People-staff and patients both-confide secrets to strangers. We all need to unburden in a way that won’t come back to bite us.
Significance for practicing psychiatrists
At the age of retirement, I was unceremoniously and discourteously given 2-weeks’ notice. I was medical director of a struggling community mental health center stealthily down-sizing to show profit to then find a buyer, and I’d been deliberately kept out of that loop. I never saw it coming. Embarrassed and angry I impulsively signed up with a temp agency and became a locum tenens, a first for me, to get away and forget what had just happened, block it out of my mind. I joined our medical “Foreign Legion,” as it were-home for misfits and adventurers as I’d imagined this practice-to disappear and not have to deal with my shame, pain, and loss.
I took my first assignment in another state. Once I began seeing patients, I couldn’t help but view them as having been thrown under a bus just like me. They were stuck there and coming to me for help getting unstuck and back on course; I began keeping a journal. I had to. The familiar issue of boundaries was not only germane, it was a minefield.
Many months and several assignments later when I began to process what had happened to me; I discovered I didn’t want to stop this locum work. It wasn’t the novelty, salary, or perks. It was the renewal I’d begun experiencing as a physician and mental healer. But how is that possible for someone who is always a stranger, outsider, and about to leave, three obvious psychiatrist liabilities? The answer, I realized, lay in my attitude. Would I see myself as there to hold down a fort until help arrived, or would I be the help they’d been waiting for, meaning that if the fort wasn’t protecting it would be my responsibility to tear it down. If a treatment wasn’t working, it would fall to me to change it.
The following is what I discovered during my 5 years of locum practice: there are unexpected and unheralded benefits to both doctor and patient: to being a locum psychiatrist and for having a locum psychiatrist.
As an outsider and stranger you bring fresh eyes. The question is will you apply them, especially to patients who are floundering, that haven’t had psychiatric input for a long time or even, never had psychiatric input? Or cases seen by a succession of locums who’d dutifully held down a dysfunctional fort? I found at team meetings about such cases that simply saying I saw the case differently drew and held everyone’s attention. And explaining my formulation and its implications for treatment-the changes they’d have to make-were usually met with relief and support. When cases flounder and staff are demoralized, simply validating that reality can restore hope and boost morale.
For patients, too. Temporal lobe epilepsy (TLE) mimics neurotic symptoms, psychotic symptoms, behavior disorders, and personality disorders. It can destroy a life and ruin a family. It is easy to diagnose, easy to treat, the prognosis is often good for relief and improved functioning, but you have to think of it. Once I started thinking of it, I started finding it. And I started thinking of it because so many of my patients came from poor families that featured frequent childhood ear infections and inadequate access to pediatric care, well-known TLE antecedents.
As a locum physician, you get to play a variety of different roles-admission officer, stopper of run-away-trains, de-frocker of sacred cows. Here are just a few roles I played during different scenarios I encountered during my 5 years as an outsider psychiatrist.
I am an Admissions Officer at a state psychiatric hospital. A bipolar woman hospitalized medically elsewhere and off her medications becomes manic and is immediately put back on her medications and referred here. She arrives after many days’ delay. I review the referral information, read the old record, and assess the woman and see that she no longer needs hospital level of psychiatric care. She did before but doesn’t now. Her meds kicked in during that long break. I don’t admit her. There is pushback. Doesn’t the referring doctor need a break? Doesn’t our hospital need to fill a bed? What about covering my back; there may be symptom breakthrough. But the referring doctor, my hospital’s empty beds, and the bottom line aren’t my concern, and career values like approval ratings and keeping my job aren’t either. It’s about the patient now, and she doesn’t want to be admitted and doesn’t need to.
A hostage-taking scenario is suddenly and rapidly unfolding. A nurse is about to be trapped inside her office with a rageful intruder who has barged in and is now closing her door to lock the two of them inside. You are first on the scene, drawn by his shouting, and immediately push back to keep that door from closing. The situation is tense but fluid and you see an opportunity. You direct people who are gathering to do something they’ve never done and are afraid to do, namely not only help keep that door open but squeeze inside as well. The room quickly fills with bodies that soon press against the now rattled and distracted intruder until he can’t move, let alone notice his captive has, on my signal, squeezed her way out of that office. All ends well. The nurse is unharmed, the intruder taken away in handcuffs, and the two security guards he’d assaulted when he’d invaded the clinic are back on their feet, uninjured. I ignore the complaints about me.
A patient finally finds the courage to share with her young, inexperienced social worker therapist-who knows her history of mental, physical, and emotional abuse by the violent alcoholic man she’d lived with and the helplessness, fear, and despair that had led 20 years ago to overdoses that never required treatment-that her intermittent suicide thoughts had never stopped. She still has them. She’s finally found the courage to take that long-delayed step forward in her treatment and talk about them. Her rattled therapist calls the police and signs an involuntary commitment form.
The police arrive and the startled patient, a black woman in her 50s, refuses to get in their cruiser. She’d never been inside a mental hospital let alone a police cruiser. She is put in shackles, forced into the cruiser, and brought to the state hospital. I am the Admissions Officer.
My mental status exam and assessment for risk-of-harm convince me she’s been railroaded. But commitment forms, once signed, can take on a life of their own, gathering steam with endorsements and justification until the train is barreling down a track towards a locked ward of a mental hospital. This is a woman who lives with her sister and is completing medical records training. This polite, cooperative, and deeply humiliated caregiver who smiles as she illustrates her craft abilities is a woman betrayed. I am the only one who can stop this runaway train. Retirement age may be no time to stick my neck out, but it may be the last time I get to stick my neck out. I stop that train.
An outside-the-box perspective
New card to play
Low expectations can be disarming. Patients sometimes forgo a power struggle with a locum whom they view as, like themselves, powerless. And it’s as if, by prefacing any treatment suggestion with the disarming, “Where I come from . . .” as if deferentially confessing you’ve only one foot in this door, any power struggle may be rendered pointless.
I’m helping out on an Admissions Unit. They’re short-handed. The admission last night, a young man with bipolar disorder in relapse, was assigned a doctor who didn’t have time to see him let alone write a note. I’m told this patient denies he has bipolar illness or any problem, won’t take meds, and never has. In the community he uses cocaine and alcohol. Then, when he can’t come down from his mania, he causes trouble, authorities are called, and he is re-hospitalized. Like now.
I introduce myself. He’s still manic and refusing meds. I tell him I’m from out of town and here only temporarily when he interrupts with this challenge, “So, do YOU think I am bipolar?!”
It’s time to play my “hapless stranger” card. “Where I come from,” I begin quietly, “we don’t bother with whether or not someone’s bipolar. All we care to know is whether or not they have a chemical imbalance in their brain because, if they do, there is a salt, an old-time table salt, that can take away stressed-out feelings.”
No response, I continue. “No one knows how it works so, if a patient asks if he can have some, we just give him a prescription and . . .”
“Can I try it?”
I pause. “You’ll have to ask your doctor.”
“Would you ask her for me!”
Later that day I do just that. “Do what you want,” the doctor murmurs as if she’s been around the block with this kid one time too many. I discontinue the antipsychotic meds he’s refusing, order lithium salt, and return to my assigned post. He takes the lithium, soon asks for higher strength, doesn’t miss a dose, and is ultimately discharged to the community, illness in remission. In the community he remains sober and continues the lithium.
Sacred cows defrocked
The state hospital Patient-at-Risk Committee has determined that this seriously regressed and “out-of-control” woman, the most difficult patient on the locked unit I’m told, will likely kill herself should she be discharged. On one-to-one supervision (she threatens suicide daily) she resists all treatment. She has no hospital privileges, a reality that fuels ever more antisocial behavior; an irresistible force meeting an unmovable object. I’ve just arrived as their locum psychiatrist, her care is transferred to me, and I immediately see a way to break this impasse.
I introduce myself to the woman and express horror at the way she’s being treated. I encourage her to continue demanding privileges and assure her the hospital is in violation of her rights. I express my determination to fix this and get her out. Not surprisingly, the more I assume command of her control issue and make it my issue the more she loosens her grip on it. The more I manifest outrage and indignation the more composed and appropriate she becomes. Finally, I’m rushing back and forth in a feigned dither trying to “force the hospital” to relax their controls while, unsupervised, she is calmly earning privileges until, one day, she is deemed “clinically stable and optimally functioning” and discharged unconditionally by that same Committee. Her transformation took just 2 weeks. It seems my staff splitting and patient manipulation, two professional no-nos, were the ticket. Over the ensuing months in the community there is neither re-hospitalization nor calls for police intervention.
Entrusted with secrets
People-staff and patients both-confide secrets to strangers. We all need to unburden in a way that won’t come back to bite us. The locum tenens psychiatrist is a stranger.
This woman I’m seeing for our final visit (I leave that week) tells me a secret, a painful memory she hadn’t told any of her former therapists over many years.
“You know I’m leaving,” I remind her. “Why are you telling me this?”
“Because you’re leaving.”
It is as if she wanted me to take that secret with me. As if she’d never told others because she’d have to look at it, talk about, and deal with it whereas she wanted only to be done with it, rid of it, her path to healing being that of avoiding pain, not revisiting it. Mindful that for everything there is a season I am comfortable respecting this. After all, wasn’t I unable to look at, talk about, and deal with my own pain until I felt ready? The advisory, “Doctor, heal thyself” misses the point because it presumes doctor healing must precede patient treatment whereas genuine doctor healing actually accompanies our doctoring. I don’t include her secret in my final note.
Dr Climo is the author of Psychiatrist on the Road: Encounters in Healing and Healthcare, an account of his Locum Tenens experience. Dr Climo reports no conflicts of interest concerning the subject matter of this article.