Special Note from the Editors: Welcome to our brand-new series written by the 2023 Psych Stars! Chosen by the Royal College of Psychiatrists, Psych Stars are medical students awarded a place in the scheme for their interest and commitment to psychiatry. To celebrate their work and success, we have invited several Psych Stars to write fortnightly articles on their visions for the future of mental health research and care, each choosing an area in which they are especially passionate.
After you read today's article, be sure to check out the excellent collection by the 2020 Psych Stars!
As a medical student, I know that medicine can be full of stereotypes. Orthopaedic surgeons are apparently all "gym bros" like Todd from the TV show Scrubs. Neurosurgeons supposedly all have type A personalities with egos to match, and pathologists allegedly reclusive introverts. One of my favourite videos is "Med Student’s First Day" by Dr Glaucomflecken. In these videos, a medical student experiences first-hand stereotyped caricatures of different specialities, such as a gym-loving orthopaedic surgeon or an exhausted overrun family doctor. Upon meeting the resident psychiatrist, the medical student is asked, "Do you have any tweed? Corduroy? Anything with elbow patches?".
Although I do enjoy self-deprecating humour, I couldn’t help but notice that psychiatrists seem to be stereotyped in a negative light. In 2018, the Cambridge Medical Journal published a study which looked at the speciality stereotypes held by students. In this study, students were asked to describe various specialities using single adjectives. The description of psychiatrists by students in this study included: talkative, crazy, mad, detached, woolly, odd, unhinged, nosy, and hairy.
These stereotypes aren’t a new phenomenon. In an older study from 1986, students described psychiatrists as "fuzzy thinkers", and as doctors who "talked a lot but did little". Quite interestingly, psychiatry as a speciality was described as having the lowest status in medicine, with psychiatric treatment being "basically fraudulent" and psychiatry being a "waste of medical education" and "the least important area of medicine". I mean — OUCH!! This is coming from aspiring doctors, yet to choose their field. This had me thinking about my own introduction to psychiatry & psychiatrists.
'Sex-Obsessed Trickcyclists'
My introduction to psychiatry was watching the TV show Fawlty Towers with my parents as a child. In one episode, Basil (the proprietor of the hotel) becomes anxious when he discovers that a pair of psychiatrists are amongst the guests. He believes that psychiatrists are obsessed with the sexual activities of others and instructs his wife to avoid talking to them at all costs. Due to his paranoia that his behaviour will be critiqued and judged, he exhibits increasingly bizarre behaviours including imitating a primate, wrapping his blazer around his head, and jumping like a frog.
Why did the mere presence of psychiatrists cause Basil to have a complete breakdown?
My "real life" introduction to psychiatrists was through the whisperings of my father. I heard him refer to someone we had just met as a "trickcyclist" (unbeknownst to me, an archaic slang term for psychiatrist) in a hushed tone so as not to be overheard. I very much got the impression that I shouldn’t interact with this person. There was a paranoid stigma — almost a fear.
Many years later when I told my father of my ambition to specialise in psychiatry, I could see that he looked uncomfortable and quite perturbed. I got the feeling that he thought it was a bizarre choice of career. I wouldn’t say that I have received disapproval for my choice, but I am certain that if I championed myself as a future ophthalmologist, cardiologist, or neurosurgeon, he would have responded with far more enthusiasm.
I had to question, what on earth is going on? Psychiatrists are doctors. They practice evidence-based medicine.
Do we have history to blame?
The origin of psychiatry in the UK can be traced back to the mid-14th century, when Bethlem Hospital in London was used to house patients with "mente capti" (latin for "caught in the mind"). In fact, it is this bastardisation of the hospital name that led to the word Bedlam entering the English language to refer to uproar, chaos, or confusion. Despite the lack of understanding of psychiatric conditions, let alone treatment, the hospital became a specialist asylum by the end of the century.
By the late 16th century, Bethlem Hospital had relocated to a purpose-built facility in Moorfields, and to raise hospital funds, public visitation was encouraged. In other words, much like we would pay admission to visit animals in a zoo, the gentry of the time could pay admission to observe the unusual behaviours of the patients. Unfortunately, by the 18th century, an entire trade had been established with public "lunatic asylums" springing up all over the UK. It was not until the Lunacy Act of 1845 that the psychiatrically ill were recognised as patients requiring treatment. This act was revised in 1890 in response to wrongful confinements and profiteering from private asylums which resulted in a psychiatry crisis in the UK.
As we move into the 20th century, despite early recognition and categorisation of psychiatric diseases, treatments were still in their infancy. Electroconvulsive therapy was introduced in the 1940s to treat schizophrenia and depression, whilst lobotomy was championed as a successful psychosurgical method (even securing a Nobel Prize for its’ pioneer).
Talk about a chequered history! For centuries, psychiatry was essentially turned into a circus with the mentally ill imprisoned for the entertainment of others, with the earliest attempts at treatment consisting of electrocution and removing part of a patient’s brain. This is an oversimplification, but that is some reputation to overcome.
Mind Reading and "Not Really Doctors"
I recently found myself reading an interesting article published in the BMJ discussing misunderstandings of the psychiatrist's role. In this short article, two statistics jumped out at me: first, 47% of patients reported they would be uncomfortable sitting next to a psychiatrist at a party, and second, 60% believed that psychiatrists could effectively read minds. In 2008 Professor Rob Howard (then RCPsych Dean) is quoted as saying "Lots of other doctors don’t think that we’re real doctors". Most interestingly, in his 1987 RCPsych Presidential Lecture, Dr Thomas Bewley discussed the public perception of psychiatrists and acknowledged that only 50% of patients believed psychiatrists to be medically trained, and 75% thought that hypnotists were psychiatrists.
So What Now?
Given what I have discussed above, it would be easy for there to be despondency in changing the perception of an entire profession with a less-than-stellar history. However, in the 21st century, there have been some promising signs that psychiatry is shedding the stigma and rising in status.
In 2015, the European Psychiatric Association published guidance on how to improve the perception of psychiatry and psychiatrists. This guidance included celebrating evidence-based research and clinical successes and improving engagement with policymakers, medical students, and the general public.
A meta-analysis published in 2017 concluded that "there is no indication that psychiatry as a medical discipline is stigmatised." and highlighted that the public readiness to seek help from a psychiatrist has increased over the past 25 years. Within the profession, we have seen the number of applicants for Core Psychiatry Training increase from 754 in 2018 to 2610 in 2023.
From my experience as a medical student, psychiatry has lost its stigma massively and we have received excellent exposure to clinical teaching and learning opportunities in this speciality. From a personal perspective, I have thoroughly enjoyed being involved with the RCPsych Psych Star scheme through which I have met talented and driven medical students with a shared passion for psychiatry. I am optimistic that over the course of our careers that psychiatry can shed the stigma, move past its history and be universally respected as a highly skilled evidence field equalling that of any other speciality.
