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The Notebook

Gunawardana, Amali

doi: 10.1097/ACM.0000000000002658
Teaching and Learning Moments
Free
AM Rounds Blog Post

A. Gunawardana is a third-year medical student, George Washington University School of Medicine and Health Sciences, Washington, DC; e-mail: agunawar@gwmail.gwu.edu.

An Academic Medicine Podcast episode featuring this article is available wherever you get your podcasts.

Author’s Note: The name and identifying information in this essay have been changed to protect the identity of the individual described.

Leah was one of the first patients I met during my clinical year of medical school. I was assigned to an adolescent inpatient psychiatry unit. Many of the patients there had experienced physical and emotional abuse resulting in posttraumatic stress disorder. The simple idea of going home exacerbated their symptoms and led to longer hospital stays or to the revolving door of being discharged and admitted again, over and over.

Leah was a thin young woman with unkempt hair and a mild demeanor. She wore sweatpants that were far too large for her small frame and hospital socks. She rarely made eye contact and fidgeted uncomfortably in the presence of others. Separated from her biological mother early in her life because of physical trauma, Leah had been tossed between abusive foster families, including her current one. Unable to bear the idea of going home, she preferred to stay protected in a residential treatment facility.

I followed Leah for the full three weeks of my rotation. She was kind and gentle, yet extremely guarded. She had a history of major depression with psychotic features and would occasionally have disturbing visual hallucinations surrounding themes of death, destruction, and violence. Leah was insistent on not going home; her mother never understood her, she said. Leah’s suicidality had been so persistent that she was at the highest level of care—five days of one-on-one psychotherapy a week. As a result, she had come to trust and confide in her therapists more than in anyone else.

Spending time with Leah every day built an alliance between us. She allowed me into her life and shared her innermost fears. I was deeply affected by her suffering and wanted to protect her from our chaotic world. Toward the end of our time together, when I asked if she thought I understood her, she said, “Just a little bit.” I kept thinking about what was missing from our relationship.

The following day, Leah handed me a notebook and said: “I want you to understand me. Please read this. I have been journaling throughout my hospital stay.” The more than 20 handwritten pages documented Leah’s personal experience with her illness and its impact on her life, as well as her reactions to perceived daily events. There were delusions and hallucinations of witchcraft and hyperreligiosity that we had never discussed. Through journaling, Leah was trying to make sense of her experiences, to live with, and recover from, her mental illness and its consequences. I was honored and grateful that she had chosen to be vulnerable with me after the weeks we spent together. However, I was shocked by the content of her journal. I had no idea that Leah had such severe symptoms. I wondered if her sharing her journal was a cry for help.

Leah wanted to keep the content of her journal a secret, as she strongly disliked being on antipsychotic medications. Yet I felt I had an obligation to tell my supervisors. Many thoughts were running through my head. I was concerned about losing Leah’s trust. On the other hand, I also wanted her to do well and receive the right treatment. Leah could have serious adverse outcomes if she was not treated. She could be successful in yet another suicide attempt. Leah could die. Facing this array of possibilities was heartbreaking for me. I ultimately decided to tell the team. Yes, it meant betraying her trust, but it also meant that a team of health care professionals could think critically about a plan to improve Leah’s mental health and safety. My attending physician was grateful that I had taken the time to listen and explore my patient’s illness. He read the journal and told us that Leah’s poor insight into her illness and her refusal to be treated was not a denial but, rather, a symptom. The team diagnosed Leah as schizophrenic.

By sharing her story with the team, I certainly betrayed Leah’s trust in that moment. However, I hope that, ultimately, we all got to know Leah better and therefore could provide better care for her. Leah taught me to actively listen and offer the support my patients need to be able to find, hold onto, and reclaim their stories and their selves. We must encourage patients like Leah to employ their narratives as resources in overcoming and living beyond their illness. Scientific evidence is important, but it is only one source of information and one thread in a patient’s tapestry, a tapestry that includes many other fabrics and hues. Within this larger and more complex picture, it is listening and observing a patient’s story of self and its construction that must remain at the center of our provision of care.

© 2019 by the Association of American Medical Colleges