The one where its not her fault

Bear with me a moment for I am having an immense bit of writer's block whilst trying to tackle this particular post.(1)  Like all aspects of life, it becomes very hard to focus on a subject when there is an immense amount of emotion tied into it and I fear that I might be a bit too heavily wrapped here.  The reason for this is simple, I am a sucker when it comes to kids.(2)  I love seeing kids playing around and having a laugh; consequently, I hate seeing a kid that is sad.  This is why I would make a terrible pediatrician.  Therefore I think it should be understood that when I say that child psychiatry is one of the hardest professions in the world, I mean it.

In this daring new world that we live in today, it is impossible to be a "normal" child.  Back when I was growing up, all a kid really had to do was find a way to keep himself entertained and that was usually good enough.  My cousins and I would regularly engage in massive games of "will doing THIS break my neck?"(3) and other fine pursuits to pass the time; usually without any dramatic results.  Furthermore whenever one of us messed up in one way or another, as kids are prone to do, we would generally receive a stern reprimand and then be on our way.  

These days however things are quite different.  Every morning you can tune into any one of the morning shows and learn the many different "clues" that point to your child being abnormal.  Dr. Oz will tell you with a smile on his face and glint in his eye that your child's juicy juice contains poison and that it is probably too late.  Is your kid acting up a little bit in class?  Well Dr. Phil seems to think that this might be a case of ADHD, and you know what he's DEFINITELY right.(4)  Did little Timmy refuse to do his homework last night?  Mr. G the weatherman knows for a fact that this is a conduct disorder and if you don't act on it now, Timmy will grow up to be a bank robber.

What I'm trying to say in this over dramatic way is that it is really hard for a kid to be a kid these days because any mishap that they do can be misconstrued as a sign of a mental disorder by their oh so loving parents.  And when a parent thinks like that, their child will inevitably find themselves in a meeting with a child psychiatrist.

The first thing I noticed when Katie walked into the room was her eyes; they were beautiful orbs of jade that looked with unbridled curiosity at Dr. Ryan's office.(5)  Katie was 8 years old and was referred to us due to her inability to play well with others; her file indicated that both her parents and her school teachers thought that she might have a disorder on the autistic spectrum and thus needed professional help.  In anticipation for her first session, I had read ahead on the various manifestations of autism and expected to see a timid and shy child who refused to meet a stranger's gaze.  Yet that was not the little girl I saw before me, here was a child who seemed for all intents and purposes...normal.  She played well with me and Dr. Ryan and even beat me a couple of times at Tic Tac Toe.(6)

When Katie's parents came into the room, her actions became muted.  Her eyes stopped shining and she stopped playing with the toys all around her; it was a heartbreaking transformation.  As we continued to interact with Katie, her parents were first interested but within minutes they had pulled out their smartphones and were clicking away.  Picture this scene in your mind if you will: a child in a room full of toys, refusing to play with any of them while her parents sit three feet away refusing to pay any attention to her.(7)

All of a sudden, the reports in Katie's file started to make sense.  Based on our interaction with Katie with and without her parent's presence, it was clear that the likelihood of her having a disorder on the autistic spectrum was minimal.  Rather, her problem seemed to be her parents.  Children are immensely complex and trying to understand them is an impossible task.  However it is well understood that they feed off of the emotions of the people around them and react with a far greater degree than adults.  Give a child encouragement and they will thrive, make a child scared and they will tremble.  But far worse than any of those is indifference for in Katie's case, her parents were completely indifferent to her.  They never paid any attention to her and by doing that they severely hindered her social interactions.  How can you expect a child to play well with others when she isn't even encouraged to play with her parents at home?

After our assessment was complete we talked to Katie's parents and told them the good news that their daughter did not have a psychiatric diagnosis.  While they were thrilled to hear that, they were very unhappy when we informed them that our analysis pointed to them as causing Katie's problems. They accused us of not knowing what we were talking about and flung numerous obscenities at us.

Unbelievable.

What does it say about parents when they would much rather their child have a medical disorder rather than be told that they are bad parents.  How do the two even compare to each other?  Dr. Ryan was also a bit taken back by the parent's reaction but she informed me that she has seen similar responses numerous times and it is something that child psychiatrists have to be prepared for.  There is no clear cut solution, and usually a lot of family therapy is needed before any headway can be made.  Thankfully however, kids are resilient and with enough time and guidance, the damage that their parents inflict on them can be reversed.  And eventually Katie's parents came around and started their long jourey of family therapy.

The sad truth is that most cases such as this do not end in happy endings.  Kids these days are constantly being bombarded with errant diagnosis given by well wishers who would rather look out for the interests of the parents rather than what is best for their child.  There are not enough child psychiatrists to go around and sometimes even when they are present, their advice is not taken seriously.  Is there a solution?  Yes.  Instead of listening to Dr. Phil and Oprah tell you whats good and bad for your children, how about just spending some time with them?  Drop the parenting books and pick up a copy of Clifford the Big Red Dog.(8)

I understand that being a parent is hard work and that I shouldn't judge so easily but sometimes I can't help myself.  Sometimes I think that there should be a test that future parents have to take before they are allowed to have kids.  Some people just are not meant to be parents and being in possession of the physical capability to create a child should not be the only qualification.

_______________________________________________________-


1.  And when I say writer's block, I mean it.  I started writing this post in December, 2011.  This post messed with my head so much that I wrote a TON of other things before deciding that it was time to finally finish it.  This is long overdue.
2.  And I do mean a sucker, little kids trample all over me.  I have no defense when it comes to chubby cheeks and big eyes.  Ice cream for breakfast?  SURE!  Another video game?  DAMN STRAIGHT!  You want my wallet?  CAN I ATLEAST HOLD ONTO TO MY LISCENCE??
3.  For the record, no.  You would think that catapaulting from the second floor onto a mattress at ground level would do it, but nope.
4.  ADHD is attention deficiency and hyperactivity disorder and I do know quite a bit of people who believe their child has it based solely on the words of Dr. Phil.  I hate that man.
5.  Dr. Ryan is a child psychiatrist, one of the best in the world.  The short amount of time that I spent with her was as educational as it was fun.  It is no coincidence that she is the director of the nation's best child psychiatry program.
6.  A child is generally examined alone before her parent's are brought into the room.  This allows the psychiatrist to establish a baseline for the childs actions unhindered by parental presense.  Afterwards, the parents are brought in to understand the child's behavior around them and thus give a more complete story.
7.  We had severeal sessions with Katie and her parents before this pattern became relevant and solidified in our minds.  Every single time, her parents showed that they didn't care much for being there.
8.  I love that dog.

The one with desensitization

Picture this in your mind: You're walking down the street and you hear a homeless person asking you for some change.  What do you do?

The options running through your head are probably something along the lines of:

1.  Give the poor soul whatever loose change or bills your have on you.

2.  Sincerely apologize for not having any extra cash on you and then go on your way

3. Ignore the person completely and go on your way.(1)

Regardless of which of those options you picked, chances are that by the time you are down the block, you'll have forgotten about that person and instead will be focusing on whatever task you have at hand.

Ok now lets envision a different scenario: You're walking through a hallway and you hear a plea of agony for help coming out of a room.  What do you do?

1.  Go into that room and figure out what is going on.

2.  Ignore the plea and go on your way.(2)

The people who went with choice 1 will probably still remember this person when they move further on down the hallway.  The people who went with choice 2 will most likely forget about the scream by the time they are down the hall and will instead be focusing on whatever task they had at hand.

Before you start chastising the people who picked choice 2 in the latter scenario, lets quickly analyze what separates the first scenario from the second.

In the first scenario, we see a case that we are all familiar with(3) and are thus desensitized to.  So what if that guy is asking for money?  Homeless people are always asking for money and whether you give him any money or not won't change the fact that this is nothing out of the norm and thus not worth remembering as you move forward.

In the second scenario however, we see a case that is unfamiliar to most people.  In that regard, I would wager that most people would then go with choice 1 because certainly they would like to find out whats causing this person to plea with such agony for help.  Furthermore, most people would also probably be hard pressed to forget the encounter because of how unusual it is.

Then what does it mean to be a person who went with choice 2?  Does it make them horrible people?  Maybe, that is indeed a possibility(4).  However, more likely is the fact that for these people the second scenario is just like the first scenario: a situation to which they have become desensitized.(5)

Welcome to medicine.

I can distinctly recall how amazed I was the first time I shadowed a doctor and found out that he was able to deliver terrible news to a patient and then move on.(6)  It baffled me that here was a man who was able to offer the most sincere apology while delivering bad news from a surgery and  then be able to completely move on from the event with no apparent lingering sadness(7).  Was it all just a show?  Did he simply put on a face to appease the mourning family and take it off the moment they were out of view?

For a split second I was guilty of that very thought.  Here was a man who had spent the past three weeks showing me the beauty and intricacies of the human heart and in one phrase he had shattered all admiration I had for him.(8)  I was disgusted and fortunately for me, my face displayed my emotions for all the world to see.(9)

Dr. Smith immediately noticed that something was amiss and asked me what was going through my mind.  I tried at first to form a lie that would stop me from calling Dr. Smith a two faced arse, but the words did not come to me and  I ended up telling him that I was incredulous at how easily he had been able to wave off the death of a patient once the family was out of view.(10)  To say that Dr. Smith was shocked would be an understatement, a massive one.  He didn't get mad at me, though he should have, he simply stayed quiet until we walked past an empty room and asked me to go in.

It was there that I learned my first real lesson in medicine: the art of staying sane when all around you unbelievable sadness is taking place.  As medical professionals, we are subjected daily to human anguish that most people do not encounter in a lifetime.  It is not uncommon to see a father grieving over the immobile body of his brain dead son in one room and then move on to another room where a grandmother is coding while her family watches in agony as life slowly leaves her.  To encounter such situations and take the brunt of their emotions full on would leave anybody destroyed in a matter of days; yet we have to keep going hour after hour, day after day.

How can we do this?  Simple, we slowly allow ourselves to be desensitized to the fatigue that such encounters place on our souls.  We tuck them in the back of our minds so that we can move on and focus on the matter at hand.  It is a harsh way to live but we must be steady in our course because when we lose the ability to concentrate on the next patient, we leave an open invitation for more heartbreak to come and wreak havoc on our lives.

Dr. Smith told me that he never forgets the patients who pass away under his care, he mourns for them in his own way at his own pace.  They inspire him to work harder at being a surgeon, to read one extra research paper every day, and to teach more effectively to all of his students.  In that way, each life lost ends up saving hundreds more.  Furthermore, if he had had chosen to dwell in sadness for the rest of the day then there would be nobody to operate on the other patients awaiting his care that day. And thus desensitization in medicine can be a powerful tool.  One that allows doctors to channel their grief over one patient into salvation for another.

***

Now lets go back to the second scenario mentioned before.  Do you still think that the people who went with choice 2 are cruel, cold hearted people?   Is it possible that they are simply desensitized to such emotional assault and are simply trying to focus on their original task?  Remember that just because they ignored the plea does not mean that they do not care.  If you can think in such a way then maybe, just maybe, you'll make it in medicine.(11)

________________________________________________________


1. This is the majority of your guys, don't lie.
2. You cold hearted basterd!
3. Unless you've never been to a city, then chances are that you never encountered a homeless person asking for change.  In that case, rejoice! You still feel sympathy for the homeless and are probably one of the kinder people around.
4. You cold hearted basterd!
5. But keep in mind that desensitized is not necessarily the same as "does not care," if you keep reading you'll understand.
6. It went something like this: "Mrs. Johnson, I am terribly sorry but we were unable to take Mr. Johnson off of the bypass after the procedure was over.  It is truly unfortunate but we lost him."  :cue crying, genuine sadness from Dr. Smith.  10 seconds later as we're walking down the hall:  "Hey zeeshan, do you want to grab some lunch?  I am starving."
7. The key word here is "apparent."  Dr. Smith was an excellent surgeon, and unbelievably kind hearted.  I ran into him six years after the fact and he still remembered that case.  Turns out that being able to move on without losing a beat isn't the same as forgetting.  Hopefully, you've read the rest of this article before reading this note otherwise you'll have arrived at the punchline too quickly.
8. See footnote 6.
9. Literally the only time where my terrible poker face saved me from thinking terrible thoughts about a person for the rest of my life.
10. For clarification, this was me during my naiive college days when I did not know enough to censor my words lest they be taken as offensive.  The look of shock on Dr. Smith's face after hearing what I said still haunts me because here was a man who I had seen unflinchingly crack open ribs and massage hearts back to life and the first real moment of surprise I saw from him was due to something I said.  Strong work.
11. Says the MEDICAL STUDENT!  I apologize if this post was a bit confusing or incomplete.  The subject matter is hard and I will explore it further and in more detail at a later time.  Want to help? Leave a comment.

The one with the drunk driver

Unknown to the general public, the ED comes in many flavors (1).  There is of course the standard emergency room but to help with triage and whatnot there is usually a pediatric and sometimes a geriatric ED in most hospitals.  Furthermore, most hospitals also have a "crisis" ED which deals with people who come in with acute psychiatric illnesses (2).  This includes acute psychotic breakdowns, exacerbation's of existing mental illnesses, and even really really drunk people who start flailing around at cops with their penis' (3).   The crisis ED is also home to some of the most depressing cases in the hospital because unfortunately this is where the people who attempted suicide go (4).

It was my second day working in the crisis ED and I really thought that I had a hang of everything that went on there.  I knew how to talk to the depressed people, knew what to do with the really angry people, and even sang along with the super drunk people if it got them to calm down and cooperate (5).

Then Clarice came through the doors.

Clarice had a very flat affect (5) and looked like she had been crying for years but had recently decided to stop.  Since my attending was busy working on discharging a patient, I was given the assignment of talking to Clarice and figuring out what happened.  The EMS crew that brought her told me that Clarice had been found by her mother after she drank a couple swigs of Drano.  They didn't know much beyond that.

Fuck.

I had never dealt with an attempted suicide before and I didn't really know how to begin (7).  In my nervousness I must have stood silent as a rock in front of Clarice for an eternity before I even uttered hello.  After hearing my voice Clarice simply turned her head at me and gave me the loneliest stare I had ever received in my life and then went back to staring at the wall.  I tried for a solid half an hour to talk to her but she wasn't having any of it so I decided to go get some help from my attending.

"Everybody's left me...aint nobody here for me no more."

I stopped dead in my tracks.  It had been barely audible but she had broken the sound barrier(8) and it meant that she was ready to talk.  Over the next hour or so, Clarice told me her story and pretty much for the entire hour I stood there with my jaw dropping lower and lower to the ground.

Clarice had been a mother of three:  Tim and Sean, twin boys - 13 years old each, and Rianna, her 7 year old daughter.  She had loved her children with all her heart and had tried to raise them as best as she could.  They received good grades in school and never got into any fights.  She felt that she was one of the most blessed women in the world.

Three months ago, she had been walking home from a parent teacher meeting with the twins when she noticed that Tim had fallen a little bit behind while crossing the street.  She laughed at him to hurry up and that is when the car came out of nowhere and struck her baby boy.  They raced him to the hospital but he was pronounced dead on arrival.

The driver had been drunk.

Clarice quickly fell into despair and depression followed shortly after.   Two days before she attempted suicide, child protective services had to take Sean and Rianna from her because she had become unable to look after herself, much less her children.  She moved in with her parents to get better and thankfully that is how her mother was able to get to her before she drank enough Drano to kill herself.

After hearing her story, I was in tears.  It was the most heartbreaking story I had ever heard and to hear it from the grief-trodden mother herself was something that will never leave me.

We were eventually able to help Clarice by helping her realize that her remaining children needed her; this fueled her recovery far more than our interventions.  She was discharged three weeks later from the inpatient psychiatry ward to an outpatient facility where she overcame her depression and was reunited with her children four months later.

To say that her story changed me is an understatement.  But what I hope to accomplish by telling you her story is to prevent you from even THINKING about drinking and driving.  When you have a drink and choose to get behind the wheel, you are agreeing to ruin not only your life or the person that you hit but also EVERYBODY who is attached to both you and that victim.  Think about it, not only was Tim killed, but his brother and sister were almost put into the adoption system and his mother almost committed suicide.

Dwell on that next time you think its worth it.

______________________________________________________


1. Obviously I'm talking about the emergency department, I have NO idea what YOU might have thought upon reading "ED" and "many flavors."  Pervert.
2. A lot of hospitals don't have a dedicated section for the crisis ED, sometimes its just an area in the hallway that's partitioned off by standing curtains.  Happens.
3. Yes that happened.  Had to restrain the guy and everything.
4. Clarification, this is where people who attempted suicide but didn't really hurt themselves too badly go.  The people who REALLY get hurt go straight to the regular ED on the way to the OR.  While that is pretty sad, the cases that end up in the crisis ED are sadder because here you get to talk to the patients while they are still really really depressed and you get an idea of what drove them to it.
5. I have the voice of an angel, numerous drunk people in the NYC area will verify this claim.
6. An affect is your mood as other people perceive it, flat means that its very subdued.
7. Sometimes even really verbose people forget how to talk and this was definitely one of them.
8. A little observation I learned when I was a car salesman:  When one person who had previously refused to say a single word finally chooses to do so, it means that they are ready to talk...a lot.

The one with the band of brothers

Here's a secret for all of you guys(1) out there, medical school is frickin hard. Not just regular old "this exam is gonna be hard, why the hell do they make us learn this useless shit any way" kind of hard, its more of a "holy shit if I fail this exam I'm screwed because the rest of my life depends on this(2)" kind of hard. Imagine going through that, every three weeks, for three and a half years(3). That is enough to drive anybody crazy, full on cuckoo bananas crazy.

But here's the thing, you don't really meet too many batshit crazy doctors. Why is that? I mean all the signs say that a hefty chunk of medschool grads should be a little bit unsettled, that is what 3.5 years of constant stress should do to you. But they don't. Most of us make it through the process as sane as the day we started(4), and I don't mind sharing how.

Is your interest piqued?

Ok fine, here it goes: its because of our friends.(5)

In her book, Dr. Michelle Au compared going to medical school to being in the army(6). It isn't really a far fetched comparison when you think about it because both endeavors are harsh and require a hefty amount of teamwork to pull you through it. By the end of both you are a member of a tight band of brothers that have gone to hell and back and know each others deepest secrets. These are the ones that made you relax when you were panicking about the first anatomy exam and the same ones who slapped you back to your senses when you thought that the Step 1 was unbeatable.(7)

However, before I get in too deep with the discussion I think it is wise to point out that not all people go through the same experience.  In terms of social willingness, there are two types of people in medical school: the visible and the invisible.  The invisible people are those that you never really see in the social realm.  For numerous reasons(8), they don't interact too heavily with the other members of their year and pretty much the only time you see them is during school related activities.  No joke, during the first two years of school I got used to seeing new faces I had never seen before on exam day.  Don't expect these guys to come out to party with you.  They still make it through the process just fine.

I'm part of the other group of people, the visible ones.  Most of the strong relationships I have right now were formed in medical school(9) and I'm very thankful for that.  These friendships started in the anatomy lab when we helped each other figure out which nerve was which, continued in the study lounges and libraries where we couldn't understand the formulas for lung capacities, and were cemented the days before and after exams when we tried to erase our panicking minds with comforting thoughts.  After going through such "hardship"(10) it is only reasonable to hang out and party with the people that helped you get through it.

And so we started going out after big exams which led to going out after no exams and pretty soon the people I thought to call on a lazy day weren't the best friends I had growing up, they were the best friends that I grew up with in the study of medicine.

And its safe to say that my experience wasn't alone.  The same process that I went through happened with roughly 100 or so other classmates of mine who now have the same bond that I share with my circle.  I've grown accustomed to hearing somebody's voice in the hall and knowing exactly who they will be with, it is awesome.

Of course this is nothing new to society.  In fact situations such as this are the basis of friendship in every culture.  Yet for those of us in medicine, we know that there is nothing quite like the bonds formed through this trial.  Friendships formed during high periods of stress are somewhat different that friendships formed during ease.  They're like diamonds in that they are formed in relatively short periods of times due to enormous pressure, but ultimately lasting longer than most others.

I'll wrap up this rambling post now(11), but one final statement before I do: to all my friends reading this, thank you so much for being there for me.  Without all of you I never would have gotten this far and while there is still much work to be done, I know I can count on you to help me through it.  This one is for you my band of brothers.

__________________________________________________________________

1.) And girls, just in case any of you got offended by the male only definition. However I do hate doing the multiple gender PC statements so from here on out just assume that whenever I say "guys" or something of the like I mean "guys and girls."

2.) Another thing you should know, medical students are really dramatic.

3.) The second half of fourth year is pretty much bullshit...we'll get to that later.

4.) Mostly sane...or 3/4 sane at worst!

5.) Bet you didn't see that coming!! Its like the bus that hit Regina George, you know which Regina I'm talking about.

6.) What, you didn't think I was the only one out there writing about this experience did you? Go ahead, search for other blogs...after reading this post.

7.) True story, that exam destroyed my soul.


8.) From my experience, its usually firm grounded relationships that they had prior to school. This ranges from anything between super strong home friends, significant others, kids, etc.  You have to remember that a hefty chunk of people in the schooling process are older, they tend to already have lives of their own and don't really need to make too many new friends.

9.) Thats not to say that I have no friends outside of my classmates, far from it.  Its just that when you're in school, and single, its really hard to find time to hang out with your other friends.  Whenever they're free, you have an exam to study for and whenever you're free, they're working.  This is why most of us have such strong friends from medical school, simply because they were around and more or less on the same schedule.

10.) In quotes because lets face it, having to study really hard isn't really a hardship as viewed by the rest of the world.  That being said, shit's still hard.

11.) See what I did there? Zing!