I entered psychiatry with a goal of helping patients find hope. I thought there could be no greater honor than witnessing a person discover value and meaning — to see past their internal demons in order to make life bearable, even enjoyable. Well, it only took four months of inpatient psychiatry to discover my limitations. Sometimes, we fail our patients.
This patient was young, only in his late 20s. He had been on our inpatient unit for extended stays in the past, usually taking months to psychiatrically stabilize. I was warned he was violent and impulsive. He had spent his early adult years in and out of hospitals. His past was filled with trauma. He mistrusted the medical system. He probably mistrusted everyone. When I learned I would be his physician, admittedly, I was scared.
I tentatively knocked on the door to his room, making sure I kept a safe distance. He laid under the covers, only the cuffs of the cartoon characters on his pajamas pants visible, food trays piled up on the floor, discarded containers scattered everywhere. This certainly wasn’t the frightening person I expected. The room could easily be mistaken for a teenager’s messy bedroom, except there was no parent around to clean up after him. He was in a locked psychiatric unit. Again.
The patient said nothing to me. He didn’t even uncover his head. I asked him a variety of questions, only to receive inaudible mumbles. It went on like this for days, maybe even weeks. In researching his history, I found out that he went to prison as a teenager after getting charged as an accomplice to a crime he did not understand. In prison, he spent extended periods of time in solitary confinement, presumably for protection. I also learned that he loved basketball. And flaming hot Cheetos.
I changed my approach. I stopped asking about his symptoms. I started relaying the highlights of that night’s NBA playoff games, eagerly noticing as he made his ears visible. Finally, one day, it happened. He sat up and looked directly at me and asked, “So, you like basketball?”
By the end of the week, the patient had shared with me that he did indeed hear voices that other people did not hear. He shamefully looked down at the ground and said, “They tell me to hurt people.” Everyone wanted to know about the voices, or if he could be safe around others, or even if he had a bowel movement recently. But he did not want to talk about those voices, and he certainly did not want to tell me about his bowels. He wanted to know what kind of movies I liked.
So, I dug deep into my mental filing cabinet as he spoke to me about TV shows, movies, even candy I had not thought about in 15 years. These were things he must have enjoyed before his first psychotic break. Before his world flipped upside down. Before prison, the voices, the questions, the hospitals, and the doctors. He was talking to me like a friend.
How had this taken me so long? In psychiatry residency, we spend so much time questioning patients about their future orientation. What gives them a desire to live? How had I not thought to focus on the happy memories that must keep him going?
I’d love to conclude this by telling you that friendship solves all problems. But it doesn’t. Because I was not this patient’s friend; I was his doctor. And my four-month rotation was ending. I was hesitant to tell him. We had made so much progress. He was taking medication and attending groups. He had not gotten in any fights. He was getting better.
Psychiatry residency is different than most other specialties. We do not have a certain number of procedures that we must execute independently in order to graduate. We are not inundated with patients on their deathbed, relying on us to provide life support. But we do form relationships, and we do have to say goodbye. This was a procedure that I had no experience with yet.
I started to prepare him weeks in advance about my departure. He stared vacantly when I explained that I would be rotating to a different hospital and reassured him he would be in good hands. Did he not care? Or had he simply heard this too many times before? On my last day, I knocked on his door to find him once again buried under his covers. As I thanked him for allowing me to be his physician he warily uncovered his head. He looked at me with a hatred in his eyes that I had never seen before and said incredulously, “Why are you leaving? I thought you were going to help me.”
I felt a tightening in my throat as flood of nausea rushed over me. I left the unit quickly, before anyone could see me cry. These words have stayed with me long after the tears have dried. What had I done to help? How was I any different than all the people who had abandoned him in the past? Had I done more harm than good?
The patient did eventually get discharged. And he did get readmitted months later, once again decompensated and not taking medications. Once again devoid of the hope and meaning I so badly thought I could help him discover.
Since this patient, I have had many opportunities to terminate care. I still catch myself by surprise every time I get choked up saying goodbye, and I still wonder if I did anything to help the patient in front of me. I desperately want to believe our time together did make their life more endurable, even if for a brief time. I suppose the hubris of believing you can save someone is equally as dangerous as the indifference of passionless care. There has to be some middle ground. That’s a procedure I’m still learning.
Kathryn Kinasz, MD is a second-year adult psychiatry resident at the University of California San Francisco. She plans to complete a child and adolescent psychiatry fellowship after her adult residency with a research focus in eating disorders. In her free time, she loves yoga, pizza, and an occasional run by the ocean.
Illustration by April Brust