In the crackling heat of a Montana July, I went fishing with 20 psychiatric patients. Images borrowed from One Flew Over the Cuckoo’s Nest unfolded as I watched the troop shuffle out of vans in a conglomerate of secondhand fishing poles and comfortable cotton clothing. The patients congregated under lodge-pole pines, swapping old stories and off-color jokes in a snapshot of startling normalcy. This trip was the social highlight of the summer for many of these patients. I quickly learned that actually catching one of the comatose trout in the warm pond was of low priority for most of the patients. On the other hand, bumming cigarettes off of each other was something of an Olympic sport. My psychiatry rotation had demonstrated none of the lunacy I had expected in the mentally ill. My patients were neither dangerous nor intimidating. Instead, they struggled with internal illness that was compounded by the external chaos of dependence and financial poverty. Their stories tugged at my interest in the same way our baited hooks tugged at the interest of the lazy brook trout.
These patients presented as if the DSM-IV had vomited forth a slurry of psychiatric symptoms. Bert did not talk much, but I knew he was listening to something no one else could hear. “It’s applause,” he told me a few days previously. “I hear applause with everything I do.”
Chris had spent a few years as an Evangelical minister. The job got complicated when he went from preaching the word of God to preaching that he was the son of God.
Joanie was 40, tiny, round, and diagnosed with a personality disorder. She spent most of her time watching the Disney channel and painting ceramic figurines in marvelous acrylic shades.
Gilbert, who was fascinated by my battered Ford Taurus, was a mouth-breather diagnosed with bipolar disorder.
The rag-tag team marched around the lake in search of prime fishing holes in an odd parade. Other families at the lake watched with varying emotions because some of the patients laughed too loudly, their personal hygiene varied widely, and a few lurched and fidgeted—a side effect of prolonged use of some antipsychotics. We settled into the shade. A few patients tossed lines into the tepid pond. Jerry started telling a story about hunting with his father the previous fall. It was the third time we had heard the story that day, prompting a mild confrontation with Chris. “You tol’ us that one twice, man! You got any other stories?”
Diplomatic mental health workers quickly smoothed the situation over and suggested, “Jerry, why don’t you tell us about how you went to the Dairy Queen with your caseworker last week, instead?”
A patient dressed in an oversized Mickey Mouse T-shirt crept along the perimeter of the lake. Jenna was a sweet, middle-aged woman made soft and flabby by the medications that kept her moods stable. She blushed when I spoke to her and timidly offered me a cookie from our picnic.
“You’d never know that she lost her kids to the state,” the social worker whispered to me.
The gentle person in front of me did not correspond with the image of an “unfit mother.” I had naively assumed that compassion was supposed to be reserved for those who suffered innocently. I was struck by the realization that this woman labeled as “unfit” also deserved compassion. As saddened as I was for Jenna’s children, the real question became, “What happened in Jenna’s life to make her an unfit mother?”
Several months later this notion was reinforced when I began taking care of injection drug users in a metropolitan hospital. I was startled because I liked so many of these patients. They were often the most receptive to care from a medical student. I began to pick out commonalities in their history, and I learned to view and treat them with a guarded respect. I did not expect to find that people labeled as “distasteful” by society could elicit such feelings of empathy.
By the end of the afternoon, Chris had tripped and fallen into the lake, and a trace of sunburn colored Jenna’s sagging cheeks. We piled back into the vans and started the hour drive back to the city.
“Gilbert, please remember boundaries! We don’t touch the med student,” a social worker reminded the large gentleman sitting suspiciously close to me in the vehicle.
Gilbert moved a few microns from me, peered over his thick glasses and asked, “What kind of mileage does your Taurus get?”
The mountains faded and the urban landscape mushroomed into view through the windshield as patients laughed, argued, and napped. We stopped at a gas station and the attendant eyed our disheveled group with leering amusement. Perhaps Randle Patrick McMurphy himself needled my consciousness as I wondered if, like Kesey’s protagonist, I too might be part of the sane masquerading as the insane. I wanted this outsider to know that this was not a troop of loonies: that Joanie had sold three of her figurines at the fair; that Jerry served in Vietnam; and that Jenna loved to sing in the church choir. I wanted him to know that these patients taught me that humans may be deeply flawed, but rarely unworthy of compassion. These patients taught me that humanism is the act of caring for patients in their imperfect entirety.
Patients in all specialties are flawed. Some seek solace in forgetful liquor and opiates. Medications are taken inconsistently, and home may be a sleeping bag stashed in an alley. Some talk to people who are not there, and others are unwilling to talk. Patients cheat on their spouses and yell at their children. They eat food that comes with a side of French fries. In medicine, we frequently care for the misfits, the poor-all-around-decision-makers. Yet, these imperfect individuals draw us into their lives. We gain insight into their struggles; we begin to care about their burdens. And, sometimes, if we are lucky, we get to go fishing with them.
(Patient names and identifying characteristics have been changed or omitted.)
The Francis A. Velay Humanism in Medicine Essay Contest Presented by the Arnold P. Gold Foundation
The Arnold P. Gold Foundation is a not-for-profit organization founded in 1988 to nurture and sustain the time-honored tradition of the compassionate physician. Today, students, residents, and faculty participate in at least one Gold Foundation program at 92% of our nation’s medical schools and at schools abroad. Its programs and projects are derived from the beliefs that compassion and respect are essential to the practice of medicine and enhance the healing process; the habits of humanistic care can and should be taught; and medical role-model and mentor practitioners who embody humanistic values deserve support and recognition.
In 1999, the Gold Foundation instituted the annual Humanism in Medicine Essay Contest as a way to encourage medical students to reflect on their experiences in writing. Since the contest’s beginning, the foundation has received close to 2,000 essays from more than 110 schools of medicine and osteopathy.
Contestants for the 2008 Humanism in Medicine Essay Contest were asked to draw on real-life experiences to explain, “How patients teach their doctors about humanism in medicine.” Winning essays and honorable mentions were selected by a distinguished panel of judges. For the seventh year in a row, Academic Medicine is pleased to publish the winning essays from the contest. The first-place essay by Emma Layton Swingle appears here.
Winning essays are also published on the foundation’s Web site (www.humanism-in-medicine.org) and in the foundation’s DOC newsletter. For further information, please call The Arnold P. Gold Foundation at (201) 567-7999 or e-mail: ([email protected]).