The best physicians heal their patients, but in turn, heal themselves and face the depths of human vulnerability and suffering, pursuing a meaning much greater than themselves.
Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Ramin Rajaii, a medical student at the University of California, Irvine School of Medicine and MBA candidate at the Indiana University University Kelley School of Business. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.
I stepped into the room, a wary medical student on the second day of my psychiatry rotation. My task: interview three patients, present their stories at morning rounds to my attending physician. Simple, I thought to myself. But I was already so jaded and disillusioned.
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I was considering a nonmedical career. Medicine was broken, insurance companies were thieves, providers were superficial in their care, patient-centered care was anything but. Throughout three years of medical school, I had been hospitalized for depression three times, once placed on a 51/50 psychiatric hold, confined to a mental rehabilitation facility, been diagnosed with bipolar disorder, experimented with seven medications and am now pursuing TMS (transcranial magnetic stimulation) as a last resort for treatment-resistant depression. I was emotionally and spiritually broken-frozen-yet ironically the poster child for the very rotation I was embarking on.
My expectations for this experience were slim, at best. I had myself been a patient too many times. I knew exactly what it was like to show up in the ED so anxious you’re deemed psychotic. I knew exactly what it was like to wake up in a hospital bed in rehab with a roommate-a middle-aged disheveled man-who was constantly crying and threatening to kill himself if you left the room. I knew exactly what it was like to be stared at, poked and prodded, your symptoms thrown into the gears of clinical analysis, evaluation and deduction, then churned out as a generalized diagnosis that seemed to check the appropriate boxes.
Called unstable, unorganized and irrational by the treatment team-mere steps outside of your room. Involuntarily held indefinitely, forced to participate in group therapy with heroin addicts, ex-prostitutes, victims of domestic abuse; take mandatory “smoking breaks”; be “tweaked” with antidepressants and antipsychotics until you were numb to all around you. Depression and anxiety had taken so much from me; all efforts to help me were futile and superficial. I cringed at the thought of serving as a provider in the very system that had let me down.
I placed my hand on the bed, with the patient-let’s call her Amanda-turned away from me. I introduced myself. “I’m Ramin, the student doctor, it’s a pleasure to meet you.” I waited. Nothing. I tried again. “Could I get your name?” Still nothing. The nurse shook her head in resignation. I walked a few steps to face Amanda, reclined in her bed-a frail, pale middle-aged woman stabbed with multiple IV lines, gripping a bible tightly to her chest. Did she not hear me? Was she angry? Was she mute? Had I already done something wrong? As questions and insecurity seethed within me, the nurse whispered, “She’s catatonic.” With utter confusion, I excused myself to the hallway to hastily Google the word. “Catatonia: an abnormal neuropsychiatric condition that results in unresponsiveness in someone who appears awake, characterized by stupor, mutism, negativism and posturing.” According to Psychology Today, it could apparently be caused by any number of situations-severe vitamin B12 deficiency, infection, exposure to toxins, extreme trauma or schizophrenia.
I stepped back into the room. “How long has she been catatonic?” I asked the nurse warily.
“91 days. She doesn’t even eat or drink anything. We’ve had to put her on total parenteral nutrition just to prevent her from dying. Her condition has deteriorated. And she shows no sign of improving.”
I had prepared a study guide of questions I was to ask in my interview. A check-list for bowel movements, diet, suicidality, homicidal ideation, auditory and visual hallucinations. I stuffed the sheet back in my pocket. I looked at Amanda and caught her gaze. She stared at me, past me -through me-with the most sunken, sullen eyes. At that very moment, I knew what the gaze of true hopelessness looked like. I asked her how she had slept. I asked her what she was reading. Nothing. She was completely motionless, unresponsive, rigid, inflexible, gaunt-frozen.
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I stepped out. I rushed to my attending physician in utter disbelief. “There MUST be something we can do for Amanda. She’s hypoglycemic, hypotensive, she refuses all meals and drinks, she is literally wasting away before our eyes. Why? There must be some medication to help her.” My attending gave me a stern yet understanding expression. Amanda suffered from catatonia of unknown cause, he told me.
B12 deficiency, infection, trauma, schizophrenia, mood disorders-all ruled out. We literally had no idea why this poor woman ate nothing, drank nothing and moved not an inch. My attending had tried various antidepressants and benzodiazepines-a sedating class of medications that ironically helps in catatonia-to no avail. Amanda had been hospitalized for three months, currently weighed 79 pounds and was refused to be admitted by the Medicine Department because they did not view “catatonia” as a legitimate medical ailment. I was utterly enraged. How could the docs in internal medicine not accept someone dying right before our eyes? The psychiatry team would constantly consult Medicine as a way to pressure them to continue being involved in Amanda’s care. This was the best they could do.
My attending placed his hand on my shoulder. There was still hope, he said: Electroconvulsive Therapy (ECT). According to the literature, ECT-a targeted shock to the brain, under general anesthesia-provides 80-100 percent relief in catatonic patients, even in those whom pharmacotherapy with benzodiazepines has failed. A wave of relief overcame me at once. She won’t waste away after all, I thought. I asked why ECT hadn’t been carried out already. My attending, with a drawn-out sigh, explained that because she is completely mute, she did not have the capacity to provide legal consent for the procedure.
For the past month and half, her father had been navigating the process of applying and being approved as a court-appointed surrogate or proxy. A month and a half. The father felt stuck within the gears of the medical-legal system, helpless, while his daughter deteriorated, while her hope, her body and her mind withered away. The glimmer of hope that came to me quickly vanished. A system that had once failed me, was now failing Amanda.
This is when I realized that medicine was not simply the sum of objective, calculated clinical decisions. So much of the power of healing came from nurturing the patient, guiding the family, offering a light at the end of the tunnel, even when the odds were stacked against you. Medicine was not a one-way road of healing, either. The best physicians heal their patients, but in turn, heal themselves and face the depths of human vulnerability and suffering, pursuing a meaning much greater than themselves.
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I made a resolution to update Amanda’s father every day, to help him find an attorney, to be at Amanda’s bedside each day, without words, just present. There were some good days, when she would smile or chuckle in response to jokes, and of course bad days when it seemed she was just withering away. But throughout this humbling process, I discovered that my own depression was slowly withering away. A fire had been lit within me; a fire of meaning, of purpose, of humility as a student doctor. A fire that unfroze me. A fire that we must never forget in order to provide the utmost compassion, sincerity, and humanity to those we care for.
As fate would have it, one month later, while on an elective in child psychiatry, a staff member was speaking about a patient on the adult inpatient unit who had finally received shock therapy. I turned rigid. I immediately ran toward the unit, stopping briefly only at the nurses' station to inquire, "In which room is Amanda staying?" I stepped into the room, watchfully, greeted by the same face I had seen unmoving so many times. But this time, her mouth moved. She spoke. She spoke in full sentences. She was responsive; she had been eating. Her voice was tranquil and deliberate, just as I had always envisioned. Her memory was moderately intact, her affect bright. A single tear trickled down my face. Extraordinary.