An Interview with Awais Aftab, M.D of Psychiatry at the Margins
A collaboration, right here on Substack.
The Frontier Psychiatrists started as a room on Clubhouse with Carlene MacMillan, M.D…. It has turned into this newsletter written by Owen Muir, M.D. I love writing here on Substack because I get to connect with people likewho writes . He’s an interview I did with him. More collaborations to come, perhaps?
1. Owen: Why are you a psychiatrist?
Aftab: I’m a psychiatrist because I am intellectually fascinated by psychopathology and I want to improve the lives of people who are experiencing mental health problems. I realized pretty quickly in medical school that given my interests in psychology and philosophy, and given my particular temperament, psychiatry was really the only specialty that spoke to me. I grew up in Pakistan and attended medical school there, and due to the intense stigma that existed around psychiatry as a specialty at that time, I toyed with the idea of going into neurology or radiology, but ultimately, I realized that I won’t be happy doing anything else, and also that if people like me give into thestigma, then we cannot hope for things to change. In retrospect, I’m very glad that I made that choice. I think I would’ve left medicine if I weren’t a psychiatrist. In the US, it's wonderful to see that psychiatry as medical field has become so much more attractive and desirable for medical students, and the proportion of US medical students applying to psychiatry keeps going up. Before I started medical school, I wanted to go into philosophy as an academic. I consider myself lucky that I can still pursue my philosophical interests (thanks to the blooming philosophy of psychiatry community). This might just be a rationalization, but I am glad that I became a psychiatrist instead of a philosopher because I think clinical work keeps you grounded in a way that working with abstract ideas doesn’t.
2. Owen: What do you wish patients could know about you without having to tell them?
Aftab: I don’t really wish patients could know anything about me particularly. I hope that they see me as an empathetic, compassionate, competent clinician, but that’s also something that I hope is demonstrated during clinical interactions. I do wish more patients knew about the constraints under which most psychiatrists are working, the constraints regarding time, and documentation, and billing, and hospital policies. And I wish more patients understood that there is tremendous pressure on psychiatrists to be overly conservative and to minimize legal liability in ways that sometimes conflicts with providing good clinical care.
3. Owen: What do you hate about being a doctor?
Aftab: I don’t like the moral injury part of it. I don’t like how the systems just expect us to go along with it. The more you work with the most vulnerable members of our societies, the more moral injury you experience. It’s corrosive, and it gets to a point where you either break or you become this strange, calloused-up creature that you never imagined you’d become when training as a doctor.
4. Owen: Have patients stalked you?
Aftab: I fortunately have not been stalked. I have been threatened. People have swung at me or tried to attack me, unsuccessfully. I know colleagues who have been less fortunate.
5. Owen: You do know some of those colleagues, it’s true! Next Question… Keeping these punchy! How much research do you feel is pointless?
Aftab: A lot of it does feel pointless, doesn’t it. Too much of it is pointless. This may partly be because people who are designing and conducting these studies don’t have enough contact with the complexities of the clinical world. A study should meaningfully inform clinical decision-making, but a lot of research is not optimized to do that. It is chasing some other outcome, like trying to get a significant p-value so that your drug would get FDA approval. There is also this trend of doing more and more systematic reviews. I’d take a large well-designed, well-conducted clinical trial over a systematic review of a dozen, small studies any day.
6. Owen: What are the most useful books that aren't about the field that you find helpful?
Aftab: I absolutely love The Fabric of Reality and The Beginning of Infinity by the physicist David Deutsch. The books are not perfect by any means, and academics, especially philosophers, would find a lot to object to or disagree with. But Deutsch changed the way I think about the nature of knowledge and the nature of reality. The books left a huge impression on me. And they provided me with a useful set of tools to tackle questions about the nature of psychopathology and the nature of psychiatric knowledge.
I also really liked Peter Salmon’s biography of the philosopher Jacques Derrida, An Event, Perhaps. Meaning, knowledge, language… they are all vulnerable and fallible in a manner that we don’t usually appreciate.
7. Owen: How do you keep building a skill set to be better?
Aftab: When psychiatric work is approached with curiosity and inquisitiveness, it is a very humbling experience. We know so little, we are just scratching the surface. The more I search and the more I study, the more I keep discovering new things to learn and new skills to acquire. What happens is that at some point, and this point is different for everyone, we become complacent, and we find our comfort zone, and we don’t challenge ourselves in the way that would enable more learning.
8. Owen: If you could dispense with all medical language and replace it with a cannon of language from another field of endeavor, what would It be and why?
Aftab: I don’t know why we would wanna do that! Different disciplinary languages have evolved to address different problems and the languages becomes rich repositories of the histories of the disciplines. It’ll be great to supplement the language of medicine with language from, say, philosophy and anthropology (and part of the fun of working with philosophers of psychiatry is getting to do that), but to dispense with all medical language would be a great loss.
9. Owen: Why aren't you deploying TMS? :)
Aftab: My exposure to TMS during my training was somewhat underwhelming. Regular rTMS, it works slowly, and outcomes in treatment-resistant depression are far from impressive. However, recent developments with deep TMS, accelerated TMS, the SAINT protocol, all these are quite exciting, and if I found the right opportunity, I would love to use TMS as a clinical intervention.
10. Owen: Would anyone believe a cure for depression existed even if it did?
Aftab: A cure for depression – in the strong sense of the word cure – may just be too good to be true. It’s like saying we can cure pain. Depression may very well be enmeshed with human biological evolution in a way that we cannot eliminate it. We can certainly treat depression, and we can get to a point where we can treat it very well, but I think there will always be this need to engage and grapple with depression as a human phenomenon. Carl Erik Fisher wrote these beautiful words about addiction inhis book The Urge: “If addiction is part of humanity, then, it is not a problem to solve. We will not end addiction, but we must find ways of working with it: ways that are sometimes gentle, and sometimes vigorous, but never warlike, because it is futile to wage a war on our own nature.” Something similar may be the case for depression as well. I’ll qualify though that depression is a broad, fuzzy, heterogenous, and dimensional phenomenon. Extreme states of depression are so disabling and impairing that they are recognizably pathological, and there is no reason why we cannot find highly effective interventions to treat and prevent them. But depression itself, as a broad clinical phenomenon existing on a continuum with ordinary misery, may be here to stay.
Thanks for reading this interview!
Carl Erik Fisher is a friend of mine! Maybe he will be up next? He was my favorite supervisor at LIJ in the ER! Subscribe towhile you are at it!