“I took the pills”: Coping with Expectations in Medicine

My child psychiatry rotation began with the understanding that my career would not include children or psychiatry. The limited availability of advanced courses that would fulfill graduation requirements led to an interesting decision: opt for an advanced surgery rotation or an advanced psychiatry experience. As a budding internist, I of course chose the option that would ensure a safe distance away from any surgical suite. Now three weeks into my rotation, I am getting increasingly comfortable talking to teenagers with a range of psychiatric diagnoses, levels of participation, and understanding of their illness. Although this semblance of comfort took weeks to build, it took a single challenging conversation to retreat.

Our morning virtual rounds led us to “Sara”: a high school student with crippling anxiety, depression, and PTSD who struggled in school due to specific learning impairments. She presented to the Partial Hospitalization Program after two separate suicide attempts and was transitioning well to the group therapy setting. After Sara entered the virtual breakout room, it was clear to me – and, as I would learn, blatantly obvious to my attending – that something was not quite right. My usual series of questions, including some more pointed ones, yielded more avoidance than objective information. My attending finally stepped in and skillfully uncovered that Sara attempted suicide several hours earlier. The events following this revelation happened quickly; Sara’s mother was asked to enter the meeting, she was updated, and it was agreed that Sara would be taken to a nearby hospital.

At this point in my medical education, I have shared conversations with actively psychotic individuals, families who just lost a loved one, and patients receiving terminal diagnoses. Despite these experiences, Sara’s story seemed to hit me differently. My initial thoughts centered around the reality of mental illness and what it means for a patient to die by suicide. What had happened, or not happened, to Sara to make her feel death was the only cure for her suffering? What does she need from me? What can I actually do for her? These early thoughts reinforced a certain humility in me; the very practice of humanistic medicine underlies the importance of recognizing what I can and cannot control in a patient’s life. As I waded through possible answers to such questions, I felt many of the same emotions Sara described to us. I was scared for Sara, I was sad that Sara had to live with such an illness, and I was anxious as to what Sara’s treatment trajectory would look like.

As I continue to reflect on Sara’s story, I now question the pursuit of normalcy in medicine. Much of what I have been taught both in the classroom and on the wards is how to get patients to “normal”; we monitor labs to make sure they are within “normal” limits and we perform scans to ensure “normal” anatomy. In Sara’s case, I do not know what normal would or should look like. Sara’s psychiatric diagnoses, although persistent and severe, are seemingly one aspect of hardship in their life. Sara has experienced significant physical trauma, homelessness, and numerous other social needs in less than two decades of life. As a future medical provider I have hope for Sara’s future, however, this optimism is balanced with very real expectations. How could I expect someone to overcome such psychiatric illness when mental healthcare remains stigmatized in medicine? How could I expect any medical intervention to work in the setting of overwhelming social challenges? What does a safe, normal life look like for Sara?  At this point in her treatment, the hope I have for Sara is static; I hope she does well in the hospital, transitions to an outpatient treatment program, and consistently receives appropriate social and mental health support. My short time with Sara epitomized the role hope played, even in the face of realistic expectations, in the care of struggling patients.