Somebody’s Baby

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By Alex Pearce (c2019). Photo credit @ilumire.

*Names have been changed for confidentiality purposes.

Jack* did not come into the shelter quietly. He blew in angry, yelling, slamming doors, and pointing fingers. His ongoing monologue was heard by everyone within 10 feet — sometimes it formed logical sentences, and sometimes it did not. From what I could gather, he was annoyed with a man named Ernest* – it wasn’t his fault, he would like everyone to shut the **** up, and he didn’t need any of this ****ing ****. To describe him medically, he seemed to be responding to internal stimuli, and his drooping red eyes, lack of coordinated movement and slurred speech pointed to some level of intoxication.

When asked by the staff if he wanted to come in to chat, he responded with an emphatic “no” and stormed off into the main lobby. Something was atypical about Jack’s presentation. Off to the left of the room, standing with her arms folded around herself, was his mother. Her eyes were heavy with the look of someone who had been through this with her son several times before. Yet, her eyebrows were knitted together with genuine concern over her son’s current condition. In order to try and de-escalate the situation, we took Jack’s distraught mother into the clinic room while a social worker went to talk to Jack one-on-one, and we let them know Jack was welcome to come and join the conversation at any time.

In the room, the staff I was with introduced us to Jack’s mother, and let her know that Jack was a client that was familiar to her, as he was a frequent visitor to the clinic building. The staff let her know that while we weren’t at particular liberty to disclose any information we had about Jack, she was welcome to share with us whatever she was comfortable with sharing, even if only for the therapeutic effect of talking about it. Jack’s mom proceeded to give us a full picture of how Jack’s life had played out up until the point where we had seen him today, yelling and angry in the shelter. She described a lifetime of mental health struggles, learning difficulties and neurocognitive concerns about Jack — a myriad of ways Jack’s brain had struggled throughout the years to help him take care of himself. On top of this, Jack had experienced several traumatic events throughout his lifetime that his mother said had caused him to spiral further away from a place where she felt she could help him. He had been abused by a family member at a very young age, and had started purposely hitting his head off of any surface he could find from the age of 18 months. From then on, his mother had watched as he struggled through school, struggled to cope with self harm, depression and social interactions, and then eventually struggle to cope with substance abuse.

All of these things had led him to where he was, in the shelter today, describing vivid hallucinations and bizarre thoughts, confused, and running out of options. He had been kicked out of his previous shelter for this behaviour. Jack’s mother  had seen him in plenty different states before, but never like this, she said. She was becoming increasingly worried about him, and didn’t know how to help him. If you were merely walking past Jack in his current state, you might have cast him as a classic young man living on the streets — seemingly intoxicated, aggressive, accusatory and destructive.

It is a rare opportunity to hear such a thorough life history, from birth to present moment, to give you a complete picture of how someone has ended up experiencing homelessness. It is a good reminder that everyone you meet is somebody’s baby.

The next thing we knew, Jack came knocking on the door of the clinic room. When we opened the door, a totally different Jack was standing there, social worker behind him. Jack looked meek and walked in quietly and then sat down next to his mom and held her hand. He apologized quietly and sat there on the examination table, head down, feet dangling off the edge of the table. Suddenly, it felt as if he had shrunk five sizes. After calming down with the social worker, he agreed to come chat. He admitted that the reason why he was so distraught today was that what he thought was weed last night had turned out to be peyote — something he only found out after consumption. He had been seeing and hearing all kinds of things ever since and seemed genuinely scared, ashamed, and unsure what to do. His eyes locked in on his mom like she was the only thing in his life not spinning wildly out of his control.

As a student observer in this situation, I became acutely aware that to anyone without the privileged view that I had at that moment, Jack was still that intoxicated, accusatory and destructive street youth — no evidence of anything otherwise.

He eventually agreed to stay at the shelter that night, and to come to the clinic the next morning to check in on how he was feeling. Agreeing to do that did not untangle Jack’s complicated situation, nor did it resolve any of the larger issues contributing to where he was that day. But for Jack — his mother held his hands and said, “Remember what we talked about about making one good decision a day? You just did that. And I’m so proud of you”.

In medicine, we are privileged to see people in significantly more detail than the rest of the world does. At the same time, we don’t always get the whole picture, and we often get to see people at their worst. My time on this elective, and this appointment in particular, taught me a lot about compassion, and the importance of always remembering that patients come into the office with a whole story behind them. We are just seeing today’s page.

 

Loneliness and Artificial Intelligence: A Looming Crisis in Mental Health

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By Kazim Mirhadi (c2019). Photo credit: https://www.akuaroworld.com/robots-vs-humanity-5-pressing-ethical-issues-in-artificial-intelligence/

Loneliness and Artificial Intelligence: A Looming Crisis in Mental Health

Modern society is enraptured by the prospect of technological progress. We focus on the increased convenience, connectivity, and sheer shininess of the new, even to the point of disparaging critics as luddites. Today, we are on the cusp of a revolution in artificial intelligence and automation (Frey & Osborne, 2017, 255); this transformation will have implications for human relations and may exacerbate one of today’s most pressing problems—loneliness. Loneliness is a key risk factor for mental health disorders and a prognostic factor in determining mental health outcomes; rates of which have been cited as one in five in Canada (Star Editorial Board, 2018).

There are many instances in human history where societal transformations have impacted psychological wellbeing. Drawing on the missteps of the past will help us avoid errors in the future. I’ll begin this paper by briefly highlighting how mental health management in the 20th century suffered because major social changes over the centuries prior were not adequately managed. I will then discuss future technological changes and their possible implications for mental health; finally, I will suggest some measures physicians can take to approach the challenges of tomorrow.

Modernity, Urbanization, and Mental Health

Western modernity has changed the nature of relationships. Communitarian structures of indigenous North American societies and medieval Europe, inculcated a sacred culture of shared responsibility that insulated individuals from bearing psychological distress and life’s hardships alone (Muir & Bohr, 2014, 67) (Hovden et al., 99). The extended family—not the individual or the nuclear family was considered to be society’s building block.  Over the past three centuries, the modern nation state upended medieval social structures in Europe and appropriated North American lands previously inhabited by indigenous peoples. These modern states became heavily influenced by a business elite made rich in part through the early industrial revolution of the mid 1700s (Polanyi, 1957, 135). Economic productivity necessitated the centralization of human beings which resulted in mass urbanization, and thus a move away from rural communities. In place of the community, mental health concerns had to be managed by the nuclear family and nation state. The nuclear family, overwhelmed by the responsibility of mental health challenges looked to the nation state which resorted to mass incarceration, heralding the ignominious phase of “psychiatric institutionalism”. Individuals suffering with mental illness were held in confinement en masse often without the hope of re-integrating into society (Chow & Priebe, 2013, 1). Mental health struggles were stigmatized. Over the last five decades, tremendous efforts have been made to create mental health support groups, train mental health counsellors, and open up space for mental health to be discussed within various public and private institutions. This effort has unfortunately come too late for many. Clinicians of today should proactively consider how future societal changes will impact mental health if the blunders of the past are to be avoided.

Future Technological Changes and Mental Health

In the last two decades, the internet, social media, and smart phones have changed relationships once more. We know more people, but have fewer deep ties—bonding through “likes”, texts, and tweets over substantive conversation. We connect online not to nuanced human beings but to shallow, airbrushed profiles that portray exciting lives seemingly bursting with joy. Even in person relationships have been impeded quite literally, as we stare into our smart phones enamoured by the superfluous happenings of social media, and unwittingly alienate ourselves from those immediately around us. We are now witnessing the rise of a new technological era that will likely accentuate loneliness in contemporary life. This includes more automation, robotics, and artificial intelligence in driving, delivery services, internet based education/courses, restaurants, household cleaning services, and even intimate relationships.

The implications of these changes in the realm of social interaction may be that human relationships that emerge as a by-product of essential or nearly essential human action—such as commerce, education, and leisure will be eroded. Despite the added convenience, there could be substantive alterations to social ties. For example, will social isolation become exacerbated when the elderly can go about their day with less reliance on sentient human beings? How will intimate relationships be impacted if romantic human interaction can be achieved through artificial intelligence? What will it mean for mental health if there is less engagement with peers at higher education campuses because of online courses/degrees? What will be the impact of drastic changes in workplaces leading to layoffs and fewer interactions in physical spaces?

As technology mediates changes in relationships, the long term mental health implications remain to be seen. Nevertheless, it is important to have a pragmatic picture of how social relationships will be altered by technology so that clinicians can mitigate and harness its effects. Public awareness campaigns can elucidate the mental health risks of loneliness as well as identify periods of vulnerability such as after child birth, loss of employment, or the passing of loved ones. Physicians can begin to screen for loneliness, especially as one gets older, and a greater emphasis can be put on in person group interaction for individuals who may not suffer from mental illness but need social support. While human beings tend to have an innate drive to be social, we also have competing drives to be “un-social”—to avoid embarrassment, to save time, to skirt the efforts of making face to face connections with strangers. Disorders of mood, anxiety, and more can thrive on loneliness and making deliberate efforts to bring people together might just be an antidote.

 

References

Chow, W. S., & Priebe, S. (2013). Understanding Psychiatric Institutionalization: A Conceptual Review. BMC Psychiatry,13(1), 1-14. doi:10.1186/1471-244x-13-169

Frey, C. B., & Osborne, M. A. (2017). The future of employment: How susceptible are jobs to computerisation? Technological Forecasting and Social Change,114(C), 254-280. doi:10.1016/j.techfore.2016.08.019

Hovden, E., Lutter, C., & Pohl, W. (Eds.). (2016). Meanings of Community across Medieval Eurasia: Comparative Approaches. LEIDEN; BOSTON: Brill. Retrieved from http://www.jstor.org/stable/10.1163/j.ctt1w76w6c

Muir, N., & Bohr, Y. (2014). Contemporary Practice of Traditional Aboriginal Child Rearing: A Review. First People’s Child and Family Review,9(1), 66-79. Retrieved May 19, 2018.

Polyani, K. (1957). The Great Transformation: The Political and Economic Origins of Our Time. Boston: Beacon Press.

Star Editorial Board. (2018, January 21). Governments Should Tackle Growing Problem of Loneliness. Retrieved from https://www.thestar.com/opinion/editorials/2018/01/21/governments-should-tackle-growing-problem-of-loneliness.html

 

Why Do You Want to Become a Physician?

 

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By Anonymous (c2020). Photography by Tom Hussey

I am starting to realize why certain physicians ask pre-medical students why they want to become physicians. I catch myself asking that of myself more and more often. I recently finished the book Bloodletting & Miraculous Cures, and the ensuing twenty-four hours really stressed me out. If I were to be honest, it still sort of stresses me out a little (a lotta) bit. I found myself walking in the shoes of two of  the protagonists, Fitzgerald and Chen, more and more often as the book continued. The author’s writing transported me forty years into a hypothetical personal future – and it terrified me. Fitz started off drinking to handle his personal issues and he eventually became an alcoholic – I had started having night caps at the end of long days to take the edge off in recent years. Chen is no longer embarrassed as a staff physician that he drives a hulking doctor cliché, a CLK 430 Mercedes Benz – I came into medical school hell-bent on avoiding becoming a physician who cares about money and status. Will I inadvertently eventually turn out like Fitz or Chen? Am I doomed to walk in the path of my predecessors? Who am I to think that I will turn out differently? Would knowing about this possible future somehow immunize me against turning into a walking cliché? Something about the process of becoming a doctor must change people – it seems to me at times an unrelenting force bent on remaking us. Bent on taking out our living, bleeding, and fallible organs, and replacing them with shiny, confidence-filled mechanical replacements, which will enable us to work tirelessly, continuously, and with just enough emotional detachment such that we do not end up living our patients’ misery (but not so much that the patient would feel like we don’t care). These newfound organs will turn all of us into people who can withstand death on a regular basis, withstand patients who yell obscenities at us and threaten to sue and ruin our livelihoods and reputations, and who can withstand the crushing pressures of the expectations, hopes, and dreams of patients’ family members, communicated by their furtive glances at the doctor. All of this is to be carried on the physicians’ shoulders; to be ruminated over within our hearts in the quiet moments that we steal for ourselves.

When I catch myself asking that question (Why do you want to become a physician?) of a pre-medical student nowadays, I realize that I’m not really, truly, trying to determine whether or not they are worthy of joining our ranks as physicians (let’s be honest, they’re all probably smarter than me – each successive generation is smarter and better, just based on the increasing difficulty of getting into medical school over the past decades). At the heart of it, I think when I ask this question, I really am trying to communicate how difficult of a life it might become. I am trying to determine if they might become burnt out over time, with their original sense of compassion and empathy warped into the practiced dissociation of one who has crashed into the lives of their patients with life-altering diagnoses one too many times. But… how could I possibly predict someone else’s future, if I can barely get a handle on my own? It  scares me that I catch myself thinking this, because I am starting to wonder whether or not my ideals and principles (however strong they may be now) can withstand forty years of practice. Perhaps the school made a mistake in letting me in – perhaps I will burn out after all, walking in the path of the mentors I have inadvertently fallen in step with – mentors who are physically stooped over and bitter about the way that their patients treat them. I no longer have the original worry from reading Bloodletting & Miraculous Cures – I no longer worry that Dr. Lam might be showing me a glimpse of a hypothetical future. The reason I freak out now about Bloodletting & Miraculous Cures is that I can understand the steps along the way which could turn me into either Chen or Fitz. What terrifies me now is not the conclusion, but the truth of the process. It is no longer imaginary – I can see the stepping stones which could eventually lead to a jaded and burnt-out physician. I have observed the clerk, the first year resident, the final year resident, the newly-minted staff, the veteran physician, and the final step: the physician holding on for dear life at the hospital until they can cash out and retire in peace.

I also realize the futility of this line of questioning. I remember before I became a medical student…When I was asked why I wanted to be a physician, I provided such optimistic answers and was so proud of the ideals by which I stood. I was so proud of my ability to explain to the physician why I should be allowed to join their ranks. I was so proud of my resume which detailed how great of a person I was, of my various volunteering activities which described my heart for the needy, and the ideals which would make me a physician for the people, as opposed to some money-grubbing power-hungry maniac. In my mind’s eye, I am now sitting in the physician’s chair. I am in this moment sitting across the table from my past-self, and as I hear the words coming out of his mouth, I can only shake my head in sadness at the naivety that the boy before me is displaying. And I can see the boy across from me reacts to this – he furrows his eyebrows, his mouth turns slightly into a frown, and his head tilts to the left in the way that it does when he wants to show concern but also deference to the individual he is talking to. He has interpreted my subtle shake of the head as a sign that his answer was somehow at fault, lacking, or incorrect. But I’m not sad because he gave the wrong answer – I am sad because he gave me all the right answers. I’m also sad because I know that he is just smart enough to make it, but also probably not strong enough of heart to come out of the forty years with the same high-minded principles and ideals. The boy across from me at the table will ask me what about his answer was off, in hopes of altering it such that it will be ready for the round of interviews that he had been invited to at the various medical schools to which he had applied. But I would only shake my head and ask the question again, “Why do you want to become a physician?”, because I am unable to articulate the weight of my feelings, ineffectively reducing them to a glib, seven-worded question.

 

Art Series: Hands

We are beginning a series showcasing artwork done by our medical students here at McMaster. To kick this off, here is a piece by Jennifer Guan (c2020). Jen enjoys painting and doing illustrations in her spare time, along with running workshops with others to promote wellness and artistic pursuits.

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“Hands,” Jennifer Guan (c2020). Watercolour with pen and ink.

To the choir

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By Anonymous (c2020). Photo courtesy of author.

I started to bite my nails in June
the morning after he took
Everything
from me.
We used to ride the bus together.
He sat at the back,
made fun of me
for living on the poor end of the street.

Boys will be boys

You know they like you
when their words
cut.
Push you down in the playground
and spit on your shoes.

Adults are just kids who
keep on playing games.
Tag
you’re it
touch you without your permission.
Hide
go seek
corner you in the dark.

Someone once told me that anxiety made you weak
lesser than;
admitting you have a problem
and you can’t help yourself.
Strip off your armour
child
your private battle is not so private.
Let them see you
Naked.
White walls
green gowns
cold duck lips
and a bit of pressure.

Someone once told me that anxiety feels like
you are leaning back on a chair
and
all of a sudden it starts to tilt backwards
like the world is spinning
off of its axis.

You don’t need to tell me
I used to sit in that chair every day.
Where I would sit
the cushions were threadbare,
Imprints from a time I couldn’t get up.

Someone once told me that anxiety is like a fog
creeping across the highway on a dark night.
Coming up from the ditch
thick like velvet.
You don’t notice it
until it envelops you.
You can’t see what’s ahead.

Go on child put on your mother’s lipstick and
sing your siren song, but
Heaven forbid you sing for help.
Like Odysseus and his crew
they think
you are trying to sink their ship.
They will plug their ears with wax
tie themselves to the mast
avert their eyes
and sail on.

Someone once told me that anxiety makes your heart beat fast
the feeling you get when you meet someone
for the first time
someone you might want
to share it All with.
But
the butterflies become bats
they come out at night
like monsters that live in the closet
Roxanne and her red dress
nocturnal.

Someone once told me that anxiety is like a pet dog
eager to please.
Cat
one moment, playing
the next
biting
clawing its way up your throat
Cat got your tongue.
Grab her by the pussy.

Someone once told me that anxiety will make you incapable of healing people.
You feel too much
forget things
can’t listen to someone’s story when
you’re trying to make sense of your Own.
How can you heal bodies when
your scars do not fade.
Striae,
deep purple
skin stretched all too quickly
before it was ready.
How can you be the right person
to translate
put her pain into words
and her words into language they hear
when you spend so much time reading faces
thinking
they hate you.

These little white pills leave
a bitter taste in my mouth
when I forget my glass of water.

I wrinkle my forehead
and swallow.
I count to three
before I look at myself in the mirror.

One
For the first time in months
Two
Years
Three
Lifetimes

I sleep.

Mrs. DB

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By Giuliana Guarna (c2019). Photo from iStock.

“We have a 90-year-old female DNR coming in from nursing home in respiratory distress. ETA is 2 minutes”

I felt the pressure immediately. I hadn’t witnessed the passing of a patient yet, but I had a feeling that I would not be able to end my shift saying the same. She was wheeled in, visibly air hungry. Her eyes were rolling into the back of her head. She was clutching onto the sheets covering the stretcher for dear life. Her blood pressure was well into the 200’s.

“Push 0.5 mg of Ativan. Let’s get something for blood pressure”

Her sats began to drop. First into the 80’s, then into the 70’s.

The nurse was ready to push the BP meds. The doctor stopped him. “Take off her mask. Push another 0.5 mg of Ativan, let’s make her comfortable”

We removed her mask and wheeled her into a private room off to the side. No family was around. We couldn’t get a hold of them, voicemails were left. We gave her a warm blanket.

“Ok,” my staff turned to look at me, “She is your patient for tonight.”

I returned to the room. I held her hand. I checked her pulse – thready, slow, and weak. Her breathing was sharp and shallow, barely 5 times a minute. I brushed her hair to the side. I told her I was there. I stepped out for a moment to ask the nurses what to do. I stepped back in, checking on her again, everything was slower still. I stepped out once more.

I came back. No pulse, no signs of breathing. I placed my stethoscope to her chest. Silence greeted me. My staff walked in. He wheeled the POCUS to her side, checking to make sure that there was no cardiac activity.

“Time of death, 21:21”

The tears spilled out of me. I held her hand and wiped my tears.

“Take all the time you need.”

I wept by her side. I brushed her hair back, I stroked her hand. One of the nurses I was on with walked in – “Do you mind if I pray for her?”

I gave her a nod. She grabbed Mrs. B’s hand and began to pray, honouring the life that she had led. She gave me a hug as she left, leaving me to collect myself before walking back into Zone 1, where the sickest people in the department were waiting for us. I took a deep breath and stepped back into the chaos.

 

Reflections from an ER Patient

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By Jennifer Guan (c2020). Photo by @rawpixel.

Mr. X was about thirty years old and had been dealing with severe, unexplained chronic abdominal pain for years. Before seeing him, the ER staff physician I was following, Dr. Y, showed me his test results – a huge collection of x-rays and scans and blood tests and laparoscopic procedures that all failed to give us any insight as to why he felt such crippling pain from a day- to- day basis. Dr. Y was not very optimistic and gave me a generous fifteen minutes to take a lengthy history but stated that she had seen this patient before and he likely just wanted some more opioids. When I walked into the small room, Mr. X was sitting on the bed. He looked like he had experienced a rough life and had missing teeth, bones protruding from his small frame, and a forlorn expression. Mr. X told me that this pain had been ongoing for years and years, that he didn’t know what to do about it, and that the medications were not working. It was unbearable last night, which is why his dad brought him in today. He told me about his smoking and drinking, work, past surgeries, poor appetite, unstable living conditions, previous medical history and medications, and I added everything up to the list of differentials in my mind.

Luckily, we had just been studying abdominal pain, and I ran through the differentials to Dr. Y, which were one by one struck down based on the tests results. Liver function tests were normal despite multiple alcoholic drinks per day. But maybe they’re just abnormally normal because so few liver cells remain to pump out enzymes! But then why would the biopsies and scans show a healthy liver? Could it be kidney stones?! No, his ultrasounds were clear… Fibromyalgia? Symptoms didn’t really match… Diverticulitis? Appendicitis? All had a corresponding test that gave a resounding “No”. I asked Dr. Y what she thought, and she said there was likely nothing we could do at this point, for Mr. X had already been seen by multiple specialists. Dr. Y and I returned to Mr. X. She told him our thoughts and said that he was already on the highest dose of pain medications that she is comfortable giving. She said that she could give him a local numbing shot but that the efficacy was well below the medications he is already on and so he would likely not feel any difference. Mr. X didn’t accept this. He demanded a better answer and solution to his pain but Dr. Y explained that over the recent months, he had already gone through every test she could order, which had all come back as negative.

In the end, we didn’t do anything at all for Mr. X. He had simply sat in the waiting room for hours, talked to me for fifteen minutes, then both Dr. Y and I for five minutes, before walking out of the hospital that day. As he left, I smiled at him, but he didn’t see me. Between other patients, I voiced again how disappointing it is that we couldn’t do anything for him and Dr. Y casually mentioned that he had had previous suicide attempts.

I regret not sitting with him to just chat and show him that we do care and are thinking about him, even if it doesn’t seem like it. I regret letting him walk out of the ER without a nurse or doctor or medical student to reassure him and keep him company. This day happened many months ago, on a day where there was still snow on the ground. I do not know how Mr. X is feeling right now, if he has seen any other health care professionals in the meantime, if he still has a place to call home, or even if he is still alive.

I am certain that if Mr. X had been an affluent, good looking, middle-aged man, we would have acted differently. That same day, a cardiovascular surgeon came to the ER because his chest had been feeling tight during an operation. The way this surgeon was treated was in stark contrast to the way Mr. X was treated. Of course, one can argue that this was the surgeon’s first episode of chest pain, that chest pain in an older man is very worrisome, that it is potentially life threatening. But I highly doubt the same care and consideration and utter respect would have been granted onto Mr. X if this had been his first time in the ER as well.

Looking back, I’m not sure if we could have done anything differently with Mr. X.  In pro comp, we have done several scenarios now to contrast “bad” behaviour with its corresponding “good” solution. But that is often too simplified of an approach. It is too easy to say that a good physician would give up his lunch break everyday to sit with a patient and the family and spend enough time with everyone to build a strong rapport that ends with the sharing of personal stories and tears of relief. That is not reality. If one patient receives 2 hours of undivided attention, then 10 others go without being seen. I am realizing more and more that it is perhaps practicing this woven balance between low voices of reassurance and pointed questioning and direct tests that is the art and science of medicine we hear so often of.

I still think about Mr. X from time to time. I wonder how he is doing and although I’m still not sure if I acted in a way most representative of this balance between art and science, this experience has illustrated to me more about the humility, balance of resources, and diagnosis of medicine than any other.