Mihir Upadhyaya, MD

“A leader is someone who helps improve the lives of other people or improve the system they live under.”

— Sam Houston

If my motivation to become a doctor was ever the supposed glamour and prestige conferred once “MD” is added to your name, that delusion was quickly wiped away on my first day of residency; not at work, but on my way there.

I live in New York City—a city that relies on buses and subways, where the wealthy and elite go to work using the same modes of transportation as everyone else. Unfortunately, because the shelter system in New York isn’t nearly large enough to accommodate the vast homeless population, many homeless people sleep in the subway at night. It’s not uncommon to see a still-sleeping homeless person on the subway in the early hours of the morning, and I encountered one on my first official day of work as a doctor.

There I was, dressed for the occasion in a new, freshly ironed white button-down shirt and black slacks. There he was, haggard, disheveled, and smelling of alcohol, lying on a subway bench with an empty bottle of vodka tucked into his pants pocket. Out of both pity and fear of what he might do if someone attempted to wake him, people allowed him to sleep, and politely stood around him as the train proceeded on its route. The homeless man had his legs tucked in the fetal position, and I saw there was enough space on the bench for someone to sit. I wondered why nobody else chose to use that space by his feet, and I saw no harm in sitting there, so I did.

Within seconds of sitting down, the man extended one of his legs and kicked me in the chest while still asleep. Not hard enough to cause pain or injury, but enough to leave a dirty boot print on my shirt. I had to wear that shirt for the rest of the day, and so I spent my first day of residency explaining to hospital staff and patients alike how I was branded by a drunk homeless man on the subway as he slept.

As time wore on in my first year of residency, I learned that encounters with individuals like these were not rare. The majority of the patients I see are people like that man on the subway. “I sleep on the subway” is often the answer when I ask a patient about their living conditions. “I’m on public assistance” is what I hear when questioning what a patient does for money. “I don’t have money to take the bus” is a typical explanation for why they missed their doctor’s appointments and ran out of medicine. And, sadly, “Because I’m lonely” is the main excuse for why patients engage in self-defeating habits such as drug and alcohol abuse.

I didn’t anticipate this part of psychiatry when I applied for residency in this specialty. My notion of this profession was far more romanticized. I was enthralled with the science of neurotransmitters, the parameters of DSM criteria, the interpersonal skills required to elicit information from a patient during an interview, the deliberation in arriving at a diagnosis, and the ever-changing nature of psychopharmacology. That’s the psychiatry I expected to learn when I got on the subway for my first day of residency. It wasn’t until later that I truly considered the human toll that psychiatric illness takes on the individual who suffers from it. To that person, the science behind their illness and the suffering they endure isn’t romantic at all; it’s a burden to be lifted.

Continue to: We use the term...

We use the term “underserved” to identify challenging patient populations, but there are categories of patients that fall below the threshold of merely underserved. I am mortified to know that one-third of homeless people in the United States have a serious and untreated mental illness. Individuals discharged from psychiatric hospitals are 3 times more likely to obtain food from garbage. They are also far more likely to be the victim of a crime than perpetrators of it. As I’ve discovered since starting residency, if a patient doesn’t have a place to live, food to eat, and some semblance of a support system, then it’s often meaningless for them to take pills, regardless of how those pills work in theory.

No definition of sound mental health is complete unless it gives deference to those who lack basic human needs. This is a realization that was literally kicked into me, and one I hope will guide me in the years ahead.

“A leader is someone who helps improve the lives of other people or improve the system they live under.”

— Sam Houston

If my motivation to become a doctor was ever the supposed glamour and prestige conferred once “MD” is added to your name, that delusion was quickly wiped away on my first day of residency; not at work, but on my way there.

I live in New York City—a city that relies on buses and subways, where the wealthy and elite go to work using the same modes of transportation as everyone else. Unfortunately, because the shelter system in New York isn’t nearly large enough to accommodate the vast homeless population, many homeless people sleep in the subway at night. It’s not uncommon to see a still-sleeping homeless person on the subway in the early hours of the morning, and I encountered one on my first official day of work as a doctor.

There I was, dressed for the occasion in a new, freshly ironed white button-down shirt and black slacks. There he was, haggard, disheveled, and smelling of alcohol, lying on a subway bench with an empty bottle of vodka tucked into his pants pocket. Out of both pity and fear of what he might do if someone attempted to wake him, people allowed him to sleep, and politely stood around him as the train proceeded on its route. The homeless man had his legs tucked in the fetal position, and I saw there was enough space on the bench for someone to sit. I wondered why nobody else chose to use that space by his feet, and I saw no harm in sitting there, so I did.

Within seconds of sitting down, the man extended one of his legs and kicked me in the chest while still asleep. Not hard enough to cause pain or injury, but enough to leave a dirty boot print on my shirt. I had to wear that shirt for the rest of the day, and so I spent my first day of residency explaining to hospital staff and patients alike how I was branded by a drunk homeless man on the subway as he slept.

As time wore on in my first year of residency, I learned that encounters with individuals like these were not rare. The majority of the patients I see are people like that man on the subway. “I sleep on the subway” is often the answer when I ask a patient about their living conditions. “I’m on public assistance” is what I hear when questioning what a patient does for money. “I don’t have money to take the bus” is a typical explanation for why they missed their doctor’s appointments and ran out of medicine. And, sadly, “Because I’m lonely” is the main excuse for why patients engage in self-defeating habits such as drug and alcohol abuse.

I didn’t anticipate this part of psychiatry when I applied for residency in this specialty. My notion of this profession was far more romanticized. I was enthralled with the science of neurotransmitters, the parameters of DSM criteria, the interpersonal skills required to elicit information from a patient during an interview, the deliberation in arriving at a diagnosis, and the ever-changing nature of psychopharmacology. That’s the psychiatry I expected to learn when I got on the subway for my first day of residency. It wasn’t until later that I truly considered the human toll that psychiatric illness takes on the individual who suffers from it. To that person, the science behind their illness and the suffering they endure isn’t romantic at all; it’s a burden to be lifted.

Continue to: We use the term...

We use the term “underserved” to identify challenging patient populations, but there are categories of patients that fall below the threshold of merely underserved. I am mortified to know that one-third of homeless people in the United States have a serious and untreated mental illness. Individuals discharged from psychiatric hospitals are 3 times more likely to obtain food from garbage. They are also far more likely to be the victim of a crime than perpetrators of it. As I’ve discovered since starting residency, if a patient doesn’t have a place to live, food to eat, and some semblance of a support system, then it’s often meaningless for them to take pills, regardless of how those pills work in theory.

No definition of sound mental health is complete unless it gives deference to those who lack basic human needs. This is a realization that was literally kicked into me, and one I hope will guide me in the years ahead.

“A leader is someone who helps improve the lives of other people or improve the system they live under.”

— Sam Houston

If my motivation to become a doctor was ever the supposed glamour and prestige conferred once “MD” is added to your name, that delusion was quickly wiped away on my first day of residency; not at work, but on my way there.

I live in New York City—a city that relies on buses and subways, where the wealthy and elite go to work using the same modes of transportation as everyone else. Unfortunately, because the shelter system in New York isn’t nearly large enough to accommodate the vast homeless population, many homeless people sleep in the subway at night. It’s not uncommon to see a still-sleeping homeless person on the subway in the early hours of the morning, and I encountered one on my first official day of work as a doctor.

There I was, dressed for the occasion in a new, freshly ironed white button-down shirt and black slacks. There he was, haggard, disheveled, and smelling of alcohol, lying on a subway bench with an empty bottle of vodka tucked into his pants pocket. Out of both pity and fear of what he might do if someone attempted to wake him, people allowed him to sleep, and politely stood around him as the train proceeded on its route. The homeless man had his legs tucked in the fetal position, and I saw there was enough space on the bench for someone to sit. I wondered why nobody else chose to use that space by his feet, and I saw no harm in sitting there, so I did.

Within seconds of sitting down, the man extended one of his legs and kicked me in the chest while still asleep. Not hard enough to cause pain or injury, but enough to leave a dirty boot print on my shirt. I had to wear that shirt for the rest of the day, and so I spent my first day of residency explaining to hospital staff and patients alike how I was branded by a drunk homeless man on the subway as he slept.

As time wore on in my first year of residency, I learned that encounters with individuals like these were not rare. The majority of the patients I see are people like that man on the subway. “I sleep on the subway” is often the answer when I ask a patient about their living conditions. “I’m on public assistance” is what I hear when questioning what a patient does for money. “I don’t have money to take the bus” is a typical explanation for why they missed their doctor’s appointments and ran out of medicine. And, sadly, “Because I’m lonely” is the main excuse for why patients engage in self-defeating habits such as drug and alcohol abuse.

I didn’t anticipate this part of psychiatry when I applied for residency in this specialty. My notion of this profession was far more romanticized. I was enthralled with the science of neurotransmitters, the parameters of DSM criteria, the interpersonal skills required to elicit information from a patient during an interview, the deliberation in arriving at a diagnosis, and the ever-changing nature of psychopharmacology. That’s the psychiatry I expected to learn when I got on the subway for my first day of residency. It wasn’t until later that I truly considered the human toll that psychiatric illness takes on the individual who suffers from it. To that person, the science behind their illness and the suffering they endure isn’t romantic at all; it’s a burden to be lifted.

Continue to: We use the term...

We use the term “underserved” to identify challenging patient populations, but there are categories of patients that fall below the threshold of merely underserved. I am mortified to know that one-third of homeless people in the United States have a serious and untreated mental illness. Individuals discharged from psychiatric hospitals are 3 times more likely to obtain food from garbage. They are also far more likely to be the victim of a crime than perpetrators of it. As I’ve discovered since starting residency, if a patient doesn’t have a place to live, food to eat, and some semblance of a support system, then it’s often meaningless for them to take pills, regardless of how those pills work in theory.

No definition of sound mental health is complete unless it gives deference to those who lack basic human needs. This is a realization that was literally kicked into me, and one I hope will guide me in the years ahead.