Week 33: PSYCH110 in Fresno

UCSF Fresno hello!

I wasn’t quite sure what to expect about PSYCH110 in Fresno – but I can say I was blown away. We joined a consult psych service where the residents and attendings we worked with were all thoughtful teachers who made us laugh often and were deeply invested in our learning. We were based out of Community Regional Medical Center, the safety net hospital for Fresno and parts of the Central Valley. The patient population was a little different then SFGH… But it still included a lot of folks with incredible suffering who have been failed by society in one way or another.

I saw a number of patients in different types of psychosis – ranging from flight-of-ideas-manic-put-a-waffle-in-his-orange-juice to withdrawn-refuses-to-leave-her-blanket-cocoon-can’t-tell-us-her-name-for-seven-days. There were a lot of substances, mostly methamphetamines (I learned that Fresno is a meth capital of the country). I heard about a lot of trauma – sexual assaults, homicide attempts, neglect, physical abuse- and saw how the aftermath of these events manifest into people’s minds, behaviors, relationships, future. A few of our patients were recovering from traumas acutely – two on the same day were side by side in the burn unit after hitting a tank of sulfuric acid and getting hot oil thrown on her respectively.  I made a police officer leave the room so I could talk to a patient who was incarcerated (“bold” my attending said, and I’m not sure he meant it as a compliment LOL). Some patients had a touch of depression, others were completely debilitated by years of disease that went untreated. I saw conversion disorders and medical mysteries that stumped multiple teams consulted on the case. We saw older patients in varying stages of dementia. Some of our patients were put in restraints for days – and it was great to see how fiercely the team advocated against that. Some of my patients were likely at the end of their lives.

I picked up the first Indian patient I’ve ever followed. The family didn’t speak much English and he was barely able to speak to us at all. I didn’t know their language but I felt like I understood something about his sister tried to make sense of his symptoms, how his mom wrapped her dupatta around her head helplessly as she wept about his decline, how his room always had a bhajan playing in it. Our patient was a young man who used to love singing Bollywood songs. But now he spoke so softly that a phone interpreter couldn’t pick up much of his responses. A nurse who spoke Punjabi was able to translate for us in person on his last day. I’m not sure how much we did to move his care forward, and plenty of questions remain. The family’s biggest concern at the moment was navigating their limited insurance options and the magnitude of his medical illness. I wish there was more we could have done for him – but in the hospital, when so much of mental health care relies on the outpatient setting, our hands are kind of tied. It’s not very satisfying.

One thing I struggled with was integrating the full clinical picture. My patients would say bizarre things but they were usually MOSTLY fine – and sometimes I clung too tight to the well-adjusted, logical, organized parts of our conversation and let the abnormal float into the background. When it came to the inevitable bargain between honoring patient autonomy and protecting patient safety, I’d leave feeling uncomfortable with keeping a patient in a locked facility even though at some level, I knew it was the safest choice that day. But still I struggled – we had one black pregnant patient who refused her oral antipsychotic which meant she got held down and given an intramuscular shot; yes, she was in the depths of psychosis and needed it but it’s an ugly image that I won’t forget.

As one of my attendings Dr. Kirsten put it, “Why do you have the need to explain away your patients’ psychiatric symptoms?”. I think it comes from a deep place of wanting to trust my patients – which can be a dangerous thing to do in this field. But my four weeks of psych have taught me that if I pay attention, there is a way to trust what my patients show me. I can listen to the words they’re saying, but I can pay attention to how they’re interacting with me, how much insight they have about their disease, how their hospital course has progressed. A patient who was floridly psychotic yesterday but is eager to leave today doesn’t show a lot of insight; she doesn’t seem to realize the danger she’s in so while I can hear her desire to leave… I can see why she’s not ready to.

And I shouldn’t just stop at my patients’ words – I need to dig deeper. A patient who is suddenly not suicidal after days of expressing thoughts to hurt herself? It’s not safe to just accept the change of heart, I have to ask her why and then why again in order to understand where she’s coming from. It’s so easy to just let words fall as they are and to nod along; I’ve had a harder time holding my patients’ accountable and probing a little further than what they offer at first. I blame it on my need to be impeccably polite and well-mannered. Cutting through the fog is something I’m still working on but psych has made me resist accepting the superficial easy answers and attempting the boldness needed to ask harder questions.

One reminder from our attending Dr. McGee that I always need to hear was this: our job isn’t to judge, it’s to understand. I have this need to classify things as either GOOD or BAD and what if our choices aren’t good or bad, they’re just choices? That’s another habit of mine that’s going to take time to undo. My issue isn’t judging things harshly; it’s actually the opposite where I (sometimes desperately) search for the good so I can classify the thing in question appropriately. But I don’t have to condemn or approve my patients’ choices, she’s the one who made them and lives with them. My job is to answer the consult question and my personal goals are to make my patients feel warmth and safety during our encounter. We don’t have to connect – but it’s always nice when I think we do. Accepting things as they are instead of furiously trying to categorize them as “good” (because y’all know there’s not much I’d put in the “bad” bucket) is how I’ll get better at zooming out to soak in the whole clinical context instead of zeroing in on the fun moments I’ve had with patients.

I think Fresno actually is a great place to do psych. There’s something about the pace here that makes me want to slow down. I’ve learned that the most effective encounters are ones that I go in relaxed and ready to listen and make sense of it, not ones that I’m feeling rushed about checking all my boxes off. My nature is to rush and be kind of thinking of the *next thing* – but for psych, I have to be super present and pick up on the things that I would have missed before I slowed down for this rotation. It’s about being comfortable myself to make my patients feel comfortable so that they tell me things that I can’t get by asking explicitly. It’s pretty validating to get a golden nugget of history just slip out casually, without directly questioning someone about it.

This rotation may be the worst I’ve been about boundaries. Since this year started, I’ve seen sad, disturbing, tragic, painful, unsatisfying things (and lots of good things too, don’t worry!) – but I was able to leave most all of them at the hospital. This block, I took some of my concerns home with me. I agonized over a few patient cases that were especially stressful to me. I woke up in the middle of the night once thinking about it (and I never get nightmares!!). Interacting with family members of our patients also tugged on my heartstrings; I teared up in the library one day thinking about my own family members who had to navigate this brand of uniquely difficult suffering, seeing a loved one get worse and never quite knowing what to expect with each new day. I feel so deeply compassionate for families who have a member who is profoundly ill. And for that person. And truly deeply really all people with mental illness and addiction. I hope I can always stay grounded around my psychiatrically ill patients. They’re trying to make sense of a world that doesn’t make sense. I believe that people try their best with what they have and that they are good at heart.

On one especially draining day, I accidentally stumbled upon a line from my personal statement for medical school – which was written more than three years ago! It said “I hope my future patients know that I’ll advocate for them regardless of their background to get them the care that they deserve” and it felt like I lived up to this vow that day. Even if I’m not sure if I’ve moved patient care forward or made a concrete difference, it’s still nice getting to keep my own promises to myself.

Psych has taught me so much, and the lessons I’ll take away are still in progress. Excited for what’s next… OB/GYN at Highland Hospital in Oakland promises to be an adventure! 

Sure am gonna miss this stellar team 

(ft pretty good basement lighting)

xoxo

Juhi