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A salient question for the psychiatrist with a strong psychoanalytic and psychodyamic orientation is, How much do we immerse ourselves in the more conventionally physicianly concerns of patient somatic health and illness? Jeffrey H. Boyd presents a strong case for adding more of this physicianly ingredient to the dynamic psychiatrist's usual stance than many among the Journal's readership would find acceptable. Below, perhaps in line with those hesitant to accept Boyd's argument, I will express my own concerns. Following my comments, this collegial debate continues with a rebuttal by David V. Forrest. To be clear, I do not dispute the legitimacy of Boyd's and Forrest's position, but I do have my worries.
Boyd argues that psychiatrists are well suited to screening for the metabolic syndrome because they spend more time with their patients and understand their motivations better than non psychiatric physicians. Yet we are hesitant, he says, to take blood pressures, weigh patients, or measure their girth. Why are we hesitant? Perhaps, he suggests, we are smart enough not to preach what we don't practice. Do we fear ‘prescribing’ exercise or dieting regimes because prescribing was once disreputable among analysts? To circumvent the embarrassed patient's concern about standing on a scale in front of the psychiatrist, Boyd suggests that the patient do so with the psychiatrist's eyes averted, and to write down the number for later comparison. In a similar fashion, patients can monitor their own girth. Boyd supposes that the patient will feel positive regard for the psychiatrist who has expressed legitimate concern about the patient's weight and health. Yes, if skies were never cloudy and transferences never ambivalent and we could count on such positive regard, he would be right. Too often, behind such positive regard is the secret, unexpressed concern that the psychiatrist is a tyrant, a critical parent, the recipient of negative transferenc