When we care for our patients are we perhaps not focusing enough on the right things? Before I delve into what I mean, let me first ask you to ponder the following question from your personal life by way of analogy.

If one of your friends texted you “Hey, the group of us are planning a weekend getaway on the third weekend of next month. Are you game?”

My question to you: If you’re indeed free that weekend, what information do you need most to make your decision? What’s most important? Who’s going? Where you’re going? Or what you’ll be doing?

All are important in their way. But which answer would most persuade you to go or, conversely, dissuade you from going?

I argue that who’s going is most important. When we’re among good friends or family we love, what we do and where we go is not that important.

But if you’re with people you don’t feel close to, then even a weekend in Paris would be a chore.

It’s about the people: the people we feel good with, the people we trust.

Remember the TV commercial with the tagline “It doesn’t get better than this”? It was “so good” for the characters featured because of the sense of togetherness the ad highlighted, with the group of buddies laughing, jostling, and raising a toast.

Now getting back to patient care: I argue that the foundation for successful outcomes for your patients is a quality relationship between you and each of your patients.

Yes, yes, I’ve heard this idea many times before and you probably have too. But let’s dig deeper. Imagine this scenario.

A woman in her thirties has bipolar disorder. She finished college at a good school but since then is unable to hold a job. She’s been hospitalized three times and in IOP a half dozen times more. She’s gained a lot of weight from the meds, and her hair – well, let’s just say that every day is a bad hair day for her – also because of her meds. Now imagine what goes through her mind, perhaps every day:

“Here I walk, feeling blah but ok today, but I have no idea what tomorrow or any other day holds for me. Any day I can lose my mind. I can be out of control. “I’ve had times when I’ve spent my life savings buying art supplies and leasing a store-front downtown because I thought I’m the next Picasso. I’ve been picked up by the police swimming naked in the river, with dozens of onlookers. I’ve threatened my family and neighbors because … well, I don’t really remember why since my mind was so screwed up at the time.”

Now consider how this person feels, what she fears, what she needs most in life. And what she needs most from you.

Sure, she needs meds. And she needs to take them day in and day out, year after year. But taking daily medications, ones with crappy side effects, and even when one doesn’t have a psychiatric illness, is challenging.

What will keep her taking her meds? What will make her want to reach out for help when she’s feeling oh-so-good at the moment, but surely on the way to out-of-control mania? What will give her hope and comfort when she’s thinking of taking her life?

Who does she have to tell how frightening it is to have lost her mind? To know that it will surely happen again? To guess that her illness will hurt her or maybe kill her one day and, maybe, someone else too? That once she was a normal girl and young woman, but now she isn’t and her dreams have died over and over again?

Maybe you’re the one she’s been waiting for.

Maybe she’ll sit down in your office at her next appointment and say, “I was thinking about what you said last time. And I thought maybe I’ll try what you suggested.”

Maybe one day she will hold a bottle of pills in her hand and decide not to overdose because she doesn’t want to hurt YOU!

It’s kind of frightening how much influence we can have over someone’s health and life. That’s what makes being a psychiatrist so challenging and so rewarding. But the first step is realizing how much influence you have and how to use it wisely. That is the point of my scenario, to remind you of that.

As I write this I’m reminded of something a young psychiatrist once said to me, by way of a complement. He said, “Dr. Jack I’m glad I took your [Psychiatry Oral Board] course. I’ve changed the way I interact with patients. I work at the VA and we have these huge monitors. When a patient comes in, I can’t even see them. I ask them questions and type their answers. Now, I realize I need to sit and look them in the face. So I sit on their side of the desk. The problem is now I’m way behind on my notes since I can’t type as I’m talking to the patient. But thanks anyway.”

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At the time I smiled to myself, thinking I now knew what being damned with faint praise felt like, that my big intervention was to get this psychiatrist to look at his patients as they conversed. But now I’m not so sure: maybe the change the psychiatrist made was important; maybe it was the start of thinking differently about how interacting with him could be a healing experience for his patients.

And, of course, this memory also reminded me of how the way we’re expected to practice can work against our effectiveness. We are judged by the quality and timeliness of our progress notes. We are not judged, however – except by our patients who may or may not know better – by the care we put into listening to the patient, the comfort we provide, and the healing we give the space to occur.

It’s not easy to offer a healing environment. Most things of value aren’t easy. And many things of value are not appreciated. It’s up to you to decide how you want to take up the challenge.

Until next time,

Dr. Jack


Today’s Quotes

Ben Okri is a Nigerian novelist, poet and essayist. In 1991 he won the Booker Prize for his book The Famished Road – excerpted below. The protoganist is a spirit-child, speaking from the spirit world, considering whether to choose to be born into our world.

There was not one amongst us who looked forward to being born. We disliked the rigours of existence, the unfulfilled longings, the enshrined injustices of the world, the labyrinths of love, the ignorance of parents, the fact of dying, and the amazing indifference of the Living in the midst of the simple beauties of the universe. We feared the heartlessness of human beings, all of whom are born blind, few of whom ever learn to see.

I love this paragraph, from the first page, because of its lyric beauty. But also I will always remember how I came upon it. This Spring my family and I spent Spring break in London. We rented a house in Islington – near the Regency Canal, a picture of which I shared with you a couple of LB’s ago. One night when I couldn’t sleep I went down to the living room – I don’t know what that room is called in England – and pulled a random book off the shelf. It was The Famished Road.