From the Wards
comment 1

Anonymous in Training: How Mental Illness Gets Overlooked In The Hospital

The day Mr. Webster appeared on our service, I was late for morning rounds with our resident. Morning rounds are the time set aside for each medical student to present a summary of their patients: why they required surgery, how their recovery is progressing and what the plan for their care will be. Out of necessity the surgeons, surgical resident doctors and the medical students all adhere to a strict schedule in which students arrive at the hospital in the wee hours of the morning, sometimes before 5 a.m., to speak with their patients. As students, “history taking” was our most important duty. If we were seeing a new patient we needed to gather any pertinent information that could aid in diagnosis. If we were seeing someone who had been through a surgery the previous day, it was essential for us to recognize any symptom that could signify a postoperative complication. The medical students would then present their patients to the residents at 6 a.m. in walking rounds that brought us to each patient’s bedside, often before there was light outside. By 7 a.m. we would gather in a windowless physician’s lounge to present our plans for our patients to the attending surgeons who are ultimately responsible for patient care.

There is a sense of urgency to these rounds and an economy with words is perhaps the most valued attribute to a medical student’s presentation of a patient: Please, just the facts. The surgeons expect to leave by 7:30 a.m. to head to the operating room. On this particular morning I had drastically underestimated the amount of time two of my patients would take to interview. When I arrived down in the ICU to see my third patient, rounds had already begun.

It was in that distracted state that I first learned of Mr. Webster’s serious postoperative complications that landed him in the intensive care unit (ICU). The ICU is reserved for patients with the most delicate medical states requiring the closest monitoring. Another student, my soft-spoken colleague Andrew, explained how Mr. Webster’s routine thyroid removal surgery had taken a frightening turn when the patient developed serious postoperative swelling of the neck. He furthermore developed tremendous agitation while in the ICU and required sedation. The resident believed he might be in a state of acute withdrawal from alcohol. Looking at him now, lying sedated in his ICU bed with his eyes taped shut and his limbs in four-point restraints, I was struck by how young Mr. Webster appeared compared to our usual surgical patients. I glanced at his chart — he was 42.

Our team followed Mr. Webster for over a week. As his neck swelling abated he was transferred upstairs to the regular floor, where more stable patients receive care. No longer obtunded by pharmacy, Mr. Webster made an indelible impression — screaming at nurses, spitting at technicians, demanding to see the attending surgeon at once. Andrew refused to accept that Mr. Webster was really so hateful. I spotted Andrew spending extra time with Mr. Webster after rounds and before he left the hospital every evening, sometimes speaking softly, but more often just listening.

The day before Mr. Webster was supposed to be discharged, Andrew presented the update on him during morning rounds. In addition to listing his vital signs and his treatment plan, Andrew’s presentation took an unexpected diversion:

“I spoke with the patient for a long time yesterday evening about why he is so angry. He says that his father was an alcoholic and he beat him from the time he was eight years old. He also told me that he was sexually abused by a family member, and that it has been very difficult for him to come to terms with this. He has been hospitalized three times for psychosis and depression. He would like to have a therapist to talk to about these problems or try some antidepressant medication.”

It had probably taken Andrew less than a minute to give the patient’s full psychiatric history, but in the setting of time-pressured surgical rounds it felt like a very long time. I found myself wincing when I realized Andrew was about to mention these issues. I could see from the way others reacted — fiddling with pens and avoiding eye contact — that the room shared my discomfort. Andrew had plainly misread the culture of this rotation.

“Get him a psych consult,” Dr. Hall muttered brusquely once Andrew had finished.

Rounds were over, and we students hurried upstairs to write our notes. Another student on the rotation echoed my thoughts: “That was awkward.”

“I know,” I said. “How did he not know that surgeons don’t want to hear about psych issues? He could have brought it up with a resident after rounds.”

But as I considered my unease with Andrew’s presentation, I realized I was uncomfortable because of more than just a disruption in the mood of the room. I was ashamed because I knew I wouldn’t have done what Andrew did — I wouldn’t have gone back to see Mr. Webster after rounds to try to understand the anger that created a barrier between him and his caretakers. I would have hid behind my own limp beliefs that it wasn’t my role, that there weren’t enough hours in the day to sit next to a troubled man and ask him about his life with the hope of rupturing the bubble of despair that seemed to enclose him.

The reality of medicine today is that mental illness is common, but also commonly overlooked. In hospitalized patients with a dizzying array of complications involving multiple organ systems, addressing mental illness such as addiction is rarely a prioritized concern. Some chronic issues like longstanding depression or schizophrenia may not require much attention from the patient’s primary service while in the hospital if they addressed appropriately in an outpatient setting. Yet many mental illnesses, such as Mr. Webster’s addiction, go undiagnosed and can have life-threatening consequences in the hospitalized patient. My experiences in my third year of medical school have shown that disparities exist among specialties in their willingness to address mental illness.

Indeed, mental illness is exceedingly common — it is a broad term encompassing mood disorders such as depression or bipolar disorder, psychotic disorders such as schizophrenia, anxiety disorders, eating disorders and disorders of delirium, dementia and substance abuse, among many others. The National Alliance on Mental Health estimates the prevalence of mental illness, not related to substance abuse, in the general population to be 18.5 percent. According to the National Institute on Alcohol Abuse and Alcoholism, the prevalence of alcohol abuse disorder is 7.2 percent or about 17 million adults in the United States. Approximately one-third of people suffering from mental illness also qualify for a diagnosis of substance abuse disorder, making Mr. Webster’s clinical presentation common among the general population admitted to hospital. His case wasn’t posing a rare challenge for the surgical team; rather, the surgeons and residents would have been accustomed to postoperative courses complicated by mental illness and substance withdrawal.

Medical ethics courses, ubiquitous in the first two years of American medical schools, impart guiding principles to fledgling doctors: autonomy, beneficence, non-maleficence and justice. Students work in small groups to parse out which principles apply to theoretical cases. But in the setting of a third year surgical clerkship, what’s clear in theory becomes murky on the hospital floor: What is the duty of the surgical team to the patient’s mental health? Wouldn’t mental illness be more skillfully treated by a psychiatry consult? Was Andrew neglecting his duties as a student on a surgical rotation by devoting time, the most precious resource we students have, to listen to the worries of a patient who was medically ready for discharge?

Two principles seemed relevant and in opposition in the case of Mr. Webster. Beneficence, the principle that physicians should act in the interests of the patient’s well-being, suggests that the surgical team identify and “own” all of the problems contributing to Mr. Webster’s clinical picture. Mr. Webster’s alcoholism and subsequent withdrawal clearly complicated his postoperative course; his depression likely contributed to his poor interactions with people treating him and created barriers to his receiving ideal care. However, justice — the concept that scarce health resources should be distributed equally — would dictate that it was questionable for a student to spend so much time with one patient. On any given day, students are constantly on the go. We are obliged to round on patients and present them, write notes outlining treatment, observe and participate in surgeries, attend outpatient clinics and manage delicate communication among residents, nurses and patients to facilitate patient care. The time Andrew spent with Mr. Webster had to come at the expense of some other activity.

Weighing the principles of beneficence and justice seems a high-minded exercise in the setting of 14-hour workdays and scant sleep. All of us students were suffering from our schedules. One of my classmates slept in his car rather than lose the time driving home. Another woman admitted to choosing between dinner and sleep most nights. While driving to the hospital one morning in the predawn hours, I even remember telling myself aloud that I just had to avoid hitting a pedestrian in the haze of my sleep deprivation. What continues to trouble me, months after the completion of my surgical rotation, is the thought that I was uncomfortable with Andrew’s interaction with the patient. Even with enough time to address the patient’s mental health, I would have avoided doing so.

Rounding on my patients each morning, I embraced the speed and single-mindedness of postoperative care. I inquired about ambulation, bowel movements and pain control. I jotted down vital signs and serum electrolytes from the electronic medical record with an eye for aberrations. The work seemed entirely navigable by algorithm: if a lab value was abnormal, do X, then Y, then check Z. Underlying this observation was my belief that my classmates and I were ultimately responsible for little of significance — every plan we made for our patients was checked with first the resident and then the attending. The only unsupervised decision I would make each day was ordering my lunch. There seemed to be no advantage of getting to know our patients. As I reflect back, there may have been a feeling of safety in that near anonymity — we were responsible to our residents and our attendings, but with our patients we felt practically anonymous. If we were anonymous, our empathy would not have mattered anyhow.

Yet I was surprised at myself for how willingly I sidestepped these difficult conversations with patients. When I decided during college to apply to medical school, there were many reasons motivating me. I was fascinated by physiology and wanted to better understand disease; I enjoyed meeting interesting people and hearing their stories. Medicine seemed a wonderful intersection of the two. And of course, I wanted to help people. This objective, expressed almost unanimously in medical school applications, is perhaps more illustrative of the life stage of medical school applicants — the formless altruism of the early twenties — than an explicit goal.

Then I entered medical school, and these vague but pleasing goals were quickly tempered by the very real workload pressed upon my classmates and I. Surviving my surgery clerkship in my third year seemed to require a singleness of purpose when entering a patient’s room — get the pertinent facts and get out without the delay of attending to anything “nonessential.” Foremost among things deemed nonessential would be allowing the interview to delve into the patient’s emotional state. At 5 o’clock in the morning, most patients were content for me to leave and allow them to rest. Still, a few would become upset when discussing their postoperative pain or their anxiety about going to rehabilitation, while I tried to be sympathetic but brief in my response.

I followed my surgical rotation with my rotation in psychiatry. My experience was in many ways the opposite of surgery — there was more time to care for each patient, and there was more time to care for ourselves. I would show up at 7:45 in the morning, spend the day conducting lengthy interviews with my one or two patients and then rounding on these same patients later with the team, leaving by 5 p.m. It was refreshing to have time to study, exercise and sleep. But the work itself troubled me. These patients, despite the huge variability among the types of psychiatric disease with which they struggled, seemed almost unvaryingly alone and unreachable. Many surgical patients I’d seen had hospital rooms filled with flowers and visitors following their operations. Most did not seem to need a great deal of emotional support from the medical team. While some psychiatric patients had a spouse, child or parent visiting, this was much less common. This seemed to reflect a fundamental isolation surrounding diagnoses of mental illness — these patients seemed apart from the world, as did Mr. Webster with his depression. In my six-week psychiatry rotation, I never saw flowers in a patient’s room.

There was a second challenge in caring for psychiatric patients as a medical student. When trying to gather a patient history, I felt stonewalled. History-taking is perhaps most essential in psychiatry out of all medical specialties; physical exam, imaging techniques like X-rays or MRIs, and lab results are generally not useful in diagnosing mental illness. On my psychiatric rotation, it seemed that every time I interviewed a patient, everything about their history changed when we later rounded as a team. A middle-aged woman who had been too delirious to offer me any details about her psychiatric history that morning was friendly and articulate when we rounded with the residents and attendings in the afternoon. A young man who was admitted to the ICU following a drug overdose told me he would like to be admitted for inpatient psychiatric care, but was resistant and argumentative two hours later. A woman with debilitating anxiety, begging for medication when I saw her at 8 a.m., would refuse her afternoon benzodiazepine. Psychiatric illness thus seemed a moving target for diagnosis and treatment. In the small library where the psych team discussed patients, a printout picture of Sisyphus scotch-taped to the wall echoed the seeming futility of our mission: we could try and try, but we couldn’t change anything for our patients. There was no wayward gallbladder or thyroid to remove to alleviate their suffering.

Little wonder then that surgeons taking on a heavy schedule of surgeries, clinic, and teaching would resist opening the Pandora’s Box of a patient’s mental illness. After the briefest exposure to the work done by psych residents and attendings I felt hopelessly lost. While many psychiatric patients have a keen understanding of their illness, many more lack that insight, denying psychiatrists the narrative of the disease. Choosing to specialize in psychiatry, then, seems a purposeful embrace of complexity over clarity. I asked one of the psychiatry residents why he chose his specialty. He told me he enjoyed that each patient with mental illness came with a singular history and unique diagnostic and treatment challenges. Each day presented new cases to puzzle over and try to solve. While acknowledging the frustrations in not being able to help many patients get better, he told me that the challenges made the successes that much more satisfying.

What I found most profound in my psychiatry rotation was the way in which attending psychiatrists persevere after years or decades of treating patients with illnesses refractory to treatment. Mr. Brown was a gaunt-faced man in his early forties admitted to the medical service for endocarditis, a serious complication of his longstanding IV drug use. The psychiatry team was consulted to evaluate his addiction. Mr. Brown spoke softly in answer to the attending’s questions, pausing before answering, with the forlorn look of a child without his mother. He had lived in men’s shelters and on the streets of Boston for the past 22 years after using sex to pay for heroin and other opiates. It seemed unlikely that he would ever gain control over his addiction. I remember my attending psychiatrist saying to Mr. Brown, “If you come back here relapsed a hundred times, I’ll take care of you a hundred times, ok?” And that may have been the one assurance this patient needed to hear. An addiction that had isolated him from his family and from society was met by this psychiatrist with acknowledgment and compassion. My psychiatry rotation also demonstrated the need for doctors to humble themselves in the face of disease. The team would treat this patient’s addiction in the best way they could — with a referral to a methadone clinic and outpatient counseling — but ultimately their own power was finite. I could see that to a surgeon, in whose hands cancers could be cured and failing hearts could be replaced, not being able to help a patient would be maddening.

I cannot be the first person, patient or caretaker to note that not all doctors show body and mind equal concern. But what is unique about the third year of medical school is that it offers the chance to participate in various specialties in quick succession, affording an inside view into these specialties’ strengths and weaknesses. My glimpse into surgery, and to a lesser extent into other specialties, suggested that the organization of these specialties makes it difficult to address mental illness. It could be argued that a surgeon, or any kind of doctor other than a psychiatrist, has little business addressing a patient’s mental health beyond obtaining a psychiatric consult. But that’s not the reality of medicine today. A shortage of psychiatrists and underfunding of mental illness treatment mean many physicians are not specifically trained in diagnosing and treating mental illness must offer patients this type of care. Primary care doctors routinely handle common mental health complaints, prescribing antidepressants and counseling patients through depression and anxiety; programs exist to train family medicine doctors to prescribe Suboxone to patients addicted to opiates. Doctors caring for patients in a hospital setting might do well to follow their lead.

Moreover, patients with mental illness are often poor, uninsured, incarcerated or previously incarcerated and lacking any family who would advocate on their behalf. When surgeons fail to address mental illness before discharge, they leave vulnerable patients to fend for themselves. The tasks needed for adequate postoperative home care are not simple: patients must pick up prescriptions and follow dosing regimens, adhere to critical postoperative instructions to prevent complications and make outpatient follow up visits while arranging transportation for those visits. Those compromised by untreated mental illness frequently develop avoidable complications and return to the hospital, worsening their health outcomes and increasing healthcare costs.

I am not currently in a position to recommend a way to address mental illness in patients admitted to the hospital for non-psychiatric causes. I could imagine designing a clinical trial in which patients hospitalized for non-psychiatric reasons but with untreated mental illness could be randomized to receive a psychiatric consult, or a discussion about the mental health issue with the admitting team. This would be compared to no intervention, and researchers could follow these patients to determine their health outcomes and costs for ten years following this hospital admission. I could dream up study designs and clinical endpoints, and perhaps one day I will put those ideas into action. For now though, my power rests in how I as a student, and in the future a resident, react to patients with mental illness. There will be mornings when the patient load is too heavy and I rush past someone’s mention that they have been feeling anxious or down. But if I push myself to listen further to as many of these patients as I can, I may identify some whose care could be tangibly improved by addressing their mental health. To reframe these thoughts in the structure of medical ethics, it seems to me that the concept of beneficence is most relevant in addressing this problem. Even if the medical team did not feel the situation warranted attention, perhaps just being another person listening to them, acknowledging the difficulty of their situation, would bring them some comfort. It would then fall to me as the practitioner to have the humility to recognize that often mental illness is bigger than something addressable in a single encounter, and to work with the patient to arrange for appropriate follow up.

About three weeks after Mr. Webster’s discharge, I was about to head home when I realized I’d left my textbook upstairs on the inpatient floor. I returned to the floor and was just grabbing my book when I heard a familiar gravelly voice out in the hallway. I looked out to see Mr. Webster speaking to another one of our medical students. He was shorter than I had realized after weeks of seeing him only lying down in a hospital bed. He held a motorcycle helmet in his hand.

I heard him tell my classmate, “In hindsight I couldn’t believe myself. I knew I had to come back to make things right with everyone here, after they took care of me for so long.” It was lovely to see a patient who’d been so ill looking so well, and I had to believe the effort Andrew made had improved Mr. Webster’s experience during his hospitalization. I was certain it was why he’d returned. I passed by the two as I headed for the exit, and I heard Mr. Webster call to me, “Hey, it’s good to see you again!” I spun back around, surprised that he knew my face.

Katelee Barrett Mueller Katelee Barrett Mueller (2 Posts)

Contributing Writer

Tufts University School of Medicine

Katelee Barrett Mueller is an eighth year MD/PhD student at Tufts University School of Medicine, with interests in clinical and translational research and narrative medicine.