This is a lecture about what it is to be a psychiatrist in clinical practice for more than 30 years. It draws on my experience of treating patients across a range of settings. It is intended to offer a perspective on working within a large mental health system that cares for individuals at different levels of need. We will examine the different systems of care that shape psychiatric practice: inpatient units, outpatient settings, community programs, and long-term care. We will reflect on how the treatment of severe mental illness has changed over the course of my career; what has improved, what remains limited, and what continues to challenge us.