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A Third Year Opus — Chapter Four: A Walk on the Ward

Sunrise on the psych unit.

A tentative, yawning flicker, a wash of tired fluorescence, and the hallway shudders to life — or something approximating life anyway. Bluish light cascades down greenish walls, rushes over the carpet and crawls under door frames into the rooms beyond where it meets the golden brilliance that beats upon the narrow gap in the wall that calls itself a window. The doors creak open, and the sunbeams spill through the glass, reaching at shadows that live here, before fading against the electric light. The shadows, and the shadows’ patients, trudge into the hallway, wearing thin the fibers of their socked feet, the silence replaced by the rhythm of their shuffling over the stained carpet.

Night shift signs out to day shift in the staff lounge as patients emerge from their rooms, hair wrapped in towels, with toothbrushes clenched in their jaws. Most had an uneventful night. Most slept poorly. A handful were tearful, another handful were belligerent. Francine showered, changed her clothes, and even cracked a joke — moreover, her eyes had finally stopped screaming, a harbinger of good things to come.

Leon was status quo. Flat. Withdrawn. Reclusive. Selectively mute. Leon was borderline catatonic, which was a modest improvement from how he initially presented weeks earlier — full-blown catatonia. My attending suggested I start seeing him myself. This was either a desperate attempt to shake up Leon’s routine or to brick-wall my not inconsiderable — and wholly unearned — ego that had developed over the past nine months of third year clerkships. I was in the home stretch now — mere weeks from achieving the esteemed title of “fourth-year medical student.” It’s the little things.

So, I saw Leon first. More accurately, I saw Leon’s roommate first. Upon my entrance, he fervently shook his head in a No-I’m-Not-Leon sort of way, his dreadlocks thwapping against each other, giving the appearance of a tornado on a human head. He left, the sound of thwapping diminishing in the corridor, leaving me alone with the shadow on the cot and the person casting that shadow.

Leon’s body was postured in a series of right angles — most notably at his neck, which pointed his head facelessly into his lap, which remained downward as he limply took my hand in an awkward finger-handshake. I pulled up a chair.

Later that afternoon, my attending and I reconvened in an office designed to give the local fire marshal chest pain. Hands interwoven over his rotundity, he stared blankly at me as I presented my conversation with Leon. I didn’t get as much as a smile when I revealed that Leon had actually spoken to me after weeks of near-silence to the entire ward staff. Not one iota of acknowledgement for a feat that should have earned me a Nobel Prize — or at least an early dismissal from the ward.

“Okay. Go ahead and see him again tomorrow,” he said, smearing a check mark on his list.

Sunrise on the psych unit.

Leon and I sat quietly in the shadows of his room. It was our tenth straight minute of silence — I had been speechless after the first five. Leon had changed since yesterday — from minimal eye contact to no eye contact, from soft-spoken fluency to complete opacity. Even the right angles of his posture seemed more pronounced. In the standoff, my mind began to wander. I could envision my attending shivering in schadenfreude-infused laughter, making one too many references to Icarus.

I began ransacking my brain for ideas. Maybe Leon wasn’t a morning person. Maybe he was just toying with me.

Or maybe it was my opening question asking how he was feeling that raised his guard. Leon had been selectively mute with much of the ward staff — interactive until they began asking about his mental health; then, the walls would come crashing up. My attending, who greeted me with resignation rather than mirth, agreed and encouraged me to keep seeing him. He spared me the Greek mythology reference.

For the next several days, Leon and I sat in silence. Ten, twenty, thirty minutes, exchanging nothing but a handshake. It was only then, when I had all but given up on interviewing him, that I finally began to notice some small details. I noticed that we were the same age, our birthdays only a few weeks apart. I noticed the comic books and John Green novels strewn — mementos from home. Most importantly, I noticed the table in the corner, past his downward gaze, past his shadow, where dozens of origami, painstakingly folded out of Kleenex, were piled upon one another. Cranes and swans, roses and carnations. Crude but beautiful. When I complimented them, Leon gave me one of his crumpled flowers. Marker ink colored the petals, bleeding into the tissue.

The next day, Leon sat and folded into right-angled silence in preparation for our not-talk. I gave the silence fifteen minutes. I stood, pushed my chair back — its legs scraped the tile with a bored snort — said “Let’s go for a walk,” and promptly walked from the drab of the darkened room into the drab of the darkened corridor.

A few tense moments held the weight and anticipation of an hour and were interrupted by the soundless padding of sock feet on carpet. My shadow was joined by another. I looked over at him to exchange a knowing smile to complete the cliché, but his chin remained pinned to his chest; I made eye contact with his hairline.

As we started walking, Leon maneuvered by peripheral vision, sidestepping patients and staff without once interrupting his staring contest with the floor. We passed the attending in the hallway, and he smiled before rolling his eyes.

Leon and I did laps around the ward each morning and most afternoons. Along with morning sign-out, med pass and group therapy, our walks became part of the ritualized life on the unit. At first, the silence followed us like a shadow; but after a few days, Leon began engaging me. It was small talk, mostly about our respective families. Even the vaguest reference to his mental health resulted in a complete shutdown. Our walks were a nice change of pace, but nothing had really changed for Leon — he remained guarded, paranoid, withdrawn and mostly mute. I felt less like Icarus and more like Sisyphus, pushing a boulder up a hill relentlessly, perhaps even pointlessly. All I had to show for it was a growing origami bouquet.

Leon had endured week after week of inpatient hospitalization and multiple medication trials without much of a change in his symptoms. After spending some time on a waitlist, my attending told me that Leon had been accepted for transfer to a long-term residential facility.

“What would he get there that he isn’t getting here?”

My attending shrugged. “Not much, it would just be cheaper than a hospital bed.”

A reasonable and wholly unsatisfying answer.

“Think he’ll get better?”

“He might. He might not. He’s still pretty sick.”

This time I shrugged. “I suppose he wasn’t getting much from us anyway.”

“Yeah … at an absolute minimum, he got a few good walks.” He smeared a checkmark.

Sunrise on the psych unit.

Or just before it, anyway. I arrived on the unit early Monday morning to find the hallways still dimmed. Leon and his shadow were gone now, discharged to more intensive long-term therapy a week earlier. I dropped in the staff lounge to ditch my bag and catch a bit of staff sign-out when the bulletin board caught my eye.

Posted were a series of thank-you poems, adorned with drawings of flowers and vines. An origami tulip was scotch-taped alongside a post-it note: “Leon did these for us!”

I left the lounge and walked into the hallway as it flickered awake. The patients walked into the corridor in sock feet, and I listened to the sounds of sunrise on the psych unit.

Author’s note: All names and identifying information were changed to protect the identity of the patients.

M.D. or Bust

Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.

Ajay Koti Ajay Koti (17 Posts)

Columnist and in-Training Staff Member

Morsani College of Medicine at the University of South Florida

Ajay is a pediatric resident and a Class of 2017 graduate of the SELECT MD program at the University of South Florida. He is passionate about delivering primary care to underserved populations—specifically, low-income and homeless patients in urban centers. Ajay will be specializing in pediatrics, with a particular interest in child maltreatment.

M.D. or Bust

Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.