My Ambition and Psychiatry

I have recently had to go through a big shift professionally. I had believed there was a reward for working my hardest and striving to be the very best psychiatrist I can be. This fueled me to work long hours, make personal sacrifices and drive myself as hard as I could. I thought the more patients I saw, while providing the highest quality of care I could meant I would be on an upward path in this career. I sought out mentorship to improve my therapy skills and would contribute regularly in case rounds.

Turns out, this is not the case. This may sound hilariously obvious, but there is no such thing as being the best in psychiatry. It is not a competition, we are all just trying to help people the best we know how, while in a mental health crisis, when we are all drowning. This has really changed how I see myself and the work I do.

It is no mystery how I got here. I was told I had to be the best throughout high school to make it to a good university. I was told I had to be the best in university to make it into medical school. Then I was told I had to be the best in medical school to make it into the residency of your choice. Every academic step I have taken has been incentivized with external validation and judgement.
There were certainly experiences throughout that told me that the real world did not work this way, that the real world is not a meritocracy. But because so far, my achievements matched the work I put in, for me, it was.

But the rat race to the top, for the precious few spaces available ended after my residency. I chose not to pursue a fellowship and I chose a relatively non-competitive specialty in medicine. I still believed however that there was some kind of big brother watching, to reward me for the efforts I put in. This big brother was a superior at work. What did I think this person could get me? Even if he did see the work I did, I have no idea. I see now how juvenile I have been in how I saw this career. I thought I would get promoted (whatever this means in psychiatry), given more teaching opportunities, and gain the respect of colleagues.

But again, this is not what happens in mental health care. A reason why I did not appreciate this for a long time, that there is no ladder to climb, no more people to impress, no meaningful accolade worth attaining, is my relationship with my own ambition. I want to be ambitious, but boy did I choose the wrong career for that! And I have the wrong passion for that ambition also. In medicine, ambition, success and influence are mainly in the world of research. Being a good doctor, is just what is expected.

The big shift for me then was to see this field for what it is. When Psychiatry is your calling, it is all about the patient interactions. There is no procedure, lab investigations or imaging used regularly in clinical psychiatry to improve our outcomes. The passion is the patient care. There is no glory here. If you seek glory, you have missed the whole point of the field. The best psychiatrist focuses on the patient, one patient at a time. We do not get graded, we do not get a report card. In fact, there is no way to objectively measure how one psychiatrist may be better than the next. So ambition for external reward in this field does not make sense. But if you believe there should be an external reward of some kind, this can foster, as it did for me for a long time, anger and resentment. It manifests in disdain for patient suffering, a belittling of your colleagues and an off-putting defensiveness. It lead me to shut down and withdraw socially in professional settings and it put me on a constant search for who to blame for my feelings of being unacknowledged (I had the hubris to believe I was the best at one point). "Where were my external rewards!?!" An inner part of me roared. The entitlement in me grew, and I also looked at being a woman and a minority as reasons why I was invisible, which only made me angrier.

As you can probably tell by now, my identity as someone who had ambition in medicine worked against my goals of being a good psychiatrist. I became an angry psychiatrist, a self-absorbed psychiatrist and an impatient psychiatrist. I did not like how my definition of ambition in medicine made me practice psychiatry and how it made me feel.

The idea of a different kind of ambition came to me after a discussion with my friend who was learning a new psychotherapy. She described a patient who responded well to it and I could identify I too had patients like this only I was not getting good results like she was. Up to that point, I had concluded that it was not my issue but the patient's, because I was the best wasn't I? I put in the hours didn't I? Turns out I wasn't the best and what's more, I can not be the best, not for everyone anyway. But the best psychiatrists will not stop improving themselves until they are the best for everyone. This is ultimately an unattainable goal, but a worthy one that only the best take on.

The humility, calm and relief that flooded me after this conversation opened my eyes. I was trained to want external validation. Who isn't? But this is not sustaining or healthy for me. Instead, there is such a thing as internal ambition, and this now drives what I do and how I do it. I will no longer pursue numbers and efficiency in my care, where quality and depth are needed. I will not let the pressure of a waitlist distract me from doing what is the best for the patient in my office. This is what matters, this is what good psychiatry is to me.