Faculty Peer Reviewed
CC: “I’m stuck in the hospital at 9:30 p.m.”
HPI: L.G., a female G1P1 medical student immediately s/p the grueling hours and night-float duties of her OB/GYN clerkship, experienced acute onset elation about her next rotation: psychiatry. She felt excited for the clerkship—and for the tantalizing promise of a 9-to-5 schedule, which would allow her to see her four-month-old daughter for more than 30 waking minutes per day.
At the end of her second day on the inpatient psychiatry ward, word came that a new patient was being transferred from the emergency department. L.G.’s task: Get the H&P.
As the late summer sun began to set over the city, symbolizing her diminishing chances of seeing her daughter awake that evening, she introduced herself to the newcomer[*]: a young, thin, homeless man, with a distant gaze and a groomed goatee, who wore only a hospital robe and leather shoes. L.G. asked how the patient had ended up at the hospital. In a slow, drugged-out manner, he stated that there were warrants out for his arrest, the CIA had been following him, and federal agents had thrown acid on him in the subway, prompting him to head to the E.R. to be examined (no injuries were found). He confessed to L.G. the reason he was being followed: He had done something “close to rape” of several boys and girls, aged 2 months to 16 years. As L.G. heard his admission, it occurred to her that she’d missed the chance to see her baby that night because of a child predator—one whom she was obligated to care for and treat with professionalism and respect. She took a deep breath and continued with the interview. At 9 p.m., she returned to the call room to write the H&P, and let out a sigh about this “9-to-5” rotation.
Past Medical & Surgical History: Noncontributory
Medications: 100mg liquid caffeine PO BID
Allergies: Acid-base physiology
Family History: Significant for familial reproductive hyperstupidemia (her father also had a baby during medical school)
Social History: L.G. lives in New York City with her husband, daughter, and mother-in-law (provider of the world’s best child care), whom she has been holding hostage since the beginning of her clinical clerkships.
REVIEW OF SYSTEMS:
General: Medical school-induced sleep-deprivation
HEENT: Bitter taste after hearing confessions of child abuse
GI: Gnawing hunger s/p lunch 8 hours ago
Extremities: Tired feet
Psychiatric: Separation anxiety, with occasional worries that her baby won’t recognize her.
VITAL SIGNS: wnl
General: Female in NAD, A&Ox4, wearing professional attire and a ponytail that’s beginning to look scraggly
HEENT: Eyes bleary
Heart: Displaced PMI
Abdomen: Linea nigra still intact
Extremities: Fingers feverishly typing the H&P
ASSESSMENT & PLAN: A G1P1 medical student developed mild distress while working late in the psychiatry ward, having missed the chance to see her infant daughter that evening.
1) Quit whining, maintain a positive attitude, do your best to help this patient, and try to have some fun along the way.
2) Refer to cute baby photos on cell phone PRN.
The patient was admitted to the psychiatric ward and started on an antipsychotic and an SSRI. Each morning after rounds, L.G. went to see him. He was always calm and cooperative, but confused, paranoid, and depressed, with marked psychomotor retardation. He spent his days lying on his bed in the dark, eating at off-hours to avoid others, and asking repeatedly when he could leave the unit.
L.G. contacted collateral sources. She learned that the patient was a teetotaler who didn’t smoke or do drugs. Three weeks prior to admission, he had started making vague, paranoid-sounding statements about his “crimes,” and abruptly cut off contact with everyone he knew. He was not actually homeless (though he’d recently taken to the streets, believing he’d been evicted) or unemployed (he worked for a nonprofit organization,placing people into drug rehab programs). He frequently carried peanut butter sandwiches to hand out to the homeless. He had no criminal record, there were no warrants for his arrest, and there was no evidence to suggest that he’d ever harmed any child.
Very gradually, the patient began to show improvements in relatedness, affect, and cognition, and his paranoid thoughts softened. He seemed to appreciate his daily conversations with L.G. and her earnest attempts to fill the gaps in his understanding. She enjoyed their friendly rapport and feeling like one small part of his visible progress.
After five weeks, the patient was discharged from the unit, his symptoms stabilized and a careful follow-up plan in place. Two days later, L.G. was discharged from her psychiatry clerkship with a new appreciation of how, in medicine, first appearances can be misleading. A self-professed homeless child-molester had emerged as something quite different: a well-loved man with friends, a home, and meaningful work, interrupted by mental illness. He no longer felt like an inconvenience to L.G., a cruel predator, or a barrier between her and her daughter. He felt like her patient, and something close to a friend. More importantly, L.G. was forced to confront her own bias. The demands of motherhood and medicine may occasionally pull her in opposite directions, but she hadn’t set out to treat only the patients she liked, exclusively during business hours. What if this patient hadn’t turned out to be so decent? How would she approach the next admission who struck her as loathsome, or who arrived at an inopportune time? Would she allow her feelings or outside obligations to sour her perspective or alter the care she provided? She made a commitment to try harder, to do better, and to embrace the lessons that come with 9:30p.m. admissions.
Laurel Geraghty is a fourth-year medical student at NYU School of Medicine
[*] Some identifying details have been changed.