I met Winter under auspicious conditions. My first rotation since taking Step 2 in the field I actually want to go into—psychiatry. He had already been on the psych ward a few days. Admitted recently against his will following two other recent psychiatric admissions. A 25 year-old male wallowing in his first psychotic break.
Very high functioning prior to the break, but enjoying every second of feeling like god. The first information I heard about him in morning report: “Winter was cheeking his meds.” My first task: switch him to liquid antipsychotics. Our first conversation… very similar to the last, and every conversation in-between. He did not want to take his mind destroying meds.
Over the next three weeks, the same story. But because I was a psych ward novice, I could not accept the result. I dug into the data and printed out antipsychotic studies. I printed articles about the impact of antipsychotics on history, how most beds before Haldol were psychiatric, and how antipsychotics give people freedom. I even gave him Ken Kesey’s novel written from the perspective of a psychotic patient making his same arguments.
This taught me an especially important life lesson: boundaries.
I built rapport, spent time persuading and emptied out emotional capital. I noted the first signs of Parkinsonism and facilitated the switch to his antipsychotic of choice. I spoke with the mother. I spoke with the father. I coordinated a solid post-discharge plan with all parties. When I became overwhelmed with anger and frustration at the lack of fruit this effort yielded, my sage attending taught me about boundaries. Her favorite show is the Sopranos. She explained that in one of the final episodes, Tony’s psychiatrist freaks out and attacks him. “It was a blow to the psychiatrist’s ego that after years of therapy she could not change her patient.” For me, it had only been a couple weeks and I was new to psychotic disorders.
My patient had a terrible disease and Western medicine still struggles with severe cases. It was just as much as a failure of the healthcare and legal systems. Is it arrogant to believe that somehow you can be the one that makes a difference when so much is out of your control? He fooled me about not taking the meds or following through with our plan, but he was also fooling himself and couldn’t see it.
Failing to make a difference in every patient is frustrating when you start out, and I blamed the patient for his disease.
My attending knew I was compromised, but she wanted to see how I handled the pressure. What she did not fully appreciate is that I had done a lot of collateral work and obtained the medical records from the patient’s longtime therapist. I knew things about him that he had never mentioned to any other person. When we spoke about taking medications after discharge for the last time and he said: “[not taking medications] is a price I’m willing pay,” I lost it.
“When you stop medications, maybe some of that positive feeling of divinity will return, but so will negative emotions such as guilt.”
“Guilt? What are you talking about?”
“I spoke with your therapist about feelings of guilt you had previously.”
“Guilt about what?”
“Guilt about sexual orientation, guilt about gender identity…”
“What!?”
My attending turns to me immediately with a look of shock and scold that pierced my soul. I quickly changed the subject but the damage was done. To my grade, but more importantly to my own emotional and professional integrity. I knew it was wrong before I said it, but it just happened. It was an unconscious spontaneous utterance meant to harm. I had violated the Hippocratic Oath.
I recovered quickly and managed to dig myself out of the Freudian hole for better or worse. But I knew what had happened, and so did everyone else.
I am not a smart guy. I do not learn from the mistakes of other people. I need to make my own mistakes. Over and over and over again. And suffer the painful consequences. That is the only method that seems to work for me. To learn. The real lessons. The lessons about human behavior and my own behavior that I spend so much cognitive effort trying to conceal from myself.
“What’s the best predictor of future behavior?” my attending asks me in debrief. “Past behavior,” I sigh. “But I thought if I put more effort in, I could break the pattern.” “You voluntarily violated the integrity of your emotional and time boundaries, the result was an involuntary violation of your integrity as a physician. Happens all the time. Now you know.”