Wednesday, November 30, 2005

G-d and mind

I think I've pinpointed what is most disturbing about the psych ward. It's in the very nature of the problem. What we see as a human is based upon the mind, and when the mind is disturbed, it is difficult to see the human.

Flowing from that, I wonder what the standing of the schizophrenic patient is before G-d. If someone lacks, or seems to lack, all capacity to reason, what are they? I guess the Western idea "I think, therefore I am" is an unconcious part of my value judgments. I realize, on one level, that G-d loves all His creations, and that the elect, no matter who they are, will be saved, but when there is literally nothing you can do to get through to a person, when there is no hope of external, human forces making any change on a person, it forces you back to utter reliance on the providence of G-d. There is no room for witness, no way preaching or demonstrating is going to change a mind incapable of change.

So what is to be done? I can pray for my patients, but little else. I know too much and too little. I know medically how little can be done, I know that the medicines we give them will give them diabetes or Parkinson's, but I know that without them, these patients will commit suicide, even without meaning to. I know spiritually that I can pray for them, I feel humanly that it is a failure of faith or effort on my part when they don't improve, and I know intellectually that G-d is in control. The conflict between free-will and predestination is quite clear. Can my prayers help more than medicine? Where is the boundary between professional ethics and spiritual responsibility?

I take heart in a poem by John Greenleaf Whittier, one of my favorites. He wrote to a young physician of his acquaintance:

The Healer
To a Young Physician, with Dore's Picture of Christ Healing the Sick

So stood of old the holy Christ
Amidst the suffering throng;
With whom His lightest touch sufficed
To make the weakest strong.

That healing gift He lends to them
Who use it in His name;
The power that filled His garment's hem
Is evermore the same.

For lo! in human hearts unseen
The Healer dwelleth still,
And they who make His temples clean
The best subserve His will.

The holiest task by Heaven decreed,
An errand all divine,
The burden of our common need
To render less is thine.

The paths of pain are thine. Go forth
With patience, trust, and hope;
The sufferings of a sin-sick earth
Shall give thee ample scope.

Beside the unveiled mysteries
Of life and death go stand,
With guarded lips and reverent eyes
And pure of heart and hand.

So shalt thou be with power endued
From Him who went about
The Syrian hillsides doing good,
And casting demons out.

That Good Physician liveth yet
Thy friend and guide to be;
The Healer by Gennesaret
Shall walk the rounds with thee.

And yet it makes sense

I had a meeting this afternoon with my preceptor, the senior physician who tries to integrate my learning on this clerkship. And in the course of our discussion, I realized that despite all the frustrations, and the strange conclusions that Freud and Erikson seem to reach, when you actually get out and talk to people who are having a difficult time integrating in society, their schemas make a lot of sense. Some people don't get past Trust vs. Mistrust, or Initiative vs. Guilt. And when they get stuck at a given stage, they react to their environment in a socially unacceptable way.

That may not make any sense unless you have a some grounding in psychology. Basicallly, Erikson came up with the idea that people go through 8 stages of life, and that to react to the environment appropriately, to be "normal" you have to go through these eight conflicts. If they are successfully negotiated, the person is "well-adjusted" and if not, they have problems and may be mentally ill.

All this seemed a bit suspect to me until I saw it in practice. It may still be suspect, but it is an excellent way to frame the problem. And when you think in these patterns, a host of deductions can be made about people and what motivates them. It feels like playing Sherlock Holmes.

Most of medicine it seems is learning to think algorithmically, and once you understand the the algorithms of a given specialty, the third-year med student job gets much easier. I am, at the end of my psych rotation, finally grasping the algorithms of this specialty.

Also my preceptor made an hilarious comment. He said that "axis II patients we never forget. No matter how much we drink."

Tuesday, November 29, 2005

A relatively standard day on the psych ward. A patient trying to avoid jail time claims to be suicidal and homicidal. The patient with borderline PD has decided to start hitting on the patient with MDD, who actually shows some mild improvement with the attention, and a patient with paranoid schizophrenia who thinks that "they" are watching all the time keeps peering over at the group of doctors discussing her case, maintaining a knowing, watchful expression.

Psychiatry would be great if it weren't so depressing. The hours are short, roughly 7 to 4, which is phenomomally brief compared to OB or surgery. But there is something quite depressing about dealing with patients who lack the insight to know what is wrong with them. And with some patients, you wonder if there really is something wrong with them. For example, when a patient comes in complaining that her husband is trying to kill her, and the husband is denying it, who do you believe? Sure, she has some factors in her history which imply she might be psychotic, but she seems to make sense, and she isn't acting psychotic now.

Every day I wrestle with the idea of what exactly constitutes mental illness. How hyperactive does a patient have to be before they are considered "manic"? Sure, the DSM-IV gives us strict guidlines, but how much of that is just conjecture? Is being sad, or melancholic, always such a bad thing? In days past, some of the people on this ward, or being seen in this clinic would have been poets. Now they take their anti-depressants and go out to be "normal." I'm sure some of the painters or composers whose works we admire today would be treated now with quetiapine or ziprasodone. What do we lose as a culture by leveling everyone's performance? I'm sure it helps some, but how many does it hurt?

A lot of that may be idle speculation. Some of these patients, and maybe all of them, are indeed ill. Bio/Psycho/Social factors really have gotten the best of many of these patients and with help some of them can go back and lead what we see as normal lives.

Also, the steadily increasing amount of respect and attention my recommendations for patient care command is fulfilling. When I posit that a patient may improve with 10 mg Geodon bid, my chief actually agrees and countersigns an order to that effect. I am feeling more responsible for my patients, and I enjoy the feeling.

Most things have a beginning

Not a particularly auspicious title or first post, but it will have to do. I've decided to start a blog, to chronicle at least the next year and a half, my final time in medical school. I wish I had started sooner, to preserve some record of how I've changed, how this process changes those who go through it, but maybe, if this lasts long enough, I'll do that with residency. We shall see.

My only hesitation here is a quote from Theodore Dalrymple, who said (while discussing the fall of the British monarchy, of all things) that "for modern man, baring his soul is the only proof that he actually has one" But I think in the final analysis, my point here is less to bare my soul, such as it is, and more to record something which may prove instructive. And I might even have fun. So here goes.