Related: 1/4, 2/4

[Content warning: psychiatry, suicide. Note that all stories involving patients are mixtures of several different people which have been obfuscated and changed around in order to protect confidentiality. The ethical standard I have heard in this situation is “must be so well disguised that the patient would not recognize himself if he read it” and I have tried to meet that standard – which means that these capture the spirit of situations only. The same is true of some of the other stories here, just in case. Please do not link.]

I.

I’m back at Our Lady Of An Undisclosed Location hospital now as a final-year resident. You wouldn’t think a year would make so much difference, but it does.

Identifying residents by their year is easy. The first-years walk around, deer-in-the-headlights look to them, impossible to confuse with anybody except maybe a patient having a panic attack. The middle-year residents are a little more confident. And then the final year residents, leading teams, putting out fires, taking attendings’ abuse in stride.

(True story – last week an attending yelled at me for not knowing some minor detail about uraemic encephalopathy. Later I couldn’t find the detail he’d mentioned, so I asked for a reference, and he said it had been discovered by one of his friends at the big university hospital where he used to work, but the friend had died before he could publish his findings. I think the attending realized as he was talking that it might have been unreasonable to expect me to know a fact whose discoverer took it to the grave with him, but he didn’t apologize.)

It’s only sort of a facade. 99% of things that happen in a hospital are the same things that happened yesterday and the day before, so if you hang around long enough you can learn what to do, or at least which consultant you can call to make it not your problem anymore. On the other hand, Actual Pathology is still a gigantic mystery. I’m not sure this ever changes. One in every X patients with symptoms won’t have any of the things that could possibly be causing those symptoms, won’t respond to any of the treatments that are supposed to cure those symptoms, and you’ll still have family members and hospital administrators demanding that you fix it right now (and in psychiatry, X is probably a single digit number). All you can do is keep up the facade, put your skill at taking attendings’ abuse in stride to good use, and start learning necromancy so you can summon the one big university hospital researcher who studied it but never got a chance to publish their findings.

II.

Two of the most important things I learned during my third year were “Tell me more” and “[awkward silence]”.

“Tell me more,” works for every situation. Part of the problem with psychotherapy is that you’re always expected to have something to say. As a last resort, that thing is “Tell me more”. It sounds like you’re interested. It sounds like you care. And if you’re very lucky, maybe the patient will actually tell you something more, as opposed to their usual plan to stonewall you and hide all possibly useful information.

I saw something on Tumblr the other day which, despite being about a 9-1-1 operator, perfectly sums up being a doctor too:

my bf has many interesting stories and observations from his new job as a 911 operator my favorite is how meandering people are, even in the midst of a terrible emergency they respond to “what is the emergency” with “well, the thing is, four weeks ago–” and then he’s like “WHAT IS THE EMERGENCY RIGHT NOW” and they’re like “so what happened this morning was, i said to my wife, i said–” “WHAT IS CURRENTLY HAPPENING AT THIS MOMENT” “oh i’m having a heart attack”

And:

my second favorite is how specific he has to get sometimes like, “what is your emergency?” “i’m sitting in a pool of blood.” “… is it… your blood?” “yes i think so” “do you know where it’s coming from?” “probably the stab wound” “have you been stabbed?” “oh yah definitely”

Psychiatry is like this, except it’s all very vague, and your patients are really suggestable, and people are always afraid that if you just ask specific questions like “Are you depressed?” then they’ll say yes to make you happy and won’t talk about how the real problem is their anxiety or something. So instead, the patient says something like “I’m sitting in a pool of blood”, and I say “Tell me more…”. They say “Well, it’s my blood.” I say “Tell me more…”. After repeating this process a couple of times, we finally get to the stabbing, and the patient doesn’t feel like I railroaded over their chance to tell their story.

Or it helps you figure out what’s important to the patient. If someone said “I hate my husband so much,” my natural instinct might be to ask “Why?”. But maybe why isn’t the question the patient cares about. Maybe what she really wants to talk about is how guilty she feels about hating their husband, and if I asked her why then we’d get on a tangent about what the husband is doing that never addresses her real problem. Maybe she’s agonizing every moment about whether or not to divorce him, and losing sleep over it, and coming to me for a sleeping pill. Maybe she’s just hatched a plan to kill him and wants to check it over with me to see if I can find any flaws. In any case I should probably figure out why they hate him eventually, but if their real issue is whether or not I approve of their murder plot then we should probably get to that first.

So instead, it’s “I hate my husband so much.” “Tell me more.”

“I’m feeling depressed.” “Tell me more.”

“Sometimes I think life isn’t worth living.” “Tell me more.”

“Listen, if you don’t give me a prescription for Adderall right now I swear to God that I will stab you right here in this office!” “Tell me more.”

This has seeped into my personal life. I was on a date with a girl earlier this year, and whenever she started telling me about her life I would just say “Tell me more”, and it worked.

And then there’s [awkward silence]. I learned this one from the psychoanalysts. Nobody likes an awkward silence. If a patient tells you something, and you are awkwardly silent, then the patient will rush to fill the awkward silence with whatever they can think of, which will probably be whatever they were holding back the first time they started talking. You won’t believe how well this one works until you try it. Just stay silent long enough, and the other person will tell you everything. It’s better than waterboarding.

The only problem is when two psychiatrists meet. One of my attendings tried to [awkward silence] me at the same time I was trying to [awkward silence] him, and we ended up just staring at each other for five minutes until finally I broke down laughing.

“I see you find something funny,” he said. “Tell me more.”

III.

If the patients are cryptic, the doctors are even worse. In a worst case scenario, I’ll be filling in for another doctor – this happens all the time at free clinics, but it happens at least a little wherever there are doctors who go on vacation. The documentation will be obscure or missing. The patient’s family is out of contact range. My only information will be the patient in front of me, whose information-transmitting ability is on par with that person from the Tumblr post who took four tries to mention that they’d been stabbed.

So imagine this – a guy from out of state moves in, comes to me without any documentation, and says in a monotone that his only problem is feeling “weird”. All my “tell me mores” and [awkward silences] fail to get him to explain further. I look at his medication list, and he is on a cocktail of supramaximal doses of really old-school antipsychotics that I could not imagine giving anybody unless they were an axe murderer who had killed their last three psychiatrists and I wanted to cool their metaphorical brain temperature to the level of winter on Pluto. Sure enough, the guy is stiff, displays no emotions, and his only hobby is staring at the wall – all exactly what you would expect of somebody who is super-drugged on all of the strongest chemicals known to mankind. I ask him if maybe he’s schizophrenic, or bipolar, or something. He says no, he just feels “weird”.

I know that if I don’t change the medication, he will probably be a zombie like this until such time as somebody else does change it, which may be never. But if I do change the medication…well, there must be some reason somebody put him on that, and the idea of somebody who needed that much medication not being on it is too horrible to imagine. Also, I’m only seeing him once, and then he gets transferred to someone else. What do I do?

The maxim is “do what lets you sleep at night”, so I punted. I kept him on his medications and turned him over to the next guy. I just hope the next guy gets my documentation instead of thinking “Dr. Alexander kept him on all this medication…I wonder what he knows that I don’t.”

IV.

“Instead of putting patients on these toxic medications, why don’t you just give them therapy?”

Sometimes I worry I might be the worst person in the world to do psychotherapy. My coping strategy is to not talk about or react to my emotions and wait for them to go away. This usually works. I know this is exactly the opposite of what psychotherapy is supposed to teach, and all I can say is that it works for me and I seem to be pretty psychologically healthy and maybe I am just a mutant.

My relationship strategy is the same. Date really low-conflict, low-drama, agreeable people. If we have a conflict anyway, then agree to disagree and wait for the problem to go away. Apparently this is terrible, and maybe this is why my only really serious relationship only lasted a year or two, but it leaves me with something of an understanding deficit for the people who want to replay every single argument they’ve ever had with their spouse and figure out exactly what it means about their mental state.

Heck, even polyamory is like this. I can’t tell you how many patients I’ve had come in because their partner is cheating on them, or they worry their partner is cheating on them, or they’re cheating on their partner, or their partner worries they’re cheating on them, or something, and my natural instinct is to just say “Have you considered not worrying about it?” and as usual my natural instinct is terrible. So instead I just say “Tell me more…” and listen to them describe how the possibility of their girlfriend cheating is rending their heart in two.

This is even worse in any form of therapy based around investigating childhood traumas. Look, I’m sorry you didn’t like your mother, but have you read The Nurture Assumption? But of course I can’t say that. I just have to play along. And then somebody expects me to come up with something to heal the maternal trauma that I’m not even sure people really have, and then if I do come up with something it feels like a clever fake.

Cognitive behavioral therapy is a little better, because it tends to be pretty common sense techniques that any reasonable person would agree with. The problem is, it’s pretty common sense techniques that any reasonable person would agree with. I think that I and most of my friends would respond to the average CBT session with a sort of anger at being condescended at, combined with annoyance at the therapist for wasting our time with obvious things. “My job sucks”. “Well, have you considered making a list of good and bad things about your job?” “Yes, that was the process by which I determined it sucks. How much am I paying you again?”

Most of the time I do therapy, I feel cringeworthy, unnatural. I feel like a fraud, even when (according to the supervisors watching me) I’m doing it exactly right. I feel like I’m responding to people in fake, silly ways, like they’re coming to me with problems from the depth of their being and I’m giving them facile non-answers. It doesn’t even help that most of them get better anyway. In a way, that just makes it worse. How dare you get better after me telling you stupid things I feel embarrassed to say? That’s just going to encourage people to make me keep doing that!

V.

I nevertheless hold a special place of annoyance in my heart for psychoanalysis/psychodynamic therapy.

The attending who started my training in psychodynamic therapy (I got a new psychodynamic supervisor recently who I don’t know too well yet) was an elderly doctor in an office attached to the clinic, full of creepy modern art statues. He is convinced that patients’ lives revolve around their therapy and their therapists. I know that in moderation this is the idea of “transference”, a genuine and important tenet of the therapy style. My attending does not do it in moderation.

My patient will say something like “My best friend moved away and now I am sad”, I will think “That sounds straightforward, better bring it up to my attending and see how he wants me to deal with this.” My attending will invariably say “What your patient means is that he’s afraid of losing you, his therapist.”

I will say “No, I’m pretty sure he actually lost his best friend. He told me all about how they’d been together since middle school, but now he moved away to take a job in Texas, and then he broke down crying.”

Then my attending will get really angry and tell me that if I’m just going to take everything my patient tells me exactly literally, then I shouldn’t be in psychiatry, because a monkey could listen to a patient say he was sad about losing his best friend and conclude he was sad about losing his best friend, and my duty as a trained professional is to be able to see beneath that to the true thought which my patient is trying to express. Which is always, 100% of the time, about how much the patient cares about psychodynamic therapy and wants to continue doing it.

Even worse, he wants me to do this to the patient. When the patient says “I’m really upset about losing my best friend”, I’m supposed to answer “Are you sure this isn’t about how you’re worried I’m sort of like a friend to you and one day you’ll lose me?” If talking about relationships and cognitive therapy makes me cringe, this super quadruple makes me cringe.

Still, I have to do it, because my attending grades me and if I don’t pass psychodynamic therapy I don’t get to graduate. So I do it, and then my attending declares he was right all along based on extremely strained interpretations of whatever happens next. Like, if the patient misses their next appointment, he’ll say “I see your patient missed their next appointment. That means they’re having a defensive reaction to the fact that you called them out on their being afraid of you leaving them. And to think that you told me you weren’t sure that was true! This just shows how much you still have to learn about psychodynamics. I certainly hope that after this you won’t keep questioning me every time I try to help you.”

But when I leave for good, I’m getting him a present, and it’s going to be a copy of The Nurture Assumption. Heck, maybe I’ll give that to all the psychoanalysts I know.

VI.

It’s kind of morbid to feel smug about your patients not attempting suicide, but I guess I am a kind of morbid person.

The doctor down the hall from me had one of his patients attempt suicide in October. Then another doctor I knew had two of his patients attempt suicide in the same week in January. And I was really sympathetic and tried to comfort them, but I also had a part of my mind thinking “Hey, I haven’t had any of my patients attempt suicide yet, this is pretty good.”

March. April. May. My coworkers told me their stories, but I kept my secret morbid goal – I was going to go the entire year without any of my patients trying to kill themselves. I mean, on one hand this sounds like a pretty minimal standard. On the other, when you’re taking care of like a hundred mentally ill people, many of whom have really bad depression and a history of past suicide attempts, it’s not exactly trivial.

I got the call just a few weeks ago. The patient was a former heroin addict who had been clean for a long time. He slipped, took heroin, felt terrible, and stabbed himself in the heart.

Luckily the heart is a little to the right of where most people think it is. Stabbing yourself in the lung isn’t great either, but he was a young healthy man and he could take it. He went to the hospital, they patched it up a little, and he was fine. He said it was the best thing that had ever happened to him and now he knew how low he could get and he was going to stay clean forever and today was the first day of the rest of his life.

A lot of things in psychiatry are reverse lotteries. In the regular lottery, you pay a constant small cost for the possibility of a stupendous benefit. In the reverse lottery, you get a constant small benefit at the risk of a stupendous cost. Lots of things are like this. If you give someone a powerful medication, then they’ll definitely recover, but there’s a risk you’ll have a catastrophic side effect. If you let a severely ill patient leave your office when they promise they’re okay, then you definitely save them the trauma of an involuntary hospitalization, but there’s a risk they’ll do something disastrous. If you don’t check someone’s vitals every time you see them then it definitely makes the appointment quicker and smoother, but there’s a risk you’ll miss something really bad.

It’s really easy to fall into playing reverse lotteries. I think almost everybody does it to a degree. The usual pattern is to play some of them tentatively, do more and more of them as you reap the benefits and nothing goes wrong, then boom, close call, and you resolve never to do anything like that again and you’re going to do a full half-hour neurological examination on everybody who comes into your office including random passers-by who just want to use the bathroom.

After my patient stabbed himself I spent a week totally neurotic, looking over every aspect of his case – could I have checked up on his Narcotics Anonymous meeting attendance more frequently? Maybe if I’d given him a long lecture every appointment about how heroin was definitely still bad, that would have changed something? Maybe if I hadn’t forgotten to check his blood pressure that one time…? In the end, I decided I had done a pretty okay job on that case – which just made me more acutely aware of all of the reverse lotteries I was playing on everybody else. Now I’m a little bit paranoid. Maybe that’s temporary. Maybe it’s permanent. I don’t know. The DSM-V says you have to have it six months before you can give yourself a schizophrenia diagnosis, so there’s that.

I am getting good at dealing with annoying attendings, meandering patients, unreasonable requests, and silly bureaucracy. Actual Pathology remains scary, mysterious, and really hard to predict. Hopefully that’s what fourth year is for.