On the first day of my psychiatry rotation I was anxious, and like most students I worried. I worried I would not have anything to say and I worried I would say too much. I worried I would say the wrong thing at the wrong time and I worried that my words would be more consequential than I ever intended them to be. I worried about my worry. My internal monologue was extremely intrusive, though I welcomed the change from my previous few weeks in the operating room, and I looked forward to exercising a new set of skills. Perhaps I simply felt relief that no one could yell at me for not knowing how to read people’s mind while looking outrageously enthusiastic with only my eyes while in the operating room.
I also found comfort in the fact that I would be spending time practicing how to be an effective communicator and my worries were somewhat quieted as I reminded myself that this was an opportunity to learn. At the start of the rotation I discovered that I was assigned to the eating disorder unit. Faced with the intimate opportunity to truly get to know the patients on this 11-bed unit, my worry set back in.
When I first met Sarah, she appeared apathetic. She wore black oversized sweatpants with bright pink leopard printed socks peeking out of the bottom, and a red flannel shirt pulled down past her fingertips. In her left arm she cradled a book with a few loose-leaf papers poking out of the top. She moved lazily into the room and she almost threw her body into the sun-bleached green chair. She pulled her right knee up to her chin and stared back at us. Her blank stare seemed to contradict the iridescent blue eyeliner she had painted on that morning. I introduced myself as a student and she turned her head toward me in an incredibly slight but intentional sweep — just enough to acknowledge my presence and indicate that it had no effect on her. She wanted to seem unbreakable but there was sadness in her eyes. I entered her life in an entirely arbitrary cross-section. She had been on the unit for two months at that point. This was her third inpatient stay.
The discussion that morning seemed to pick up where she had stopped the previous day. I listened intently as she described her mother’s pessimism for her successful recovery due to too many previous relapses. She was torn between her belief in herself and her mother’s belief in her failure. She answered deeply personal questions without the natural hesitation most feel before succumbing. She struggled with seeing the care team as an authoritative parental figure, herself an indecisive child, and the fact that she felt she was on the cusp of real adulthood did not help. Aside from her current lack of physical independence, she did feel like she was capable of caring for herself and working through her setbacks without additional support. She got understandably upset when privileges were taken away when she didn’t follow protocol on the unit, but she would then journal all day and reflect on her situation. She was floating in this place between temper tantrums, self-reflection and self-acceptance.
After a few days with the team I had the opportunity to talk with her further and lead the discussion during our morning rounds. Initially I again worried that I might disrupt the homeostasis my attending worked every morning to maintain during rounds. This was very narrow-minded of me — to treat her like she was so breakable. She had, after all, been through far more than I really wrap my head around.
As I spent more time with her, without the formality of the team she continued to unabashedly reveal her tumultuous history. It became clear that I was suddenly privy to a deeply personal relationship without having to ask and without the worry that previously consumed me. Our conversation flowed without pause to extrapolate the perfect words. She spoke to me about her time in high school. How she struggled to separate herself from her twin. She was the smart one, the successful one, yet in her eyes, the difficult one. She had studied hard and participated in sports. She got good grades and always dreamed of working with children. She continued to dream of working with children and she was happy whenever she spoke about it. She smiled because she was content with that part of herself. She was hopeful and adamant that she would someday follow through on her childhood dreams.
She started to purge when she was 13. This seemed like a natural transition for her after a few years of restricting. She explained that she purged for punishment — because she did not deserve happiness. She purged when her mother was critical of her, to feel anger and express her pain. She purged when a close friend assaulted her, because that was all she felt she could do in response. She purged out of helplessness, she explained, out of strong will.
The extensive discussions in our training about expressing empathy did not seem to fit into this particular situation. While, yes, I could sustain appropriate eye contact, acknowledge her words through repetition, and nod agreeably, it felt impersonal and distant. I felt like I was lying to myself. It was impossible for me to feel like I could empathize realistically. It was as though our lives were too far removed from one another. The chronicity of her struggle and her ability to keep persisting was overwhelming.
In many ways her vulnerability made me feel more exposed. The insecurity she tried so hard to overcome that instead started to internalize and grow. There was a lot of uncertainty that came along with that insecurity. It was difficult to determine where the feeling took its roots and it was therefore impossible to address without sufficient attention and care. She sought acceptance from herself and those that surrounded her. She desired independence from her parents, yet craved their approval of her major life decisions. She was at a crossroads trying to decide if she should look for a job, choose a career, go back to school, live on her own, trust her parents, trust her friends or even trust herself. Her fears manifested differently than mine, but they were the same at the core.
I thought about how easy it was for me to expect myself to be in such a protective role prior to spending time on the unit and with her. I had jumped far too quickly to the conclusion that my words hung by a thread and that she couldn’t handle truth. It was foolish of me to think that I was truly in a position of authority. She was the one who was really in control of her outcome. We were there to remind her of what she seemed to already know, to provide her with a space that she felt safe, and to encourage her to discuss what she struggled with most.
This experience will shape the way in which I approach patients in all settings. I will move forward with the knowledge that though I may never live through the hardships of those I care for, I will view these differences as a bridge rather than a wall between us. It may have simply been naiveté that made me think I was too far removed from her life circumstances to feel as much compassion and understanding for her as I ultimately did. Obviously if that were true we would struggle to find meaning in most relationships outside of healthcare as well. While I knew this, I felt like I was underprepared for my reaction to her reality. I was just starting to get a sense of what it really meant to be a caregiver and I was reminded of the inherent intimacy that comes with that role. It had been easier in prior patient experiences to focus on the disease and the circumstances, to try and learn as much as I could about the treatment, and to express concern and understanding in an appropriate manner. It was the first time I felt I understood the levity of being a doctor for another person, of being a genuinely compassionate caregiver for another human life. This was an incredibly humbling feeling. While the level of intimacy she and I shared is unlikely to develop with every patient I will encounter, I will never forget the heart of this particular interaction.