Nicolas Badre, MD

“Success is a journey, not a destination. The doing is often more important than the outcome,” said tennis player Arthur Ashe, Presidential Medal of Freedom Award recipient and one of the people featured in a motivational poster at my residency hospital.

We enter residency after having surmounted undergraduate, medical school, and Match Day. For the most part, our lives have been a series of milestones. Those hurdles lead us to practice what is arguably the most important profession, one of caring for a person’s health.

In psychiatry, not only do we get to care for others’ well-being but we also share in one’s deepest emotions and secrets. In residency, I wonder if the goal was not just to reach this milestone but to actually have been a psychiatrist all along.

Here I am, 4 years older, 4 years wiser, and 4 years into my journey. When thinking of an analogy for my experience of residency, I looked for a concept that emphasizes process over content, focuses on the moment and not the result, and one that has always existed, beautiful, like human relationships can be.

Sand Mandala is a Tibetan Buddhist tradition that spans centuries. During this process that lasts several days, monks create stunning circular art pieces (mandalas) out of colored sand. Once completed, the design is destroyed as part of the ritual to confirm the value of the process over the result. Similarly, our journey to graduation is a path that should not be mistaken for an end product but appreciated throughout its course.

The department of psychiatry at the University of California, San Diego School of Medicine (UCSD) is a unique amalgam of tremendous researchers, extremely ill patients, and outstandingly accomplished residents. The commitment to research, clinical care, and teaching tug at each other constantly.

Much needed research holds the key to our future, but it can also seem out of touch with the reality of everyday care. Dedicated clinicians juggle the need of managed care and endless documentation requirements, while desperately making time for a little teaching along the way. Finally, didactics serve to make sense of it all and help to keep us motivated in what we do. Under those varied pressures, it is not surprising that even at such a competent program, some may think of residency as an obstacle course without much purpose other than the elusive goal of completing it.

As I leave the academic nest, I wonder if I misunderstood residency along the way. I am about to begin a comfortable-and meaningful-job, as medical director for the local jail system, as well as a private practice focused on psychotherapy. My dreams of Ericksonian generativity are well on their way. Furthermore, an agreeable residency in psychiatry only solidified my Ericksonian intimacy. I wonder whether residency was something other than achieving some intangible privilege. Instead, perhaps the process itself embodied the goal all along.

The grueling hours of certain rotations forced me to confront my own fears and overcome discomfort. My endlessly imposing super-ego only made my failures and shortcomings harder to take. In particular, the suicide of one of my patients pushed my sense of self worth to its brink. Such experiences were, looking back, crucial in my development. My rigidity and idealism needed to be broken in order to accept myself as I am. This renewed appreciation for my imperfections allows me to care for patients in a much more human way.

Many challenges in residency became the greatest learning tools. I am not sure I would have grasped the true meaning of hard work had I not seen a therapy patient after a 14-hour night shift; understood the despair of psychiatric illness without witnessing a patient rescued from a suicide attempt in the emergency department (ED); or appreciated the amount of work that giants in our field exert had I not seen my mentors writing one grant after another.

Most importantly, residency gave me the opportunity to be a psychiatrist from the second day. On July 2, 2011, I saw 6 ED consultations. I staffed those patients with my attending over the phone when my senior resident was too busy. Despite my uneasiness, I became a psychiatrist with my own patients that day. From then on, I had already achieved my lifelong goal to care for a patient’s well-being, share in his deepest emotions, and listen to her secrets.

Since the beginning, I have had the chance to participate in the life of endless emergency and inpatient encounters. I have found a true love for connecting with patients at a deeper level that only individual psychotherapy permits. Since my second year of residency, not one week has passed without seeing a patient for individual therapy. Thinking that those interactions were training requirements would miss the point-that those relationships I created with patients were all I wanted and needed for a sense of self worth.

Once I realized that I had found some of my answers, I had the privilege of becoming chief resident of outpatient psychiatric services at UCSD, supervising an incredibly talented group of residents through their discovery of outpatient care. Over the year, I had the opportunity to watch them grow, struggle, and fight with and for their patients. But most importantly I saw and guided them through their journey in becoming psychiatrists. I am not sure that I got to show them all I wanted. However, I know that they realize how right Carl Rogers was when he reminded us the most important maxim of psychiatry: our most valuable tool is our relationship with our patients.

Like residency, Sand Mandalas require teamwork to accomplish a common goal. The group effort by both Sand Mandalas and residents results in a transformative and stunning experience. However, the Tibetan tradition also teaches us an important lesson about our role, our place, and the purpose of it all. Failing to recognize our residencies as necessary and at times difficult steps to board certification in psychiatry misses the point that actually allows us to grow into excellent psychiatrists. As Rogers suggested, “When I accept myself as I am, then I can change.”

To upcoming interns, I wish you the chance to have an experience like the one I had and take advantage of the unique opportunity to be a part of the greatest of all professions. My only advice: do not wait for residency to be over to enjoy it. You’ve already made it.

Dr Badre is the past outpatient Chief Resident of psychiatry in the department of psychiatry at the University of California, San Diego School of Medicine. He recently was named a Laughlin Fellow, as well as a Group for the Advancement of Psychiatry fellow for his dedication to the field of psychiatry. He has engaged in research on dementias, substance abuse in older adults, and more recently has been interested in the areas of teaching and systems of care. He is currently starting as Medical Director of Psychiatry at the San Diego County Jails as well as clinical volunteer faculty at UC San Diego.

On Becoming a Person: A Therapist’s View of Psychotherapy

Articles

Like residency, the Tibetan Buddhist tradition of Sand Mandalas requires teamwork to accomplish a common goal. The group effort by both Sand Mandalas and residents results in a transformative experience. 

Sand Mandala and Reflections on Residency

“How could they see anything but the shadows if they were never allowed to move their heads?”

 is a constant reminder that as clinicians we only see a part of our patients.

 We see the part we project onto them. This selected view of our patients is often further narrowed in our inpatient units. Patients are in distress, displaying only a part of their character. Psychiatric units, with their routines, rules, structures, and boundaries, only allow for the manifestations of certain select aspects of one’s identity and symptomatology. Managed care payers, with their need to minimize cost and duration of inpatient stay, preclude comprehensive evaluations. Finally, our desire for clear diagnoses for our patients can blind us to a multifaceted picture.

We present the case of a patient for whom different attending providers had markedly different interpretations, despite similar presentations within a year. As the case unfolds, we invite you to reflect on your diagnostic understanding of each presentation. We believe that a combination of these factors led to repeated diagnostic oversimplification in our case.

, is an 18-bed acute psychiatric unit. Over 800 patients are admitted to the unit each year. In almost half of the patients (48%), there is a diagnosis of some form of psychotic disorder, consistent with the acute nature of the unit. In the vast majority of the rest of the patients, a mood disorder is diagnosed (bipolar 27%, depression 21%). The mean length of stay is short, and averages just 5.9 days (this figure is inflated by unfunded or underfunded patients with long waits for long-term facilities). The unit has a large disenfranchised population, and the majority of patients (53.7%) are either uninsured or have state assistance. The unit is staffed by 2 attending psychiatrists, a chief resident, and 3 or 4 junior residents, as well as 4 medical students.

Chris is a 22-year-old man who has been treated in many mental health facilities since the age of 19, including long-term private residential programs. He has been hospitalized numerous times for psychiatric problems (usually for depression or failure to maintain housing). During this time, he has spent little time outside of residential facilities or inpatient psychiatric units.

His family history is unremarkable and is only notable for a maternal grandfather with depression. There is no evidence of abuse or significant trauma. He meets developmental milestones and there are no problems with his social development. Chris graduated high school with his peers although he had a learning disability. He attended college for 1 year but was unable to function well in that environment, which led to his placement in various treatment facilities.

He has been treated for schizophrenia, depression, and attention-deficit disorder with haloperidol, risperidone, aripiprazole, quetiapine, olanzapine, and clozapine. At presentation, he is nonadherent to his medications. For the past 2 years, Chris has lived at a private treatment center for mental health in San Diego. His recent departure from the facility was due to resistance to participating in required chores and activities.

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, which are derogatory in nature. During the intake interview, he has difficulty in answering questions, which was considered thought blocking. He uses disjointed sentences and some words repetitively, which are assessed to be clang associations and disorganized speech. He also exhibits odd trunk and limb motions, considered to be stereotypy as seen in some forms of catatonia. He is assessed as acutely psychotic. His descriptions of his interpersonal difficulties at the long-term facility are deemed to be a demonstration of the avolition due to psychosis. The main goals of the treatment plan for Chris is to re-start his antipsychotics and provide psychoeducation on the importance of adherence.

Chris demonstrates a prolonged pattern of interpersonal difficulties. His work at 

 suggests severe personality deficits that culminated in his current state. His parents are no longer talking to him because of his constant dependency on them for financial assistance and lack of action in providing for himself. His departure from the long-term facility in San Diego was another demonstration of his constant ambivalence to commit to independence. His lack of initiative is deemed to be secondary to his need for advice and reassurance.

His movement and speech impairments are assessed to be unconsciously motivated to obtain attention and assistance and to feed his need for others to assume his responsibilities. His father suggests that Chris’s request for antipsychotics is a form of Munchausen, a means to experience adverse effects that will require help from the staff. The diagnosis is a dependent personality disorder with psychotic features. His antipsychotics are stopped because they are hypothesized to be causing severe akithisia; there is no evidence of significant psychosis and Chris is discharged with the recommendation to obtain treatment that focuses on personality traits.

 and an unspecified learning disability since childhood. His interpersonal difficulties with the staff and his family are due to developmental deficits in social communication and interactions. Chris demonstrates poor social reciprocity and poor awareness of nonverbal communication. His odd movements are restricted and repetitive, with marked stereotypy. His inability to cope since having left the long-term–care facility is thought to be secondary to the need for sameness and inflexible adherence to routine. The patient is assessed as being on the autism spectrum and a recommendation is made to discontinue antipsychotics and engage in a well-structured behavioral program.

 are invariably elevated in a psychological decompensation requiring hospitalization, Chris’s clinicians want to clarify the differential diagnosis in order to provide targeted, patient-specific treatment. As such, Chris is administered a number of neuropsychiatric tests. The results of the Minnesota Multiphasic Personality Inventory (MMPI) show a thought disorder, some increased psychopathy, and an increased hypomanic scale (of irritability and psychomotor agitation); overall, the MMPI is deemed to be most consistent with schizophrenia.

The results from the Millon Clinical Multiaxial Inventory show increased dependency traits, mania, narcissism, and delusions, but no schizophrenia impression, most consistent with the diagnosis of dependent personality disorder. Results from the Thematic Apperception Test show impoverished capacity to mentalize and relate, as well as a paucity of content consistent with 

 challenged the psychiatric paradigm. He postulated that our psychoanalytic reductionism had permitted us to lose sight of objective evidence. Our need to find analytic meaning in our patients allowed our field to label any behavior with a psychic significance. “The facts of the case were unintentionally distorted by the staff to achieve consistency with a popular theory of the dynamics of a schizophrenic reaction.” This task was so time-consuming that the average time spent with a patient per day on an inpatient unit was 6.8 minutes for all practitioners combined.

This case exemplifies many cognitive errors in diagnosis

psychiatric units have little time to examine complex personality characteristics

our need to satisfy insurance payers has resulted in the pendulum swinging too far in the other direction

studies suggest that almost half of our patients have personality disorders

The introduction of the NIMH RDoC may resolve some of these issues

Today we ponder whether our tendency for 

 and our need to satisfy insurance payers with short hospitalizations has resulted in the pendulum swinging too far in the other direction. Our wish to categorize all psychiatric manifestations under defined diagnostic criteria may have clouded our judgment of our patient. Diagnostic criteria remain guides to follow and not rules to be bound by.

Most likely in the case of Chris, all of the symptom descriptions are partially correct. He has many features consistent with autism, dependency traits, and schizophrenia. As such, a label is less useful than our awareness that any of these possibilities is justifiable. The temptation to project onto the patient an overlearned diagnostic paradigm reduces him to a shadow of whom he truly is, similar to the reality of the prisoners in Plato’s cave allegory.

Modern inpatient psychiatric units have little time to examine complex personality characteristics. Nonetheless studies suggest that almost half of our patients have personality disorders.

 Current diagnostic manuals discourage amalgams of pertinent features from multiple diagnoses, favoring broader and more encompassing diagnoses; however, “explanatory pluralism is preferable to monistic explanatory approaches, especially biological reductionism.”

In many ways, this case exemplifies many of the cognitive errors in diagnosis 

 “Availability” bias may have led the clinicians to see Chris’s phenomenology as consistent with the illnesses they encounter most often, or do research on. “Overconfidence” bias may have led to the inability to examine different differential diagnoses. “Confirmation” and “sunk cost” biases may have led to the interpretation of each symptom to fit the previously assigned diagnosis. “Vertical line failure” bias may have led to the inability of the clinicians to think outside of the confines of diagnostic criteria. These cognitive errors were likely fed by the system of care in which Chris was seen. Having a clear understanding of our own biases and those of the system of care will result in fewer diagnostic errors, less oversimplification of patient presentations, and improved care for our patients.

The introduction of the NIMH’s Research Domain Criteria (RDoC) may resolve some of the aforementioned issues. RDoC offers us an opportunity, as well as a challenge: to expand our understanding of mental illnesses as etiologically complex.

 The risk, however, is to further simplify and codify human experiences on the basis of narrow biological factors, denuded of any applicable significance in cases like the one described in this article. As the RDoC process continues, the onus is on clinicians and clinician educators to recognize and challenge unconscious and systems biases. Otherwise, understanding their patients may be merely a shadow of the reality.

Dr Badre is Resident Physician, Dr Khalafian is Resident Physician, and Dr Steiger is Attending Physician in the department of psychiatry at the University of California, San Diego School of Medicine. They report no conflicts of interest concerning the subject matter of this article.

 Rosenhan DL. On being sane in insane places. 

 Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. 

 Kendler KS. Toward a philosophical structure for psychiatry. 

 Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. 

 Insel T. The NIMH Research Domain Criteria (RDoC) project: precision medicine for psychiatry. 

We present the case of a patient for whom different attending providers had markedly different interpretations. As the case unfolds, we invite you to reflect on your diagnostic understanding of each presentation.

Nicolas Badre, MD

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Sand Mandala and Reflections on Residency

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