1MISEDUCATION
The ominous signs began to appear as soon as I left the highway. Turn left for the federal prison. Right for the juvenile detention center. Straight ahead for the alcohol and drug treatment facility. I had taken a detour from the traditional hospital and clinic settings I was used to and entered a hidden world where society puts those it doesn’t want to think about. What happened to the institutionalized people out here, and what was going to happen to me? Instinctively, I double-checked to be sure my car doors were locked.
On this cold, foggy winter morning in rural North Carolina, I was about to start the first day of my six-week psychiatry clerkship. Till then, my clinical experiences in medical school at Duke had taken place in mainstream hospitals and outpatient clinics, where I’d worked alongside surgeons, general internists, and family physicians. For my psychiatry rotation, however, I’d been assigned to a state-run psychiatric hospital, a place devoted exclusively to the treatment of mentally ill people. Knowing nothing about such hospitals when I’d started the clinical year of medical school a few months earlier, I had been partially reassured by vague comments from more senior students, throwaway lines like “You’ll learn a lot there.”
In the week leading up to my start date, however, current classmates who had rotated at the hospital started issuing not-so-cryptic warnings: Don’t turn your back on a patient. Don’t stay in a room by yourself with one either. Don’t allow a patient to sit between you and the door. Don’t wear a necktie lest it get used to choke you. They made the place sound like a jail or prison, at least the kind I’d seen on television and in movies. I figured they were exaggerating, or that if they were genuinely afraid, my experience as an oversize black man would be radically different. Until I saw the road signs. By then, it was too late to change course.
By that point in the academic year, I’d logged four months in clinical settings: two on the surgical service at our main hospital and another two at a family practice clinic in a medical park near campus. The state hospital, in contrast, was twenty miles away, in a different county. The location itself hadn’t seemed odd to me until I saw what other institutions were nearby. Suddenly, it felt as if I had crossed some kind of invisible boundary. Was psychiatry going to be as distant from other medical fields as the state hospital was from the other clinical locations I’d known? Was this the best way to teach medical students about treating mental illness?
My heart fluttered as I approached the parking lot. This place didn’t look like the hospitals I’d seen in and around Duke, nor like the half dozen or so I’d visited during my medical school interviews a few years earlier. Instead of a multistory design that housed emergency wings, surgical suites, and medical beds, this hospital was a vast expanse of old, interconnected, single-floor brick buildings. It resembled a barracks. Or a jail. As I left the car, I noticed my knuckles aching from having gripped the steering wheel so tightly.
Nothing about the building I entered brought to mind a medical setting. I saw no doctors or nurses, no front desk check-in window where staff asked for health insurance cards, no patients seated in a waiting area, no signs for laboratory or X-ray. Instead, it felt like I’d walked into a rural, county government office. Quiet. Sedentary. Overlooked. Moments later, I joined three classmates in a midsize administrative conference room for an orientation session.
A muscular, middle-aged man with thick, graying hair and suntanned skin introduced himself to us as a security supervisor. Why aren’t we meeting with a doctor, nurse, or other medical staff? Is this really a hospital? I thought.
“Is this everyone?” he asked.
We looked around and nodded collectively.
“Good. No girls this time around. It’s always easier when it’s that way.”
That sounded nearly identical to what I’d heard from an older surgeon months earlier. Both felt men were physically and emotionally better suited to “difficult work” and seemed to long for the bygone era when medical students were overwhelmingly male. His words were unquestionably sexist, yet in the moment, when my focus was inward and not on what his attitude might mean for my female classmates, I let his comments pass by without much thought. Maybe working at a psychiatric hospital, despite initial impressions, wasn’t going to be so different from the months I’d spent in operating rooms and surgery wards.
A half hour later, after we had completed administrative paperwork, we received the temporary ID badges and keys that would enable us to circulate around the hospital. I clipped the badge to my shirt and placed the keys on the ring next to those for my apartment and my car.
“Make sure you look around before you open the door on a unit,” the man told us. “Patients have been known to try to elope. That’s bad for everybody.”
On that upbeat note, he escorted us to the building that housed the patients. Moments later, each of us went our separate ways and met the pair of staff members we’d be working alongside for the next six weeks. Given his diatribe about women and safety, I was surprised to see that my supervisor was a woman, just as I had been the one week when I worked under the direction of a female surgeon. This psychiatrist had short brunette hair and a light olive complexion. She appeared fortyish. DR. BEAL was printed in black block letters on her ID badge.
“Hello,” she said to me softly before quickly turning her gaze toward her colleague.
“I’m Alice,” said the shorter, younger woman who stood next to Dr. Beal. “I’m the social worker working with Dr. Beal.”
Before medical school, I’d only thought of social workers as the people who got involved with child protection cases or to help people receive government assistance. During my rotations in surgery and family medicine, however, I’d learned how important they were in making things happen in the medical sphere: getting patients transferred from one hospital to another hospital or to a different medical facility; coordinating the array of outpatient medical services some need after being discharged from the hospital; and so on. At this hospital, each psychiatrist paired with a social worker, who did similar tasks.
I followed Dr. Beal and Alice down a long hallway as they carefully opened the door and entered a male-only patient ward. In contrast to the medical and surgical floors at Duke and other general hospitals, these units were separated by gender. The goal was to prevent consensual or unwanted physical interaction (at least of the heterosexual variety), which reinforced my impression of the place as a correctional facility. Dr. Beal seemed to sense my unease.
“Have you been inside a psychiatric unit before?” she asked me.
I told her I’d seen emergency departments, operating rooms, medical floors, and intensive care units, but never a psych ward. “It’s very different from a regular hospital,” I said.
“You’ll get used to it after a few days,” she assured me.
My anxiety ebbed a few notches as we walked toward the central nursing station and the first few patients breezed right past without noticing me. While I had seamlessly blended in with my surroundings a few years earlier on the basketball court as a college athlete, the opposite had proved true in hospitals or clinics, and in most other areas of life. Day in and day out during my medical school rotations, as a six-foot-six black male, I’d get some combination of “How tall are you?” or “Wow, you’re tall,” or “Do you play basketball?” or “Where do you play?” or “Can I have your autograph?”
Yet here on this unit, the patients seemingly had more pressing things on their minds than whether I had a good jump shot or could dunk with both hands.
“Can you let me out of here?” asked a man approaching me with desperate eyes. “I don’t belong in here with all these crazy people.”
He had a smallish frame, leathery skin, and patchy, gray facial hair. Obviously, he didn’t agree with his doctors about being in the hospital. I looked over to Alice and Dr. Beal, who both ignored his pleas. They told me he was assigned to a different medical team. I followed their lead and started to walk past him. He shifted tactics.
“If you can’t do that, can you at least get me my smoking privileges?”
Why would a hospital give patients smoking privileges? I wondered.
Seconds later, another patient approached, his eyes wide, hair matted, and teeth yellowed. The smell of his breath caused me to hold mine while he spoke.
“I need to use the phone to call the police,” he asserted, his voice filled with conviction. “I need to reach DPD. I’m being falsely imprisoned by the CIA and FBI. I think ABC, CBS, and NBC will want to know about this. CNN too.”
My head hurt trying to process the barrage of three-letter acronyms and how they might connect to the man uttering them.
“Welcome to our world,” Dr. Beal said, smiling for one of the few times I saw during that rotation. “Wearing the white coat makes you stick out like a sore thumb on the unit.”
I’d remembered to ditch my necktie, a staple on other rotations. Apparently, the white coat was optional too. Dr. Beal wore a tan blazer as her top layer; Alice, a powder-blue blouse. Classmates on the pediatric service rarely wore their white coats, as they’d been told that garb might frighten some of the younger children. I wondered if my white coat was having the same effect on some psychiatric patients. Maybe the people who I thought had ignored me had avoided me out of fear. As I looked at Dr. Beal and Alice, then glanced down at my white coat, I realized that sexism wasn’t the only reason a patient might see the three of us and reasonably conclude that I was the “medical” person.
Toward the end of the rectangular hallway, we approached Gene, a young man who paced in a fashion that mimicked the geometric dimensions of the unit.
“Good morning,” Dr. Beal said to him. “How are you today?”
He stared at us—me, as the new face, longer than the others—then looked away.
“I’m fine,” he mumbled.
The unit housed adults eighteen years old and above, which made Gene the thinnest walking and talking adult I had ever seen. He was probably six two (his mini-Afro made him seem even taller) but could not have weighed more than 120 pounds. The hospital-issued pants that barely fit his waist stopped mid-calf, and his torso seemed completely lost inside his top. Aside from scraggly hair around his chin and mouth, and a few creases across his forehead suggesting some wear and tear in his life, he could have been a gangly prepubescent sixth grader on his way to becoming seven feet tall.
“Is there anything you’d like to discuss with us in private?” Dr. Beal asked.
He shook his head. During my surgery rotation, patients had their own hospital rooms where we spoke with them daily as they recuperated, as did patients at the family medicine clinic. Here, though, we were more likely to chat with patients—at least those who had been there a few days—in full view and earshot of others. Neither doctor nor patient seemed to mind it much; in fact, it seemed preferred by both parties. It was the exact opposite of the psychiatry stereotype, where a person lies on the therapist’s couch in a secluded office. Maybe it was as simple—and problematic—as the difference between what a wealthier, private-pay person could receive compared with what a poorer, largely black, group of patients could get. Or maybe, in this correctional-like setting, both doctor and patient were wary of the other, so they mutually agreed to keep interactions, whenever possible, in plain sight of others.
“How did you do with breakfast?” Dr. Beal asked Gene. “One of the goals we talked about yesterday was for you to try to eat each meal.”
“I only want apples,” he replied as he scanned the area around us and then glanced toward the floor. “Apple a day keeps the doctor away. But you all keep bothering me.”
Dr. Beal and Alice suppressed smiles. It would have been funny if we had been in an ordinary setting talking with a healthy person.
“It looks like you refused the medication that we ordered for you,” Dr. Beal said.
“I only need apples,” he replied.
“Okay,” Dr. Beal said. “We’ll see you tomorrow.”
That was it? This thirty-second exchange seemed to accomplish nothing based on what I’d seen from doctors elsewhere. Dr. Beal didn’t ask any of the usual medical questions about pain, bodily functions, and the like that I’d heard recited to one patient after another. Even more surprising, she didn’t probe his mind much either with questions about his mood, anxiety levels, or sleep patterns. But we did know that he wasn’t eating his food as Dr. Beal wanted and that he refused whatever drug she had prescribed. Perhaps, for her purposes, those were all the details that mattered.
“He’s really skinny,” I said as we walked down the hallway toward the central nursing station. “Does he have an eating disorder?”
“He has schizophrenia,” Dr. Beal told me. “This is his second time here. Part of his delusion is that he is being poisoned, although for some reason, he’s latched on to apples as a safe food. He thinks his parents are trying to kill him to collect on a life insurance policy.”
Alice then explained to me that no such policy existed. She said that people such as Gene were unlikely to qualify for good life insurance anyway.
“Why?” I asked.
“Because people with schizophrenia die about ten or fifteen years sooner than the average person,” she answered. “For insurance companies, that puts him at high risk.”
I tried to envision how terrifying it must have been to be convinced that your parents were poisoning you and, from the other side, to be a parent unable to reach your son lost in the clutches of psychosis. But these emotions reached me only at some surface level. I couldn’t imagine anyone I knew thinking or acting in this way. He reminded me of the dozens of downtrodden homeless men I had seen over the years, people I could keep safely at a distance up until then. Though I was standing in a hospital ward, a place where someone in his mental state could improve, I couldn’t connect with his plight in the way I could a woman whose appendix was removed and now felt better. Anyone could get appendicitis. But not schizophrenia, I told myself.
“Is he at risk of serious health problems,” I asked, “from being so skinny?”
“Not in the short term,” Dr. Beal answered. “All his tests were essentially normal. Long term, it could definitely be a problem. The medication I ordered should get rid of those delusions. Plus it has the added benefit of weight gain as a side effect.”
“But I thought he refused to take it?”
“He’ll get it today,” she replied in a matter-of-fact tone.
I looked at her, genuinely confused. He didn’t seem like he was easily persuadable.
“It’s different here than it is on your other rotations,” she said.
Dr. Beal explained the hospital’s policy on forced medication. One of her psychiatrist colleagues had seen Gene that morning and agreed with her assessment that this approach was needed for him to improve. Starting later that day, each time he refused to take his prescribed pill, he would be forced to receive an injectable form of an antipsychotic drug in his rear end. Eventually, she told me, he would take the pill form when a nurse offered it to him. Eventually.
My jaw slacked. On my surgery rotation, our team had a patient who refused insulin to treat his diabetes. After a few contentious days, they agreed to discharge him home against medical advice once he had sufficiently recuperated from his operation. Despite the serious health risks, no one talked about forcing him to receive insulin. The consensus, as I understood it then, was that people had the right to make poor decisions, even if this caused serious disability or even death. All we could do was present them with the facts and hope they reconsidered.
Copyright © 2024 by Damon Tweedy
