I went to medical school with a clear goal: to eventually become a psychiatrist. With a background in psychology, I knew I adored the field of mental health and was already sure that was the specialty I wanted to do. As much as I would like to have dedicated the whole program to psychiatry, I knew this wouldn’t be the case as we have to study every system to become an MD, condensed into just 4 years of theory and practice. The first two years were hectic and depressing. Half the subjects bored me to the point I couldn’t even function (who likes histology anyway?). This was coupled with my mental health hitting rock bottom. But somehow, I survived. Just last month, I began my third year. I chose my yearly schedule to start with the 4-week required psychiatry clerkship (medical school rotation in the department). To be honest, this wasn’t just an excitement-related decision, but it was also convenient to postpone the surgery clerkship (hence delaying a possible depressive episode). It also worked with my silly little dream of seeing Taylor Swift in concert during a July vacation, having a ticket already bought last year. Back to the main story, this rotation concluded a few days ago, making my passion for psychiatry and mental health grow more prominent and vibrant. I feel like the years of planning are already yielding something slowly erasing my previous years of distress, with the dream just having to be paused for now. Only for some time, as I finish the other clerkships and become a doctor. But right now, sitting on my couch at 1 AM, why not reflect on some lessons I’ve learned on the psychiatry floor since I haven’t posted on this blog for so long? Let’s go.
Psychiatry is for me. Definitely. Certainly.
If you follow me on X/Twitter, you’ve probably seen me ranting about this before. When I tell people I want to be a psychiatrist, they sometimes assume it’s a mild guess of a field I prefer over others. I don’t blame them. Many medical students are not sure about their future specialty, and that’s absolutely valid. However, it just gives me an unpleasant feeling when my dreams are assumed to be transient and “might fade away as I see what it’s really like.” But now I feel more confident saying that I want to do psychiatry since people know I’ve been on that floor. I’ve seen an overview of almost everything: interacting with patients, crises in the emergency room, ECT, and calm outpatient appointments. Hence, it’s not a theoretical job I imagine liking. I’ve seen it, I’ve lived it. And I’ve found myself there.
We Need More OCD Awareness
As an OCD patient myself, it’s hard not to realize how much obsessive-compulsive disorder (OCD) is left out of the conversation about mental health. I understand it’s not a competition, but OCD shouldn’t be dismissed because the public just doesn’t “dramatize” it enough as they do for other disorders. I realize the issue might stem from the mental health field itself sometimes, as OCD is often misunderstood and receives relatively less research. For instance, I was having a casual conversation with a trainee from a related field but from a different university, and she spoke about OCD in a manner that made me extremely uncomfortable. It wasn’t just uncomfortable, but also inaccurate and based on centuries-old prejudices. It made me wonder, what if I had been her patient? What if I heard these words uttered by my own therapist? I would have felt extremely uncomfortable if she was my healthcare provider, and probably too ashamed to talk about any OCD symptoms further. Luckily, I haven’t been in such a position before, but I think it would be foolish to deny its plausibility. This person didn’t seem very judgmental about other topics, so I’m not sure it’s a general character issue. Rather, it could reflect an underlying disregard for proper OCD education in our mental health educational systems. In other psychiatric conditions, there sure remains stigma and misconceptions, but people seem to at least have a basic understanding of what the conditions are. For example, many people believe schizophrenic patients to be violent. While this is an untrue and very dangerous belief, most people still probably recognize that schizophrenia is about symptoms like hallucinations and delusions. On the other hand, many healthcare professionals or members of the public probably can’t define or deal with OCD basics. While I don’t think pointing fingers will just solve the issue, there needs to be more work to ensure that OCD is taken for what it is: a serious, potentially debilitating disorder that is just as valid as other mental disorders.
Never lie to the patient.
On one day of my rotation, a patient presented with severe distress and denial of a recent traumatic event. I will not mention the details (for her privacy), but I will say it wasn’t a sexual trauma for clarity. Seeing some non-doctors try to reassure her that the event didn’t happen tore me apart. I felt like I wanted to scream at these people. As she indirectly asked me if that event didn’t happen, I couldn’t lie to her. I felt horrible but I hesitantly hinted at the truth. I tried to tell her “I don’t know,” but eventually I shook my head slightly to deny her false hope. It was the right thing to do. This brings me back to a topic I have explored in previous essays. Why do we do things just for our conscience when they won’t help the people? Isn’t telling her that the event didn’t happen just a nice act for a quick “relax” and for us not to feel rude? Why not have the more difficult, but needed conversation about the truth? Luckily, she didn’t hate me despite me not reassuring her with false hope. We actually had an agreeable chat later as I took her history when she was calmer and in less denial.
Today, I was watching “Scandal,” the TV show, and Olivia Pope told a similar story that reminded me of that patient. “Don’t ever promise an outcome we can’t deliver,” she told her associate. And I just wish more people lived by this. Indeed, it is our duty as health professionals to never guarantee anything we can’t ensure. Of course, we need to instill reasonable hope, as it can help with recovery and treatment outcomes. But false hope can be dangerous, and understanding the fine line between healthy and false hopes is something that I need more time to learn more profoundly.
Mental Health is Multidisciplinary. For real.
For years, I’ve studied that medicine is team-based and doctors from various specialties collaborate all the time. Of course, I understood the value of that idea, but I honestly thought it was an idealistic vision. Frankly, I expected most of the psychiatry patients to be entirely treated by psychiatrists and some psychologists. However, I was proven wrong. The floor was indeed very multidisciplinary. We had constant consultations from other departments such as neurology, gastroenterology, dermatology, cardiology, and others. At some point in the past, I even questioned why psychiatrists went to medical school. And I’ve heard this question asked by many others as well. For instance, why not teach more pharmacology to psychologists so they can prescribe medications? While I still think the distinction between psychiatry/psychology is vague and may not be necessary (debatable, but that’s a story for another day), I’ve become more aware of how essential general medical knowledge is for a psychiatrist. And how 2-3 additional courses in psychopharmacology wouldn’t be sufficient to fulfill this knowledge.
I learned something I already knew, again: The Mental Health System is Incredibly Flawed
In my country, insurance companies often (if not always) refuse to cover psychiatric fees. What is supposed to be a safe place for people at their lowest can become a luxury that many people cannot afford at all. But what can a medical student do? What can even a doctor do? Run in the hospital with $20,000 and pay the bills of 5 patients every day? It’s hard to be a hero when what’s needed is a proper system. But there are issues other than the finances. The hospital where I’m training is mainly for acute care, rather than long-term; so my understanding of long-term facilities is limited. However, the concept of institutionalization seems even more gloomy to me now. Another example of a flaw in the mental health system is entertainment: psychiatry floors are often just…dull. Patients often complained about how bored they were, which seems mundane but is actually quite important for recovery. Of course, other topics make the mental health systems flawed across the world: ideas of consent, psychiatric emergencies, and other complex issues cross my mind but their nuances are beyond the scope of this piece.
Treating a Patient Involves Treating the Family
Psychiatric patients are often accompanied or visited by family and/or loved ones. While we can label the patients with a diagnosis and/or symptoms, their family’s behavior can be even more concerning even if it doesn’t fit a clear label. In many cases, dealing with a patient was easy for me, but with the family not so much. You get all kinds of family: the calmly scared, the uninvolved, the judgmental, the dismissive, the loving one holding hands, the anxious falling apart etc. And the communication we needed to do with each differed greatly. At many points, families come with requests that are unreasonable and not necessarily in the best interest of the patient. I learned how important it is for me to constantly remember that our duty is to the patient first, and not to the family. I understand that dealing with a mentally ill family member may be challenging, but my patient will always be my priority. If the family treats the patient as an inconvenience, I cannot contribute to that.
Maybe, Maybe, I’m not a Psychopath
I know you might be reading all the above and thinking: what is this guy even doing? He’s just a med student. Why is he writing about being so “saintly”? Does he want an applause or something? Is he too confident that he’s such a good person? Far from it. In the first few days of the rotation, an old OCD obsession reoccurred in my mind: what if I am a psychopath? What if I am unable to feel empathy? What if I’m a bad person? When someone described to me a case that vaguely reminded me of my youth, I got uncomfortable. This made me even more questioning: can I only feel emotions that are related to me?
I spent quite some time describing this to my therapist, how I feel that although I care for my patients, I don’t feel that the “chemical empathy” sensation in my body is strong enough. To my OCD, if I’m not bordering on tearing up might mean I’m not empathetic, even if I am preoccupied with caring for the person. This sometimes made me “monitor” my emotional responses to stories, to check whether I was non-psychopathic enough. Naturally, my therapist told me how this was clearly another OCD theme (which it is) and I’m not really a psychopath. Of course, I believed her. Somewhat.
The thing is, these feelings didn’t match my behaviors. In the external world, I genuinely tried to make every patient comfortable, and for them to like me, and it kind of worked. Many patients found me pleasant. Sadly, OCD often turns beautiful things into issues and useless moral dilemmas. And the fact that being nice, being liked, and helping someone made me feel good about myself was a big question mark for OCD. Are you an evil person because you feel good when you help others? Is it about you?
Thankfully, my insight and control over this obsession increased after the first week. What helped was therapy and reminding myself that it’s actually a nice thing if my pleasure or “psychopathic manipulation” (obviously it’s not the appropriate description, but we’re dramatizing here) is gratified by helping others.
Back to the patients, I had one indicate an interest in being my friend (not feasible, but a flattering compliment nevertheless). Another patient asked me“I won’t ever see you again?” with a sad tone on my last day. At this point, I don’t think I was going all OCD anymore and was capable of appreciating these heart-warming comments that made me feel less of a failure. After all, wasn’t this obsession just a cynical way of trying to say the very normal, “I like to help others and to be liked?” And isn’t that what people write in their medical school motivation letters anyway?