The middle-aged veteran curled up on the uncomfortable foam mattress appears irritated. Perhaps he is irritated at himself, knowing that he has gone through this process multiple times, or irritated at his providers, who simply think of him as a chronic alcoholic. I greet him for the first time, sitting on the empty bed opposite him. I ask him a set of questions that I must go through with every patient each morning, ending with the most critical one: “do you have thoughts of hurting yourself?” Despite his disheveled appearance – which I attribute to those overly large, horrid brown, hospital gowns – I sense the swirl of emotions being processed. He curtly replies “no” and turns to face the wall.
I wonder what he is thinking. Is it that he is ashamed of having relapsed for the fifth time while pushing away his family and friends; or the prognosis about his decompensated cirrhosis has eroded his will to live; or that he has repressed such thoughts in a step to escape the austere environment of the inpatient psych unit? His reaction to my question is not uncommon on this service. Many patients simply prefer to be left alone. And for those who have been through the hospital system countless times and have met slews of doctors, nurses, and phlebotomists, a third-year medical student is the furthest person to understand his pain.
I return to my computer and begin to craft my plan for rounds. I have managed patients with alcohol use disorder before on my internal medicine rotation, but now I am approaching this from a psychosocial perspective. We are taught throughout medical school about good bedside manner; however, I find that the art of medicine is hardly emphasized. Superficially, inpatient psychiatry can seem impersonal: we bombard patients with questions, prescribe several psych medications, observe whether they respond and stabilize, and if they deny suicidal ideation, we prepare for their inevitable discharge the next day. If not, we return to square one. Throughout each patient’s stay, I begin to learn the nuances of delivering information, tactful questioning, and that pauses and silences do not always need to be filled. However, this entire process only takes a few days, which makes it difficult to forge deep connections and truly master these skills.
After rounds, my attending and I interview the patient together so she can log the interaction permanently into the electronic record. He sits in a chair centered under a metaphorical spotlight with a downcast gaze. We ask some starter questions, and then I begin to probe. But as a third-year medical student, my motivational interviewing skills are still imperfect. I hesitate when asking about sensitive subjects because I have not found the best words to convey what I want to say. I strike a chord — he begins to cry, but I find myself exposed as well. My stumbles have poisoned his mood, like food coloring in water. Frustrated, he bursts from his seat and announces to the team that I have failed this interview miserably, which is the last thing a medical student wants his attending to hear.
My attending is a seasoned professional. She knows that the most effective learning is through experience. She can sense my nerves as sweat beads on my forehead; her humor quickly alleviates the tension in the room. Recognizing a textbook state of projection, she assures me that his reaction was not my fault. I am reminded that having an experienced mentor to offer a fresh perspective is vital when navigating the first attempts at challenging conversations. It helps to learn from my missteps with patients and will prepare me to provide the same support to students in the future.
I visit him frequently over the next several days. Although he has not expressed suicidal ideation, he is still not well enough to be discharged. We talk about his past life as a car dealership consultant, his service to the Army, deployments during Operation Desert Storm, and his failed marriages. He proudly tells me he had 12 liters of fluid drained from his abdomen, and I cannot help but be impressed. As he becomes more vulnerable, my awkward pauses and forced phrasing melt away. My interviewing skills and responses become crisp and fluid – navigating us through a sea of dialogue toward a mutual understanding of his maladaptive coping mechanisms. It becomes time to discuss his goals for treatment, and together we explore rehab options outside the confining walls of the psych unit. He expresses that our conversations have empowered him to face the next leg of his journey; I feel the same.
When the day of his discharge comes, we finally fulfill his number one request throughout his stay: he wants his own clothes. I hand him his belongings, briefly embrace, and I head to my attending’s office thinking this is the last time I will see him. We hear a knock on the door and turn to see a man dressed in a bright tie-dye T-shirt, and matching orange pants and Converse shoes. The striking contrast to the drab brown hospital gown makes me laugh. He exclaims “this is how I usually dress!” and heads out feeling like himself again. I will never forget this last image of him, which always serves to remind me that patients are people. They will always have diverse backgrounds, styles, and personalities, and appreciating them as unique individuals not only increases the effectiveness of their medical treatment but makes all of us better physicians.
Albert Zhou is a medical student.
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