It’s 8:30 on a Monday morning. David Goldbloom, a psychiatrist and professor of psychiatry at the University of Toronto, shows up for one of his irregular shifts in the emergency room of the Centre for Addiction and Mental Health (CAMH) in downtown Toronto. He is one of approximately 4,200 psychiatrists who practise in Canada. These physicians share the dubious distinction of working in medicine’s most stigmatized specialty. Dr. Goldbloom is currently working on a book about contemporary psychiatrists with his colleague Dr. Pier Bryden, who is a child and adolescent psychiatrist at the Hospital for Sick Children and an assistant professor in the department of psychiatry at the University of Toronto. In the following exclusive story for Maclean’s, the two doctors depict one of Goldbloom’s days in the ER. The names and identifying details of the patients described have been changed.
Being a psychiatrist is a peculiar job in many ways. While other doctors ask patients questions that few others will ever ask—“How are your bowel movements?” “What are your drinking habits?”—psychiatrists have an even more unusual mandate. We want to know about our patients’ first days at kindergarten, sexual fantasies, spending habits, moods and relationships. We interview criminals and pedophiles on a routine basis as part of our training, and spend hours on call in the middle of the night calming down individuals who believe—usually erroneously—that they are the victims of an international conspiracy or that scientists, extraterrestrial or otherwise, have implanted speaker devices in their brains. During the day, we may treat the depressed businessman, the panic-stricken college student, the substance-abusing medical colleague.
Even patients can initially be put off by us. Very few people wish or believe they or their child will ever need to see a psychiatrist. A family doctor, an obstetrician perhaps, and arguably a surgeon to remove a recalcitrant appendix or to fix clogged arteries, but not a psychiatrist. Patients enter our offices with trepidation.
Our medical colleagues also tend to be wary. Medical students considering psychiatry as a specialty usually conceal it from their non-psychiatric supervisors, surmising correctly that it will be a mark against them. “Why don’t you do something really useful? Won’t you miss real medicine? Do you really want to spend your time listening to miserable people?” Nor does the stigma lessen after training. Physicians forced to consult psychiatric colleagues for assistance with hospitalized patients frequently fail to let their patients know they have done so; as a result, when the psychiatrist appears at their bedside, the patients and their families are horrified and want to know why Dr. M felt they needed to see a shrink. “Does he think I am crazy, that this is all in my head?” The greatest compliment a surgical or medical colleague can pay us runs along the line of, “You don’t seem like a psychiatrist . . . ”
Arguably, the stereotype associated with psychiatrists’ professional identity is borrowed from the far greater stigma suffered by our patients. Patients with mental illness have historically been hived off from the majority of medical patients into asylums and, later, into large gloomy psychiatric hospitals built, like prisons, on the periphery of towns and cities. It is a relatively recent phenomenon—after the Second World War—to see psychiatric wards in general hospitals.
There is some truth to the old adage that psychiatrists have much in common with our patients. We are more likely to have had experience with mental illness ourselves or in our families than doctors in other specialties. Students who choose psychiatry tend to have more non-authoritarian attitudes, open-mindedness and a greater interest in theoretical issues and social welfare than their colleagues. Psychiatrists are also more likely to have an undergraduate degree in the arts and humanities.
I started medicine at McGill University in Montreal in 1977 with no sense that my future career lay in psychiatry. The reaction to my decision to enter psychiatry was mixed. Some relatives and friends thought I was “throwing away” a medical education or abandoning a family legacy. I come from a family of pediatricians that now extends across four generations. Others gave me the backhanded compliment that I was “too much of a regular person to be a psychiatrist.” One senior psychiatrist at McGill, a family friend, expressed her disbelief that I was going into her profession, saying, ‘You don’t like to listen; you like to talk.’ ” I am forced to admit that her observation was at least partly correct; my psychiatric training has been important in teaching me to be a better listener.
My younger self was determinedly un-psychologically minded. When I interviewed for the residency program in psychiatry at McGill, a staff psychiatrist surprised me with the question, “Have you had any sad experiences recently and can you tell me how you have dealt with them?” I thought for a few moments and replied, “I haven’t had any.” When I told my wife about the interview later, she quietly reminded me that in recent months both an aunt and a friend my age had died. I still think I answered the interviewer’s question honestly. My capacity for denial, coupled with an inherently optimistic temperament, has helped me ride out the inevitable hard times of a career in psychiatry.
The site where I work houses Toronto’s busiest psychiatric emergency service, operating 24-7 and seeing about 4,000 patients a year. Located on the ground floor of the hospital, it features a sign on the door that says “Emergency” in a huge array of languages. Most days, police cruisers can be seen in the parking lot of the building, transporting the city’s disruptive, suicidal, or simply most distressed citizens to its doors.
The ER is staffed by a rotation of psychiatrists and psychiatric residents, a team of nurses, a social worker, a ward clerk and a psychiatric assistant (who in an earlier era would have been called an orderly). Because this is a teaching hospital, the morning begins with eager but fatigued residents who have been on call for the previous 24 hours presenting their cases to the incoming shift of doctors, nurses and crisis workers. My job is to listen, look for chinks in the resident’s defence of his or her diagnosis, and identify issues and themes that can be used as a segue into teaching.
This morning, the ER waiting room is empty; the residents have seen, admitted or discharged everyone, and the whiteboard in the nursing station is blank. I like to start the day this way—not sifting through the impressions and decisions of others but encountering new patients. There remains a short-stay unit behind the ER where up to eight patients can be housed for several days of observation prior to either hospitalization or discharge. This morning, four patients are there, awaiting their daily re-evaluation. I take on one.
Luana is a 26-year-old woman who has been detained under the Mental Health Act of Ontario for 72 hours of psychiatric evaluation. She was diagnosed with a manic episode last year, hospitalized and treated elsewhere. She discontinued her medications without medical consultation six months later with no immediate consequences. However, two weeks ago, she became uncharacteristically elated, stopped sleeping, and started to behave with unprecedented sexual impulsivity.
I escort her into the glassed-in interview room. She is dressed in a hospital gown. As she talks, Luana looks frequently through the glass wall at apparent distractions—although none are visible or audible. She starts to answer questions, speaking rapidly, losing herself within her expansive answers. She describes herself as “maybe one-quarter to one-third manic” but tells me that she doesn’t need any hospitalization or treatment. I remember a patient whom I had seen during my residency, 25 years earlier, who was also in a severe manic episode. That woman had had impulsive sex with every man she could seduce in her condominium building. When the mania subsided, she was so humiliated by her behaviour that she moved. I don’t want Luana to humiliate herself or worse, even though the risk of that is imperceptible to her at the moment.
Thus the morning begins with depriving my patient of one of democracy’s fundamental civil liberties—the freedom of movement. Luana stares stonily at me as I hand her the legal document advising her of her new status. Involuntary admission in the interests of the patient or societal safety is a thankless task at the time, but I have over the years experienced gratitude from some patients as they recovered.
I dislike slow days so I am relieved to discover that two new patients are registering at the front. I ask Tish, a friendly nurse who hails from Cape Breton Island, whom I should see first.
“Allan,” she replies. “He’s really sick.”
Two weeks ago Allan stopped talking to everyone. I peer out the glass window of the nursing station where Allan sits calmly and silently with his father and his youth worker. I go to the waiting room and introduce myself and extend my hand; Allan shakes it but doesn’t make eye contact. I say why I am here, and that I want to help. I then turn to Allan’s father and youth worker to take the history. Just 20 years old, he was hospitalized at CAMH six months ago on the Early Psychosis Unit, which focuses on young people experiencing their first episode of possible schizophrenia. He could hear snatches of conversation among people he didn’t know saying disparaging things about him. He held a knife to his mother’s throat for seven hours until the police intervened and brought him to the ER. He was admitted involuntarily, improved, and was discharged on antipsychotic medication. Two months ago, he stopped it for unknown reasons.
Today he is listening and following everything and responds with nods and shakes to my questions in an appropriate way. Allan is able to agree that something is indeed terribly wrong; he still feels people are laughing at him and taunting him. He concedes he doesn’t feel safe on the streets and acknowledges his last stay in the hospital was a positive one. He is willing to come back in and to get some help. Fortunately, a bed is available on the inpatient unit where he had previously been admitted; the staff and surroundings will be familiar to him. Everybody is relieved—the youth worker, the father, Allan and me. Part of my relief is that although this young man is ill, he is not violent or threatening. Within the confines of his silence, Allan is able to acknowledge his distress. This time he enters the hospital as a voluntary patient.
I erase Allan’s name from the whiteboard. It is starting to fill up faster than I can erase names. The nurses are ready with a new case for me.
The next patient, Mohammed, is sitting in the waiting room with his cousin Abdul. As I peer out through the glass and see the two men sitting on the bench, Tish says, “The guy on the left; he’s from Ethiopia.”
Mohammed had come to Canada in 1990 to escape the war in Ethiopia; he got a job in construction. He returned to Ethiopia in 2002, thinking that the tensions there had subsided.
Three weeks ago, he flew from Addis Ababa back to Toronto. “I can’t sleep,” he says, in response to my query about what’s bothering him. He also divulges that in 1982, he went to Somalia as a refugee and was hospitalized twice psychiatrically, each time receiving electroconvulsive therapy with benefit. Beyond that, he is unable to provide much detail. He is a tall, fine-featured man in a nondescript T-shirt and shorts. He speaks softly.
Mohammed speaks English reasonably well and, although he does not display a broad range of mood, is friendly and polite. He appears bewildered. I speculate as to what is causing his confusion. Is it the huge culture shift from rural Ethiopia to downtown Toronto—even though he has lived here before? The difficulty of the journey itself? Did something horrible happen to him in Ethiopia? Has whatever affected him in Somalia in 1982 recurred? Mohammed is preoccupied with his inability to sleep and doesn’t acknowledge any other difficulties on initial questioning.
I turn to Abdul for his view. Abdul reports that his cousin was initially fine on arrival in Toronto, but that within two to three days he began to change—sleeping during the day but up all night, fearful on the streets that strangers were talking about him and claiming to be able to hear them—even though he and Abdul were inside Abdul’s car with the windows up. He also points out that Mohammed had been chewing khat daily in Ethiopia, a drug only superficially familiar to me. Finally, Abdul adds that Mohammed cannot stay with him any longer and has no place to stay. He has no money and his Ontario health insurance card has expired, although he is a Canadian citizen.
I excuse myself to look up khat online. My search locates over eight million related websites in 0.16 seconds, including video footage of people chewing and talking about the drug. It is a plant that may have originated in Ethiopia and it is a stimulant when chewed, releasing chemicals with amphetamine-like properties. Lethargy, depression, nightmares and tremors are listed among the withdrawal symptoms, and khat-induced psychosis has been described—and associated in one British study, with a high recurrence rate. Mohammed tells me that he hasn’t chewed khat since returning to Canada.
I phone Mohammed’s general practitioner, a fellow Ethiopian. I hope to get a more nuanced, culturally and historically informed perspective on Mohammed.
“Do you remember this patient?”
“Of course I do [laughing]. I saw him last week and I used to see him when he lived here before.”
“What did you think was going on with him?”
“He’s crazy [laughing]! He was bothering everyone in my waiting room and told me he couldn’t sleep. I gave him some Ativan and Risperal samples. He wasn’t like that before.”
It is clear that not much more information will be obtained. Mohammed’s symptoms, while loosely defined and of uncertain origin, are interfering with his sleep, his sense of safety, and his behaviour with both family and friends. Mohammed, Abdul and I all agree that something needs to be done.
“Would you like to come into the hospital so we can help you get some sleep and understand what’s going on?”
“Yes, that would be nice.”
I admit Mohammed to “the back” for further observation, prescribe a sedating antipsychotic at bedtime, and wonder what the hell this is.
I see two more patients before my final patient of the shift, a woman, Mimi, whom Tish had told me earlier could wait. I look for her in the waiting room but cannot find her.
“She’s gone to put money in her parking meter and maybe get a coffee,” Tish informs me.
“Should we be worried?” I ask.
“She’s not suicidal. She just doesn’t want to get a parking ticket.”
I now know that Mimi is both responsible and able to afford a car. She returns in a few minutes, apologizing for the delay.
Mimi is a 37-year-old architect by profession, married to an investment banker and mother of a 23-month-old son. Four years earlier, she had left her position at a prominent Toronto firm to be with her husband who was transferred to the London office of his company. In the wake of that move, she had felt depressed, and guilty about feeling dissatisfied and unhappy in the midst of material comfort.
She became pregnant in London, and her mood dipped further after the birth of her son, Michael. From time to time, she wondered about getting help. On the family’s return to Toronto, her family doctor, extremely concerned about Mimi’s untreated postpartum depression, sent her to a psychiatrist for a consultation, and medications were recommended. But she was breastfeeding and was concerned about not exposing her son to any risk. The psychiatrist then went on maternity leave.
Mimi is soon in tears as she describes how awful she feels, how poorly she is functioning, and how bleak her future looks to her. Although she doesn’t want to kill herself, she feels that her husband and son would be better off without her, that she is a burden to them both. She averts her gaze as she recounts that she and her husband have been sexually intimate only four times since her son was born.
Her son is eating solid foods like any two-year-old, but still wakes in the middle of the night to breastfeed and sometimes also breastfeeds during the day. I try to ask as neutrally as possible why this is continuing.
She knows intellectually that the major benefits of breastfeeding for her son have passed. But he is in a routine and so is she. In the midst of her depression, her pervasive sense of inadequacy compels her to continue to provide her son with the one thing that no one else can.
I recommend that Mimi attend an outpatient psychiatric clinic at another hospital that specializes in peri-partum disorders, because the ideal intervention will also involve her husband and son. As an alternative, I encourage her to consider reconnecting with the psychiatrist she saw 18 months earlier. She thinks these are reasonable suggestions and says that she will follow up. When she leaves the ER, I wonder if she will. I also hope that I haven’t overestimated her ability to seek help; postpartum depression is notorious for its ability to paralyze apparently competent women in supportive relationships with sometimes disastrous results.
For every patient discharged, there is the curiosity about what will unfold and the worry of not knowing. For every patient admitted, there is a cascade of events, good and bad, that will have an indelible impact on that person’s life. I was told at the beginning of my training that psychiatry was a profession that required a high tolerance for ambiguity.
Most people envision psychiatric care as the gradual unravelling of a story, with the psychiatrist monitoring symptoms as they evolve, and developing a therapeutic relationship with the patient that deepens as the months and years pass. Such lengthy relationships can be rewarding for both patient and psychiatrist. But there is a different kind of satisfaction that comes from the heat of the emergency encounter which appeals to me—the immediacy, the challenge, the help that can be provided when people are feeling at their worst.
As I wipe Mimi’s name off the whiteboard, the evening crew of three residents arrive, eyeing the list of unseen patients warily. I tell them I have no cases to hand over. It seems cold comfort to them in anticipation of a sleepless night punctuated by arrivals of people in more disarray and distress than those who visit during the day. I wish them a good shift and pack up to head home.