How Can I Help?

A Week in My Life as a Psychiatrist

David Goldbloom, Pier Bryden, M.D.

• Publisher: Touchstone
• Year: 2016
• ISBN:
  9781476706801
• Topic: Social Sciences
• Subtopic: Social Science Biographies
• Index: Social Sciences

A humane behind-the-scenes account of a week in the life of a psychiatrist at one of Canada's leading mental health hospitals. How Can I Help? takes us to the frontlines of modern psychiatric care. How Can I Help? portrays a week in the life of Dr. David Goldbloom as he treats patients, communicates with families, and trains staff at CAMH, the largest psychiatric facility in Canada. This highly readable and touching behind-the-scenes account of his daily encounters with a wide range of psychiatric concerns—from his own patients and their families to Emergency Department arrivals—puts a human face on an often misunderstood area of medical expertise. From schizophrenia and borderline personality disorder to post-traumatic stress syndrome and autism, How Can I Help? investigates a range of mental issues.What is it like to work as a psychiatrist now? What are the rewards and challenges? What is the impact of the suffering—and the recovery—of people with mental illness on families and the clinicians who treat them? What does the future hold for psychiatric care? How Can I Help? demystifies a profession that has undergone profound change over the past twenty-five years, a profession that is often misunderstood by the public and the media, and even by doctors themselves. It offers a compassionate, realistic picture of a branch of medicine that is entering a new phase, as increasingly we are able to decode the mysteries of the brain and offer new hope for sufferers of mental illness.

1

Family Medicine

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SUNDAY

My mother rubs her eyes. “I can’t think why I’m having so much trouble with my vision these days. I keep seeing something moving, almost like a fan turning, but I know there’s nothing there. Nancy, what do you think? Should I get my eyes checked?”

My wife, Nancy, and I are chatting after lunch with my parents in the family room of our Toronto home. My parents are visiting from Halifax for the weekend to attend our older son’s graduation from law school. Nancy, an ophthalmologist, takes a surprisingly long time to answer.

“I have some ideas, Ruth,” she says finally. “Do you want to hear them?”

This is one of those moments when life slows down – when, for example, you know for certain that your car is going to crash into the vehicle in front of you, or you get the message that your child’s school is calling unexpectedly. We wait – Nancy, my father, and I: an ophthalmologist, a pediatrician, and a psychiatrist, respectively – for my mother to speak. Usually I focus more on people than on my physical environment, but now I watch the June sunlight coming through the window, lighting up the swirls of dust particles in the air like spun sugar. My diminutive but wildly energetic mother, diagnosed and treated for lung cancer six months ago – successfully, we thought – looks at her hands before flashing a glance at my father, sitting preternaturally still on our sofa.

“I’d like to hear what you think,” my mother replies.

My physician wife has realized immediately that my mother’s deteriorating vision is most likely caused by lung cancer spreading to her brain. Nancy chooses her words carefully, as she has been trained to do. All doctors have varying degrees of formal training or clinical experience in breaking bad news: Don’t convey certainty prematurely when the news is bad and confirmatory tests are pending. Don’t take away hope unnecessarily. Nancy talks about possibilities, about brain metastases, about ruling out certain diagnoses, about being thorough. This way, the patient – who on this warm June afternoon happens to be my mother – has time to get used to the possibility that she may eventually hear something that previously seemed unfathomable.

Bad news. It is an aspect of doctors’ work that separates us from everyone else except our professional relatives: nurses, ambulance staff, police. Physicians live in a world where the everyday statistical likelihood of bad news is reversed: we see the seven-year-old with fatal leukemia, the mother with two young children killed in a car accident, the grandfather dead of a heart attack after a family dinner where he complained of indigestion. It makes it hard in our personal lives to maintain a balanced perspective. Some of us have to work hard to remind ourselves that not every headache is a brain tumor or a stroke, and that not every child’s high fever is meningitis. Others soldier on with cavalier assumptions of their own immortality, a maladaptive coping strategy that lends itself to excessive risk taking. Every physician of my generation remembers a celebrated professor or two who smoked incessantly between patients or surgeries, even in the face of decades of grimly accumulating evidence about cigarettes’ extraordinary capacity not just to shorten lives but also to make the days left miserable.

I am more of the second type – assuming that my health and that of my family members will be robust until forced by undeniable evidence to admit otherwise. My experience to this point has largely supported my outlook. Both my parents have lived unusually long and healthy lives into their late eighties, a fact that has allowed my two siblings and me the illusion that we are still young things, barely flirting with middle age, despite being well into our fifties and sixties. We are the children of an optimistic pediatrician father and a tough-minded mother who made a career out of volunteering. As we grew up with the usual childhood maladies, my father exhibited healthy denial, while my mother, uncontaminated by any formal medical education, saw all forms of illness as character flaws.

In the Goldblooms’ handbook for life, one written by four generations of physicians, illness is part of the human lot, and anticipatory worrying or feeling oppressed by its appearance in oneself or one’s loved ones is not only a waste of time but also a potential roadblock to a good joke.

LATER SUNDAY EVENING, after the convenient distractions of Nancy’s composing and faxing a letter to my mother’s GP outlining her concerns and recommending next steps, organizing an earlier than scheduled flight home for my parents, and driving them to the airport, I am finally alone with my wife.

“How are you?” she asks.

I know she will not judge. “Fine, I think. Everything’s organized. There’s nothing more we can do until after the scan.”

Nancy doesn’t question this ridiculously superficial answer. It’s the advantage of having a spouse who has stuck with me for almost forty years and known me since childhood. She knows when to probe and when to allow me my illusions, at least temporarily.

“Yes, we’ll take good care of her.”

I hug her tightly, thinking of the myriad times in my life when Nancy has nudged me closer toward acknowledging feelings to which I cannot immediately gain access. This probably seems a strange thing for a psychiatrist to write, but as many of my patients, family, and colleagues have told me over the years, I am not the stereotypical psychiatrist.

I have heard the old chestnut that there is nothing like a parent’s impending mortality to make you think about your own, but this evening I have no intention of allowing my thoughts to bury either my mother or me prematurely. As I organize my belongings for the next day, I realize I haven’t thought for a long time about my decision in 1980 to choose psychiatry as the area of medicine (my version of a family business) that I wanted to pursue. There is – with the striking and influential exception of my father-in-law, Nate Epstein – a dearth of psychiatrists in my family and a plethora of Goldbloom pediatricians across four generations. Given my temperament, which has been characterized since birth by extroversion, a dislike for introspection, a love for performing (particularly comedy routines), and a general chattiness, my decision surprised almost everyone who knew me. These days, that decision comes to my attention only when an eager medical student or psychiatry resident facing his or her own career choice asks me how I made mine. Tonight, it does not take Nancy to point out to me that my reminiscences are an effective distraction from thinking about what news the week will bring.

THERE IS NO DOUBT that psychiatry is a peculiar job. While other doctors ask questions that few others in your life will ever ask – How are your bowel movements? What are your drinking habits? – and enter orifices of your body to which no one else will ever have access, psychiatrists have an even more unusual mandate. We want to know about your moods, your thoughts, worries and preoccupations, your relationships, your experience of school and work, and your grandmother’s tendency to put tinfoil inside all her hats to avoid electronic surveillance. We routinely interview police officers, criminals, and homeless people as part of our training, and we spend hours on call in the middle of the night calming individuals who believe that they are the victims of an international conspiracy or that scientists, extraterrestrial or otherwise, have implanted speaker devices in their brains. During the day, we may treat a depressed businessman, a panic-stricken college student, a substance-abusing medical colleague.

Being a psychiatrist also creates a considerable social barrier, at least initially. Announcing one’s career as a psychiatrist at social gatherings tends to produce a lull in the conversation while listeners seek to respond appropriately. Some say, “Oh, God, are you analyzing me?” and hastily review what they have previously said; others take the opportunity to divulge highly personal information in the hopes of a quick professional opinion.

Even some of our patients are initially put off by our profession. Very few people wish or believe they or their child will ever need to see a psychiatrist. A family doctor, an obstetrician, and arguably a surgeon to remove a recalcitrant appendix or to fix clogged arteries, but not a psychiatrist. Some patients enter my office and answer my initial questions with the enthusiasm of someone referred to a periodontist for gum surgery. Some are fearful that something said inadvertently will result in being “locked up” or fundamentally transformed by treatment in a bad way. Others dissolve in tears as they sit down for the first time, having waited too long to talk about something private and profoundly troubling.

Medical colleagues also tend to be wary. Medical students considering psychiatry as a specialty usually conceal it from their nonpsychiatric supervisors, surmising correctly that it will be a mark against them. “Why don’t you do something really useful?” “Won’t you miss real medicine?” “Do you really want to spend your time listening to miserable people?” After one long night on call in the ER during my residency, I met a friend, a resident in another medical specialty, for breakfast in the hospital cafeteria. She marveled, “I can’t believe you’re in psychiatry. I couldn’t do it. I would find it so depressing.” She was training in oncology.

It doesn’t get better once in practice. Colleagues forced to consult you for assistance with hospitalized patients frequently fail to let their patients know they have done so; as a result, when you appear at the bedside, they and their families are horrified and want to know why Dr. W felt they needed to see you. “Does he think I am crazy, that this is all in my head?” The greatest compliment either a patient or a physician colleague can pay a psychiatrist runs along the lines of “You don’t seem like a shrink . . .”

Arguably, the stereotype associated with psychiatrists is borrowed from the far greater stigma suffered by our patients. Patients with mental illness have historically been hived off from the majority of medical patients into asylums and large gloomy psychiatric hospitals built, like prisons, on the periphery of town. It is a relatively recent phenomenon – post–Second World War – for there to be psychiatric wards in general hospitals. Long before film and television, let alone the Internet, Charlotte Brontë’s Jane Eyre, published in 1847 to instant acclaim, depicted Mr. Rochester’s first wife as a violent, fire-setting lunatic, kept locked in the attic. Her caregiver, Grace Poole, resembled her unstable ward in both her demeanor and lack of social graces. Charles Dickens’ Great Expectations, first published in 1861, was equally well received, with its portrayals of the eccentric and demented Miss Havisham and her troubled adopted daughter, Estella. Neither masterpiece did anything to increase sympathy among readers for the mentally ill or their caregivers.

It hasn’t improved over time. In the twentieth century, F. Scott Fitzgerald, in his semi-autobiographical 1934 novel Tender Is the Night, described Dick Diver, a psychoanalyst, who marries his schizophrenic patient (modeled on Fitzgerald’s troubled wife, Zelda) and almost destroys himself with alcohol. More recently, films such as One Flew Over the Cuckoo’s Nest, Frances, and Girl, Interrupted have continued the theme of caregivers who resemble their wards in their unappealing psychiatric profiles. Nurse Ratched has entered the psyche of the English-speaking world as the epitome of the sadistic, parasitical torturer of the mentally ill who masquerades as caregiver.

The portrayals have some basis in historical reality. Psychiatry’s past has more than its fair share of horror stories: from the overcrowded asylums of the late nineteenth century with their unwashed and uncared-for patients, to the unheeding savage rush toward psychosurgeries in the United States and Britain from the 1930s to the 1950s, and the postwar psychoanalytic community’s endorsement of the cruel and unscientific concept of the schizophrenogenic mother. In this sense, psychiatry shares a history with the rest of medicine, which has its own repertoire of horrific treatments enthusiastically endorsed and subsequently abandoned.

There is also some truth to psychiatrists having things in common with their patients. Psychiatrists are more likely to have had experience with mental illness ourselves or in our families than doctors in other specialties. This shouldn’t be surprising. Some physicians who experienced insulin-dependent diabetes in childhood, or witnessed it in a close relative, have understandably become endocrinologists, driven by both noble and self-serving goals to improve understanding and treatment of that illness. Others have chosen oncology after a parent or sibling died of cancer.

Educational researchers describe medical students interested in psychiatry as a career as being more reflective and responsive to abstract ideas, liking complexity, and being more tolerant of ambiguity than their colleagues. They also have more nonauthoritarian attitudes, more open-mindedness, a greater interest in social welfare, and a preference for aesthetic values. Psychiatrists are also more likely than their medical colleagues in other specialties to have an undergraduate degree in the arts and humanities.¹

On a more mundane level, psychiatrists face ignorance about the day-to-day nature of our work. The common image of a psychiatrist’s practice is of a middle-aged professorial type – not a “real” doctor – who conducts rambling intellectual conversations with interesting, troubled people in an office resembling a sitting room rather than the workplace of a medical doctor. My working life, and that of the majority of my colleagues, bears no resemblance to the professorial stereotype, appealing as it may be.

Most people don’t understand who psychiatrists are and are not in this day and age. We are not predominantly psychotherapists, and were rarely ever so outside North America. This fact causes confusion for the lay public, which has difficulty differentiating among the various types of mental health professionals, most of whom engage in the so-called talk therapies to a greater or lesser extent.

Psychologists are usually graduates of either a master’s or PhD level university program whose training includes the acquisition of therapy skills, the study of the mind in health, distress, and disease, and expertise in the measurement of individuals’ psychological states and function.

Social workers also train in university programs that focus predominantly on social and cultural determinants of mental health and function, and tend to acquire skills in interpreting families, systems, and relationship dynamics for the purposes of intervening for health.

Other therapists may train outside universities in programs that focus more narrowly on a single type of therapy: art, music, play, and dance, among others.

Psychoanalysts, practitioners of psychoanalysis, historically the best-known talk therapy and the intellectual child of Sigmund Freud and his disciples, have now largely been cast out of mainstream psychiatry. Contemporary psychoanalysis exists in institutes and centers outside hospitals and universities, and is practiced by professionals and academics from a variety of disciplines, including medicine, who have been trained in its origins, theory, and technique and who have undergone psychoanalysis themselves.

Each of these groups of mental health professionals – psychiatrists, social workers, psychologists, analysts, and other types of psychotherapists – has its own history and culture, not to mention professional territory to secure, and relationships among them have shifted at various times and in various countries. There can be frank competition for patients in private practice and a high degree of collaboration and teamwork in hospitals and community agencies.

Psychiatry is the only one of the mental health disciplines that lives within medicine and whose practitioners are all medical doctors. Psychiatrists may, as a result, struggle with a dual identity: on the one hand, they are physicians trained in the traditional model of medical science, and on the other, mental health practitioners who acknowledge multiple determinants of psychiatric disease and who work with colleagues from a wide variety of academic and philosophical perspectives. Depending on your viewpoint, this has either enriched psychiatry to an extent that it now offers medicine an extraordinarily diverse path forward to bringing mind, body, and society back together, or has led to an inferiority complex where psychiatrists feel the need to prove themselves “real doctors” by focusing on medications or neuroscience to the exclusion of other disciplines. It is probably clear by now that I am in the former camp.

Psychiatry has been a struggle for me, not the natural fit that pediatrics or surgery would have been, with their relatively sunny outlooks – at least within the medical profession – and fix-it approaches. The vast majority of children in the West in a post-antibiotic era grow to adulthood, and most surgeons have the satisfaction, at least in the short term, of removing, replacing, or resizing the offending body part that is causing their patient distress. In contrast to these specialties’ action-oriented fixes, I found the stereotypical psychiatrist’s probe of “Tell me how you feel about that” hackneyed and not particularly helpful. Patients are usually effective in telling me how they feel, consciously or unconsciously, without my asking. It is also the case that I am a doer, and I like to fix things. I come from a privileged background – both economically and genetically – that was often far from the experiences of my sickest patients, whose illnesses relegated them to society’s margins. And I was a bit of a jerk when I chose psychiatry: full of youthful narcissism, arrogant, loving the sound of my own voice, and convinced that I was going to make psychiatric history in some undefined way, coming from a lineage, by blood and by marriage, of people who made their marks on the world of pediatrics and psychiatry.

But from the beginning there was something in psychiatry that brought out the best in me. My natural curiosity and liking for people drew me to the patients’ unusual stories, as did the opportunity to spend longer periods in conversation with them than was possible in other faster-moving medical specialties. In psychiatry, the time spent talking with the patient was seen as essential to determining diagnosis and treatment. During the course of those conversations, I learned that the vast majority of patients were not weak or lazy but victims of both genetic and circumstantial bad luck. This misfortune took the form of a strong family history of mental illness, or the loss of j...

Table of contents

• Cover
• Dedication
• Introduction: “They” Are “Us”
• 1. Family Medicine: Sunday
• 2. Listening for a Diagnosis: Monday morning
• 3. Coping but Not Cured: Monday afternoon
• 4. Shocked: Tuesday morning
• 5. Bridging Distances: Tuesday afternoon
• 6. Emergencies I: Wednesday morning
• 7. Emergencies II: Wednesday afternoon
• 8. Restraint: Thursday morning
• 9. Off the Path: Thursday afternoon
• 10. Doubt: Friday morning
• 11. Public and Private: Friday afternoon and evening
• Epilogue
• Authors’ Note
• About David Goldbloom, M.D. and Pier Bryden, M.D.
• Notes
• Further Reading
• Index
• Copyright