Perhaps it's not one of those questions that most parents will have to confront, unlike say, those about Santa, sex, or death, but it seems like a reasonable way to start this discussion, especially in light of nine-year-old Molly's precious Tuesday post about the mysteries of puberty. So as the token psychiatrist on this blog, just a few months away from completing my psychiatry training, I feel qualified to ask and answer that mysterious question: How do psychiatrists become psychiatrists? I'm glad you've wondered.

The straightforward answer is that after four years of medical school, a doctor enters a four-year psychiatry residency program. Residency programs are essentially apprenticeships. You learn by doing. The first year of any residency program is called the intern year. That year is the most demanding by far. It is a year spent doing primarily medical and neurology rotations. The second year is when the budding psychiatrist finally gets immersed in treating mental illness—12 months of inpatient rotations—treating the sickest of the mentally ill. “Inpatient” refers to the hospitalized patient. These are the suicidal patients, those with psychosis (whether schizophenic, bipolar, or psychotically depressed), or those who have stopped caring for themselves. These are exciting months. The severity of illness is shocking and the stories you hear are the best of your residency. The 3^rd and 4^th year are typically spent in the outpatient setting, usually in Medicaid clinics, where the patients are much less sick, but struggle with serious financial and social burdens.

The point of the first two years of residency is to learn how to quickly diagnose mental illness according to the DSM (the Diagnostic and Statistical Manual of Psychiatric Disorders), which is the psychiatrist's Bible—a rather controversial Bible, but still the text accepted in court rooms and by insurance companies as the descriptive authority on all mental illness. A review of the forty year DSM controversy was recently well-analyzed in the New Yorker, for those who care to know more.

Additionally those first two years are meant to train a psychiatrist in the pharmacotherapy of treating mental illness. There are almost 300 medications used in psychiatry (from the oldest, Lithium, to the newest, Cymbalta). Many meds have fallen out of routine use, but all FDA approved psychiatric medications are fair game for the Psychiatry boards that one takes after completing residency. Still, learning medications (and DSM diagnosis) is something that med school students could master in a few months.

The last two years of residency are, broadly speaking, designed to learn a variety of psychotherapeutic techniques. This is the part of residency that draws on more than memorization skills. It is difficult to learn psychotherapy by watching someone do it or reading about it in a book. It is a skill learned as you stumble through it. You say the wrong things or miss the opportunity to say the right thing. Sometimes you hurt patients. To some degree all medical training is a skill learned at a patient's expense. Atul Gawande has written eloquently (again in the New Yorker's “Annals of Medicine”) about this dilemma inherent in the training of all physicians.

So that's the rough overview of a psychiatrist's training. But who are these folks who go into psychiatry?

Psychiatrists were once stereotypically white Jewish men. And they were the small minority of their med school graduating class. That part is still true, the percentage of U.S. med school grads choosing a specialty in psychiatry has declined slowly to a current 4.8% or 653 U.S. med school grads in 2005. At the same time, the number of residency positions has grown steadily (from 2000 to 2005, the number of positions grew from 933 to 1026). This means that only about two-thirds of the residency positions are filled by U.S. Grads, and the remaining third are filled by FMGs (Foreign Medical Grads). These are most commonly Indian, Asian, Eastern European, or Arabic. FMGs are the new face of psychiatry—and, the new accent of psychiatry.

Interestingly, FMGs are often more experienced and intelligent than their U.S. counterparts (they have often already completed whole residencies and have fantastically high USMLE board scores); however, the presence of FMGs is also code for a less prestigious residency program. Of the five residency programs in Philadelphia, only Penn and Jefferson do not have FMGs. During my interviews for residency programs the class system of residencies became quite clear. The psychiatry interview circuit is an obviously marked trail for U.S. med school grads.

But that's all so boring. What I haven't said yet is that there are crazy people going into psychiatry. Seriously. In my graduating class, there are seven residents. I would say two of them are pretty wounded. And two others are sane, but I would only relectantly refer a patient to them. Pretty sad statistics. I mean, I think all of my classmates learned how to be psychiatrists, they know how to use the DSM, prescribe meds, and do basic psychotherapy, but they have deficient interpersonal skills and they are unmistakably odd people. And worst of all, only one of them has a therapist. That is the tragedy. I think perhaps the most important thing in training to become a good psychiatrist is engaging personally in the process of therapy. I am actively involved in the therapeutic process of understanding my own maladaptive patterns of thought and behavior. That process ideally means that I will understand the other side of therapy, that I will be a more experienced and empathic psychiatrist.

Now, with all that said about the process of becoming a psychiatrist, I can go forward with the more interesting issues in psychiatry, the question on everyone's mind: what kind of crazy shit do you see out there?

Stay tuned.