Nidal Moukaddam, MD, PhD

Tales From the Clinic: The Art of Psychiatry

, we visit the addiction clinic to discuss accidental overdose deaths. Although death by suicide is known to greatly impact psychiatrists, the impact of overdose deaths on physicians is not well studied. Despite the best efforts exerted in treatment, patients on medications for opioid use disorder may die of accidental overdoses on opioids, having misestimated their current opioid tolerance, or overdose on other substances such as sedatives/hypnotics and stimulants. This article is dedicated to 3 patients lost in this past year—AK, EG, and AW—with heartfelt wishes to their families.

“Ms Verona” was a 45-year-old female enrolled in an addictions treatment program and a mother of 7 children who struggled greatly with 

 and anxiety. She was motivated to stop her opioid use, as it was taking a toll on her health and her family. Ms Verona’s children would sense their mother’s lack of engagement with them, as she was constantly preoccupied with how to mitigate the inevitable opioid withdrawal symptoms. She was a good candidate for buprenorphine therapy, as she met criteria for severe opioid use disorder, and she preferred partial agonist therapy as opposed to naltrexone and methadone. Ms Verona was inducted onto buprenorphine, and her dose subsequently increased to 16 mg total daily in order to adequately address opioid cravings.

As treatment progressed, Ms Verona displayed a chronic tendency to arrive more than an hour late to appointments. Despite her tardiness, she would plead to still be seen, often citing traffic or lack of childcare arrangements. The psychiatrist, Dr Smith, would attempt to be flexible, given the understanding of treatment barriers stemming from social determinants of health, as well as recognizing the time-sensitive nature of 

 refills; however, these accommodations were placing Dr Smith and the treatment team under time constraints in a busy clinic. Such accommodation would either cause the psychiatrist to be late for other appointments, or it would lead to the appointment with Ms Verona feeling rushed. After the patient was accommodated for lateness over a few visits, Dr Smith became aware of his growing countertransference toward Ms Verona.

 (ADHD) may have been affecting her presentation. Ms Verona was noticeably circumstantial during sessions and required frequent redirection. She also described a childhood history with symptoms of difficulty concentrating. It was also explored whether her lateness was a manifestation of her inability to focus, organize, and prioritize. She often talked about having gotten Adderall “but not recently, doctor; I know you would not let me.” Dr Smith worked with Ms Verona in problem-solving therapy to help reduce treatment-interfering behaviors and promote punctuality. Ms Verona was also started on bupropion to target ongoing depressive symptoms and simultaneously provide a nonnarcotic option to treat attention-deficit symptoms. There was a concern for her using stimulants or other substances between appointments. Despite these treatment approaches, tardiness to her appointments continued and she appeared even sedated at times, despite negative urine drug screens.

One day, Ms Verona was more than an hour late. She was informed that she could not be seen and had to be rescheduled. She was visibly upset and opted, likely due to splitting defense mechanism, to reschedule to see a different provider in the clinic when this boundary was set. After this, Ms Verona ended up seeing a different psychiatrist for the next 6 months.

One day, Ms Verona’s former psychiatrist met with one of his active patients, Mr Kim, and the following dialog ensued:

Mr Kim: “One of my friends passed away, and I’m attending the funeral. I think you actually used to treat her before.”

Dr Smith: (Somewhat surprised) “I’m sorry to hear about the loss of your friend.”

Mr Kim: “Yea, it was sad… she (Ms Verona) said she used to see you. She was still on buprenorphine, but the suspicion was that she was taking alprazolam the whole time she was in treatment and did not tell anybody, and it is a suspected unintentional overdose. I used to see her all the time, and she would be nodding off. You didn’t hear about this?”

How Do Physicians Cope With Patient Suicide or Overdose?

Dealing with the loss of a patient due to suicide or 

 has a significant impact on the treating physician and is not often talked about. There are a variety of factors that determine how a psychiatrist will be impacted in such a situation. Younger clinicians and trainees are often affected more adversely, as they have not been exposed to the scenario and may feel more vulnerable in terms of their experience and knowledge base.

 According to literature, about 25% to 60% of psychiatrists will report having a patient who died by suicide during their career.

 The number of physicians who lose patients to overdose is not known. However, the rate of overdoses involving opioids jumped by 200% from 2000 to 2014, and between 2013 to 2019, the synthetic opioid-involved death rate increased 1040%.

 The sheer magnitude of these numbers suggest that most physicians dealing with addiction must have been exposed to patient death by overdose.

With these figures in mind, as well as the significant amount of perceived stigma and guilt surrounding disclosure of these outcomes, and with the fear of lawsuits that may occur in these situations, the overall emotional toll it can have on a clinician can be quite intense. The psychiatrist in this scenario was flooded with feelings of guilt related to potential responsibility for the outcome. In addition, there is a possibility of additional emotions of anger toward the patient who was already deceased. We hear team members often saying, “Oh, but they were doing so well,” or “So sad—they stayed off heroin but could not keep off meth.”

When one is processing the suicide of a patient, one should be mindful to not isolate oneself. Efforts should be conducted to reach out to colleagues, as it is likely they would have dealt with similar experiences in the past and can normalize and validate the experience. Discussion of experiences and coping mechanisms may have therapeutic effects for physicians going through such experiences. Clinicians, as part of an organization or group practice, can utilize case conferences—a pragmatic, systematic, and therapeutic approach to exploring the case outcome in more detail. Risk management reviews or meetings could help with apprehension about any impending or perceived lawsuits. This is especially important for clinicians in private practice, who may be more isolated given their work environment structure. The message we need to hear is that a patient loss does not undo or discard the multitude of meaningful life-changing and life-preserving work done with both living and deceased patients. Support and validation go a long way in reminding us why we do what we do.

How Can We Promote Honesty About Recurrence of Substance Use?

 (SUDs), it may be helpful to try to acknowledge and normalize the fear of disclosure of relapses, as well as to emphasize the importance of honesty in recovery from the very beginning of treatment. Although feelings of guilt and internal shame are common, they are not easy to talk about for patients. Whereas the patient may perceive recurrence of use as “starting from scratch,” the clinician can reframe a recurrence of use as a learning point and a way to troubleshoot the circumstances surrounding the use. Being too harsh or strict with the patient may backfire, lead to sustain-talk, erode the therapeutic alliance, and provoke even more feelings of guilt or shame. Relapses sometimes occur because being off substances uncovers a cooccurring mental illness, or because of stress in real life, to which patients with SUDs are more susceptible.

By definition, addiction is a relapsing and remitting illness. Similarly, depression is also a relapsing and remitting illness, but no one benefits from being kicked out of treatment for having a recurrent depressive episode. Thus, patients should not be terminated from treatment for recurrence of use as if often done—they should actually receive more intense care when in a greater time of need. Although recurrence of use might have clinical significance on modifying treatment plans, patients should be informed that using is only a setback if they do not seek further treatment to address it. Patients may be relieved if asked about any internalized and unfounded fear they may have about being terminated from treatment if they divulge recurrence of use.

If a patient states that they are feeling punished for having more frequent visits during recurrence of use, it may help to first empathize with concerns and then reframe the change in treatment plans as a goal toward well-being as opposed to punishment. Utilization of motivational interviewing may be helpful if the patient is still ambivalent about recovery. It is crucial for a provider to have a nonjudgmental approach toward relapses, both past and present. Subconscious criticism, even in the form of subtle body language, can promote denial or reliance on more primitive defense mechanisms in a patient and lead to poorer treatment outcomes, especially if the patient has a harsh superego or difficulty with trusting others.

Previous recurrence of use may lead some patients to think they are a lost cause and lack the willpower and discipline that might be needed for recovery. Internalizing this belief is characteristic of patients with complicated SUD histories. It is important to modify a patient's internal process and remind them that it is not solely willpower or motivation that determines the ability to improve, but also coping and relapse prevention skills, which can be taught through any type of therapy, but especially cognitive-behavioral therapy.

How Do You Find a Balance of Boundaries With the Patient?

Finding the right balance in setting boundaries can be a challenge in a busy schedule, and it requires being mindful of the patient’s perspective while simultaneously acknowledging a patient’s subconscious need for structure to meet treatment goals.

It was important in Ms Verona’s case to validate her struggle with circumstances in her life. After all, the social determinants of health (ie, social, behavioral, and environmental factors) are a predominant influence on treatment outcomes.

 In addition, it is important to acknowledge the role of untreated ADHD (like in Ms Verona’s case) in reducing recovery success.

 At the same time, the medical ethics concept of justice should also be considered. Although justice in this situation may apply to acknowledging Ms Verona’s barriers to care, it may also expose the caveats of this approach since other waiting patients were affected by the patient’s tardiness. A provider is tasked with collectively benefiting all of their patients, treating all with equity and making accommodations where necessary, and without putting 1 patient at risk at expense of another.

In this case, did the boundary-setting change the course of Ms Verona’s clinical treatment? Yes. Would it have been better without it? Not necessarily. Part of the treatment frame is for both physician and patient to be accessible, at a mutually convenient time. Reneging on appropriate boundaries may distort or enable certain expectations of the patient, which can undermine the patient’s perceived responsibility in treatment, reduce the patient’s ability to problem-solve, and lead to the approach that the physician drives the treatment, instead of the dyad making a shared and mutual responsibility. The physician can communicate these messages with empathy and genuine concern in the hopes that the patient will adopt that responsibility. In the case of mitigating overdoses—a poorly understood field—it is essential to know if the patient is using secondary substances outside the opioid being the target of treatment. Secondary substance use significantly increases risk of overdose.

From a larger perspective, a physician’s taking of the alternate approach can contribute to burnout and distress, and potentially adversely affecting outcomes for the other patients. Thus, boundaries can be a mechanism of protection for both the patient and the physician.

Triple Threat of Death: Suicide, Unintentional Overdoses, and COVID-19

Although there is growing literature about how patient 

 can impact physicians, there is a lack of data particularly on how substance overdose may impact a physician’s mental well-being. The lack of data on overdoses and how to cope with them is further compounded by the problem that busy schedules or shift work may inadvertently reduce the physician’s ability to access resources for support while the physician also thinks that “I must carry on.”

In addition, it would be important to differentiate how suicide and overdose are not necessarily the same. Overdoses are not always done with the intention of taking one’s life. In fact, most overdoses are accidental, but ultimately occur due to overestimated tolerance, unknown ingestion, or increasing amounts taken during stressful/inciting events. In 2014, only 12% of drug overdoses were intentional according to the Centers for Disease Control and Prevention (CDC).

 Although the percentage of intentional overdoses is the minority, another thing to consider is whether clinician perception of guilt is more intense if the overdose is intentional. A physician can be vulnerable to guilt for not effectively being able to treat a patient’s addiction or form a close enough relationship to know of their usage—even if the patient knowingly did not disclose use. Then there is the question of whether some severe addictive disorders could be considered like a “terminal illness,” where a clinician may feel that no matter how many treatment approaches have been tried, it is a matter of “not if, but when” in regards to either overdose or a chronic decompensation toward death.

Although we have seen that doctors who hear about their patients overdosing may actually reduce the amount of their opioid prescribing,

 mental health clinicians may be affected in a somewhat different capacity, as their role is also tied inevitably into also treating comorbid depression, anxiety, and suicidal ideation. The COVID-19 pandemic has further exacerbated this problem, as the estimated prevalence of suicidal ideation today is higher in comparison to the prevalence prepandemic.

If a clinician’s natural tendency to do more and become more hypervigilant following the loss of a patient, it is noteworthy to mention that most physicians suffer from burnout at one point in their life. A cross-sectional study was able to demonstrate that increases in suicidal ideation endorsement were significantly correlated with physician burnout rates.

 Considering that overdoses can be as lethal as suicides, it would be a fair but unproven assumption that it would also similarly contribute to physician burnout.

We believe further research is necessary to understand the many ways in which patient overdoses are affecting physicians, as well as developing more efficient strategies and support for dealing with the aftermath. 

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He is Director of Harris Health Substance Addiction Treatment Program and Associate Program Director for Baylor College of Medicine Addiction Fellowship Program. 

is currently a resident in psychiatry at Baylor College of Medicine. 

 is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the 

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Articles

My Patient Overdosed and Now I Feel Guilty… 

 I really enjoyed the roundtable discussion. I really enjoyed how thorough everybody was. There were a lot of questions about “Well, how did you make the diagnosis of bipolar I? Give me more details about the mania. Flesh out the case for me.” I would not want to give someone a diagnosis of bipolar I, which is a lifelong disorder, without knowing exactly what they've been through, and I thought that was nice. People talked about dilution of care and how quick encounters where patients are not given the time that they need is not a good thing, and I agree. People also talked about how important it is to educate patients and work with them and establish that nice rapport that makes you know your doctor is on your side. Your doctor is really trying to get you to be functional and happy. I also thought it was interesting that you have people who are willing to start with atypical second-generation antipsychotics and people who are willing to start with lithium, and I'd say the room was evenly split. That probably indicates that the trends in treatment of bipolar disorder are changing throughout our country.

Videos

Dr Moukaddam discusses key takeaways for the management of bipolar disorder.

Takeaways for Bipolar Disorder Management

 In the United States, medications would be approved by the FDA [Food and Drug Administration]. If you were in Europe, they’d be approved by the EMA [European Medicines Agency]. That’s the equivalent of the FDA here. The medications can be approved for the initial stage of bipolar disorder, which is mania. That would be acute treatment, but a medication could also have an approval for maintenance treatment. Obviously, one would want to initially go with treatments that have FDA approval. That being said, when a patient is very sick, sometimes you end up with some off-label prescribing, but that should not be your first step. The field has evolved a lot. As I’ve said, we have a lot of options now. You have your mood stabilizers: lithium, Depakote, carbamazepine, and lamotrigine. You also have your atypical antipsychotics and second-generation antipsychotics. Second-generation antipsychotics are a fascinating drug class because they take what the previous class of antipsychotics have done, which is dopamine agonism, and work on dopamine but not in the same way, not to the same extent, and not on the same receptors. Now, as a clinician I have a lot of choices. I can start with a mood stabilizer: lithium, as in the case of this young man. Or I could start with an atypical antipsychotic. Usually, what you’ll see is that patients don’t know. Thus, it is up to us, but we develop algorithms depending on where we’ve trained and how we’ve trained and the populations that we treat: very sick or not very sick.

Where do we go from here? Based on the metabolic profile of the patient, their family history, their medical history, and what I’m seeing right now, I would have to pick an agent that hopefully catches the symptomatology and controls it. First, we want it to be monotherapy. It’s always better to do monotherapy instead of 2 or 3 agents. People don’t like it when you give them 3 or 4 prescriptions because they feel that they’re broken; they feel that they’re really sick. Sometimes we need that, but ideally, monotherapy is what your patient will stay with. We’re thinking a little about dopamine, glutamate, and serotonin here, and it’s beyond the scope of this talk to talk about all the receptors. But with dopamine agonism, the older agents used to focus on the detour receptors. The newer agents would lean toward D3 receptor agonism, and instead of having full agonism or full antagonism, now we have partial agonism and partial receptor agonism, which is extremely precious because it gives you more nuanced effects. Some of the newer atypical ones will have partial agonism, and that’s helpful. Also, in this type of treatment, we really value the effect on serotonin receptors, and when the atypical and the second-generation antipsychotics first came out, it was a really big deal that they worked on 5HD2 and conversely on 5HD2C. 2A and 2C are the 2 serotonin receptors that are opposing in action, but activation of 5HD2C as in the case of olanzapine could trigger some of the weight gain.

Why do we care about serotonin? We care about serotonin because it modulates dopamine release. Dopamine is a big agent in bipolar disorder. It’s a neurotransmitter that causes a lot of these symptoms, and modulating dopamine is one of our goals. We do it via serotonin and glutamate, but because there are so many other receptor subtypes involved when we pick an agent, we want that agent to cover a wide variety of profiles. We want that profile to cover some dopamine, some serotonin. We would like to have some histaminergic agent to help with sleep but not too much, and we definitely don’t want a muscarinic agent because this is when you get your anticholinergic adverse effects.

One of the considerations we have not talked about, but it would change how you approach things, is age. You want to make sure the person knows that this is potentially a lifelong treatment and that if they are female and of childbearing age, this will change. They would have to use contraception, and if they get pregnant, then it could affect them. The treatment could affect the pregnancy, and bipolar I disorder could also affect the pregnancy, and the pregnancy in turn could affect the bipolar I symptomatology. Thus, with women, you want to caution them that the postpartum period would be a very high-risk period for depression, etc.

My approach to the treatment of patients who have failed multiple therapies is to make sure that I’m maximizing the use of psychosocial treatments, especially psychotherapy, and then to deviate from monotherapy to maybe adding other agents.

My first step would be to add psychotherapy. I would want to make sure that the patient really understands what’s going on and is maximizing the use of their own psychological resources. Then, I would go beyond monotherapy, and I would consider adding a second or perhaps a third agent. In the case of this young man, we have lamotrigine and quetiapine. I would consider 2 agents and then maybe consider an adjunct. Maybe this person needs a little bit of help for anxiety or for sleep, so I would like to combine psychosocial treatment with psychotherapy and then change agents. I would also talk to the patient about how realistic it is when we talk about mood control and adverse effects, and this is where the tough conversation of benefit outweighs risk comes in. If they have a 5-lb weight gain, could that be acceptable? If they tell me a 20-lb weight gain I would say, “No, that’s really too much.” But if it’s a small weight gain or if it’s an adverse effect that’s mild, could we then accept it if the medication gives us benefit? That conversation has to be very customized and very tailored to the patient’s presentation and it relies on your rapport with the patient. If you have a good rapport with the patient, usually you end up with a much better outcome when treating those conditions. There are other things we have not talked about; ECT, which is electroconvulsive therapy for mania, is there when somebody is really ill. There is hospitalization, but we’re assuming for the purposes of this case that this is outpatient.

Nidal Moukaddam, MD, PhD, provides insight on the evolving treatment landscape for bipolar disorder and optimizing therapies for disease management.

Treatment Selection for Bipolar Disorder

 The art of psychiatry is making sure to look at the patient holistically and having a comprehensive history that then links to treatment, because you don’t want to ignore important things such as their medical history, metabolic profile, constraints on their job, and family history. Let me go into some of these. If you think that the treatment that they would benefit from is a pill that’s given 3 times a day, but their work does not allow them to do that, then you would not want to proceed because the patient would not be adherent. Similarly, financial considerations are very important. If I think a particular pill would be fantastic for the patient, but they cannot afford it for more than a month, then it would not be sustainable.

These would be your first considerations: Can they afford it, will it mesh with their schedule, and does it fit well with their medical profile? We have not talked about this patient’s medical history but somebody who has obesity, diabetes, or other conditions could not potentially take an agent that causes weight gain. Because even though the agent could be beneficial for psychiatric symptoms, the weight gain would be unacceptable and make the other conditions worse. Those are huge considerations: the metabolic profile and medical history. As mentioned in the case, this patient developed hyperthyroidism, so that’s one of the things we consider with lithium, especially long-term treatment.

The one other thing you discuss with the patient, which is really important, is that bipolar disorder doesn’t typically go away. You will have to be on medications for an extended period of time, perhaps for the rest of your life, so we really want to find a medication regimen that is comfortable for you. When I say treatment, treatment is not only medications. We have to consider whether there’s any therapy that could work. Psychotherapeutic modalities are extremely effective for certain things, especially for rhythm therapy and making sure people know how to manage their sleep and energy and how to catch symptoms before they start. Psychoeducation is your first step. You can do that in office, but therapy is often missed or underused, and I think that would be important for anybody making a treatment plan.

Dr Moukaddam shares factors to consider when approaching the treatment of bipolar disorder.

Approaching the Treatment of Bipolar Disorder

 Today, we’re going to talk about a new case. A 30-year-old man has taken short-term disability leave from work due to the progression of a depressive episode. He received a diagnosis of bipolar I disorder about 10 years ago. He had his first episode of mania at the age of 20 and 2 subsequent episodes of mania between the ages of 21 and 29. He was treated with lithium, which was highly effective, but he experienced excessive thirst and developed hyperthyroidism. His lithium level at the time was in the therapeutic range of 0.8 mEq/L. He was switched to valproate; however, valproate lacked the efficacy of lithium and caused adverse effects of sedation and weight gain. During his third manic episode, he started on olanzapine but experienced excessive weight gain. He was then cross-titrated to quetiapine, which improved his manic symptoms. However, weight gain again became an adverse effect, and he also complained of sedation. The patient reported sleeplessness and made unnecessary online purchases when unable to sleep, but the quetiapine sleepiness was unacceptable. Despite these adverse effects, he continued taking] quetiapine until he decompensated into his third depressive episode. The quetiapine was then augmented with lamotrigine, which was titrated up to 300 mg per day but demonstrated no efficacy. At the time of presentation, the patient was adhering to the medications. He did not have a substance use disorder, which was confirmed by a negative toxicology screen. His TSH [thyroid-stimulating hormone] level was in the middle of the normal range, and he had no suicidal ideations or psychotic symptoms.

I think the most important thing to do when somebody comes to you, even if they tell you they have a diagnosis, is to confirm the diagnosis. You want to start by making up your own mind, and sometimes the patient is not a good source of information. But in the case of bipolar disorder without psychosis, you expect the patient to be able to give you a solid history. Typically, the part of the history that’s hardest to nail down is mania. When people experience mania, they have excessive energy and excessive activation that creates the need for sleep, and sometimes they like it. They feel that this is the way it should be, so they don’t point it out as pathological. Now, the 

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

] criteria tell us that mania that leads to hospitalization or some negative consequence like incarceration is problematic no matter what the duration is. Assuming the patient did not end up in the hospital or in prison, we want to verify the story of mania. In the current case presentation, I can see many of my colleagues saying, “Hey, you’re not giving us enough symptoms of mania. He’s a bit sleepless. He makes frivolous purchases. That’s bipolar disorder but not bipolar I; maybe it’s bipolar II.”

Thus, my first step would be to explain that this patient had at least a week without sleep. During that week, he was spacing, had pressured speech, and was talking fast to the point that others around him commented about it. He became more impulsive, and buying things was the tip of the iceberg. He also became more sexual to the point where it got him in trouble in his relationships, he spent more money than he had planned, etc. These examples of impulsivity often nail down the diagnosis of bipolar disorder. Of course, these symptoms change with the time that we live in. For example, before unlimited plans on cell phones, you would have been taught to ask: “Do you get a very high bill on your phone when you’re manic?” Because patients with mania talk a lot, and the bills would be higher when they call across state lines or internationally. First, I would recommend verifying the diagnosis. My impression of the patient is that this is somebody with a set diagnosis of bipolar I. Three manic episodes is a lot. He has impairment because of it, and it’s affected his job. Thus, my first step is confirming the diagnosis. My second would be a lot of psychoeducation; make sure that the patient understands what he’s up against and why he needs treatment.

Nidal Moukaddam, MD, PhD, presents the case of a 30-year-old male diagnosed with bipolar 1 disorder and shares her initial impressions on diagnosis.

Patient Case: 30-Year-Old Male With Bipolar Disorder

(In honor of Women’s History Month, we invited our contributors to write about the women who inspire them.—Ed.)

“Generosity is giving more than you can, and pride is taking less than you need.”

The setting: a city in the midst of a civil war. Let’s not dwell too much on the details—it could be anywhere, and war is terrible in any form. The year does not matter, either. In this chapter of this nameless war, the electric grid has been hit and running water is erratic. The city is plunged in silence earlier than usual, deprived of its busy, noisy social varnish, and the flickering of lanterns, candles, or the stray cell phone that has not lost power yet are the only lights.

However, this civil war has lasted enough that people have acclimated. It has been months—years—with intermittent exacerbations. They have nonperishable foods stored. They have their preferred news channel and political analyses to plan their day and calibrate the risks they take. They strive for a desperate sense of normalcy between fighting interludes.

The woman I will tell you about was lucky enough to live in a section of the city that still had power—during this chapter of the war, at least. She was determined to help others in her own discrete way. She never bragged about it—never even thought of herself as helping—and yet her actions are seared in my memory.

One day, she comes home with a couple of shirts. “I need to iron them; this is for Joe.” Joe, who could really be anyone, just like this story could be anywhere affected by strife, was an elderly gentleman who was very embarrassed that he could not iron his shirts, look presentable, or take care of his grooming the way he wanted. He had stopped leaving the house completely. Joe was, in fact, an esteemed writer who just happened to live in a section of the city without water or power.

His wife, an artist made famous by her delicate carved compositions, had shared in a private conversation how embarrassed he was, and how she felt bad that she could not solve this problem for him. He did not wear T-shirts, they had nowhere else to go, and they could not leave the city—they just had to wait. He would never ask for help—he was just isolating instead. To the mind of the 7-year-old I was back then, this was baffling. Why didn’t he wear T-shirts? You did not need to iron T-shirts. I did ask that question, with the gusto, and perhaps cruelty, of a child.

So, the shirt turns out to have a hole in its sleeve—a large enough tear that it could not have gone unnoticed to its owner. It also had a patch, closely matching in color, which would blend in when ironed. I recall the conversation that ensued about the patch, and the fact that people may need help, but not ask for it. And when they do ask, they may be simply glossing over heaps of deeper issues. The patch was neatly ironed into the shirt that day, and no one spoke of it ever again. Joe and his wife’s financial misery was not mentioned, and their pride and respect were preserved. My 7-year-old eyes did not get it that day, and I never asked whether financial assistance—food, cash, anything—went back with the shirt. But decades later, this event still lives in my memory as one of the most inspirational, subtle, and understated ways I have witnessed anyone give help.

Small moments count and make our lives what they are. Small moments like the one shared above are what gives medicine—especially psychiatry—its depth, joy, and purpose. When patients come to us, we cloak their sadness, misery, or fear in hope and respect. We treat the human being they strive to be, with their priorities and their dreams. We look at the ironed, polished shirt—not at the hole that has been patched. And my mother, who taught this lesson without saying a word, will forever be the most inspiring person in my life, for what is life without dignity and respect?