Dr. Sarah Whitman is a Board Certified Psychiatrist in practice for 19 years in Pennsylvania. In her private practice, she works primarily with patients with chronic pain. She has published articles in both the academic and lay literature about chronic pain. She also is founder and writer at her website and blog, How to Cope with Pain (www.HowToCopeWithPain.org). As well, Dr. Whitman teaches psychiatry residents and is the psychiatrist at a local university. Her current interests include spirituality and pain, and the use of mindfulness for pain.
Why did you pursue a career in psychiatry?
When I entered medical school, I really knew nothing about psychiatry. I had taken psychology courses in college, but didn’t know about psychiatry as a field.
In the 3rd year of medical school, my psychiatry rotation was seeing patients who were on the medical units of the hospital about whom the staff had some psychiatric concerns or questions. For example, if someone had just been diagnosed with cancer and didn’t seem to handle that well. Or a patient was in the ICU and seemed to be out of it – what was going on. So these were people just like you and me who were having psychological problems while in the hospital. That intersection of psychiatry and medicine seemed really interesting to me. It also allowed me to continue to use my medical knowledge.
Another clue that psychiatry was right for me was that on all rotations in medical school, I found the medical specialties interesting – for example, I got a kick out of doing surgery and suturing – but what intrigued me the most was how patients were doing with their medical problems. What did it mean to the 70 year old man who had just had a heart attack? How was the young woman who just had an abortion handling that complicated issue. I really enjoyed sitting and talking with patients about their medical situations, and the meaning of their diseases in their lives. Psychiatry is a specialty that you can talk at length with patients, help them learn to cope with adversity in their lives, and help them focus on what’s most important to them in their lives. It’s one of the few specialties that you get to know your patients at a deep, personal level, and truly have the time to work with them. That appealed to me.
Another field that I found fascinating was ICU medicine – where the patients with the most serious illnesses are, and the problems are the most complex. That quick, complicated problem-solving was intellectually appealing. However, that work has an incredibly high stress level that goes with it. There are life and death decisions each hour. I thought over the long haul that degree of ongoing stress didn’t match my personality.
I’ve told medical students who aren’t sure what field of medicine they want to go into to look at what field seems endlessly fascinating to them. What do they want to learn more and more about? In what field do even the common problems seem interesting? For me, that was psychiatry.
Within psychiatry you’ve focused on chronic pain. What interests you about this area in particular?
I had a personal experience with chronic pain which initially got me interested in the field. As a medical field, it’s complex, which appeals to my intellectual curiosity. We’re also at a point where we’re understanding more and more about pain, so the field is dynamic. Pain medicine is on that intersection of psychiatry and medicine, in which I can use both my medical knowledge as well as my psychiatric skills.
In terms of patient interaction, these are patients who are facing significant crises and for whom you can make a true difference. Patients with chronic pain face often face high levels of pain 24/7. This is not something that most people go through, and it’s very, very difficult – think about having, for example, your worst headache, but that pain never going away. These patients also often experience drastic life changes – loss of their job, family or relationship problems, inability to do favorite activities or hobbies, etc. So it’s not just the pain they must learn to cope with, but handling life changes as well.
How do you think you’ve helped people with chronic pain?
In working with patients with chronic pain, I focus both on the pain itself as well as the consequences of having a pain disorder.
For the pain, I look at skills they can learn to decrease and cope with pain. Such techniques as breathing, relaxation exercises, visualization and guided imagery, sometimes hypnosis, can help. Medication can help with pain as well. One phrase I use is how can they live as full a life as possible, despite chronic pain. They sometimes can continue to do things they enjoy, but many times have to find new things in life that appeal to them.
The other area I work with patients is in is the rest of their lives, what’s not working anymore because of changes brought about by pain. For example, do they feel distant from their kids because of not being able play basketball with them anymore. What can we do about that? How can they discuss the situation with their family? Could they still go out to the basketball court and cheer? Can they do another activity as a family instead?
What excites you about practicing psychiatry?
Two main things make me love pain medicine. The first is helping patients in what can be the most challenging situation in their lives. That’s rewarding when you can make a gigantic difference in someone’s quality of life. The second is the challenge of figuring out what’s wrong and what can be done to help. Both from a psychological perspective as well as understanding the medical disease from a medical perspective.
What frustrates you about practicing psychiatry?
Not much, in the type of work I do and the type of practice I have. General psychiatry has many more problems. Poor insurance coverage. Many clinics where psychiatrists work make doctors see too many patients, for not enough time, and not frequently enough. Psychiatry education is sometimes too focused on medication management, rather than therapy, which is a great loss for both doctors and patients.
I assume you’ve worked with patients who do not think you’re making a difference. How do you think about this sort of situation?
I would look at such a situation from several viewpoints. First, if I agreed that things weren’t improving, I’d review to see if I missed something. Had I missed a part of the diagnosis, or picked a wrong treatment? Was there a medical reason for symptoms rather than the patient having a psychiatric disorder? Sometimes, too, a doctor and patient just don’t click for whatever reason. I might suggest a second opinion, to get someone else’s take on the situation or use someone else’s expertise, or even refer a patient to a colleague.
There are some times patients may contribute to not improving, such as if they don’t take medication as prescribed, or not at all, or if they’re not practicing exercises and skills that have been taught in session. One complicated scenario that I occasionally see when working with patients with pain is when there’s a legal case. A patient may feel caught between 2 goals – one, to get better, but the other, to continue to have symptoms so their legal case is stronger. Another scenario is if I think there has been improvement, but the patient feels otherwise. Then I would look at our expectations, or if there are personality factors that make a patient overally critical or prone to sabotage treatment. In any of these cases, I don’t just say, “gee, it’s your fault.” But I try to understand why a patient may be in his/her own way, and then figure out what I can do to move things forward.
When things don’t work out, I always try to learn from these situations and to improve my knowledge and medical care. But no one can expect to be right for 100% of patients, or to be an expert in every disease and each treatment. Humility is important in medicine – being comfortable with what you don’t know and willing to ask questions and make use of your colleagues’ expertises.
What characteristics do you believe would help people succeed in doing psychiatry?
Psychiatrists need to have a genuine interest in other people, their stories, and their problems. To really enjoy the work, they need to like getting to know people and have great listening skills. You have to be empathic, but not feel overwhelmed by the serious problems of others. Having patience, warmth, and a optimistic outlook help a lot too.
I would imagine that it can be a challenge at times not to be overwhelmed by the problems of others. Are there any techniques or skills you’ve learned to use in these sorts of situations?
That’s one of the most common comments I hear about being a psychiatrist, “I could never do that. I’d feel too bad, and get overwhelmed by the problems of others.” (The other being, “I better be careful what I say, because you’re probably analyzing me right now.”
Being able to listen to others, but not get overwhelmed, is probably partly temperament. Having good boundaries, as we say, is crucial – being able to listen, but not take on the weight of our patients’ issues. I think of the difference between sympathy and empathy. Sympathy is feeling sorry for others, feeling their feelings. Empathy is understanding their feelings, but not taking them on.
Doctors in general learn to distance themselves from the pain and trauma of medicine, disease and death, to be able to continue to function and provide care when others might be overwhelmed. A really interesting study recently came out about physicians and mirror neurons, those parts of our brains that can watch others do something, and respond as if we’ve done it ourselves. The mirror neurons of doctors respond much less dramatically when viewing physical injury in others, compared to non-physicians. So our ability to non get overwhelmed becomes hard wired.
There are times, of course, that what a patient is going through is too close to what the doctor is dealing with herself. In those cases, you would know that you can’t function optimally as a doctor, and you would refer a patient to someone else. But those very experiences can, after some time and healing, make us even better doctors, when we use difficult experiences of our own to help us understand what are patients are going through and be more empathic.
I understand that you’re on the academic faculty in Psychiatry at Drexel University College of Medicine, and that you supervise residents. Can you tell us a little about your teaching experience.
When I started in academic psychiatry, about 75% of my time was spent supervising psychiatry residents (who have completed medical school, then started their specialized training in psychiatry). Now I supervise a couple of students each year. When you like your career, it’s enjoyable to share your knowledge with others who are learning the field. I supervise 3rd and 4th year residents (psychiatry is 4 years of specialized training), so they already have a good base of knowledge. I teach outpatient psychiatry, both psychotherapy as well as medication treatment.
To be a good teacher, you obviously have to know thoroughly the content of what you’re teaching. I think you also have to teach well, that is, help students learn the material in different ways, get them to figure things out themselves rather than just telling them everything, and to impart the spark you have for the subject. For residents, I try to help them learn the knowledge base they need for psychiatry, for example, how to diagnose and treat psychiatric disorders such as depression and anxiety. Just as important is helping them fine-tune their ability to be a good doctor – to listen really well, express care for each patient, be present with each patient, and enjoy their profession.
I like being creative in how I teach. At one point, I used the HBO show The Sopranos to discuss psychotherapy. As many will know, this was a great dramatic series about a NJ mafia family, and the main character Tony saw a psychiatrist. We would watch parts of the show, discuss Tony’s diagnosis and treatment, and figure out what we would do the same and differently if Tony were to come to see us.
I also taught medical students about psychiatry. I enjoyed this because, although most medical students don’t go into psychiatry as a specialty, I felt I could teach them 2 important things. The first was to be interested in the psychological issues their patients would have, and that they needed to do this to be good doctors. It’s not enough to medically treat Mr. Jones’ cancer. You have to address how he and his family are coping too. The second was the doctor-patient relationship part of being a good doctor. All those things I mentioned above as important for psychiatry residents – to listen really well, express care for each patient, and be present with each patient – are crucial in all fields. These are important for all doctors to learn and practice.
What specific topic do you enjoy teaching the most?
I love teaching about pain medicine, as it’s complex and our knowledge is growing fast. It’s also commonly misunderstood, so sharing knowledge in this area can really help patient care. I also enjoy teaching both psychiatry students and others in medicine about improving their relationships with their patients.