I had just finished my 8-week rotations. And with arguably misaligned priorities, I welcomed my psychiatry rotation because it was notably less time consuming than others. Prior to beginning this rotation I hadn’t put much thought into what I wanted to get out of the experience, it was just sort of…there. This isn’t to say that I did not have an initial sense of respect for the field. My best friend in medical school plans to be a forensic psychiatrist and her passion for the field is infectious. I have, by osmosis, obtained a surprising knowledge base of serial killers, true crime, and everything in between….but I digress. What I did not foresee was that the six weeks I would spend on psychiatry would give rise to some of the most fulfilling clinical experiences that I have had thus far.  

For the first two weeks of my psychiatry rotation I was on the consults service. For those not familiar with what exactly that entails, it is essentially the service that tends to the psychiatric needs of anyone on a medical floor of the hospital who is being treated for a primary medical illness. I was most nervous about this service, and my discomfort stemmed from my inexperience with how to evaluate psychiatric patients. I knew what questions to ask about chest pain, but hallucinations? Delusions? A completely different animal. I assumed that patients would not be open to discussing their psychiatric history or current battle with psychiatric illness. I have never been so wrong. Somehow, after initially entering the room and explaining that you are working with psychiatry, patients are more than willing to discuss the most personal aspects of their history. For me, this had never been the case when working on a medical service. Bringing up alcohol or drug use had previously begged a follow-up “what does that have to do with anything?” What I came to understand while on consults was that, in fact, it has to do with everything. I had previously never appreciated the impact mental illness and substance abuse had on the overall health of the patient. Consults came in every age, race, size and gender. They came with the heart attacks, the diabetes, and the broken legs. Psychiatrists have the privileged position of  being allowed into the darkest part of patient’s lives, to view patients through a lens often inaccessible to other specialties. Perhaps treating an individual’s depression would allow them to get out of bed long enough to exercise, cook healthy food or follow-up regularly with their PCP.  

My next stop was the Older Adult Behavioral Health Unit. The soundtrack of this previously unexplored wing of the hospital was essentially the same each day: a little old lady in a chair by the nurse’s station yelling “help” over and over for no reason, someone violently protesting being assisted in the shower, another person yelling “get out of my room!” to the psychotic wanderer. I found it ironically charming. Everyday I would follow the same patients and talk to them about how they felt they were doing, “what did you learn in group sessions yesterday?,” “how do you feel about your medication adjustment?” “Any thoughts of hurting yourself or others?” “Who do you think is stealing your money?” I developed a special relationship with each one of my patients and upon discharge a few of them thanked me for helping them. Let me repeat that. I, a third year medical student whose only skill is taking up space, actually was being thanked for really helping someone. And, I got a hug! It occurred to me that although I could not make the final decisions related to patient care, nor could I place orders or write for medications, I could talk…and more importantly I could listen. I knew these patients well and was actually contributing to the treatment team. I had the privilege of being on the journey with them as they gained insight into their conditions. It was remarkably unique and unexpectedly rewarding.

My last stop was the Adult Behavioral Unit. These patients are younger and tend to have more energy, as well as more recent diagnoses of psychotic disorders. I did a lot of patient intakes; these are essentially hour-long conversations about every aspect of these newly admitted patient’s lives. Through the course of the interview you start on the surface — lists of previous admissions to the psychiatric unit, lists of drugs they have abused, lists of attempts at suicide. You read prior notes about patients getting violent in the ED, notes describing behavior unparalleled in bizarreness, but I always tried to access the nucleus of the patient in attempts to understand what they really needed from us. If you spend enough time, you can find the human in most people. These were people that, on paper, I should have been scared of…but I welcomed the challenge of looking beyond that.

Thus far I have made psychiatry sound like glorified therapy, which it most certainly is not. So, let’s talk about medication. Many non-medical folks naively believe that people with psychiatric illness may be over-medicated, and that we should be “trying to get to the foundation of the problem instead of covering it up with drugs.” These are patients that are ill, have detrimental chemical imbalances, structural changes to their brain, and voices telling them to harm themselves or other people. Most don’t need a long leather couch and a tissue box, or to be incarcerated; rather, these patients need us to employ our current understanding of these disease processes in order to help them become functioning members of society who are not a danger to themselves, or others. For many these illnesses will be a lifelong struggle, but we do the best we can. My experience in the Adult Behavioral Health Unit allowed me to see the effects of these medications — I saw people who were, for lack of a more descriptive cluster of words, out of their damn minds. I saw people who were so depressed they physically could not move. I saw people who had so many racing thoughts they simply could not function. I also saw all of these people get better. After a few days, weeks, or even months of medication adjustment I was able to go from being randomly yelled at in the hallway to hearing my patients play guitar, or tell me about their kids. It was, in many ways, remarkable.

Last year I told my friend that I believe she is attracted to the field of psychiatry because she finds most people annoying or obnoxious — bare with me here. In medicine you encounter a lot of unsavory people who treat you terribly because they just…aren’t great people. But, in the psychiatric population, there is usually a reason for someone to yell obscenities or show aggression, essentially pathology behind being a jerk. I think there is a twisted sense of comfort in this. Comfort in accepting that mental illness is, and should be treated like any other medical condition; and that hopefully psychosis or depression can be alleviated in the way we alleviate physical pain. I am deeply grateful for everything I learned on this rotation, particularly as someone who plans to work in Emergency Medicine. Patients are often at the peak of their struggle with psychiatric illness when they enter the emergency room and I firmly believe a little empathy will go a long way. When I encounter a frustrating psychiatric case in the middle of the night in the ED I will always think of the patients that let me into their lives, and the lessons they provided me. This is the least I can do in helping to make progress towards appropriately addressing mental health in this country.

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