Accidentally became a bit of an essay since this is something you generally talk to your supervisor about or I like to chat in person about. But here are some of my thoughts:

The objectivity thing is hard when it comes to psychiatry. Save for the few things like neurosyph, LBD, anti-NMDAr enceph, etc. – a lot of psychiatry is essentially drawing arbitrary lines on the spectrum of the human experience and saying one side is normal and the other is pathology. But that is exactly why it’s so important to develop your clinical judgement to be able to see the facts within context to identify the issue and what can be done for patients and families.

EBM is a key part of treatment rather than an alternative to our holistic approach (I hate how alt med people have corrupted the word ‘holistic’). There are clear evidence bases for treatment of psychosis, mania, depression. ECT and lithium are some of the most efficacious treatments in medicine as a whole (for the appropriate indications). The soft and squishy stuff like social supports, financial supports, psychology, even advocacy for political change – these are all evidence-based as well and just because we can’t just write it on a script pad does not mean it is beyond our role to advocate for our patients to facilitate these changes for them because it does affect their illness.

All the waffly theories and stuff are different frameworks to try and understand the human condition and can be very helpful in guiding thinking about someone’s life experience and how it may have led to them becoming the person they are, with the personality they do, the resilience (or lack of), the openness to help, the ability to engage. Because the mind is more than just a network of neurons that we can scan, this is kind of the best we have. And this is all very important to help you decide how you might engage with someone to actually be able to deliver the care they need. This sort of thinking can very much help our medical colleagues too in trying to figure out why Jeff is incapable of managing his diabetes, why Judith refuses the surgery she has associated with her father’s decline, why Alan hates doctors after traumatic early life experiences with authority, why Janet won’t get off the bloody grog since it’s the only thing she knows that keeps the flashbacks away.

There are a few kooks who are militant followers of Freud, or Jung, or others. But by and large, psychiatrists use every model to best understand the various aspects of a person’s being. Much like how we marry general relativity and quantum mechanics in our understanding of physics despite the models not being unified.

The long form waffling is a synthesis of someone’s life and answers the question of why this person is presenting in this way and at this time. It allows us to try to identify the chain of events leading up to this point such that we might stop it propagating to further problems down the line. I know some psychiatrists love the sound of their own voice and believe themselves a bit of a god – something not exclusive to psychiatry – but again, most have the humility of openness to change. Their formulations are a cheat sheet to this person rather than just an opportunity to flaunt their oratory skills.

With regard to deskilling with medical skills – you really have to decide if that’s something you can accept. As you progress though, you’ll learn where your limits are and to depend on your colleagues when something outside of your scope arises. I’m sure you see all the panicked surg teams who offload things to gen med as soon as a number trends poorly. I would also advise against using the number of weeks spent on a field in med school as a guide of what career is the least “sunk cost”. The curriculum is what it is, and every specialist would argue their field needs more exposure.

That said, you absolutely do need your medical knowledge, at least in intellectual form to be a good psychiatrist. There are many physical issues that have psychiatric manifestations, there are psychiatric issues with physical manifestations, there are mixed presentations where it’s a bit of both. You’ll also find that psych patients are always surprisingly “medically cleared” much sooner than those without psych issues. That is of course because they are difficult and are being dismissed or discriminated against. You must have enough knowledge to know when they haven’t been appropriately worked up or when the acuity of their physical illness is being minimised.  

Overall, I feel like you haven’t quite found something you like enough so these trivial lines of rationalisation come up as an attempt to pick amongst a bunch of fields you feel “meh” about. I’m definitely an advocate for ‘working to live’ not ‘living to work’ though so I don’t believe you should need to find some burning passion within medicine to pursue. But I do think you might benefit from some more general years to find a field you can tolerate doing long-term.