I was a medical student in Manhattan in the late 1980s. From the beginning, I knew I wanted to go into psychiatry, and I watched the psychoanalysts and psychopharmacologists chase each other back and forth across town from institution to institution, debating questions of nature vs. nurture for the both the cause and cure of mental disorders.
When I moved to Baltimore to begin my psychiatry residency at Johns Hopkins Hospital, I was introduced to a way of thinking about human behavior and emotions that involved considering the individual from four different perspectives as described by our chairman, Dr. Paul McHugh, and our residency director, Dr. Phillip Slavney, in their book, The Perspectives of Psychiatry. At the time, this approach seemed almost obvious to me; of course the causes of psychopathology were multifactorial; how could they not be?
Fast-forward two decades and what seemed obvious to a newly minted psychiatry resident no longer feels quiet so evident. We’ve become a field of diagnosis by checklist and rapid-fire appointments to ask about symptoms and side effects. In fact, most psychiatric care is rendered by primary care physicians with little formal training in psychiatric diagnosis. Twenty years later, and it seems we’ve lost our curiosity (“no time”) and with that, the inclination to learn about a patient’s difficulties in the context of not only a disease, but also by giving consideration to their motivated behaviors, their individual temperaments, and their complete life stories.
So on our current landscape of checklist diagnosis and the full-court press by insurers to reimburse psychiatrists best for brief visits, it is refreshing to read Systematic Psychiatric Evaluation, A Step-by-Step Guide to Applying The Perspectives of Psychiatry, by two of my residency classmates, Dr. Margaret S. Chisolm and Dr. Constantine G. Lyketsos, M.H.S. Nothing about this book is about learning to diagnose in Chinese menu format, or about rushed appointments with patients; instead it is about how to do thoughtful and caring evaluations (including, but not limited to, diagnoses) of patients with emotional and/or behavioral turmoil.
The authors begin with a hint of humor – probably best understood by those of us who live in Charm City – by presenting the historical case history of Baltimore poet Edgar Allen Poe, done first as a typical psychiatric presentation, and then as a full case study per the four perspectives. They go on to present a series of patient case histories, beginning with reconstructed interviews, an analysis that integrates a multifactorial approach to understanding the problems, a conclusion, and summary points.
One of the treasures of this book is that the back-and-forth dialogue of the interviews is included, illustrating to students exactly which words an experienced clinician might use to elicit specific material, and giving the reader the sense of being in the room during the interview. The wording is designed to convey empathy, warmth, and to put the patient at ease. And while the case studies are comprehensive, the book is done as an engaging, concise, and quick read.
Whether or not psychiatrists choose to practice in time-pressured environments, teaching institutions need to remain a place where our students learn to evaluate patients in a systematic and comprehensive manner and, in psychiatry, this is not a quick process and it does not involve cutting corners or boiling the complex work of psychiatric evaluations down to checklists.
Systematic Psychiatric Evaluation is the best go-to book I have seen for teaching thoughtful evaluation.
Please also see Dr. Chisolm’s guest post about her book on the main Shrink Rap blog here.
—Dinah Miller, M.D.
Dr. Miller’s books and novels are listed here.