An excerpt from Becoming a Doctors’ Doctor: A Memoir.
After about six months of my residency in internal medicine, I began to feel something was missing, though at the time I couldn’t quite put my finger on it. Then, after a series of general medicine rotations, I started an elective in gastroenterology. This was a game-changer. Enter Dr. Bill Kiely, psychiatrist and chief of the consultation service to medicine. I had never met a physician, let alone a psychiatrist, like him before this time. He appeared on the ward, asked me to summarize my patients, then said: “Let’s go meet these fine folks, and I’ll see if I can help.” We walked together into the multi-bedded room, and the first thing he looked for was two chairs so that both he and I could take a seat by the patient’s bedside. What this magnificent man taught me is best conveyed by three pivotal takeaways.
First, yes, we’re the doctors here, and we need to figure out what’s wrong and fix things, but in order to do that, we should be at the patient’s level, not standing over and looking down on them and making them feel more diminished than they already are by laying sick in their bed.
Second, start your initial encounter with your patient by asking an open-ended question beyond: “What brings you to the hospital today?” or: “How are you feeling this morning?” Instead, Dr. Kiely would ask: “Tell me about yourself …” All of my patients were stunned by this question and would respond with a frown or a gesture of “huh?” to which he would say: “Let me help you. I’d like to get to know you a little bit. Can you tell me what you do for a living?” But then he waited for a response before asking the next question, then waited again. He talked to my patients as if he had all the time in the world. They opened up about what was going on in their lives before they started to get the awful cramping in their bellies or bloody diarrhea or vomiting or high fever and sweating, common medical symptoms of GI distress.
And third, that your patients are much more than their medical symptoms. You have to understand the context of their lives and how much factors like fractious or distant relationships with family members, unemployment, loneliness, religion, ethnicity, trauma, and so forth round out the picture. You need to treat the patient, not just the signs and symptoms of their illness.
I then was able to pinpoint what was missing in my training and the source of my frustration. Not only was this kind of psycho-social thinking rather foreign in internal medicine training of the 1960s, but it was almost impossible to put into action. There was no time, and you’d never be able to move onto your next patient, who was often critically ill and emergent. You needed to ask rapid-fire questions, complete your physical examination, and get on with your treatment plan.
In addition to this gnawing feeling that I’ve just explained, there was another thing on my mind, and this was not a complaint about internal medicine, indeed just the opposite. It was internal medicine that exposed me to suicide, more precisely, patients who had attempted suicide, and I learned how to treat them and often save their lives. But still, there were too many times where we didn’t save their lives, and this troubled me.
I treated many patients who had made serious suicide attempts. Overdoses of powerful sleeping medications and other barbiturates were not uncommon and lethal in high doses, and many of these patients died under my watch in our medical intensive care units without ever regaining consciousness. But despite my limited understanding of suicide in those days, and my busyness with treating my patients’ catastrophic medical problems, I struggled with the “whys” – why would such a beautiful young person want to die? What was so wrong with their life? Why do people lose hope? Walking out of the ICU into the waiting room and talking to their anguished relatives – their girlfriend or husband or mom or dad – was tough, and I had minimal training in this most vital dimension of being a doctor, the art of medicine. I was fortunate to have a number of compassionate attending physicians who were my role models. Their gift was helping me say: “I’m sorry … Sandra’s coma has deepened overnight and her blood pressure is falling” or “I’m very sorry… your husband died a few minutes ago… I’m sorry.”
I realized that training in psychiatry would give me the opportunity to understand suicide far better, and hopefully allow me to make a difference at an earlier stage. My exposure to psychiatry in medical school was clearly not enough. I was ill-equipped to fully grasp when individuals begin to have thoughts of suicide and when those thoughts progress into planning or researching methods – and then acting on them. As I thought back to the numbers of dead-on-arrival patients that I attended to in Detroit – dead by overdoses, self-inflicted gunshot wounds or stabbings, electrocution, asphyxia, drowning or jumping from tall buildings – I knew that I wanted to do more than pronounce people and fill out death certificates. Becoming a psychiatrist could help me save some of these despairing souls.
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