First Break

Embarking on a career in academic and clinical psychiatry was not my mission. I was intrigued by the complexities of psychosis since undergraduate work in psychology, found my passion for inpatient psychiatry during medical school, and became inspired to specialize in first-episode psychosis during psychiatry and fellowship. A mentor saw in me something else: an educator. In reality, I had taught a lot in residency and fellowship, was a Pilates instructor prior to medical school, and even a tutor from as far back as I can remember. While I appreciated the insight of someone I admired, doubt and insecurity overwhelmed me. Was I really capable of educating future doctors? My career path was leading to establishing the first early psychosis intervention clinic in New Orleans; that path had not included an emphasis on teaching. Accepting an offer to become the Director of Medical Student Education in Psychiatry was a surprising turn of events.

The past 5 years into this position has been filled with the challenges of site visits, curriculum development, attending wards, clerkship training sites closures, alongside managing my own quickly growing first-episode psychosis program. Burn-out had been creeping up on me, in the form of more meetings and deadlines, leading the state in expansion of first-episode psychosis programming, managing a major grant, and of course, the intense needs of my patients and their families. Straddling multiple profession roles was spreading me thin and bringing up many questions: Is it possible to be an educator and grow your clinical practice? How can I keep up? Am I actually making a difference for students as well as for my patients? I was overwhelmed and I was uninspired in my role as an educator. I thought maybe taking medical student education out of the equation would be the answer. It came as a surprise then, when my path became illuminated by one of my medical students.

During Alana’s clerkship, she was an impressive student. Utilizing her bilingual skills, she was assigned to a young patient first experiencing psychosis two months after his immigration to the United States. The case was challenging from a psychiatric, cultural and linguistic perspective. I found myself wanting to convey so many perspectives surrounding this young man’s experience, both as an educator as well as a clinician. Does she know the differential diagnosis for psychosis? Will she appreciate the ‘clinical high risk’ state even though it may not be on her standardized psychiatry clerkship exam? Will she realize what a pivotal time this is in his life where early treatment is critical? Will she be able to establish the rapport necessary for someone to trust a doctor while in the throes of psychosis?

Our clerkship students are required to write a reflection about their experience on their clerkship and the following is what I received from Alana.

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First-Break

What did you imagine when you set out on your journey? What beautiful daydreams inspired you to keep walking, step by step, the hundreds of miles until you came to the Promised Land? I doubt you pictured living between these colorless walls or wearing these green paper scrubs. You couldn’t have known what it would feel like to see a doctor, to be inside a hospital or to swallow a medication. They were all new experiences.  

What made you leave? What could justify the sacrifice you made? Were you searching for an education in the Land of Opportunity as your brother said?

Was it the violence that took over your country? Or the fear that hung in the air so heavy it wilted the wildflowers in your village?

Was it the terrifying voices that hid from your view? Voices, which began as a whisper. At first you thought it was someone pranking you, hiding so well you could never find them. But then the one voice became two, and two became many and you could not deafen yourself to their mocking.

You thought you could walk away from them, but they followed your footsteps down the mountain, across the deserts, through the streams, and over the border.

So, you turned to God who you were told could cure everything. You went to church more, counted the beads on your rosary, and said your Hail Marys. But when the voices began to turn to visions, the Holy Father said you were blessed with the spirit.

So, the community began to pray for you. Day and night their knees kissed the holy ground, relieving themselves only for the necessities: a bathroom, a sip of water, a tamale. They prayed until their bruised knees were too tender to hold them up and their voices too coarse to utter dios one more time.

Then you turned to other gods, whose powers were felt immediately. A god that lived in a bottle and tasted like the sweat you used to kiss on your father’s face. A god that rolled into a blunt, whose smoke smelled like the fires your mother used to cook over. A god whose fine white powder felt like the Guatemalan sun burning its blessings onto your face.

But when you drank and smoked and sniffed their powers dry, the void left by their absence soon filled with the voices and images you thought you had escaped. You fell deeper and deeper into the echo chamber unable to distinguish sounds from voices, images from people, where your body stopped and the Holy Spirit began. You fell until you landed in a hospital bed in a foreign land where no one spoke your language.

“Do you remember me”? I asked.

His eyes slowly scanned the table that separated us and traveled up my body. Their golden tinge like the last burst of light before the sun surrenders, bowing below the swampy bayou waters. They seared across my face, anxiously tracing back and forth, leaving zigzagged burns that faded as quickly as the green flash at sunset.

Earlier that morning at I sat in a chair across from him. His small frame swimming in the x-small hospital scrubs as he sat in at the edge of the bed. He was dwarfed by the thick black blanket curled around his body. Those are the tear-proof blankets for patients on suicide watch. Their uselessness pathetically more obvious next to his hospital gowns with easy to rip sleeves, his roommate’s sheets crumpled on the ground a few feet away, and the sharp corners that decorated the unit’s many surfaces, glistening their temptations.

He looked smaller than the 5 feet he was gifted. He looked like a child waking up from a nightmare, anxiously trying to shake off the fear that taunted his sleep. His body suddenly convulsed in pain, he clutched his sternum.

“Can you point to where you are hurting?” My voice seemed to startle him. He straightened up.

“Now it is gone again.” He lifted his gown for an exam. No markings, rashes, lumps or bumps. Heart and lungs sounded normal. Abdominal exam was unremarkable. Labs and imaging had come back without abnormalities. 

He said it started on Wednesday. The pain came and went, and moved around. He couldn’t remember if anything made it better or worse. He might have taken some vitamins for it, but wasn’t sure. He hadn’t eaten anything new, no inedible objects.

In the long pauses between each exchange, he eyes roamed the room.

“Are you hearing voices?” I asked him.

“Yes.”

“What are they saying to you?”

“They are laughing at me.”

“Why are they laughing at you?”

“I don’t know.”

“Are they talking to each other?”

“I think so. I don’t know.”

“Do you know who they are?”

“God. And Jesus Christ.” His gaze looked past me, falling on the bedside table to his left, then to the door left open to milieu. 

“Is there someone else here?”

“Yes.”

“Who else is here?”

“Jesus Christ. No, he just left”

“What did he look like?”

“Tall. White. Long hair.” His body shuttered again and he gripped his stomach. He fell back in bed, as though in slow motion, into a fetal position. He wrapped himself with the stiff blanket for protection. He did not know that no thickness of blanket could block out the voices he was hearing, or hide him from the figures that kept looking for him.

“We spoke earlier today. Do you remember?”

After a long pause, he responded.

“No. I don’t remember.”

“Do you know why you are here?” I asked.

“Yes. Because I am…sick.” Each word moved as quickly as molasses on a cold winter day.

“How are you sick?”

“I am sick in the mind.”

The words seemed to tremble through his body. His shoulders began to shake, his stoic face twisted in pain as folded into himself, grabbing his upper abdomen.

“Do you know how you got here?”

The wave of pain left as quickly as it came.

“My brother.” He sat upright again.

“Do you know why he brought you here?”

He slowly shook his head and looked at me. The sun had set behind his eyes. The moon had not yet risen. There was no light to guide our path.

So we waited.

Day by day, pill by pill, we waited.

We waited for the dark to settle deep so we could see the stars, long enough for them to guide us back to safety.

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This essay, she called first break, struck many chords. The beauty of her words coupled with the intensity of the experience sent me a message of hope and resiliency. She understood and absorbed the clinical side, the human side, and most importantly she learned and was inspired. This was my ultimate goal as an educator, to share knowledge and inspire future physicians. The potential my mentor saw in me was actually my first break, leading to pursuing of this academic educator position.  The unexpected gift from this journey has been the experience of our students as our own teachers, leading to even richer growth as individuals. Alana became one of my teachers. I realized I am in the exact place I need to be, with the ever-evolving balancing act between what my students need, what my clinical ambitions are, and what I need as a person. This will never be an easy balance, but small moments like this experience with my student, can be enough to deliver us back to our path. What we do as physicians day-to-day is challenging, but what we can offer our students, and what they can offer us, even in one meaningful clinical experience, is forever.

- Ashley Weiss, DO, MPH