people part two: patients

I came to medical school for real people stories. Blogging by nature is self-involved and I usually have little to write about other than myself, which in college I found to be the main thing I wanted to change about my life. The first year of school has been fulfilling in huge part to feeling that, albeit very slowly, I'm on the way to doing that.

We've been introduced to patients in different ways. One of my favorite classes this past semester was Biological Basis of Behavior, which had us study a small corner of psychiatry on a neurobiological and personal level. After each lecture a patient with an illness related to the lecture came in to talk to our class for an hour. This included PTSD, drug addiction, schizophrenia, OCD, binge eating, depression and narcolepsy. The thing that really struck me about them, overall, relates to something Allison once said about how psychiatric disorders are on the extreme end of a spectrum that we're all a part of. For these people, the things we all do were greater in degree and longer in duration.

It was hard to see how memories plagued the Vietnam veteran with PTSD so longer after the war. I always thought my memories lingered abnormally long, but here was a person defined against his will by his past. The man with drug addiction was a doctor, whose career had been put in jeopardy because of his problem. He had real insight into his disorder; he seemed to understand its character so well, even as he knew that despite that knowledge, it was still a struggle to battle it. Don mentioned that his articulation was a function of his education, and that perhaps this insight doesn't come across as clearly with other patients. I hadn't thought of that, and makes me wonder how much expression really conveys comprehension, and what I need to learn to see people beyond what they're capable of showing. I wrote a little about the woman with schizophrenia in the last entry. She was shaking slightly as she spoke to us, I remember her sitting on her hands, and she shared the big and little of her life with us. The narcoleptic person talked about not being able to keep a job, how he was often let go. He said, "I should've been more of a fighter when it came to doing things for myself. I just thought it was time to move on." The man with OCD was a lawyer, whose disorder seemed to pervade his life but he also said no one but his wife and mother knew about it, said that he was good at hiding it. Made me think that patients' relationships with themselves, and with their disorders, are pretty complex. He had an incredibly patient wife, to whom he would relate all the little things that drove him nuts, each night. He'd list the things throughout the day that he obsessed about--did he lock that key, did he mail that letter. And she'd listen, and tell him he was being ridiculous. I remember being frustrated with the interview with the man with a binge eating disorder, because the questions asked of him weren't at all conducive to getting his story. Afterwards a few students came up to him to ask him more, and in those few moments we learned a lot. The absence of something made me feel a little better what I seek.

The man with depression gave us something singular. The other patients told us about their illnesses, but this patient experienced his illness right in front of us. He shed tears continuously through the interview, often without any stimulus. His wife had passed away in the eighties, and he had symptoms of depression back then but it didn't come on full-strength until a few years later and has lasted since then. When asked by a student whether he had any long-term goals, he interpreted the question as asking him what kept him going, in the face of such debilitating depression. He said that that day, his goal was to get to our class. On some days, it was to brush his teeth. He said: "Do I think it's strange that it's been so long, that it hasn't gone away? Yes. Why haven't I given up? Is there something? I don't know." After a few moments, he said, "I hope to get better."

This question brought me back to a conversation I had with the classmate who asked it, a bit earlier, after our pre-clinical clerkship session at the nursing home. Another way we've been introduced to patients and patient care is through pre-clinical clerkship, weekly sessions that expose us to different areas of medicine. We've learned to do physical exams on newborns, interviewed child/adolescent patients, examined and described art to hone observation skills.

My favorite this semester was the geriatrics session, where we performed mini-cognitive tests on the residents. I was bit blown away by how every group discovered cognitive deficits in their residents; I've been so used to practicing the neuro exam on my classmates who have mastered saying the months backwards. The patients we saw couldn't draw clocks that depicted 4:30, or think of more than a few words that started with A. The person my group spoke to knew it was April, but when asked what season it was, she paused. Instead of looking back through the window behind her for a clue from the weather, she stared ahead and I wondered what she was looking at or for. Then she said, fall and I think all of our hearts broke a little.

On the shuttle ride back to school, the classmate and I talked about the session. He'd found it depressing, because he placed so much value on cognitive ability, our capacity to think about our lives and what they're for. I told him I agreed, but that I also liked geriatrics. In the most kind way, he asked me what the point was. I didn't have too good of an answer then, aside from my usual perspective of trying despite an end, because isn't that what everything is on a large scale. Talking about it afterwards, I realized that it's about experiencing things, more so than thinking or expressing. I can't really say what those geriatric patients feel or think, but they must experience. Even if I can't ever understand it or connect to it in a conventional way, it feels worthwhile, maybe all the more so because it's fragile and remote. It feels more moment to moment, rather than continuous with memories and goals and future. With the person with depression, he didn't seem to be thinking about purpose. He just wanted to get through each moment. He just wanted to experience the next second.