know and what he cannot. It is possible that confidence is reinforced when the psychiatrist speaks authoritatively. …When in addition he admits that he, and medical science generally, do not know all of the answers to the causes of the problem, it is even possible that this may strengthen the human bond between them.

Conclusions

In spite of its medical trappings, the psychopharmacologist role runs counter to the use of a medical model in psychiatry and creates serious problems as a result. The solution offered above involves a broader take on what it means to be a physician and boils the medical model down to its simplest components. By considering these points and not taking the psychopharmacologist role to be an elemental property of psychiatry, it is hoped that administrators of psychiatry departments and training programs will be stimulated to rethink current program design and philosophy and begin a new dialogue with their trainees.

Psychiatric research continues to generate an increasingly potent evidence base, but effective psychiatric practice is guided by more than scientific data. A technologist or interventionist, such as the psychopharmacologist, is not equipped to meet this demand. Nor is the psychotherapist for that matter. The psychiatrist is, and, if nothing else, this article is a call for dedication to that identity.

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