A psychiatrist’s view on death, other difficulties in practice

In the tide of thoughts, one keeps rolling over me: at some point I won’t be able to keep doing this, practicing medicine I mean. And then I think about my peers in internal medicine, pediatrics, gynecology, surgery, pathology, and radiology, surrounded by death and decimation on one side and fragile restorations on the other… how does living in that constellation of exposures to suffering not weigh on them the way mine weigh on me? Is there something so different about our exposures, or in our minds’ relating to them? Did the winds at the periphery of medicine’s campfire circle deafen me to the tribe’s words of strength chanted at the center? Or standing so remote from the flame did the night’s chill penetrate and erode my defenses? Or when I became an alienist, a psychiatric physician, did I simply get too deep in the habit of stepping into other people’s skins?

No one suffers more than psychiatric patients, and not the least of reasons why is that they are cared for by psychiatrists. The people who will most need a psychiatrist fear us by reputation, and hence avoid our treatments through any other means until the very moment of their calamity. When they do finally arrive in the intensive care unit after a suicide attempt or in the emergency department after vigorous efforts to remove the chip implanted in their once fine auricle we promptly sew distrust by stripping away their fundamental liberties, forcing hospitalization and medication, and assaulting the structure of their hard-won beliefs. A psychiatrist, however adorned in medical degree, is loved by few.

Alongside the surgeons and other proceduralists we’re the only the group of physicians who knowingly inflict injury to provide therapy. The difference is that the patients that we must injure, for instance, by involuntary admission and treatment, uniformly believe that we are cutting for stone — attempting barbarous, technologically impossible acts of questionable medical necessity with only our nihilism to defend us. These patients reel to fathom the depth of our insanity, and can by our interventions be traumatized further in the midst of their crises. Even as the surgeon leaves scars that are prone to hypertrophy, adhesion, and herniation, our intrusions carry the risk of complication. Will some kind soul invent the psychiatric equivalent of laparoscopy? Or would that appear more frightening in practice than the current reality of overt incarceration of the world’s already unfortunate? So, there is at least one answer for my fatigue: I am routinely involved in making my own enemy and hence the fight is hard.

There is also the instrumentation problem. Briefly, you can practice most office-based medicine largely without involving yourself beyond the use of your knowledge; the manner in which you socialize with the patient and the experience of conducting exam is normally non-invasive for you as the provider. However, to make a psychiatric diagnosis you need instruments that will allow you to categorize the patient’s thought process and content, namely an immersive social experience in which you spend much time following where the patient leads. Meaningful data is not achieved exclusively through symptom-mining questions about sleep and appetite and energy and focus; you go sit beside the patient’s sadness, let it wash over you, seeing how it is bounded by other facets of cognitive and emotional experience, reconciling those disparate potencies against what you understand to be his greatest problematic failures of insight and sources of external stress. In other words, you try to understand the structure of the patient’s beliefs and his history in its entirety. Ideally every aspect of him would make sense as the product of his experience before you intervene.

These calculations are done with yourself as the subject, through empathy to the extent it can be relied upon. This empathic process, which separates the daily work and experience of psychiatrists from that of other physicians, is influential in decision-making about where to repress and enhance pharmacologically, and what words to provide in terms of psychotherapy. Treating by DSM-V diagnosis is the more valid approach, and should be done in tandem, but it is far less sound. Treating by the book, by criteria, is the equivalent of doing an invasive procedure on the basis of signs and symptoms only, without imaging. Admittedly, the risk of deluding oneself with regard to the resolution of his sight is substantial (in other words, this practice of psychiatry carries a certain risk of insanity, which we have seen timelessly…).

Do other physicians face pitfalls in practice this persistent and this many? Do they have to question themselves and their method every time they speak, or is it mainly us with our untrustworthy and mystic tradition? And yet it’s precisely the promise of these occult arts that prevent one from turning away…

One thing that I think people often overlook when they examine the reasons why we went into medicine was the attraction of knowledge that might inform the resolution of our deepest unreconciled questions. What does it mean to be human? What does it mean to die? Many of us came here thirsting for uncommon knowledge, and experiences unknown.

A psychiatrist’s exposure to death is admittedly minute compared to most physicians. But it is no less impactful. Only once in my career have I actually witnessed expiration; I was a medical student on the surgical service; I performed chest compressions with an experienced respiratory therapist. Twenty minutes later I was in the OR assisting with a routine appendectomy. As I guided the camera I remembered the family crying. That experience confused me some.

The last time my patient died, it was a morning in December between Christmas and New Year. I was on the psychiatry consult service and was making preparations to round after receiving my list. As I reviewed the patient’s chart new notes began to roll in. The patient was found down. An anesthesia resident had attempted intubation four times, and was successful, finally, after switching blades. Advanced cardiac life support team arrived. Resuscitation attempted. Pronouncement of expiration. Suddenly I realized that I had forgotten all about the fact that death was still confusing; I had stopped thinking about death as an eventuality entirely. And so the parade of thoughts began: How can something as storied and complex as human being just stop? What does that even mean, “stop”? It would be useless to attempt to practice psychiatry on a dead man, wouldn’t it? Or thinking about it the other way, what’s the point of practicing psychiatry if everyone is just going to die? The capacity to ignore information and forget questions certainly has found its uses.

So, like a good sport, ever seeking completeness, I played my patient’s final moments over in the background of my mind for days, until I could see my fate and the fate of all humankind within them. One moment he was there, delirious, drifting between scenes of past and present, only loosely bound to the organized array of senses and cognitive faculties we are bound to in states of health. And in the next some aspect of his physiology came to a grinding, mechanical halt; his reality ceased to create internally as our reality of him as a body breathing and speaking shifted to one in perpetual inertia. So be it. Perhaps someday I will be comfortable with that, for that was the point of this whole career wasn’t it? To be comfortable with the thing for which my culture could provide no satisfactory wisdom? To find some helpful view on how one should live in light of the reported inevitability of death.

Some will call me callous, or naïve, or perhaps even psychotic. Will I accidentally be mean and harmful to someone delicate in the moment that my words came to bear upon their tender puzzle? Will I send someone astray down dark paths? I hope that if you are impressionable to these words, you will remember that the author was unsure of himself, and that he trusted in your ability to seek out your own information, and your own informative experiences. Our big questions are not always the same. Our diction does not share universal meaning, but experiential meaning, and our individual valid conclusions can easily pose paradox in concert. I am convinced that the full utility of evolving this level of intelligence was not so that we should always be happy and in agreement. We should remember that when seeking peace and harmony. Our intelligence is not a pure and virtuous capacity, but one with some inherent violence and self-primacy. Without empathy it may be the greatest danger in the world.

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