While I am a medical student, the purpose of this blog is not (or at least it wasn’t when I envisioned it) to blog about my journey through med school. One of the first blogs I remember reading was called ‘Over my med body’ and it was a brilliant blog written by a (then) medical student. I’m sure there are blogs out there of med students telling their tales on the floors, but that’s not what I want to write about. I realize, however, that over the next couple years I will go through things that most people will never experience. I’m seeing things that people only hear about third hand or see dramatized on TV. Occasionally it might be fit that I share my experiences. Now is one of those times.
I’m currently on my Psychiatry rotation. I don’t wish to openly discuss the medical school I attend, but I’m currently doing a clerkship at a public hospital in one of the poorest cities in the country. In general, the people that we attend to are uninsured or underinsured. There are high rates of chronic disease such as diabetes and hypertension, infectious disease such as HIV and TB, and extensive drug use. Learning medicine in this kind of environment is learning medicine in the trenches- it is one hell of an education.
I’ll admit that I’ve always been a bit intimidated by psychiatry. I’m in awe of the brain, specifically its ability to control such complex tasks with the use of limited resources. When it comes to neurotransmitters, there really aren’t that many. The brain effectively controls all our thoughts and actions with an incredibly limited vocabulary (5 neurotransmitter “words”: GABA, glutamate, dopamine, serotonin, and acetylcholine). I’m amazed it works in the first place, and I’ll admit that I’ve long been apt to think “Glad you work- let’s leave well enough alone” when it comes to contemplating the brain. Of course, just because something is hard to study, doesn’t mean it shouldn’t be studied. Indeed, that’s the point a fellow MD/PhD student made to me when he tried to wipe the look of surprise off my face when he said he was going into psychiatry. We need more great minds in psychiatry- the specialty is lucky to have him!
If you’re interested in an evolutionary approach to psychiatry, you MUST check out Dr. Emily Dean’s fantastic blog (please do- it would be the least I could do to send a couple clicks to her blog when she refers so many to me!). There’s a lot to think about and talk about when it comes to an evolution-based approach to psychiatry, and while I think that good nutrition, good sleep, good exercise, and good stress-management are all important for good mental health, I’m going to leave the tricky stuff to Emily.
Now, after a lengthy preamble, I get to the crux of the matter- my insight from the floors.
As one might imagine, the inpatient psychiatric ward at a public hospital in a poverty and drug-stricken community is… intense. I’ll admit to being thrown a bit off kilter by the bustle and (apparent) mayhem on my first day on the floor. You know you’re in a bad way when a fully psychotic patient gives you a look and asks ‘Are you ok?’. Aren’t I meant to be asking that question? Just how pale and wide-eyed am I? Inpatient psyche in this setting is not your aunt’s depression, or your roommate’s mania (not to belittle these conditions). The people we see on the floor are there voluntarily or involuntarily for a variety of reasons, but most frequently for schizophrenia, suicidal ideations or attempts, debilitating anxiety and depression, and/or delusions (frequently a combination). These patients are fascinating, and heart breaking. Some have insight into their condition (they understand that they have a mental illness), but many do not. On this floor you see how obsession can drive you to depression, and then to attempts to take your own life. You can see how delusions lead people to circumstances where they are at risk of hurting themselves and others. You see paranoia that cripples a person. These descriptions do not do the patients justice, but I don’t think any description would. It is something that has to be seen to even start to understand, and I am very grateful I have that opportunity.
Seeing these situations first hand is eye-opening. As I said, the first day I found myself overwhelmed. The psyche ward is a very different experience than medical wards. On medical wards, most patients are confined to their bed. You might see the odd patient out wheeling their IV around, or being taken for a walk around the floor by a therapist, but the halls are generally restricted to nurses, students, doctors, and visitors. The psyche ward is very different. These patients are almost all able bodied, and being out and about is good for them- many reap benefits from the group activities and sessions. We don’t want these patients in bed, but having them all up and about makes for a very interesting dynamic. It can get loud, it can get rowdy, and if you don’t know the patients, it can get scary (it can get scary when you know them too).
As I said, the first day I was overwhelmed. I saw patients only with my resident and attending (though I did have a very long chat (a real education for me) with one of our patients about the different street drugs she had taken and the various routes of administration (I learned more in that 10 minute chat then I did in all the years of drug education)). The second day I was cautiously curious, occasionally going out on my own to talk to a patient or do a mini-mental status exam, then seeking refuge behind the Plexiglas and locked half-doors of the nurses’ station. By the third day I was visiting patients on my own, and checking in on them for updates before we rounded… I think that was the turning point.
Psychiatry, especially in this setting, is all about observation. A patient may tell you one thing, but what you observe can give you much more information. Also, getting ‘collateral’ from family members, admitting physician’s notes, and lab results is very useful. A patient may tell you that he was brought in by the police after he called to complain about his upstairs neighbors (who frequently steal his stuff) getting in an argument, but a family member may later tell you he lives in an attic apartment and has no possessions. Equally, someone may report visiting an outpatient clinic regularly, only to name a hospital that closed years ago. These patients aren’t lying- or at least they’re not trying to. This is their reality. An accurate history is important in understanding the full picture of a patient, but obtaining one from a psychotic patient is often impossible.
Mental illness is not cool. It isn’t popular or sexy. I’ve received countless requests to participate in or donate to all manner of ‘walk for the cure’ events for juvenile diabetes, cancer, heart disease… chances are you’ve donated to these things if you haven’t participated in them directly. It’s an easy sell- everyone knows someone with diabetes, heart disease, or cancer. This IS your aunt, your roommate, your neighbor, and your friend.
Maybe it’s just me, but I’ve never seen an event aimed at raising schizophrenia awareness. Chances are, you DON’T know someone with schizophrenia, though the prevalence is actually not that low (perhaps around 1 in 100). While we’ve made great progress at eliminating gender, racial, and sexual inequalities, there remains a great stigma around mental-health. The heart is a pump, the liver a processing plant… the brain is ‘us’ and a disorder that affects who we are, without other signs of disease, can be hard to comprehend and accept.
Sometimes in the world of evolutionary health and wellness we like to get lost in the utopian ideal that an evolutionary appropriate lifestyle will fix everything. Overweight? Type II diabetes? Acne? Infertility? We’ve got lifestyle-modifications for that. But there are very real and very devastating conditions out there that will not and cannot be fixed with a change of diet and exercise. I’ve found the last week of my education amazing on so many levels- the patients, the staff, the doctors, and the drugs… I am in awe. I’ll miss the ward (and I will be back), but I don’t think it’s where I want to practice in the long run. I am very happy, however, that bright minds are tackling these issues and that there are people dedicated to helping a population that is often unable to ask for help.
principleintopractice 
I learn more in about 10 minutes with an addicted patients about the latest steps forward in opiate abuse than I would in three CME courses. Psych is weird but amazing and seductive.
Indeed…
Thanks for the comment, and the blog traffic!
It is fascinating to realize that reality is so different for different people – even ‘normal’ people suffer/enjoy all sorts of delusions, both positive and negative, and perhaps from an evolutionary perspective we can guess how this can be beneficial (I know – another Just So story…). Indeed the contrasts between good and bad times is surely part of what makes us ‘human’. When the brain goes a little awry, most of us are helped by friends, parents, colleagues, etc. Chemical intervention is a brave new world – we know how addictive some external chemicals can be…. the search is on for ones to make us ‘normal’ – but would we want them????
Part of the elegance of an evolutionarily appropriate lifestyle is that, at least in my mind, it hopefully gets us to a place where we can actually start to understand what ‘normal’ is. We definitely are not all the same, and our emotions, thoughts, and feelings change with life events, but when you see a patient who is truly psychotic, you realize that this is not an issue of ‘not my normal’.
The pharmaceuticals that are developed to work on the brain can be very powerful, and yes they can be very addictive. It’s amazing to see how some can stabilize a psychotic patient (again, the brain has such a limited vocabulary, blocking a family of receptors or altering the metabolism of one of those neurotransmitters seems very much like using a jackhammer to pick a delicate lock, but they do work). It is tragic, however, to see people crippled by an addiction to meds they were prescribed (often, it seems, without adequate thought or disclosure) for a relatively normal process such as grieving, passing anxiety, or pain management.
This is a very nice post. I’ve been working in an adolescent inpatient facility for almost a year, as a tech/therapist. This coming week will be my last one there, as I’ll be moving in a different career direction. I had many rewarding experiences, and grew a lot as a person, since I was exposed to many difficult situations and had to deal with people and problems that I was always sheltered from. Nonetheless, it’s about time that I move on. Unfortunately, I was becoming a little jaded and disillusioned with the “system.” Most patients lived their lives in and out of psych hospitals, foster care, group homes, terrible family lives, etc. This made it almost impossible for many of them to really be helped (many of them were “frequent flyers”). Losing faith that I was doing any good there made it harder to show up and do more than go through the motions. I don’t mean to paint such a depressing picture. There certainly were some very rewarding successes and I got to help some pretty cool kids. My point is that I’m glad I read this. It’s reminded me of my sympathy for patients that I seemed to be losing, and reminded me of my own regrets that mental health isn’t as sexy of a cause as, say, breast cancer. Thanks for sharing.
Thanks for stopping by and for commenting. Thanks, also, for doing what you do- even if only for a limited amount of time. We too have a lot of “frequent flyers”, and it can be tragic to see- I imagine that with youths it is even more devastating to observe. Like you, I don’t think I could maintain my enthusiasm and optimism if working in this environment long-term, but I am very grateful for the people that can and do. Best of luck with your new career direction!
“…. I’ve never seen an event aimed at raising schizophrenia awareness.”… Lori Schiller’s fascinating book “The Quiet room” (1996) certainly raised my awareness about schizophrenia, particularly the insidious, mysterious onset and how the early signs can be so tragically missed. This was followed in 2001 by the movie “A beautiful mind”, the story of John Nash, Princeton professor and Nobel Laureate (1994). http://en.wikipedia.org/wiki/A_Beautiful_Mind_(film) The film won multiple awards and hopefully did raise the public’s awareness of this devastating disease.
I can recommend both and hope that even a decade to a decade and a half afterwards that these are still being read and watched.
Excellent points! I have read the quiet room, and it definitely brings home the point of how pharmaceuticals can help these patients (though the potential side effects of clozapine, as the author discussed, are difficult and can be devastating). I did think of ‘A Beautiful Mind’ when I wrote this, and it is probably the best (and perhaps only) representation of schizophrenia for many people.
You make such an important point about the lack of support and awareness for mental illness – if only there WAS a “walk for the cure” for diseases like schizophrenia and that it would be well received and successful. Mental illness may be what the world fears above almost all other illnesses. It is so disheartening that so many of us lack empathy or even a bit of sympathy when faced with a person who is suffering from such diseases, yet if that same person had cancer, we’d be comparatively overflowing with supportive commentary.
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