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Robert Howard

Published online by Cambridge University Press:  02 January 2018

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Copyright © Royal College of Psychiatrists, 2009

Robert Howard is Professor of Old Age Psychiatry and Psychopathology at the Institute of Psychiatry and Dean of the Royal College of Psychiatrists. He trained at Cambridge, St Bartholomew's and the Maudsley hospitals. His special interests are in functional mental illness in later life, and trying to raise and maintain standards in training within psychiatry.

If you were not a psychiatrist, what would you do?

As a boy I was obsessed with natural history, my bedroom was filled with cages and aquaria. Cheekily promising a Cambridge college admissions tutor that I would take him badger watching if accepted seemed to work. I spent my intercalated Bachelor of Arts year in zoology and seriously considered not returning to medicine. This got watered down to plans for a PhD on family life in the white-handed gibbon after qualification. I absolutely hated the 3 months I spent doing preparatory work in the Malaysian forest and that was the end of my career as an ethologist.

What has been the greatest impact of your profession on you personally?

The opportunity for lifelong learning about what works for people when things are going well and, of course, not so well. If I have not been able to curb my own impulsivity, psychiatry has at least taught me to appreciate and attempt to ameliorate some of the effects that it can have. I hope that it has helped me to listen more and say less, but I suspect that my family and colleagues would say that I have more work to do on this.

Do you feel stigmatised by your profession?

I can remember competing with fellow medical students to see who could come up with the most dreadful potential career outcome. Psychogeriatrics in Black Notley was the clear winner and it is ironic that I should have ended up working as I am and somewhere far less beautiful than north Essex. With the notable exception of the company of some neurologists, I have never felt stigmatised by what I do and new social acquaintances always seem interested and full of their own questions about troubling older family members.

What are your interests outside of work?

I am closest to heaven watching the Simpsons on television with my children or walking our Jack Russell on the beach in Norfolk. I have a love/hate relationship with a collection of tatty and almost worthless 1960s sports cars whose annual MOT failures cloud the transitory pleasures of open-topped country motoring between breakdowns. I do not believe that it is possible to watch too much television.

Who was your most influential trainer, and why?

Tony David was a scholarly and inspirational tutor to my very fortunate Maudsley senior house officer intake and Klaus Bergmann and Raymond Levy enthused me into old age psychiatry and academia through the examples of the giant strides that had been made in the field in their own working lifetimes. But I believe that I have learnt from and been influenced most by my much wiser contemporaries, particularly Simon Lovestone, Tony Davies and Peter Woodruff. My ideas about what is important in good postgraduate training were strongly influenced by David Goldberg and Anne Farmer.

Which publication has influenced you most?

I would have to say the AD2000 trial published in the Lancet in 2004. The whole story of the cholinesterase inhibitors has been a classic example of hope triumphing over experience and whatever the flaws inherent in AD2000 the trial showed us what we can safely tell ourselves, our patients and their carers about what these drugs do – modest (less than 1 mini-mental point) cognitive improvements, absolutely no change in disease course progression and there is no such thing as a responder. This is not to say that the drugs are not useful and important, but as psychiatrists treating a neurological disorder we should not expect the kind of improvements that we have got used to seeing in our patients with depression and psychosis.

How has the political environment influenced your work?

I would like to say ‘Not at all’ because nothing upsets me more than the notion that either clinically or scientifically psychiatrists compromise themselves because of political pressure. My outrage at the shameful connivance of the Academy of Royal Medical Colleges in Modernising Medical Careers and the Medical Training Application Service debacle in 2007 and the College's failure to put up any kind of convincing fight motivated me to stand as Dean. We should be more willing to say no to things that we can see from a long way off are going to cause disaster and be confident that our expertise and voice can influence the political environment so long as we are not seen to be solely protecting our own narrow professional interests.

What part of your work gives you the most satisfaction?

I can honestly say that nothing gives me more pleasure and satisfaction than talking with my patients. I only hope that they get something out of it too. I am very proud of the people who have trained with our clinical team, most of whom have developed into much better old age psychiatrists than me.

What do you least enjoy?

I dread committee meetings – particularly if they last more than an hour. Apparently, when the Queen meets the Privy Council, members have to stand throughout and this restricts business and discussion to a productive minimum. I fantasise about chair-filled skips in Belgrave Square.

What is the most promising opportunity facing the profession?

Any half-decent society is always going to need well-trained, competent mental health specialists. Even if the politicians within and beyond our profession do not currently acknowledge that such individuals have to be psychiatrists, I believe that the ‘Harriet Harman principle’ generally operates. This is that in the event of a mental health difficulty in themselves or a family member, access to the expertise of a consultant psychiatrist would be an immediate priority.

What is the greatest threat?

Our current failure to persuade sufficient numbers of our own medical school graduates to follow us into psychiatry. Despite atrocious treatment from the Department of Health, doctors who trained overseas have shown huge loyalty and commitment to the National Health Service and our specialty would collapse without them. But we cannot have a workforce within which UK medical graduates are not adequately represented. Although it is currently fashionable for consultant psychiatrists to express disenchantment about our posts and changes to the way we work, we need to remember that this is quickly picked up by medical students so that even those who thought that they might want to become psychiatrists are dissuaded. The College, led by the primary care trust, is working hard to connect with undergraduates and foundation trainees to paint a positive picture of careers in psychiatry, but all of us who are observed in our work by medical students need to remain mindful that we can be the best or worst possible advert to those who may follow us.

What is the most important advice you could offer to a new trainee?

Choose an area of practice, research or the arts that is relevant to psychiatry and that interests you. Find out everything you can about that area and write a publishable review. You will discover that everything becomes more interesting the deeper you delve into it and will experience the excitement and satisfaction of being an expert on something important to you. Approach your patients in the same way. You should absolutely expect to enjoy your work and have fun. Like Dr Johnson said about London – if you find you are tired of psychiatry you are probably tired of life.

Do you think psychiatry is brainless or mindless?

Sadly, I think that it is fast becoming both. Psychiatrists seem to be less interested in basic neurosciences than when I trained, perhaps understandably because, despite great promises, neuroscience has not delivered new insights into the causation of psychiatric illnesses or novel treatments that benefit our patients. I am sure that this will change but it may only be later generations of psychiatrists who see the benefits of current work. As to the mindlessness charge, I partly blame the relentless rise of vogue psychological treatments, at least in part, for the current loss of psychological mindedness among our trainees. Whatever the drawbacks, traditional psychotherapy at least offered a series of models about experiences and relationships that we could apply in our attempts to make some sense of the otherwise unmappable inner lives of those who come to us for help and understanding.

How would you like to be remembered?

As an enthusiast who did his best – even if sometimes it was not terribly good.

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