Committed: Dispatches from a Psychiatrist in Training

More than 2 yr have passed since I initially read Committed: Dispatches from a Psychiatrist in Training by Adam Stern, M.D. During that time, my admiration for this genuine, compassionate, and illuminating book has only intensified as I reflected on the author's message and his brilliant delivery describing his many profound encounters with his patients, his colleagues, and his own self-doubt. Dr. Stern has movingly captured his journey from insecure neophyte resident physician to seasoned psychiatrist with a talent for communicating and caring.The book commences in 2006, when 15 young medical school graduates embarking on psychiatry residency nervously convened on the Longwood Avenue campus of Harvard Medical School (Boston, Massachusetts) to meet one another. Dr. Stern found the gravitas of the Harvard quad to be especially intimidating, wondering whether he, an alumnus of a public medical school in upper New York State, really belonged in this coterie of young physicians who graduated from more "elite" and "prestigious" medical schools. Soon, however, the cadre tightly bonded and subscribed to the mantra, "Never worry alone." With humor and grace, Dr. Stern describes the group's growing pains as they slowly progressed from having "no idea what I was doing" to competently managing such challenging conditions as anorexia nervosa, schizophrenia, and manic depression. While honing their empathic listening skills, they also learned to skillfully implement interventions as varied as cognitive behavioral therapy and psychoanalysis. Their progress, however, was not linear. Nonetheless, with the support and encouragement of faculty and peers, combined with their individual stamina and grit, they emerged from setbacks and episodes of gnawing insecurity as committed and sentient young psychiatrists with an enduring respect for the importance of human connection.Although I enjoyed all the chapters (including those that described the author's dating fiascos), I found the episodes highlighting depression to have special resonance.Dr. Stern was careful to underscore that people often misunderstand depression as a kind of intense sadness, while more commonly patients describe a debilitating numbness or unbearable absence of feeling. Although the majority of patients with major depression respond to antidepressant medications, 10 to 30% do not improve or show a partial response coupled with functional impairment. Patients with a poor response to two adequate (optimal dosage and duration) trials of two different classes of antidepressants are considered to have treatment-resistant depression and are often given somatic therapy.I must confess that, during my anesthesiology residency in Boston, one of my least favorite assignments was to administer anesthesia for electroconvulsive therapy to patients at a satellite branch of the renowned McLean Hospital (Belmont, Massachusetts). No doubt my aversion was exacerbated by the fact that this task was the duty of an exhausted, unsupervised postcall resident who, after a (mostly) sleepless night, was required to shuffle across the street from Brigham and Women's Hospital (Boston, Massachusetts) to the satellite facility and participate in the electroconvulsive therapy ritual. I did not enjoy watching listless patients convulse. In fact, from my biased and uninformed perspective, I considered the practice primitive and barbaric, failing to observe perceptible improvement after many of the patients had experienced multiple episodes of electroconvulsive therapy. Hence, I was gratified to learn that, although we don't know exactly how electroconvulsive therapy works, we do know that it does work. (Concepts invoking neurogenesis, brain plasticity, and rapid global neurotransmitter release are often cited, without definitive confirmation.) Dr. Stern informs us that 70 to 80% of patients with refractory mood disorders respond to electroconvulsive therapy. Although electroconvulsive therapy patients may be unable to encode new memories for a while after treatment, that complication eventually subsides. More than 80 yr have elapsed since the introduction of electroconvulsive therapy, and newer treatment modalities, such as transcranial magnetic stimulation, are now available. Transcranial magnetic stimulation, which was approved by the Food and Drug Administration (Silver Spring, Maryland) almost a decade ago, has the advantage of targeting more discrete areas of the brain.Another situation discussed by Dr. Stern is imposter syndrome, a concept that also has special resonance for medical trainees, including those in our specialty. Imposter syndrome, also known as imposter phenomenon, is a psychologic condition wherein people question their skills, abilities, or accomplishments. Those afflicted have a chronic internalized fear of being exposed as frauds despite external, validating evidence of their competence. The syndrome is not considered a formal mental disorder, although the condition may respond to psychologic intervention. Dr. Stern experienced this phenomenon early in his training, questioning whether he had the right stuff to fit into the Harvard mystique. Shortly before graduation from his residency program, these doubts re-emerged, and he sought advice from his psychotherapist, who reassured him that this syndrome is extremely common among highly competent professionals. Indeed, it is almost a rite of passage on our journey to become a more self-actualized version of ourselves. Interestingly, when imposter syndrome was initially conceptualized, it was thought to be a phenomenon that was especially common among high-achieving women. Further study, however, has demonstrated that the condition affects men and women about equally.I have often thought that being a psychiatrist requires a special kind of person. Psychiatry was my first clinical rotation in medical school, and I quickly realized that I did not have the requisite patience or temperament to be an effective psychiatrist. I liked to see almost immediate and quantifiable results, to be in control (as much as possible) of situations, and to use my hands to perform procedures rather than indulge in seemingly interminable conversations. In my callowness and arrogance, I condescendingly viewed psychiatry as a pseudoscientific endeavor that lacked the precision and rationality of physiology and pharmacology. Psychiatrists work from the perspective of a bio-psycho-social model that takes into account patients' brains, minds, and lives. Meeting these exigencies is a very tall, if not daunting, order for those of us who are more procedurally oriented. It has taken some time, but my more mature self has nothing but admiration for the difficult and vital services that psychiatrists provide.When Dr. Stern finishes his narrative, the year is 2010. Anticipating a bright and fulfilling future, Adam is about to graduate from his residency program and is engaged to Rachel, an insightful, beautiful, and elegant colleague. We learn in the supplemental pages, however, that 3 yr after graduation, a beloved member of their residency cohort ended her own life. Further tragedy was revealed in the acknowledgments, when Dr. Stern writes, "Infinite gratitude also goes to the medical team that has kept me alive and well long enough to write this book and, more important, to reach for ever higher spoils in this life" (p. 302). I was stunned to read these words and, after an extensive internet search, I learned that the author was diagnosed with stage 3 kidney cancer in 2018.1 (His book was published in 2021.) After surgery and chemotherapy, he returned to work, with an uncertain prognosis. He went on to become Director of Psychiatry at the Berenson-Allen Center for Noninvasive Brain Stimulation at Beth Israel Deaconess Medical Center (Boston, Massachusetts) from 2014 to 2023, as well as an Assistant Professor of Psychiatry at Harvard Medical School. The father of two young boys, Dr. Stern remains alive as of this writing.I highly recommend Committed: Dispatches from a Psychiatrist in Training to a wide audience, but especially to those interested in understanding the redoubtable challenges that confront residents in training. Medical students, postgraduate trainees, and faculty should particularly benefit from the wisdom conveyed in its pages.