Asking someone if they want to kill themselves becomes easier every time. The appalling part is how quickly this and other taboo personal questions became a normal part of my routine. How would they do it? What drugs do they use? Do they hear things that no one else can? Gathering this information is a critical part of my job and necessary for taking care of patients, but sometimes I feel like an emotional trespasser.
As a medical student on my first clinical rotation in psychiatry, I am repeatedly surprised by the calm acceptance and honesty with which my questions are usually answered. I’m still getting accustomed to this new position and the privileges that come with it. When one of my patients, a man fifteen years older than me, respectfully answered all of my intrusive questions with “yes ma’am” or “no ma’am,” I couldn’t help but think how I still address my friends’ parents as “Mr.” and “Mrs.”
I feel even more uncomfortable behind the locked doors of the inpatient unit, where the discrepancy in knowledge and autonomy between patients and providers is more striking. Most of the patients have little insight into the reason for their hospitalization, let alone how their drugs work or why they are taking them. This is not distinct from other areas of medicine, but many psychiatric patients’ distorted perceptions of reality make this gap more pronounced. Our limited capacity to help them understand what is happening with their bodies is frustrating and makes me feel aloof and paternalistic.
This chasm between us sometimes results in providers discussing patients as if they lack intelligence or autonomy and inhabiting different versions of ourselves in front of patients and behind closed doors. It is not the manic patient following the security guard around within three inches that makes me sad; it is the sense that she is somehow the only one left out of the joke that makes me feel guilty.
A middle-aged schizophrenic man quickly became my favorite inpatient. Despite his extraordinary doses of anti-psychotic medications, he continued to experience hallucinations commanding him to punch walls. He would greet me with a smile and tell me he was okay each time we passed, even when his bandaged hands and trembling jaw said otherwise. I would see a glimmer of the person he used to be and somehow feel better. If his upbeat and friendly personality was still recognizable underneath his mental illness, it seemed possible that he could recover to live a happy and less tortured life.
My second day was the first time I was yelled at by a patient. She exercised control in one of the only forms she had left: refusing to allow me into the room. I was disappointed, but didn’t fault her. It is hard enough to have an audience sit in on your doctor’s appointment, even without feeling paranoid and trapped by involuntary commitment. I waited patiently outside, back against the wall, and tried to look busy in order to avoid questions from patients that I would not know how to answer. I realized this was the first time I avoided talking to my patients and feel ashamed I put my comfort above theirs.
When I left the unit at the end of that day, I sheepishly scanned over my shoulder for patients that might try to leave with me. I’m not sure if I was more afraid of being rushed from behind or looking foolish, but both thoughts embarrassed me as I returned to the comfortable student housing across the street.
Sitting on the roof of our building one evening, I video chatted a close friend and showed him the scenic view of the nearby harbor and beaches. I recognized a handful of psychiatric patients in the courtyard as I panned across in the other direction and wondered if they could see the sunset over the high fences that enclosed them. I tried not to think about it, but decided they probably could not.
The most jarring aspect of my first clerkship has not been the onslaught of pathologies, unfamiliar brand names or new EHR; it is the constant confrontation with vulnerable patients that challenge the way I see myself in this new role. I am exhilarated to finally be involved in real care, yet simultaneously terrified to be viewed by patients as a powerful authority figure when I am so acutely aware of my own shortcomings. Until now, students were rarely presumed to have answers; the warm security of being accountable only to oneself has been stripped away, and I am fearful I will not be up to the task. My hesitancy to speak with patients in the hallway that day makes me worry that my desire to be comfortable outweighs my desire to jump in and help.
After being kicked out of an interview today, I went for a walk with another patient experiencing delusions. I was nervous the entire time, but recognized that she was too. There was help for both of us right around the corner whenever we needed it.