Sympathy for the factitious patient

I went to the student health center last week for my annual exam. I showed up a few minutes late, and so rushed to fill out the paperwork while in the waiting room, expecting to be frowned at and told I should have arrived on time.

Instead, I was met with smiling faces, as the nurse ushered me in to an examining room, allowing me to drop my bag and jacket, before guiding me to a seat in the hall from where to take my blood pressure and temperature.

"Well, isn't that nice," I thought. "Like having a personal aide who tells you where to be and administers personalized services." Right then, I understood -- well, to some extent -- Munchausen Syndrome patients.

Patients with this disorder manufacture symptoms in themselves, usually through ingestion of toxic substances or inappropriate medications, in order to receive attention from healthcare professionals. While I don't really think I'd ever be capable of that -- Munchausen patients generally have personality disorders or history of abuse, so there's more going on than just a desire for some attention.

But in a very impersonal world, in which you can get through a day, or maybe a week, or maybe more, without any real meaningful human contact, especially if you're perhaps a little introverted or perhaps have a small-feeling job in a cubicle, this kind of attention feels really nice. It's attention not to how much work your team has produced or when you have entered and exited the building, but to you and your well-being. For a few moments, the efforts and thoughts of several professionals are focused just on you, and nowhere else. I don't have a small-feeling cubicle job, and am a student in what is maybe the most attention-intensive medical program in the country. But I can most definitely understand the desire to prolong those moments in the clinic.

It comes from all sides

Me: "Do you have any advice for me as a medical student?"

Patient: "Study incessantly."

Jumping off the hedonistic treadmill

I really like this entry from the NYTimes' Happiness Project. In it, the author talks about how, after getting a case of conjunctivitis, she had to stop wearing contact lenses. And it was only through this experience that she realized how happy she was to have the convenience of contact lenses -- which, without this deprivation, she took for granted and even sometimes complained about, given how much of a pain it was to put them in and take them out.

The problem is that becoming accustomed to all of our conveniences and privileges creates a "hedonistic treadmill", in which we continue on at a steady pace without appreciating what we have.

Having a fluctuating hearing loss is often frustrating, bothersome, and difficult, but there's this thing: when it bounces back up from its low dips, I get insanely happy. Having five senses that work! Being able to meet new and interesting people! The world is my oyster. Somehow, having this hearing loss has allowed me to jump off the hedonistic treadmill.

Only in Berkeley event of the day

I participated in a 12-minute die-in for health care reform today on Sproul Plaza. We had to move a little down the path because of a huge display of bloody fetuses by an anti-abortion group, and the counter-protest by a pro-choice group. As I left, a student was stepping up to a microphone and welcoming everyone to a celebration of Filipino Awareness Month.

Just another Tuesday in Berkeley.

Narratives

I heard a talk from Rachel Remen last week, whom I found extremely charming and inspiring, even though the talk was projected from a DVD. Apparently some people's charisma comes through even in virutal presence. Anyway, she offered the following anecdote:

Three stonecutters are sitting at their work stations cutting stone. The first is asked, "what are you doing here?" He answers, "I just sit and do the same thing every day, putting the stone through the cutter. It's terribly boring and mindless and I can hardly stay awake."

The second stonecutter is asked the same question and answers, "I am making money to support my family. Because of me my children are growing up healthy and learning about the world, and my whole family is happy."

The third stonecutter is asked, and responds like this: "I am helping to build a cathedral -- the most beautiful, most monumental building and a wonderful accomplishment of human cooperation and ingenuity."

The story tells us about the importance of the narrative. Each stonecutter is doing the exact same thing, but each bestows his own meaning to it. This is, of course, a lesson we can personally all take home as we try to bestow meaning to our own lives.

It's also relevant to my learning as a physician. A patient has his or her own narrative that will always affect the clinical encounter and the outcome of the case. In psychiatry, which I am just beginning to learn about and which for some reason makes me often think of the Jennifer Lopez movie The Cell, how the patient constructs his narrative is everything.

I asked my teacher, "But the idea of 'early life stresses'... doesn't it get blown out of proportion, and lead to blaming everything on the parents?"

But, and as her answer hinted, I don't think this is the right way to think of things. A medical model would tell you, well, stress here (and maybe a genetic predisposition) leads somewhere along the line to illness. But in psychiatry, we're not diagnosing that way. We're listening to what's going on in the patient's inner world, trying to understand how she conceives of her health, thoughts, and relationships to other people and things. It's not so much about what "really happened" but about how the patient has experienced those things.

The approach becomes not, "what is the stonecutter actually doing?" but rather, "How does the stonecutter construct his narrative about what he's doing?"

Counting Down the Hours

These are lyrics from a band that I'm a little obsessed with. On bad days, this is what I feel like about my hearing.

And I go on
Wondering if I've got a soul and
Counting down the hours 'til it goes

-- Ted Leo and the Pharmacists, "Counting Down the Hours"

Insight and humanity

There's a concept in psychiatry that most of us don't consider often. Insight, defined in my intro to clinical psychiatry book as, "the patient's awareness of his or her mental illness and the ability to connect this disturbance to other problems", is not really the most important important aspect of a patient's mental state from a diagnostic perspective.

But what strikes me is that insight is perhaps the most important factor in determining our emotional reaction to the patient. Consider an older patient with dementia, for example. He is losing his mind, forgetting who his children are, giving them gruff and slightly wary welcomes when they come to visit. Maybe we roll our eyes, shake our heads a little as we repeat what we've been telling him for weeks, that his visitors are his family, and he should be nice and sit and talk with them for awhile.

Now consider the same patient, who, in a moment of insight, realizes that his mind is slipping away past his reach. A lifetime of professional accomplishments and personal connections is blurring into an oblivion that he recognizes as the path towards the end. Our patient has now gone from a sweet old nuisance to a tragedy.

Why? What is it about this one feature that evokes such a an empathetic response? I think it's because insight gets at what makes us human. Ants will never have the insight into their situation aside from an instinct to run when they see large objects moving quickly near them. Insight implies a broader realization, a conceptual understanding of illness and one's relationship to it.

Ancient playwrights knew that insight is the stuff tragedy is made of: the entire, horrible events that lead to Oedipus's putting his eyes out happen before the play starts. Things only turn tragic when Oedipus realizes what has occurred -- when he gains insight.

Although embedded within the endless descriptive terminology that psychiatry uses, insight describes more than a symptom of an illness. It describes an expression of humanity.