Facing the Unseen

March 1, 2024
Psychiatrist Tweedy (Black Man in a White Coat, 2015) writes tenderly about transformative experiences during his medical education and clinical practice. Weaving stories of patient encounters into his discussion, he explains the differences and ""disconnect"" between psychiatry and other medical specialties. ""Our work is intangible as we navigate the world of troubled feelings, thoughts, and behaviors rather than tangible physical functions,"" Tweedy affirms. Professional burnout, emotional detachment, race relations, dilemmas in diagnosis, perilous preconceptions, overprescribing of psychiatric medications, and involuntary psychiatric hospitalizations are addressed. Featured patient vignettes include a young man having his lower leg amputated, a woman presenting with psychosis due to previously undiagnosed lupus, and a grandfather intent on shooting himself. Tweedy's voice resonates most when he reflects on emotional health, his own and that of his patients. Despite the prevalence of anxiety, depression, PTSD, dementia, and substance abuse, mental health problems continue to be stigmatized and marginalized. Access to treatment remains a major issue. Tweedy offers a moving reminder that no individual is merely ordinary and calls for more available and comprehensive mental health care.

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March 18, 2024
“When a system marginalizes mental health... patients pay the price,” according to this ardent call for change. Tweedy (Black Man in a White Coat) draws on his career as a physician and psychiatrist to examine how the medical system fails people with mental illness. The trouble starts in medical school, he contends, recounting how he completed his psychiatric rotation at an inpatient ward that was miles from the nearest hospital and staffed by doctors who resented their patients, creating the impression that psychiatry fundamentally differs from other medical fields. Illuminating the complex ways that physical and mental health intersect, Tweedy discusses how a bifurcated health system hampered his attempts to treat a veteran whose opioid addiction stemmed from a need to quell persistent knee pain. To integrate care, Tweedy recommends providing mental health services in the same setting as primary care, which might take the form of a psychiatric evaluation immediately following an annual checkup within the same facility. As proof of concept, Tweedy describes how he helped a suicidal man brought to him after an annual primary care appointment the patient had intended to be his last. The personal anecdotes will help readers understand the view from the doctor’s chair, and the argument for a “collaborative care” model convinces. It’s an edifying proposal for overhauling psychiatric treatment.

April 1, 2024
A psychiatrist's life in the medical trenches, attempting to bring the study of the mind to general practice. "Psychiatrists...are on the margins," writes Tweedy, author of Black Man in a White Coat. Much of medicine is quantifiable, but psychiatry is situated "primarily in the descriptive realm anchored in clinical experience and research." This subjective element has pushed the practice to the edges, with the result, writes the author, that patients with mental health issues, substance use disorders, and the like are often hard-pressed to find adequate treatment: "When a system marginalizes mental health, defining it as something alien and less important than physical health, patients pay the price." Patients sometimes do so willingly, refusing to take insulin to treat diabetes, thinking about suicide, and the like; Tweedy's narrative is punctuated by anecdotes telling as much. More often, however, the problem is systemic: Although all doctors learn about depression, anxiety disorders, substance abuse (or misuse, in Tweedy's formulation), their education is shallow. The result is that "patients bring to their primary care providers and other medical specialists every form of overlapping mental and physical distress, and these doctors too often don't recognize the mental health issues or don't know how to begin treating them." Fortunately, writes the author, a doctrinal shift is building, with doctors and patients alike increasingly inclined to examine mental health issues. That, in turn, comes at some emotional cost to doctors, already overburdened in a deeply flawed system of health care delivery. Tweedy is no exception; as he writes, "Becoming a doctor hadn't made me better at dealing with sickness and death; if anything, the lessons from medical school, internship year, and early psychiatry training framed them as things to fear." A charged, earnest argument for relaxing the distinction between body and mind in the treatment of both.

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