Medical training centers around the evaluation and examination of another human being. The perspective and bias of the physician can, at times, be a liability, tarnishing objectivity. Maintaining neutrality is vital during a patient interview — personal introspection and reflection are distant considerations at best.
At the start of my psychiatry rotation, I was most apprehensive about performing the “bread and butter” exam of the specialty: the psychiatric interview. I was not afraid of forgetting which questions to ask, but rather how to ask said questions. Of course I should ask a depressed patient about their mood, but how would I do that?
Asking someone directly about their current mood sounded robotic and strange. While writing the note, the cursor would remain still and blinking next to my mental status exam as I pondered how to describe a patient’s emotional state. My psychiatry fellow suggested to “just write what they said.” This simple advice proved to be profound. I began to realize that I was complicating the situation; I simply had to be upfront and honest about what I wanted to ask, then listen and record what they said.
“How are you feeling today?”
The rest of the mental status exam fell into place in a similar fashion. There was no secret code or phrase that the psychiatrists were using to assess the SIGECAPS symptoms of depression. A patient might volunteer some of this information naturally, but if not, asking “are you having difficulty concentrating?” was not abnormal. Asking what the patient enjoys or whom they lean on for support now felt like natural follow-ups instead of strange and invasive lines of questioning.
Although I expected that the assessment of patients’ mental status would be difficult, I did not anticipate what would consume most of my time on the psychiatry service: antsy hours filled with waiting — waiting for consults to arrive, for patients to change in condition, for medication responses and for more consults to arrive. Psychiatry, as it turns out, is a “patient” field — that is, “patient” in the sense of incessantly glancing at your pager, not the “patient” in front of you in a gown.
I grew to understand that the best interventions available in psychiatry take time. Medications take weeks to have an effect on mood and therapy may take months before a patient sees progress. There is no fast procedure in this field; I could not have lysed an abscess of depression or used ultrasound to needle-aspirate a collection of paranoia.
Instead, self-reflection began to fill the void of tedium and the gulf of separation between myself and my patients began to disappear. So little seemed to separate the mental state of those in the hospital bed from myself. I do not claim to be suffering from mental illness, nor do I belittle the immense suffering of those who do, but upon hearing about a man’s battle with alcoholism and depression in the setting of his wife’s death, I could not help but pause.
I have a wife, and I cannot begin to describe the devastation I would feel if she were suddenly taken. I held back tears while listening to a man who felt completely unable to part with his wife’s possessions or even move his own from their locations on the day of his wife’s death. These personal effects remained unchanged, but the man behind them was now a shell of his former self, forever isolated from his life partner and now without a close confidant in whom he could confide.
Stunned and rudderless, he asked for advice about how to take the next steps to grieve. This isolation from a loved one seemed all too realistic a possibility in my own life. There was no longer a border or veil separating me from my patient’s experiences. I did not possess some protective enchantment that he lacked — nothing unique to protect me from similar devastation.
I look down at my own arm with a new perspective; there is a scar over my forearm that was self-inflicted as a young teenager. Armed with a new vocabulary, I have a new term for it now: non-suicidal self-injurious behavior. I also have a new understanding of the action’s intent: to release emotional tension that was otherwise inaccessible.
I do not know exactly why I had done that to myself, but I now recognize that it was not healthy. I start to play back odd conversations in my head: “If you were going to kill yourself, how would you do it?” I once asked two friends, who responded with puzzled and uncomfortable glances. Perhaps a harmless, albeit strange question, but if I were to hear about such an exchange during a psychiatric interview, I would now pathologize it.
Finally, I remember my lowest moment in medical school. It was my first winter and I had yet to adjust to the monotony of gray skies, minimal sunlight and long days of lectures. I arrived home and collapsed on my bed, exhausted and lost. My fiancé asked me what was wrong. I told her that I was overwhelmed, that I just wanted to fall asleep and never wake up.
I felt that I just could not bear to be awake and to be myself any longer. It felt like so much to ask to lift my face up from the pillow. She coaxed me off the bed and out of our apartment for some pizza therapy. I was fortunate to have such support in the moment that I needed it. I felt better within the week, but the feeling was distinct and will remain in my memory forever. I hope to not revisit it.
I see myself in a new light now, with less glamor and more honesty. The people who need the psychiatrist, who need medication, who need the hospital, do not seem as foreign anymore. Maintaining objectivity and neutrality with my patient had become complicated by my own feelings. My advice for him, although fueled with an emotional appreciation for his situation, was likely consistent with what any patient in a period of grief could be told: to lean on what relationships remain and continue to talk through his feelings and perspective.
A personal attempt at appreciation for his circumstances was not a betrayal of objectivity, but a necessary step in understanding. Empathy for a patient struggling to preserve his mental health was as important for honoring his own health as it was for honoring my own.