A Chronicle for Psychiatry Applicants
Written by Julio Cesar Nunes, MD
Z is a young man, in his early 30s, and on the autism spectrum. He has a long history of psychiatric treatments, is struggling with polysubstance use and schizoaffective disorder, bipolar type. He bounces between homelessness, a group living facility, and inpatient rehabilitation. Z’s life is permeated by trauma from conception to present, struggling with neglecting parents and a court-appointed conservator, in a family where every other member lives with some form of severe mental illness. He was deemed incapable of decision-making at age 19. Medications of all kinds have been forced on his body. His life is a constant waiting game between inpatient hospitalizations. Two overdoses per year, on average. Loneliness. Lack of autonomy. Helplessness. Hopelessness.
Dr. Silva is a first-year psychiatry resident. Excited about his new inpatient rotation, he wakes up before the alarm clock with a fresh pair of scrubs and a mug of warm coffee. Silva really wants to help his patients and meets Z with enthusiasm. Still unaware of the structural fragility of the mental health care system, he believes he could be the one to change this patient’s cycle of hospitalizations. Silva’s enthusiasm was welcomed by supportive social workers, nurses, and attendings. Silva has everything: the will, the support, the team, the structure. However, in his rotation, he would learn 3 valuable lessons (and none of them about pharmacology!).
First. Good intentions must respect autonomy.
Silva had learned everything about antipsychotics and their different formulations. Long-acting injectables could be the solution to Z’s medication non-compliance and lead to longer-term stabilization. Unfortunately, Z had been subjected to years of well-intended injections that, despite theoretical benefits, failed to break the cycle. Z was traumatized, he would not accept the needles again. Silva saw his patient’s fear as they discussed such drugs and thus, decided to let go. The benefits of any medication would hardly outweigh the trauma of yet another unwanted injection. Ultimately, nobody knows the patient better than the patient himself.
Second. Some medical decisions are emotionally hard to make.
Z had been in the hospital for 34 days. He was a vegetarian, and the hospital cafeteria had once again failed to provide him with food he could eat. He did not understand why he even was in the hospital! Hungry, tired, angry, lonely, and untrusting of others, Z became agitated. He feared the nurses, doctors, and needles. Silva was called to deescalate, his attending busy at a meeting. Despite his best intentions, Silva had to think about everyone’s safety. Thorazine, intramuscular, needle. Z was scared. Silva heartbroken. Two security guards held Z down on his bed while a nurse injected the drug. Good intentions. Caring team. Nonetheless, safety came with the cost of reinforcing trauma. Despite being praised for his fast decision-making and good outcome, Silva cried that night.
Third. “To cure sometimes, to relieve often, and to comfort aways”.
Silva was inexperienced, as most interns naturally are, and he had high hopes for his patients. He expected his medications to completely wipe out the psychotic symptoms, alleviate depression, to cure the obsessions. He would soon learn that psychiatry and palliative medicine shared many of the same fundamental aspects. In asking Z about his personal goals of treatment, Silva would start questioning his own. Would Z ever be able to live independently? Go to college? Have a steady job or a family? In this case, treatment was certainly focused on allowing Z to be happy, in whatever way he could. Z taught Silva one more important lesson: life is threaded differently by each person, and what works for one might not be another’s dream. Z might not be able to live independently, but he could enjoy life playing his favorite instrument, the piano, at the group living facility. He could feel seen as Silva refused to force medication on him. He could feel protected and loved as his case manager picked him up on discharge day. We may not cure psychosis, but we can support our patients in their personal journeys.
If you are applying to psychiatry, I beg you to reflect on what our beautiful profession is about. Me and Silva share the frustration of not being able to achieve everything we want to for our patients, but we keep on working knowing that the smallest actions can help break cycles of trauma. Trust me, you will encounter many patients like Z in your career — I have just started mine and I meet them daily! When frustrated, angry, or sad, remember what attracted you to medicine in the first place, the vows you made, the promise to help others, and I am sure you will go far.
