“Great, six weeks of crazy people!”
This is the sort of attitude with which I went into my psychiatry rotation. Couple this with the fact that while most schools only have four required weeks of psychiatry, my school has six weeks. Of course, I would have more free time compared to other rotations — it is called “psycation” for a reason — but at what cost? Mental illness was something that made me uncomfortable. I didn’t feel like I could empathize with the patients.
To make matters worse, everything I had heard from the media made me believe that all I would see during my rotation would be homeless people who overdosed on meth and borderline patients with suicidal ideations. These were all people who somehow did this sort of thing to themselves, right? Wouldn’t these people just end up in psychiatric wards again and again? Are we not just medicating these people and then letting them out into the wild?
I sat in the room with my first patient, running through my list of questions like any other data-gathering third-year medical student would do. “Do you have any suicidal or homicidal ideations?” Of course she used illicit drugs, right? “Do you ever hear things or see things that other people don’t?” “Do you have any history of psychiatric illnesses in your family?” But then I got to one question that threw me off: “Do you have any history of physical or sexual abuse?”
A single tear ran down my patient’s face. I politely tried to probe. It seemed like the right thing to do. “Can we talk about what happened?” The patient began to sob, saying, “Do we really have to?” The patient then detailed to me how she had been abused as a child over and over again, first by her father, then by her uncle and then by her neighbor. She described how it caused her to never be able to trust others in relationships. The abuses she had experienced controlled her life and led her to her current situation: she just needed a way to escape the pain. I called my attending into the room. What else was I supposed to do? As I continued my rotation, similar stories played out again and again in the patients I interviewed. In one way or another, abuse had played a major role in defining the course of my patients’ lives, leaving wounds that were all too raw and real.
Yes, there were in fact multiple people strung out on meth during my psychiatry rotation, and yes, there were in fact a good deal of borderline patients with suicidal ideations. But, what I came to realize was that these were people who did not necessarily wish this upon themselves. These were people who were broken and needed a way out. They used substances and put themselves in compromising situations just to be able to deal with their pain and feel a sense of worth. The ones meant to be there for them were the very ones who caused their pain. These patients were simply crying out for help in their time of need.
Further, there is a biochemical and genetic component to mental illness. But the association of abuse with mental illness is undeniable. Studies have shown a four-fold increase in the rate of mental illness in those who have been abused. Abuse has been associated with higher rates of childhood mental disorders, anxiety disorders, personality disorders and major affective disorders. It can send a person spiraling through a vicious cycle of guilt, anger, depression and hopelessness, forever impacting the course of their lives and the decisions that they make.
Three million reports of child abuse occur in the United States every year. This works out to about one report of child abuse every ten seconds. Worse, this doesn’t even take into account the thousands of cases of abuse that go unreported. The sheer number of cases of abuse should make us pause: abuse is much more common than we think. My advice to fellow student doctors is to never write off your patients dealing with mental illness or substance abuse. The problem may be more than just a lack of willingness to change or a problem with compliance with medications.
As future health care providers, we must always take time to understand our patients. Don’t just be a data-gatherer. Be willing to ask the tough questions that no one else wants to ask. Patients put a great deal of trust in their physicians. In fact, a physician may be the only person with whom a victim of abuse may be able or willing to talk. We, as future physicians have an opportunity to stop generations of abuse with each patient that we meet. It is our duty. Don’t make assumptions about your patients based on what you have seen or heard. Each patient is worth the extra effort. It may be awkward to ask difficult questions at first, but it could make a world of difference to that patient. Always remember that each patient is unique, and each patient has their own story.