Reflections on Psychiatry, my last patient-oriented month of third year

Psychiatry was a very difficult rotation for me.  Despite their relative physical health, many of the patients on the inpatient psychiatry service – a locked unit in a part of the hospital many doctors didn’t know how to find – seemed even sicker to me than patients on other services because the level of impairment experienced by some of the patients on the unit was so devastating, even worse than many patients on inpatient medicine units.  Mental illness is powerful enough to reach into every part of a person’s life, and many of the patients had lost their jobs, their homes, their relationships, and their physical health—not to mention their self-esteem, pride, or even identity.  For many patients on other services, whatever illness brought them into the hospital was threatening one or more of these aspects, but rarely all of them.  In particular, it was tragic to see how, unlike medicine, in which a loved one’s illness often brought spouses or families closer together, many of the psychiatric illnesses struck directly at these relationships.  Watching a patient with probable borderline personality disorder interact with her mother, I saw how warped their interactions were and how tested their relationship had been because of the daughter’s mental health issues.  Similarly in schizophrenia, it was heartbreaking to listen to a patient refer to the family that had struggled for years to keep him safe and care for him at home as “just faces I see every day”; as much as the family members understood the patient’s condition, this “autism of schizophrenia” must have felt like a constant slap in the face.  I can’t imagine the pain of watching someone you love be turned into “someone else” by mental illness in a way no physical illness could.

Just as the condition of the patients on inpatient psychiatry was more serious than many patients on other floors, it was also much harder for me to maintain an emotional distance in order to protect myself.  In other rotations it has been easy for me, as a young woman with no physical illnesses more serious than allergies and mild migraines, to enforce a separation between myself and my patients: I don’t have diabetes, I don’t have liver failure, and so on, and so I was able to view their conditions objectively while still empathizing with the patient as a person.  In psychiatry, the border between my mental experience and that of the patients is much more blurry.  We all have coping mechanisms (adaptive or not), stressors, thoughts, and moods; we all have a psyche.  Many of us “normal” people (i.e. the caretakers) have even had our own mental health problems.  It felt like the difference between “us” and “them” was only one of degree, or luck.  There but for the grace of God go we…  While this made empathizing with the patients easier in a way, it also made any degree of empathy threatening to my own equilibrium as part of the treatment team, by opening myself up to the pain of their illness and being unable to dismiss it as something that happens only to other people.  As a daily defense mechanism on the unit, I observed and certainly sometimes participated in humor that derived amusement from patients’ behaviors.  At other times, I just went home and watched television for hours, to try to hide from the emotions stirred up by the day.

It was in this context of the push and pull of extreme emotional empathy and extreme emotional distancing that I finally felt the cord tying myself to a patient as fellow human beings snap – not permanently, but at the time completely, or so it felt.  My day on the psychiatry ward had ended, and I was attending an early evening session of a bedside teaching elective that had spanned the year.  An email had informed us of a special opportunity for some students during this session to accompany “Dr. P”, one of the senior psychiatrists, and discuss interviewing “difficult patients” rather than our usual pulmonary physiology or cardiac exam findings.  Since I was on the psychiatry rotation and therefore had the chance for regular teaching sessions with Dr. P already, I asked to be in one of the regular groups.  Through an administrative misunderstanding, I was put in his group anyway.

My classmate “H” eagerly volunteered her patient “Mr. C” as our interview subject.  As the small pack of us entered his room, she brightly called out, “Hello, Mr. C!  It’s me, H!”  He muttered something unintelligible.  Dr. P introduced himself politely and explained that he was teaching this group of third-year medical students about interviewing, and they began their conversation.  What followed is hard for me to remember in detail, because it was a dizzying blur of contradictions, non-sequiturs, and barely-speech.  Dr. P modeled perfect interviewing behavior by starting with open-ended questions: “Tell me about yourself.”  When that produced a tangle of thoughts that trailed off, he tried again with more specific questions: “Where did you grow up?  Any siblings?  Were you ever in the military?”  The answer to that last one was no; a few minutes later came a fragmented story about his time in the Air Force.  It was like trying to use one of those notoriously poor internet-based language translators: each response that came back was nonsensical, yet delivered with complete confidence in its sense.  Dr. P tried gamely for several more minutes, but it was clear that this interview was exhausting even his normally extensive patience and persistence.  We thanked Mr. C for his time and left the room.

In the small conference room at the end of the hall, with late afternoon sunlight streaming through the windows and a top-floor view of the surrounding leafy neighborhoods, including my own, Dr. P pieced together a discussion about difficult interviews.  My mind was still in the room with Mr. C.  I witnessed the way he lay almost motionless in his hospital bed; the lines and monitors tangled around him; the sores on his legs; his broken-down appearance that looked like more than old age (he was in his early sixties.)  He did not seem to be suffering, or in pain.  His history was hazy—something about alcohol, maybe also an accident.  Sitting in the conference room, I looked down at him through my own eyes and felt… nothing.  No stir to empathy for the depth of his deficits.  No urge to help.  No reproach for perhaps drinking himself into oblivion.  Not even pity, of the kind that builds walls.  Just an emptiness.  In my mind I responded to his unstated but unavoidable question  of, “Well?” with, “I’m sorry.  I have nothing to give you.”

While I have known patients this year who were difficult, trying, mean, or just too far gone, patients who stretched our abilities even to hold our tempers much less to provide any kind of care, this was the first patient who inspired no feelings of any kind in me.  And that was terrifying.  All of the others at least felt like human interactions: relationships marked by dislike, disgust, enmity, and of course warmth, friendship, grief, compassion, and caring.  But never before a failure to respond on the most basic human level.  This, I realized, is burnout.  I cried as I walked home, leaving the hospital by the back entrance and blinking in the beauty of the sunshine and the Fens.  The tears dried up quickly.  I threw on shorts and sneakers and went for a run, pounding the sidewalk with angry feet.  I flopped on the couch and watched TV shows back to back to back while I ate leftovers.

When I began my third year, I vowed to myself not to lose the idealism that brought me to medicine, my compassion for people that moved me to understand them and to care for them.  When I began my third year, I didn’t see how anyone could lose that, how bright-eyed medical students became the jaded, uncaring doctors we have all heard about.  I think that this one patient encounter, this one empathic failure, was a sobering gift at the end of my third year.  People often ask me how I have changed during third year, and I think it’s this: even this early in my clinical experience, I have developed a far more nuanced understanding of how compassion inspires doctors to do what they do.  We don’t love every patient; far from it.  But we can come to medicine out of a desire to help people, out of a belief that all people deserve to be helped, and this gets reinforced and rekindled by the patients who do touch our hearts.  For the rest, as I discovered in a previous rotation, we do our job anyway and give them good medical care.  So when I call this patient encounter a gift, it’s because it was a humbling warning, a call to attention that will help me to continue forward with a more subtle and also more durable sense of purpose.  I learned that I might not always have empathy for all of my patients.  But never on that day or since did I question whether I should, or could, be a doctor.

Where I am at the beginning of my third year
Where I am at the beginning of my fourth year

age: 24
age: 25

residence: Boston, MA – medical school dorm
residence: Brookline, MA – apartment with a roommate

relationship status: four years seven months, and engaged
relationship status: five years seven months, and still engaged (twelve more months to go…)

exam status: USMLE Step 1… passed, I hope
exam status: USMLE Step 1 passed (plus Surgery, Medicine, Pediatrics, Ob-Gyn, Neurology, and Psychiatry shelf exams), Step 2 CK and CS on the horizon

expected date of graduation: May 2010
expected date of graduation: May 2010

future career: physician, academic medicine in a large urban area, mostly clinical and some education (student and resident levels)
future career: physician, academic medicine in a large urban area, mostly clinical and some education (student and resident levels)

front-runner for future specialty: Child Neurology
front-runner for future specialty: Child Neurology

other possible specialties: adult Neurology, other Pediatrics subspecialties, Ob-Gyn?
other possible specialties: other Pediatrics subspecialties, Ob-Gyn

outside activities: … (when I can: yoga, meditation, jewelry-making, cooking)
outside activities: TV, gym/running, jewelry-making and other craft projects, cooking, wedding planning, NYTimes Sunday crossword puzzles

vices: chocolate, online bead stores with free shipping, Target, shoes, Target shoes, jewelry, kitchen stuff, a very messy room, RSS feeds, cuteoverload.com
vices: chocolate, Second Time Around (that’s nothing new), kitchen stuff, a usually messy room, wedding-related RSS feeds, cuteoverload.com

listening to: Tammany Hall NYC, The Weepies, or anything else from the Scrubs/Garden State soundtracks; misc. alternative/indie rock, soul, Ella Fitzgerald
listening to: Bic Runga, Ingrid Michaelson, lots of mixes

with me at all times: keys, HMS ID, wallet, cell phone, migraine meds, makeup, my Nalgene
with me at all times: keys, hospital ID, pager, iPod Touch, wallet, cell phone, migraine meds, makeup, my stainless steel water-bottle, NYTimes crossword puzzle

last time I read a book: last night
last time I read a book: umm… uhh… does Martha Stewart Living count?  [edit: I technically just got back from Spring Break, during which I read about 1.3 books, but before that...]

last time I went out to a movie: I truly can’t remember…
last time I went out to a movie: I truly can’t remember…

average hours of sleep per night: seven
average hours of sleep per night: six and a half (very variable)

coffee consumption: one per day, usually drip made at home
coffee consumption: one per day, usually drip made at home, then a cup from the cafeteria at lunchtime, and sometimes Starbucks when I think I deserve it…

All in all, not a lot has changed… at least not a lot that is captured on this list.  Stay tuned for a post on how things have.

A reflection essay for Patient-Doctor III about the same patient:

I have observed often during my clerkships that the hardest patients to deal with–for myself, and for my team–are the ones who are not easily categorized. I have heard comments about so many variations on “those people,” perpetuating stereotypes about people with back pain, diabetes, obesity, or high blood pressure. Regardless of their veracity, they sometimes seem to help residents redirect their frustrations and the stresses of their job towards a depersonalized amorphousness based on diagnosis, rather than towards a given individual. And I am well aware that over the course of the year I have absorbed many medical prejudices about what “those people” are like and how they will behave while under our care and after they leave the hospital. It is unfortunately cynical, but also a defense mechanism counterbalancing some of my naivete. Still, it is hard to only be a little cynical, or only lose a little optimism.

A patient on my service challenged my developing familiarity with these stereotypes and prejudices, not because he contradicted them in any way but because he was simultaneously so frustrating and so inspiring of sympathy. He was a middle-aged man who came in with a chief complaint of “seizures,” describing two episodes of falling to the floor and shaking his limbs. No one else had witnessed the events, but he was insistent that they were seizures. Red flags started to go up when, after hearing that a seizure meant he would be unable to drive, he began to change his story and said that “maybe it was just vasovagal.” The team got more suspicious as he told different versions of his history to different people at different times and deflected any of our attempts to redirect his circuitous and occasionally self-contradictory tale, as if he wanted to stick to a script he had in his head. He perseverated on certain topics, repeating them in response to unrelated questions, particularly his chronic pain after a neck injury in an accident; another red flag, another “those people” category. He was obese. He included extraneous information about his job, his dog, and his experiences at other hospitals. All of this already meant he was labeled as a “difficult patient”–difficult to round on because he took so much time to talk to, and automatically raising the ire of the members of the  team, who felt they were being manipulated. The last and most overwhelming piece of evidence came when we got him out of bed to watch him walk. Unsuspecting, I questioned to myself whether the two petite physicians on either side of this very large man would be able to do anything at all if he started to fall. He did sway and lose his balance, numerous times in the short walk around the room, and each time I jumped forward to help them catch him. But he never actually fell. The attending remarked to the resident “Hm, astasia-abasia,” and we left the room soon after. I learned in the hall that astasia-abasia is a “nonphysiologic” gait disturbance; in other words, a psychogenic problem, with no true neurological cause.

Now, in all our minds, this patient had become one of the worst of “those people”: a malingerer. It was revealed that he had been trying unsuccessfully to get disability benefits. From the tone of the conversation, it was obvious that we were all feeling used, exasperated, and also bored: now that we had him categorized and we had “diagnosed” his problem, he was no longer neurologically interesting, and we couldn’t wait to sign off.

Still, I left the room shaken, not by his obvious creation and magnification of invented problems, but by the depth of his true problems and the suffering they caused. Even without knowing where exactly truth stopped and fabrication began, it was obvious that what he told us had some basis in his reality. He had been healthy, a lean and muscular gym-goer, until a fall on the job damaged his neck. Unable to exercise, he went from a husky man to what the stereotypes told us was just one more morbidly obese patient compounding his own medical problems. His work as a contractor had fallen on rough times already because of the economy, and now he could seldom take whatever jobs he was offered. He was homeless and lived in a shelter. He had at some point developed atrial fibrillation. He felt weak, and had two of these seizures or whatever they were, so he wouldn’t be able to drive even if he had a car. He was depressed, he told us, and had thought about suicide. He seemed still in shock about how different his life had become, and how with each new problem it seemed harder and harder to get out of his hole.

In an in-class exercise for a writing course that night, I wrote about him as I imagined he saw himself, rather than as we saw him: not as a schemer or a whiner, but as a man somehow suddenly fallen from grace, coming to us because he had no one else to turn to. Looking back to our encounter and tapping into a wellspring of sympathy for him was effortless. Yet it had also been effortless to join in the categorization and subsequent dehumanization, and even disgust, the team collectively experienced when we met him. There was no way to reconcile the conflict of this juxtaposition, because both realities were true.

In the hall outside his room, as we began to exchange knowing looks and tear apart the inconsistent story and impossible exam, my senior resident spoke up. “It sucks for him that he’s a malingerer. It means we’ll automatically give him worse care.”  The  words stuck with me because they were neither the cynicism I had come to expect from some residents, nor were they credulous sermonizing about being open-minded and treating everyone with love. What was said acknowledged the tension between resentment and sympathy this man inspired, and let it continue to exist, only pointing out our duty to give him good care regardless. The comment captured the unresolvable conflicts that I have learned over the course of this year are confronted in every field of medicine, especially between unguarded caring and get-it-done practicality, and reminded us of our role as medical professionals. Then we all got back to work.

An in-class for my writing elective, in which we were instructed to write about a patient as if he were the protagonist in a story:

He paused, but only for a moment, as he stacked five cans of Coca-Cola on the table next to his dinner.  There was a time when he would have come home from the gym, covered with sweat and blazing from the glow of a personal weightlifting record broken, and eaten carefully: lean protein, vegetables.  He would have driven home in the beat-up but powerful car he was no longer allowed to drive after the seizure.  He would have come home to pour a bowl of water for his dog, an enormous mutt with a bite missing from its left ear.  He no longer did that when he came home; the dog was long gone, and he had no home to come to.

Before he moved out, one month too many of rent unpaid, he had cast a last look at himself in the mirror previously overgrown by boxes and cast-off clothes.  His once full hair was long, thin, and greasy–he stuffed it under a faded Red Sox cap.  His proud barrel chest that once gleamed as he ran shirtless now sloped down into a sagging belly barely contained by an oversized gray t-shirt.  His legs buckled slightly from the pain in his spine, always there since the accident, but sometimes worse.

He left the house behind, and did not go to work, because that too was over.  He was still waiting for the disability payments that might have kept him a little longer from being homeless.  A grown man, a strong man, a working man–he thought that for the first time in his life he would sit down on the ground and just cry.  Or he could drink.  Or maybe he could find some quiet place, under a sheltering tree on a grassy hill.  He could take all the pain pills left in the prescription bottles in his backpack, and hope that they would be enough to end the life he still could not believe was now his.