Dear Elizabeth,

You asked whether you should consider psychiatry as a specialty, as opposed to another discipline of medicine. As I write to you, I think about my own children, and how I would answer a similar question from them, knowing that in just a few years, I will have to do so.

So, I have reflected on your question carefully.

When you ask me whether you should enter psychiatry, your question also becomes whether I would go into psychiatry once again, knowing what I know now. Most people will tell you to enter their profession for that reason. They are justifying their own decisions. Their reply to you is a means of reassuring themselves.

I'm not going to answer your question that way. I'm going to try give you the truth as I see it now, realizing that it isn't how I saw it 20 years ago when I entered this profession, and it may not be how I'll see it in 20 years when I leave.

Let's begin with a practical matter; let's be honest about it. Deciding on a profession, even medicine, isn't all about the ethics and ideals that we write in our medical school applications. A key factor is that the profession provides money: It allows you to make a living. There's nothing wrong with that motivation. The question to think about is how much that motivation matters.

Making a living is not a dishonorable reason to decide to go into a line of work. Most everyone has to make a living. Most everyone has to find a way to pay bills. There are two ways to pay bills: increase your income, or reduce your expenses. There is much to commend the latter approach. Emerson said of Thoreau: He made himself rich by making his wants few.

The problem with this Thoreauvian solution is that modern society will impose itself upon you at some point. It may be through a tax bill, or a nasty next-door denizen, or a lawsuit, or an illness. At some point, you will need to respond to an unfriendly world, and if you have money available to you, you will respond more effectively than if you don't.

So there is something to be said for making an income, and as much as you can make while still laying your head to sleep at night without massive worry.

You should ask yourself: Is your main purpose in choosing this line of work to make a living? If it is, then you should know it is, and don't put too much effort or care into worrying about the work. It isn't your main purpose in life. Your main purpose in life could be your marriage, or your children, or your larger family. Or it could be another activity other than your main paid work, such as writing, or art, or music, or faith.

I used to criticize the average psychiatrist for just making a living—I didn't see them motivated deeply in their work—until one of my friends pointed out that it doesn't make sense to criticize the average person for being average. I wanted the typical psychiatrist to practice above the standard, but then that average psychiatrist would be at a new standard. I realized that I was asking more of the typical human being than a typical human being can be.

But it's true that everyone needs a main purpose in life. Otherwise, it's hard for our lives—brief as they are, and with a definite beginning and end—to have any meaning. This purpose need not be a "great" thing; it isn't minor to have a good marriage relationship or a happy family. Those "simple" things in life aren't simply attained, nor are they even common.

This question of meaning is very important, and something to consider deeply. It matters perhaps more than any other consideration.

The other approach would be to make your work your main meaning in life—to unite your avocation and your vocation. This is where, in the case of medicine, Osler said that it's a "calling." The other major callings have always been law, the ministry, and teaching. Some are called to heal, some to teach, others to preach, or to implement just laws.

Many claim it, but few are called. You can tell the difference in two ways. When you are called, you don't choose. You just know. You don't have an option. Every fiber in your body tells you that you must do this work; you can't do any other. And when you're called, you don't change your mind; you don't compromise; in fact, you sacrifice. Many people claim to have a passion for a line of work—they want to contribute to scientific research, they want to publish, they want to teach—but at the first (or second or third) sign of the world's inevitable resistance, they give in, and return to the safer path of making a living.

Look deep inside yourself; meditate on it; interrogate your deepest yearnings. Are you deeply called to do this line of work? If you are, you'll know it. If you doubt it, either you aren't called, or you haven't gotten in touch with your deepest feelings.

You ask about psychiatry as opposed to another branch of medicine. Let me tell you a few things about psychiatry, which you may already know, or perhaps sense.

Psychiatry is the least medical of medical branches. Some celebrate this fact, others rue it; some deny it; many refuse to come to terms with it. It's acceptable in a way, if by "medicine" we mean biological aspects of physical diagnosis and treatment, because psychiatry deals sometimes with the mostly physical and sometimes with the mostly psychological.

But psychiatry is medical, in the sense of dealing with diseases (whether mental health professionals want to admit this reality or not). The problem with that medical aspect of psychiatry is that the field is ambivalent about it. The diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) are created as social constructions, as preferences of the profession—not solely, or even primarily, as scientifically based definitions. For two decades, our profession has bound itself to these social constructions and pretended that they were scientific facts. This has been proven a lie, but we are unwilling to admit our self-deception.

This is nothing new. Before DSM's hegemony began in 1980, psychiatry had self-deceived itself with psychoanalytic orthodoxy for about half a century.

Do you want to enter a field that engages in such deep self-deception, and doesn't mind? Not just my career, but those of at least four prior generations, have passed this way. This process could easily continue for another generation or two at least. Are you willing to let your entire career pass under its sway?

You can fight it. You can make it your passion to try to raise psychiatry up and move it forward when all the influence of the status quo holds it back. Are you willing to spend your entire career fighting the powers that be? You may become a hero for future generations, if you succeed in the process of change in the long run, but that posthumous adulation will do nothing for your personal happiness in this life.

You may not care; perhaps you will ignore the larger profession's delusions, and practice well in your little corner of the world. Perhaps you'll do psychotherapy and enjoy helping people dealing with the basic struggles and stages of life. That's good work, and important. And if it's your calling, it's worth doing. But know that you'll be doing it in a larger context that's inimical to your purposes.

Society punishes those who improve it. Emerson observed this fact when he gave up a promising Christian ministry career to instead minister to all of mankind. Don't expect awards and accolades from the psychiatric profession for bettering it. The awards go to those who maintain the status quo, not to those who change it. Freud never won a Nobel prize; they gave it to the fellow who introduced frontal lobotomy.

The above dilemmas don't apply to the rest of medicine. There are no DSMs as diagnostic straightjackets in any medical specialty except psychiatry. There is no other discipline that has mostly thrown out what it believed for most of the past century. In other specialties, you can work with the mainstream, rather than constantly swim against it.

If you want to make a living, the other specialties will provide an easier life than psychiatry. If you have a calling, you may help psychiatry, but it still will make your life difficult.