At Home in the Water

One doctor shares how psychiatry can have a permanent impact on patients and their families.

COMMENTARY

Surgery most resembles a knife: precise, uncompromising, final. Psychiatry is more like water: It takes the form of surroundings, gentle but irresistible, with subtle undercurrents and immense depth. A knife may carve a fine line, but if given enough time, water may carve the Grand Canyon.

When I was 5 years old, my father would take my family on monthly trips to visit a patient of his, a 40-year-old man named Mark who was suffering from amyotrophic lateral sclerosis (ALS). He was ventilator-dependent, and his perfectly intact mind was inexorably trapped in his gradually dying body. His suffering was immense, and I could see the pain behind his clear, blue eyes. While my siblings hid in the corner of his room, terrified by the sights and sounds of the machines keeping Mark alive, I patiently waited for my turn to speak with him.

Every month, I collected as many jokes as I could find, usually from popsicle sticks or string-cheese wrappers, and would inundate Mark with them at every opportunity. Most were admittedly corny, but some of them would provoke a strangled, gurgling sound through his tracheostomy and I could see that the pain in his eyes had been replaced with laughter. For a brief time, he would forget his body’s slow, inevitable betrayal of his mind. I lived for those moments, and before he died, Mark told me that he did, too. It was at that point that I decided I wanted to become a physician and dedicate my career to alleviating suffering.

I consider myself unbelievably fortunate that I somehow knew myself well enough, despite being so young, to have instinctively chosen a field that I continue to find myself enjoying more and more with each passing day. I consider myself extremely fortunate that I had the good sense to reject my penultimate career ambition, which was to become a firetruck. Perhaps one day when technology has advanced enough, I might consider moonlighting as a firetruck, but for now, I am content with being a physician.

Actually, I take that back. I am decidedly not content with merely being a physician or with merely being a psychiatrist, for that matter. Rather, I have found myself inexorably and irresistibly drawn to the field of child and adolescent psychiatry, which is in all honesty a statement I never expected to say. I can safely say, however, by the lucidity granted by the lens of hindsight, that I honestly should have known it would come to this. But denial is powerful, catastrophizing is oddly satisfying, and reaction formation is the spice of life.

During my first 2 years of medical school, when people asked me what I wanted to specialize in, my canned response was always, “Something surgical, I think. Although I am keeping an open mind, except that I am actively avoiding psychiatry.” Perhaps the lady doth indeed protest too much, eh? My first rotation of residency was also my first experience with pediatric psychiatry, and I was absolutely dreading it. The days leading up to the rotation were spent cursing my misfortune and raging impotently at the heavens: There is no way I can handle this. The kids will be too sick; it is going to absolutely break my heart. Oh no, what about the social situations? Far too tragic for me to cope with, let alone help the patients learn to manage! What about the families then? They will be even worse, fraught with intolerable, unbearable, utterly pathological dysfunction! What obscene masochism could drive someone to choose to do this job voluntarily?

Alas, the time and energy spent fueling my inner monologue’s histrionic protestations turned out to be spent in vain. Within days of starting the rotation, my fears had transformed into rapture. The patients and their stories were utterly enthralling. I found myself deeply invested in, and insatiably curious about, learning all I could about their struggles, developmental tasks, families, friends, hopes, dreams, and obstacles standing in the way. I found that the practice requires a depth and breadth of knowledge and skill unmatched by any other field. It requires kindness and compassion, creativity and intuition, patience and self-control. The pure humanity I had the privilege to witness and the honor to be a part of, combined with the intellectual challenges I had the opportunity to tackle on a daily basis, was immensely gratifying. To put it simply, I fell in love with the work.

My home is not with the knife, like I once thought, but with the water. My impact on a patient may not be as rapid as a surgeon’s, but, given enough time, the landscape will be forever changed.

Dr Handler is an assistant clinical professor at the University of California Irvine.