Review: Facing the Unseen by Damon Tweedy, M.D.


Review: Facing the Unseen by Damon Tweedy

My Quick Take: This is the book that I would have loved to write if I wanted to tell you how it is to become a Psychiatrist. I didn’t write such a book, but Dr. Tweedy did, and it’s fantastic.

Thanks to St. Martin’s Press for a gifted copy for review!

“...the reality is that anywhere a doctor is regularly seeing conscious patients, there is a good chance mental health issues will eventually be involved.”
If I were to quote the parts of Dr. Tweedy’s second book Facing the Unseen: The Struggle to Center Mental Health in Medicine that felt extremely relevant to me, I’d simply have to copy and paste the entire book here. I suppose that’s my way of saying that I really loved this nonfiction look at Tweedy’s medical training to become a Psychiatrist and his first years in practice, and if you’re interested in this topic, I’d highly suggest you pick this one up.

And besides, Tweedy has an excellent voice for writing. The book is well-paced, full of interesting case examples and showcases his thoughtful approach to patient care, and to the dilemmas it raises.

As a retired Psychiatrist myself, there are many similarities between his experience and mine from medical school through his residency training in Psychiatry, and into Psychiatric practice. I felt such solidarity as I read of his decision to pursue mental health as a medical specialty, the experiences of seeing patients on the wards and in the ER, and early practice. It brought me back, remembering how I would be up in the ER all night seeing patient after patient, making critical decisions and treatment plans for their care. Having to admit people who wanted to go home, and discharge people who wanted to stay in hospital.

I felt acutely the stress and pressure that medical training puts on the learner, and how mentally and physically debilitating it can be. I also shared in his awe for the practice and for some of the brave patients who battle to keep going every day, and share in his celebration of the small gains that people can make.

A clear theme in the book is to highlight the disparities that face Psychiatry and its patients in the face of a bias towards non-psychiatric medicine: the divide between mind and body, where the body is prioritised. It’s a false dichotomy, of course, but his examples are pointed, and his experiences–along with my own–don’t lie. Another message here is to question the way that we’ve always done things in medicine and Psychiatry. For example, questioning our tendency to prescribe meds rather than psychotherapy, to stigmatise our patients with substance use disorders, to neglect the physical health of people once they are labelled with a psychiatric diagnosis.

I respect the fact that Tweedy raises legitimate questions–ones that present themselves during medical school and residency training–without inflammatory rhetoric. He sees from experience how bias can occur. He sees from the lens of a resident or doctor who has been up and seeing patients in dire circumstances for more than 24 hours and just wants to make an expedient decision. A safe one, to be sure, but perhaps to the detriment of whole-patient body and mind care. He gets that we work in a system that is under-resourced and that sometimes medications are the best we can offer, when psychotherapy is not accessible for weeks, or months or ever.

As a Canadian physician, there were some aspects of the US system that the author details that I am so fortunate not to have battled. Most notable was the insurance aspect. There’s a telling tale of two patients he saw in ER, one of whom had insurance and one of whom didn’t. The one who didn’t got transported in handcuffs by police as a matter of policy to the state hospital. He notes that Psychiatric beds in the US are not “money makers” and so there is a shortage. In Canada, we don’t have the insurance issue, and our hospitals are not for profit. Some of the nicest units are the Psychiatric units these days, modern and integrated into the rest of the medical floors. In all of my time practising, we took all comers for Emergency care and acute hospitalisation, no matter of income, or socio-economic status. It’s one thing that I loved about practising medicine in Canada. We have other issues, though, most notably very long wait lists and inadequate services for the moderately mentally ill.

The last section of the book takes us to his practice as an outpatient Psychiatrist, a world that I know well. In “Integration,” he ends the book by introducing collaborative care, where a Psychiatrist and other mental health professionals work alongside primary care doctors to provide same day or nearly so care to their patients. It’s a great idea, and one model that I worked in in my first few years as a Psychiatrist. I spent a day a week in the Family Doctor’s group practice and saw their patients, sharing the chart and discussing cases in the office area. It was a great but not perfect model, and it was nice to see Tweedy’s description as a possible way forwards to bridge the divide between mind and body medicine.

He speaks about how lifestyle, diet and psychotherapy aren’t the centre of medicine (Psychiatry included) as compared to quick-fix medical solutions. I saw this changing a lot in Psychiatry in the years before I retired, and I would be fully on board for Tweedy’s next book to take a look at how Psychiatry could be a leader in the medical realm for integrated pharmacological and non-pharmacological approaches to optimise the prevention and treatment of mental illness. I hope he keeps writing!
"...there can never be a clean divide between our physical and emotional selves, any more than we can live without a functioning brain and a beating heart. These and other essential organs all inhabit one body that works in concert to experience all the joys and pains, all the triumphs and tragedies of this thing we call human life. The more we can embrace this ethos as we enact laws, build hospitals, devise health systems, and educate the array of future health care workers who will one day face us and our loved ones in our greatest hours of need, the better off we will all be.”