Residents/Training

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

Medical and surgical inpatient teams often consult psychiatrists to help assess a patient’s decision-making capacity (DMC). Completing a DMC assessment can be a source of stress and frustration for psychiatry residents; however, the process can be significantly improved by following a consistent and focused psychiatric interview. In our institution, the most frequently used tool for assessing DMC is the Aid to Capacity Evaluation (ACE).¹ The American Academy of Family Physicians offers a printer-friendly adaptation² of the ACE assessment.

Reasons for a DMC consultation

When accepting a DMC consultation, make sure to specify for which medical decision the primary team would like the patient to be evaluated so that the consultation can be most helpful and specific to primary team’s concerns.³ The 4 most common reasons for a DMC consultation are:

Acute changes in mental status. These changes may be due to hypoxia, infection, medication, metabolic disturbances, or other medical conditions. Often, the diagnosis is delirium due to a medical condition, and assessing for DMC is deferred until the delirium resolves.

Refusal of a recommended treatment. One of the most frequent reasons for a DMC consultation is when a patient declines the primary team’s treatment recommendations. These recommendations may include medications, interventions (procedural or surgical), or discharge planning (such as transfer to a rehabilitation facility or skilled nursing care facility).

Consenting to a risky or invasive treatment too hastily. This occurs less often than the other 3 scenarios, most likely because capacity is rarely questioned when a patient’s decision aligns with the physicians’ recommendations.

Having risk factors for impaired decision-making. One of the most common reasons for involving psychiatry in a DMC consultation is when the patient has a risk factor that may impair his/her decision-making.

These risk factors include:

• a chronic psychiatric or neurologic condition
• a significant cultural or language barrier
• a low or unknown education level
• anxiety or discomfort with institutional health care settings
• age <18 or >85.

Continue to: When should you put off a DMC consultation?

There are situations in which a DMC consultation should be declined or postponed. A DMC consultation is not appropriate for patients who have a court-appointed legal guardian because these patients are considered legally incapacitated. Although such patients may still choose to participate in shared decision-making with the treatment team and communicate those decisions to their legal guardian, all treatment decisions are made by their legal guardian.

Consider delaying DMC consultations for patients with acute changes in mental status, including delirium, or those who are sedated or intubated. On the other hand, patients not excluded from a DMC assessment include those with mild or major neurocognitive disorders (such as Alzheimer’s disease or other types of dementia), intellectual disabilities, a durable power of attorney (DPOA), or legal charges. It is important to note that a diagnosis of a neurocognitive disorder does not preclude capacity, and capacity may therefore vary based on the complexity of medical decision.

Prepare for the interview

Prior to meeting the patient, familiarize yourself with his/her reason for admission, diagnosis, medical workup, treatment provided thus far, and proposed future treatment. If possible, attempt to gather the patient’s medical and psychiatric history from chart review, which may be obtained from outside medical records or inferred from the patient’s current medication list. Review the chart for any signs that the patient is in a delirious state, including the use of psychotropic medications for agitation, restraints, or a sitter at bedside. Finally, speak with the patient’s nurse before entering the patient’s room. This may provide valuable information regarding the patient’s willingness to participate (including any hostility or aggression toward clinicians), any barriers to the interview (such as hearing or language difficulties), and if any family or friends are present at the bedside.

During the interview

The structure of a decision-making capacity evaluation has been well documented elsewhere^1,2 and, if completed, is sufficient for determining DMC. Asking the patient about additional psychiatric histories, including hospitalizations, suicide attempts, or a family history of psychiatric illness, may be counterproductive and frustrating for the patient, especially if the interview has already been lengthy and emotionally exhausting. Therefore, it is often appropriate to shorten the psychiatric interview to assess for symptoms of anxiety and depression, perform a brief suicide risk assessment, and assess for the presence of auditory or visual hallucinations, or delusions. This allows for a complete mental status exam while still focusing the interview on determining DMC. If time allows and the patient is willing to participate, it can be helpful to perform a Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam, although a score that indicates some level of cognitive impairment (<26 on MoCA⁴) does not necessarily preclude patient from having capacity for certain medical decisions. Additionally, if the patient does not understand a question, explain it and return to it later to check for comprehension.

Making a recommendation

Patients are presumed to be capable; therefore, if the determination is not clear, err on the side of capacity. Additional information may be helpful from the patient’s family, friends, DPOA, or guardian, especially as it pertains to the patient’s past wishes and medical decisions made in similar situations. If available and pertinent, review the patient’s advance health care directive.

Communicate your recommendations to the primary team clearly and concisely, including if the evaluation is incomplete, and if the patient will be seen again by the consult team, because this may determine disposition planning. Finally, if the patient is deemed to not have DMC, the primary team must then establish a surrogate decision maker on the patient’s behalf. Because the protocol and hierarchy of next-of-kin varies by state law and institution policy, it is essential to involve social work and case management

Medical and surgical inpatient teams often consult psychiatrists to help assess a patient’s decision-making capacity (DMC). Completing a DMC assessment can be a source of stress and frustration for psychiatry residents; however, the process can be significantly improved by following a consistent and focused psychiatric interview. In our institution, the most frequently used tool for assessing DMC is the Aid to Capacity Evaluation (ACE).¹ The American Academy of Family Physicians offers a printer-friendly adaptation² of the ACE assessment.

Reasons for a DMC consultation

When accepting a DMC consultation, make sure to specify for which medical decision the primary team would like the patient to be evaluated so that the consultation can be most helpful and specific to primary team’s concerns.³ The 4 most common reasons for a DMC consultation are:

Acute changes in mental status. These changes may be due to hypoxia, infection, medication, metabolic disturbances, or other medical conditions. Often, the diagnosis is delirium due to a medical condition, and assessing for DMC is deferred until the delirium resolves.

Refusal of a recommended treatment. One of the most frequent reasons for a DMC consultation is when a patient declines the primary team’s treatment recommendations. These recommendations may include medications, interventions (procedural or surgical), or discharge planning (such as transfer to a rehabilitation facility or skilled nursing care facility).

Consenting to a risky or invasive treatment too hastily. This occurs less often than the other 3 scenarios, most likely because capacity is rarely questioned when a patient’s decision aligns with the physicians’ recommendations.

Having risk factors for impaired decision-making. One of the most common reasons for involving psychiatry in a DMC consultation is when the patient has a risk factor that may impair his/her decision-making.

These risk factors include:

• a chronic psychiatric or neurologic condition
• a significant cultural or language barrier
• a low or unknown education level
• anxiety or discomfort with institutional health care settings
• age <18 or >85.

Continue to: When should you put off a DMC consultation?

There are situations in which a DMC consultation should be declined or postponed. A DMC consultation is not appropriate for patients who have a court-appointed legal guardian because these patients are considered legally incapacitated. Although such patients may still choose to participate in shared decision-making with the treatment team and communicate those decisions to their legal guardian, all treatment decisions are made by their legal guardian.

Consider delaying DMC consultations for patients with acute changes in mental status, including delirium, or those who are sedated or intubated. On the other hand, patients not excluded from a DMC assessment include those with mild or major neurocognitive disorders (such as Alzheimer’s disease or other types of dementia), intellectual disabilities, a durable power of attorney (DPOA), or legal charges. It is important to note that a diagnosis of a neurocognitive disorder does not preclude capacity, and capacity may therefore vary based on the complexity of medical decision.

Prepare for the interview

Prior to meeting the patient, familiarize yourself with his/her reason for admission, diagnosis, medical workup, treatment provided thus far, and proposed future treatment. If possible, attempt to gather the patient’s medical and psychiatric history from chart review, which may be obtained from outside medical records or inferred from the patient’s current medication list. Review the chart for any signs that the patient is in a delirious state, including the use of psychotropic medications for agitation, restraints, or a sitter at bedside. Finally, speak with the patient’s nurse before entering the patient’s room. This may provide valuable information regarding the patient’s willingness to participate (including any hostility or aggression toward clinicians), any barriers to the interview (such as hearing or language difficulties), and if any family or friends are present at the bedside.

During the interview

The structure of a decision-making capacity evaluation has been well documented elsewhere^1,2 and, if completed, is sufficient for determining DMC. Asking the patient about additional psychiatric histories, including hospitalizations, suicide attempts, or a family history of psychiatric illness, may be counterproductive and frustrating for the patient, especially if the interview has already been lengthy and emotionally exhausting. Therefore, it is often appropriate to shorten the psychiatric interview to assess for symptoms of anxiety and depression, perform a brief suicide risk assessment, and assess for the presence of auditory or visual hallucinations, or delusions. This allows for a complete mental status exam while still focusing the interview on determining DMC. If time allows and the patient is willing to participate, it can be helpful to perform a Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam, although a score that indicates some level of cognitive impairment (<26 on MoCA⁴) does not necessarily preclude patient from having capacity for certain medical decisions. Additionally, if the patient does not understand a question, explain it and return to it later to check for comprehension.

Making a recommendation

Patients are presumed to be capable; therefore, if the determination is not clear, err on the side of capacity. Additional information may be helpful from the patient’s family, friends, DPOA, or guardian, especially as it pertains to the patient’s past wishes and medical decisions made in similar situations. If available and pertinent, review the patient’s advance health care directive.

Communicate your recommendations to the primary team clearly and concisely, including if the evaluation is incomplete, and if the patient will be seen again by the consult team, because this may determine disposition planning. Finally, if the patient is deemed to not have DMC, the primary team must then establish a surrogate decision maker on the patient’s behalf. Because the protocol and hierarchy of next-of-kin varies by state law and institution policy, it is essential to involve social work and case management

Medical and surgical inpatient teams often consult psychiatrists to help assess a patient’s decision-making capacity (DMC). Completing a DMC assessment can be a source of stress and frustration for psychiatry residents; however, the process can be significantly improved by following a consistent and focused psychiatric interview. In our institution, the most frequently used tool for assessing DMC is the Aid to Capacity Evaluation (ACE).¹ The American Academy of Family Physicians offers a printer-friendly adaptation² of the ACE assessment.

Reasons for a DMC consultation

When accepting a DMC consultation, make sure to specify for which medical decision the primary team would like the patient to be evaluated so that the consultation can be most helpful and specific to primary team’s concerns.³ The 4 most common reasons for a DMC consultation are:

Acute changes in mental status. These changes may be due to hypoxia, infection, medication, metabolic disturbances, or other medical conditions. Often, the diagnosis is delirium due to a medical condition, and assessing for DMC is deferred until the delirium resolves.

Refusal of a recommended treatment. One of the most frequent reasons for a DMC consultation is when a patient declines the primary team’s treatment recommendations. These recommendations may include medications, interventions (procedural or surgical), or discharge planning (such as transfer to a rehabilitation facility or skilled nursing care facility).

Consenting to a risky or invasive treatment too hastily. This occurs less often than the other 3 scenarios, most likely because capacity is rarely questioned when a patient’s decision aligns with the physicians’ recommendations.

Having risk factors for impaired decision-making. One of the most common reasons for involving psychiatry in a DMC consultation is when the patient has a risk factor that may impair his/her decision-making.

These risk factors include:

• a chronic psychiatric or neurologic condition
• a significant cultural or language barrier
• a low or unknown education level
• anxiety or discomfort with institutional health care settings
• age <18 or >85.

Continue to: When should you put off a DMC consultation?

There are situations in which a DMC consultation should be declined or postponed. A DMC consultation is not appropriate for patients who have a court-appointed legal guardian because these patients are considered legally incapacitated. Although such patients may still choose to participate in shared decision-making with the treatment team and communicate those decisions to their legal guardian, all treatment decisions are made by their legal guardian.

Consider delaying DMC consultations for patients with acute changes in mental status, including delirium, or those who are sedated or intubated. On the other hand, patients not excluded from a DMC assessment include those with mild or major neurocognitive disorders (such as Alzheimer’s disease or other types of dementia), intellectual disabilities, a durable power of attorney (DPOA), or legal charges. It is important to note that a diagnosis of a neurocognitive disorder does not preclude capacity, and capacity may therefore vary based on the complexity of medical decision.

Prepare for the interview

Prior to meeting the patient, familiarize yourself with his/her reason for admission, diagnosis, medical workup, treatment provided thus far, and proposed future treatment. If possible, attempt to gather the patient’s medical and psychiatric history from chart review, which may be obtained from outside medical records or inferred from the patient’s current medication list. Review the chart for any signs that the patient is in a delirious state, including the use of psychotropic medications for agitation, restraints, or a sitter at bedside. Finally, speak with the patient’s nurse before entering the patient’s room. This may provide valuable information regarding the patient’s willingness to participate (including any hostility or aggression toward clinicians), any barriers to the interview (such as hearing or language difficulties), and if any family or friends are present at the bedside.

During the interview

The structure of a decision-making capacity evaluation has been well documented elsewhere^1,2 and, if completed, is sufficient for determining DMC. Asking the patient about additional psychiatric histories, including hospitalizations, suicide attempts, or a family history of psychiatric illness, may be counterproductive and frustrating for the patient, especially if the interview has already been lengthy and emotionally exhausting. Therefore, it is often appropriate to shorten the psychiatric interview to assess for symptoms of anxiety and depression, perform a brief suicide risk assessment, and assess for the presence of auditory or visual hallucinations, or delusions. This allows for a complete mental status exam while still focusing the interview on determining DMC. If time allows and the patient is willing to participate, it can be helpful to perform a Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam, although a score that indicates some level of cognitive impairment (<26 on MoCA⁴) does not necessarily preclude patient from having capacity for certain medical decisions. Additionally, if the patient does not understand a question, explain it and return to it later to check for comprehension.

Making a recommendation

Patients are presumed to be capable; therefore, if the determination is not clear, err on the side of capacity. Additional information may be helpful from the patient’s family, friends, DPOA, or guardian, especially as it pertains to the patient’s past wishes and medical decisions made in similar situations. If available and pertinent, review the patient’s advance health care directive.

Communicate your recommendations to the primary team clearly and concisely, including if the evaluation is incomplete, and if the patient will be seen again by the consult team, because this may determine disposition planning. Finally, if the patient is deemed to not have DMC, the primary team must then establish a surrogate decision maker on the patient’s behalf. Because the protocol and hierarchy of next-of-kin varies by state law and institution policy, it is essential to involve social work and case management

I arrived at the inpatient psychiatry unit to begin my last overnight call shift as an intern. When I received sign-out from the day-shift resident, Dr. A (all names have been changed to protect anonymity), I was surprised to learn that the medical student assigned for call that day, G, did not present for his shift. In my residency program, a third-year medical student was assigned to accompany an intern during call shifts. While this assignment was for the medical student’s “learning purposes,” the presence of a medical student was vital for the intern. The high volume of patients who needed to be seen while on call was difficult to manage, and the help of a medical student certainly lessened that burden.

During her shift, Dr. A had texted G regarding his missed shift, but he replied that he was busy with a research project and did not intend to attend his call shift. Dr. A and I agreed that G’s behavior was unusual, especially because we had both worked with him before and had found him to be highly motivated and competent. Dr. A said that she was going to follow up with the clerkship director about G’s missed shift. While I was initially angry about having to work the call shift alone, I was quickly overcome with patient care. I labored through the night, and then spent the next day sleeping and recovering.

The following morning, I was back on the inpatient unit to start the work week. I was performing my usual morning pre-rounding when I received shocking news: a medical student had completed suicide on the school’s campus. After processing this news, I asked for the name of the student. It was G.

I sat in disbelief. How could a medical student who was supposed to work with me just 2 days ago have completed suicide? How could such a bright and well-presenting student decide to end his life? I voiced these thoughts to my colleague, who responded, “He must have been preparing to do it instead of coming to your call shift.” This statement hit me like a ton of bricks. Should I have done more to reach out to him? If I had spoken with him, could I have intervened and arrested his planning?

Later, I found out that G had been diagnosed with bipolar disorder. He had shared his diagnosis with some of his classmates and his psychiatry attending. G had wanted to share his success story as someone with mental illness who could have a career in medicine. However, because mental illness carries stigma, the attending had warned G about possible negative consequences in professional settings if he chose to share his diagnosis openly. G expressed disappointment with this advice. Subsequently, he had appeared more withdrawn during his clerkship engagements.

As psychiatrists, we expect to have conversations with our patients about thoughts of suicide, but such discussions with our physician colleagues are far from the norm. We know that the rate of suicide in physicians is higher than in the general population¹—particularly in women²—but stigma often prevents those who work in medicine from seeking treatment.³ Unfortunately, professional requirements and attitudes perpetuate barriers to accessing mental health care.⁴ As long as licensure concerns or other negative professional consequences persist, physicians will avoid seeking potentially life-saving treatment.

I felt guilty for having been angry at G for missing my call shift. I knew that the sequence of events could not be changed, but that did not stop me from wondering, “What if?” What if I had reached out? What if Dr. A had corresponded differently? If we want to prevent tragic outcomes like G’s, then we need to fix our flawed system. We need to allow physicians to seek treatment and share their experience without punitive professional consequences, because suicide is permanent, and there is no undoing.

I arrived at the inpatient psychiatry unit to begin my last overnight call shift as an intern. When I received sign-out from the day-shift resident, Dr. A (all names have been changed to protect anonymity), I was surprised to learn that the medical student assigned for call that day, G, did not present for his shift. In my residency program, a third-year medical student was assigned to accompany an intern during call shifts. While this assignment was for the medical student’s “learning purposes,” the presence of a medical student was vital for the intern. The high volume of patients who needed to be seen while on call was difficult to manage, and the help of a medical student certainly lessened that burden.

During her shift, Dr. A had texted G regarding his missed shift, but he replied that he was busy with a research project and did not intend to attend his call shift. Dr. A and I agreed that G’s behavior was unusual, especially because we had both worked with him before and had found him to be highly motivated and competent. Dr. A said that she was going to follow up with the clerkship director about G’s missed shift. While I was initially angry about having to work the call shift alone, I was quickly overcome with patient care. I labored through the night, and then spent the next day sleeping and recovering.

The following morning, I was back on the inpatient unit to start the work week. I was performing my usual morning pre-rounding when I received shocking news: a medical student had completed suicide on the school’s campus. After processing this news, I asked for the name of the student. It was G.

I sat in disbelief. How could a medical student who was supposed to work with me just 2 days ago have completed suicide? How could such a bright and well-presenting student decide to end his life? I voiced these thoughts to my colleague, who responded, “He must have been preparing to do it instead of coming to your call shift.” This statement hit me like a ton of bricks. Should I have done more to reach out to him? If I had spoken with him, could I have intervened and arrested his planning?

Later, I found out that G had been diagnosed with bipolar disorder. He had shared his diagnosis with some of his classmates and his psychiatry attending. G had wanted to share his success story as someone with mental illness who could have a career in medicine. However, because mental illness carries stigma, the attending had warned G about possible negative consequences in professional settings if he chose to share his diagnosis openly. G expressed disappointment with this advice. Subsequently, he had appeared more withdrawn during his clerkship engagements.

As psychiatrists, we expect to have conversations with our patients about thoughts of suicide, but such discussions with our physician colleagues are far from the norm. We know that the rate of suicide in physicians is higher than in the general population¹—particularly in women²—but stigma often prevents those who work in medicine from seeking treatment.³ Unfortunately, professional requirements and attitudes perpetuate barriers to accessing mental health care.⁴ As long as licensure concerns or other negative professional consequences persist, physicians will avoid seeking potentially life-saving treatment.

I felt guilty for having been angry at G for missing my call shift. I knew that the sequence of events could not be changed, but that did not stop me from wondering, “What if?” What if I had reached out? What if Dr. A had corresponded differently? If we want to prevent tragic outcomes like G’s, then we need to fix our flawed system. We need to allow physicians to seek treatment and share their experience without punitive professional consequences, because suicide is permanent, and there is no undoing.

I arrived at the inpatient psychiatry unit to begin my last overnight call shift as an intern. When I received sign-out from the day-shift resident, Dr. A (all names have been changed to protect anonymity), I was surprised to learn that the medical student assigned for call that day, G, did not present for his shift. In my residency program, a third-year medical student was assigned to accompany an intern during call shifts. While this assignment was for the medical student’s “learning purposes,” the presence of a medical student was vital for the intern. The high volume of patients who needed to be seen while on call was difficult to manage, and the help of a medical student certainly lessened that burden.

During her shift, Dr. A had texted G regarding his missed shift, but he replied that he was busy with a research project and did not intend to attend his call shift. Dr. A and I agreed that G’s behavior was unusual, especially because we had both worked with him before and had found him to be highly motivated and competent. Dr. A said that she was going to follow up with the clerkship director about G’s missed shift. While I was initially angry about having to work the call shift alone, I was quickly overcome with patient care. I labored through the night, and then spent the next day sleeping and recovering.

The following morning, I was back on the inpatient unit to start the work week. I was performing my usual morning pre-rounding when I received shocking news: a medical student had completed suicide on the school’s campus. After processing this news, I asked for the name of the student. It was G.

I sat in disbelief. How could a medical student who was supposed to work with me just 2 days ago have completed suicide? How could such a bright and well-presenting student decide to end his life? I voiced these thoughts to my colleague, who responded, “He must have been preparing to do it instead of coming to your call shift.” This statement hit me like a ton of bricks. Should I have done more to reach out to him? If I had spoken with him, could I have intervened and arrested his planning?

Later, I found out that G had been diagnosed with bipolar disorder. He had shared his diagnosis with some of his classmates and his psychiatry attending. G had wanted to share his success story as someone with mental illness who could have a career in medicine. However, because mental illness carries stigma, the attending had warned G about possible negative consequences in professional settings if he chose to share his diagnosis openly. G expressed disappointment with this advice. Subsequently, he had appeared more withdrawn during his clerkship engagements.

As psychiatrists, we expect to have conversations with our patients about thoughts of suicide, but such discussions with our physician colleagues are far from the norm. We know that the rate of suicide in physicians is higher than in the general population¹—particularly in women²—but stigma often prevents those who work in medicine from seeking treatment.³ Unfortunately, professional requirements and attitudes perpetuate barriers to accessing mental health care.⁴ As long as licensure concerns or other negative professional consequences persist, physicians will avoid seeking potentially life-saving treatment.

I felt guilty for having been angry at G for missing my call shift. I knew that the sequence of events could not be changed, but that did not stop me from wondering, “What if?” What if I had reached out? What if Dr. A had corresponded differently? If we want to prevent tragic outcomes like G’s, then we need to fix our flawed system. We need to allow physicians to seek treatment and share their experience without punitive professional consequences, because suicide is permanent, and there is no undoing.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.

Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.

One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,¹ I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.

Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.

What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?

Fostering human connection

To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.

Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.

Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.

One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,¹ I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.

Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.

What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?

Fostering human connection

To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.

Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.

Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.

One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,¹ I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.

Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.

What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?

Fostering human connection

To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.

Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.

During these unprecedented times, venturing into the unknown of the coronavirus disease 2019 (COVID-19) pandemic, a feeling of impending doom prevails. Almost all of us have been restricted to our homes. Although the physical dimensions of what we call home may vary, the meaning of this restriction is fairly universal. No matter how our sociodemographics differ, with no guidance for this situation from anything even remotely comparable in the past, our lives have been transformed into a work in progress.

During this pandemic, I have observed a wide range of human emotions and behavior—many of them familiar and predictable, some abysmal, and some inspiring.

’Why should I care?’

On December 31, 2019, health officials in China informed the World Health Organization about a pneumonia-like presentation in a group of people in Wuhan. On January 7, 2020, a novel coronavirus was identified as the cause, and the first death was reported a few days later. In the following days and weeks the disease rapidly spread, as did the growing sense that this was not a typical virus.

While these events occurred, the rest of the world was in what I call a ”Why should I care?” mode. Most humans tend to suffer from this indifference. This has been observed repeatedly through the years, such as when the Ebola outbreak occurred in Africa in 2014-2016. It was only when cases started to develop in Europe and the United States that other countries started to pay attention. A similar phenomenon has been observed every time we’ve faced a global outbreak (avian influenza, Middle East respiratory syndrome, etc.).

When are we going to learn? It is time to realize that global borders are more porous than we think, and human interactions cannot be blocked by any wall. When a catastrophic event, outbreak, or disaster starts in any part of the world, it is naive to assume that we will not be affected. We will eventually be affected—the only question is how, when, and to what extent? We are always all in this together.

An abundance of ignorance and stupidity

Within a few weeks of the first reports from China, cases of COVID-19 were reported in South Korea, Italy, Spain, Germany, and many other countries. Slowly, COVID-19 reached the United States, which as of mid-April had the highest number of cases worldwide. When COVID-19 hit the United States, the response was that of shock and anger. How could this happen to us? Why is the government not doing anything?

Amidst this pandemonium, ignorance and stupidity of the highest degree were commonplace. This was not restricted to any particular country or region. Almost 2 months into the pandemic, the Ministry of Tourism in my home country of Nepal declared Nepal a ”coronavirus-free zone” and took measures to bring in tourists, focusing specifically on China, where COVID-19 had already killed hundreds. In India, some people were drinking cow urine in hopes of warding off the virus. In the United Sates, thousands of young people flocked to beaches for Spring Break, disregarding measures for social distancing. ”If I get corona, I get corona,” one young man said in an interview that went viral. Personally, I have encountered people who responded to this pandemic by saying the disease was ”cooties” or ”just a flu,” and dismissing it with ”If I die from this, I die.”

Continue to: Rising panic and fear

Rising panic and fear

For most people, seeing COVID-19 at their doorstep triggered a panic, and sent many into a frenzy of buying and hoarding. Once again, we proved that people everywhere are equally stupid, as toilet paper began to vanish from stores across the globe. And yet, this again was a moment when some people began to experience a false sense of immunity: ”I have enough food, money, and toilet paper to last me for 2 years. Why should I be worried?”

When the numbers of COVID-19 deaths in Europe were first reported, the fear became palpable. In Italy and Spain, towns were locked down, and tens of thousands of people (mostly older adults) have died. It was truly heartbreaking to see people alone and at their weakest with no family members allowed to be by their side.

A glimmer of hope

Despite all of this, there were superheroes—the nurses, physicians, allied health professionals, first responders, store workers, restaurant workers, delivery personnel, and others who didn’t have the option of staying home, or who volunteered to help people in need. In moments like this, the actions of these individuals give us hope, reminding us that the human spirit is resilient, and that we will get through this.

A rotation in the emergency department during COVID-19

As a psychiatry resident, it is unlikely that my peers and I face the same risks as our colleagues in other medical specialities. But those of us who happened to be in medical rotations during this time have had the chance to experience this very closely. My personal experience, albeit a brief one, of working in an emergency department with suspected COVID-19 patients has been sobering. Watching nurses and physicians walk into a room wearing personal protective equipment, fearful inside but with a reassuring smile for a scared patient, definitely was one of the most compelling moments of my life. Living in a distant land, with my daughter, wife, parents, and extended family back home in Nepal, has made this even more challenging.

We will overcome this as we have overcome previous challenges in the past. There will be death and chaos, but we will prevail. The only thing is to ask ourselves: How do we want to continue living when this is over?

During these unprecedented times, venturing into the unknown of the coronavirus disease 2019 (COVID-19) pandemic, a feeling of impending doom prevails. Almost all of us have been restricted to our homes. Although the physical dimensions of what we call home may vary, the meaning of this restriction is fairly universal. No matter how our sociodemographics differ, with no guidance for this situation from anything even remotely comparable in the past, our lives have been transformed into a work in progress.

During this pandemic, I have observed a wide range of human emotions and behavior—many of them familiar and predictable, some abysmal, and some inspiring.

’Why should I care?’

On December 31, 2019, health officials in China informed the World Health Organization about a pneumonia-like presentation in a group of people in Wuhan. On January 7, 2020, a novel coronavirus was identified as the cause, and the first death was reported a few days later. In the following days and weeks the disease rapidly spread, as did the growing sense that this was not a typical virus.

While these events occurred, the rest of the world was in what I call a ”Why should I care?” mode. Most humans tend to suffer from this indifference. This has been observed repeatedly through the years, such as when the Ebola outbreak occurred in Africa in 2014-2016. It was only when cases started to develop in Europe and the United States that other countries started to pay attention. A similar phenomenon has been observed every time we’ve faced a global outbreak (avian influenza, Middle East respiratory syndrome, etc.).

When are we going to learn? It is time to realize that global borders are more porous than we think, and human interactions cannot be blocked by any wall. When a catastrophic event, outbreak, or disaster starts in any part of the world, it is naive to assume that we will not be affected. We will eventually be affected—the only question is how, when, and to what extent? We are always all in this together.

An abundance of ignorance and stupidity

Within a few weeks of the first reports from China, cases of COVID-19 were reported in South Korea, Italy, Spain, Germany, and many other countries. Slowly, COVID-19 reached the United States, which as of mid-April had the highest number of cases worldwide. When COVID-19 hit the United States, the response was that of shock and anger. How could this happen to us? Why is the government not doing anything?

Amidst this pandemonium, ignorance and stupidity of the highest degree were commonplace. This was not restricted to any particular country or region. Almost 2 months into the pandemic, the Ministry of Tourism in my home country of Nepal declared Nepal a ”coronavirus-free zone” and took measures to bring in tourists, focusing specifically on China, where COVID-19 had already killed hundreds. In India, some people were drinking cow urine in hopes of warding off the virus. In the United Sates, thousands of young people flocked to beaches for Spring Break, disregarding measures for social distancing. ”If I get corona, I get corona,” one young man said in an interview that went viral. Personally, I have encountered people who responded to this pandemic by saying the disease was ”cooties” or ”just a flu,” and dismissing it with ”If I die from this, I die.”

Continue to: Rising panic and fear

Rising panic and fear

For most people, seeing COVID-19 at their doorstep triggered a panic, and sent many into a frenzy of buying and hoarding. Once again, we proved that people everywhere are equally stupid, as toilet paper began to vanish from stores across the globe. And yet, this again was a moment when some people began to experience a false sense of immunity: ”I have enough food, money, and toilet paper to last me for 2 years. Why should I be worried?”

When the numbers of COVID-19 deaths in Europe were first reported, the fear became palpable. In Italy and Spain, towns were locked down, and tens of thousands of people (mostly older adults) have died. It was truly heartbreaking to see people alone and at their weakest with no family members allowed to be by their side.

A glimmer of hope

Despite all of this, there were superheroes—the nurses, physicians, allied health professionals, first responders, store workers, restaurant workers, delivery personnel, and others who didn’t have the option of staying home, or who volunteered to help people in need. In moments like this, the actions of these individuals give us hope, reminding us that the human spirit is resilient, and that we will get through this.

A rotation in the emergency department during COVID-19

As a psychiatry resident, it is unlikely that my peers and I face the same risks as our colleagues in other medical specialities. But those of us who happened to be in medical rotations during this time have had the chance to experience this very closely. My personal experience, albeit a brief one, of working in an emergency department with suspected COVID-19 patients has been sobering. Watching nurses and physicians walk into a room wearing personal protective equipment, fearful inside but with a reassuring smile for a scared patient, definitely was one of the most compelling moments of my life. Living in a distant land, with my daughter, wife, parents, and extended family back home in Nepal, has made this even more challenging.

We will overcome this as we have overcome previous challenges in the past. There will be death and chaos, but we will prevail. The only thing is to ask ourselves: How do we want to continue living when this is over?

During these unprecedented times, venturing into the unknown of the coronavirus disease 2019 (COVID-19) pandemic, a feeling of impending doom prevails. Almost all of us have been restricted to our homes. Although the physical dimensions of what we call home may vary, the meaning of this restriction is fairly universal. No matter how our sociodemographics differ, with no guidance for this situation from anything even remotely comparable in the past, our lives have been transformed into a work in progress.

During this pandemic, I have observed a wide range of human emotions and behavior—many of them familiar and predictable, some abysmal, and some inspiring.

’Why should I care?’

On December 31, 2019, health officials in China informed the World Health Organization about a pneumonia-like presentation in a group of people in Wuhan. On January 7, 2020, a novel coronavirus was identified as the cause, and the first death was reported a few days later. In the following days and weeks the disease rapidly spread, as did the growing sense that this was not a typical virus.

While these events occurred, the rest of the world was in what I call a ”Why should I care?” mode. Most humans tend to suffer from this indifference. This has been observed repeatedly through the years, such as when the Ebola outbreak occurred in Africa in 2014-2016. It was only when cases started to develop in Europe and the United States that other countries started to pay attention. A similar phenomenon has been observed every time we’ve faced a global outbreak (avian influenza, Middle East respiratory syndrome, etc.).

When are we going to learn? It is time to realize that global borders are more porous than we think, and human interactions cannot be blocked by any wall. When a catastrophic event, outbreak, or disaster starts in any part of the world, it is naive to assume that we will not be affected. We will eventually be affected—the only question is how, when, and to what extent? We are always all in this together.

An abundance of ignorance and stupidity

Within a few weeks of the first reports from China, cases of COVID-19 were reported in South Korea, Italy, Spain, Germany, and many other countries. Slowly, COVID-19 reached the United States, which as of mid-April had the highest number of cases worldwide. When COVID-19 hit the United States, the response was that of shock and anger. How could this happen to us? Why is the government not doing anything?

Amidst this pandemonium, ignorance and stupidity of the highest degree were commonplace. This was not restricted to any particular country or region. Almost 2 months into the pandemic, the Ministry of Tourism in my home country of Nepal declared Nepal a ”coronavirus-free zone” and took measures to bring in tourists, focusing specifically on China, where COVID-19 had already killed hundreds. In India, some people were drinking cow urine in hopes of warding off the virus. In the United Sates, thousands of young people flocked to beaches for Spring Break, disregarding measures for social distancing. ”If I get corona, I get corona,” one young man said in an interview that went viral. Personally, I have encountered people who responded to this pandemic by saying the disease was ”cooties” or ”just a flu,” and dismissing it with ”If I die from this, I die.”

Continue to: Rising panic and fear

Rising panic and fear

For most people, seeing COVID-19 at their doorstep triggered a panic, and sent many into a frenzy of buying and hoarding. Once again, we proved that people everywhere are equally stupid, as toilet paper began to vanish from stores across the globe. And yet, this again was a moment when some people began to experience a false sense of immunity: ”I have enough food, money, and toilet paper to last me for 2 years. Why should I be worried?”

When the numbers of COVID-19 deaths in Europe were first reported, the fear became palpable. In Italy and Spain, towns were locked down, and tens of thousands of people (mostly older adults) have died. It was truly heartbreaking to see people alone and at their weakest with no family members allowed to be by their side.

A glimmer of hope

Despite all of this, there were superheroes—the nurses, physicians, allied health professionals, first responders, store workers, restaurant workers, delivery personnel, and others who didn’t have the option of staying home, or who volunteered to help people in need. In moments like this, the actions of these individuals give us hope, reminding us that the human spirit is resilient, and that we will get through this.

A rotation in the emergency department during COVID-19

As a psychiatry resident, it is unlikely that my peers and I face the same risks as our colleagues in other medical specialities. But those of us who happened to be in medical rotations during this time have had the chance to experience this very closely. My personal experience, albeit a brief one, of working in an emergency department with suspected COVID-19 patients has been sobering. Watching nurses and physicians walk into a room wearing personal protective equipment, fearful inside but with a reassuring smile for a scared patient, definitely was one of the most compelling moments of my life. Living in a distant land, with my daughter, wife, parents, and extended family back home in Nepal, has made this even more challenging.

We will overcome this as we have overcome previous challenges in the past. There will be death and chaos, but we will prevail. The only thing is to ask ourselves: How do we want to continue living when this is over?

Several months ago, I sat with a woman just a few days after the emergent Cesarean section delivery of her first child. She cried as she told me about her entire life—childhood trauma, a pattern of difficult relationships, several miscarriages, and now, finally, a baby—delivered under circumstances so scary, all she remembered was overwhelming fear. Now, she had returned to the hospital with severe postpartum depression, layered with struggles that are common during the first days with a newborn—little sleep, loss of autonomy, guilt, and loneliness. It was hard to listen to it all, but I encouraged her to express her pain, believing that burdens are lighter when shared.

Words often fail us in times of desperation. Much of my education has involved borrowing words, phrases, or ideas from my experienced attendings and mentors, applying them like a salve when I don’t know what else to say. Sitting with another person in silence is often powerful enough, but when something needs to be said, I fall back on these inherited ideas. One of the mantras I often use, and what I said to my patient that day, is about hope: “When you’re down in this depression, you feel hopeless, and you can’t see the hope. It doesn’t mean there isn’t hope; just that you can’t see it.” I’ve watched that idea take root in patients who—despite their own beliefs in the moment—do get better, thus proving the point. Another favorite phrase: “With any luck at all, tomorrow will be better than today.” When you talk to someone on the worst day of their life, what else is there to say?

Today, my conversation with that woman seems like an eternity ago. Public discourse has been overtaken by coronavirus disease 2019 (COVID-19)—the journalism, reflections on the journalism, medical advice, debate about the medical advice, and the innumerable ways in which this worldwide strife has created pain: celebrations and long-awaited plans cancelled, weddings and funerals put on hold, isolation, loneliness, death, and, of course, the fear of death. Those feelings and any other permutations are valid; another phrase, “It’s OK to feel what you are feeling,” carries weight for me these days. I work in a hospital, so I add to the list the breathless fears about what’s going to happen in our local environment. The chronic uncertainty was wearing us thin even before we had begun to do here in Ohio what was already being done elsewhere: working extra shifts, intubating new patients, praying we don’t get sick ourselves.

Our work during COVID-19

Amidst this, my colleagues and I continue our work as psychiatrists, sitting with humans experiencing complex grief (a man whose wife died alone in a nursing home, because of visitor restrictions), confusion (delirium resulting from respiratory failure), and even psychosis (inability to access stabilizing medications coupled with crippling paranoia). These remain just as real and debilitating in a pandemic as they do in other times. In addition to pre-existing mental illnesses, for some individuals, the shared anxiety will progress to clinically significant disorders that may last even longer than the effects of the virus. The resulting complex symptoms could affect everything from home lives to interpersonal relationships to our local and global economies. These are not minor issues. Although often triaged aside in a disaster, our collective mental health remains in some ways more central than ever.

Modern psychiatry would not often use the word “love,” but that’s what I am trying to do—show love to the people who need it the most right now (which is all of us, really). This love takes strange shapes, and sometimes new forms, but it’s just about all I have to give. Like everyone else, I don’t have concrete answers for the grief and fear and panic. But I’m content to share the burden of pain, believing that burdens are lighter when shared. And I have a few words that, however little comfort they offer in the moment, are eventually proven true: Just because you can’t see the hope doesn’t mean it isn’t there. It’s OK to feel what you are feeling. With any luck at all, tomorrow will be better than today.

Several months ago, I sat with a woman just a few days after the emergent Cesarean section delivery of her first child. She cried as she told me about her entire life—childhood trauma, a pattern of difficult relationships, several miscarriages, and now, finally, a baby—delivered under circumstances so scary, all she remembered was overwhelming fear. Now, she had returned to the hospital with severe postpartum depression, layered with struggles that are common during the first days with a newborn—little sleep, loss of autonomy, guilt, and loneliness. It was hard to listen to it all, but I encouraged her to express her pain, believing that burdens are lighter when shared.

Words often fail us in times of desperation. Much of my education has involved borrowing words, phrases, or ideas from my experienced attendings and mentors, applying them like a salve when I don’t know what else to say. Sitting with another person in silence is often powerful enough, but when something needs to be said, I fall back on these inherited ideas. One of the mantras I often use, and what I said to my patient that day, is about hope: “When you’re down in this depression, you feel hopeless, and you can’t see the hope. It doesn’t mean there isn’t hope; just that you can’t see it.” I’ve watched that idea take root in patients who—despite their own beliefs in the moment—do get better, thus proving the point. Another favorite phrase: “With any luck at all, tomorrow will be better than today.” When you talk to someone on the worst day of their life, what else is there to say?

Today, my conversation with that woman seems like an eternity ago. Public discourse has been overtaken by coronavirus disease 2019 (COVID-19)—the journalism, reflections on the journalism, medical advice, debate about the medical advice, and the innumerable ways in which this worldwide strife has created pain: celebrations and long-awaited plans cancelled, weddings and funerals put on hold, isolation, loneliness, death, and, of course, the fear of death. Those feelings and any other permutations are valid; another phrase, “It’s OK to feel what you are feeling,” carries weight for me these days. I work in a hospital, so I add to the list the breathless fears about what’s going to happen in our local environment. The chronic uncertainty was wearing us thin even before we had begun to do here in Ohio what was already being done elsewhere: working extra shifts, intubating new patients, praying we don’t get sick ourselves.

Our work during COVID-19

Amidst this, my colleagues and I continue our work as psychiatrists, sitting with humans experiencing complex grief (a man whose wife died alone in a nursing home, because of visitor restrictions), confusion (delirium resulting from respiratory failure), and even psychosis (inability to access stabilizing medications coupled with crippling paranoia). These remain just as real and debilitating in a pandemic as they do in other times. In addition to pre-existing mental illnesses, for some individuals, the shared anxiety will progress to clinically significant disorders that may last even longer than the effects of the virus. The resulting complex symptoms could affect everything from home lives to interpersonal relationships to our local and global economies. These are not minor issues. Although often triaged aside in a disaster, our collective mental health remains in some ways more central than ever.

Modern psychiatry would not often use the word “love,” but that’s what I am trying to do—show love to the people who need it the most right now (which is all of us, really). This love takes strange shapes, and sometimes new forms, but it’s just about all I have to give. Like everyone else, I don’t have concrete answers for the grief and fear and panic. But I’m content to share the burden of pain, believing that burdens are lighter when shared. And I have a few words that, however little comfort they offer in the moment, are eventually proven true: Just because you can’t see the hope doesn’t mean it isn’t there. It’s OK to feel what you are feeling. With any luck at all, tomorrow will be better than today.

Several months ago, I sat with a woman just a few days after the emergent Cesarean section delivery of her first child. She cried as she told me about her entire life—childhood trauma, a pattern of difficult relationships, several miscarriages, and now, finally, a baby—delivered under circumstances so scary, all she remembered was overwhelming fear. Now, she had returned to the hospital with severe postpartum depression, layered with struggles that are common during the first days with a newborn—little sleep, loss of autonomy, guilt, and loneliness. It was hard to listen to it all, but I encouraged her to express her pain, believing that burdens are lighter when shared.

Words often fail us in times of desperation. Much of my education has involved borrowing words, phrases, or ideas from my experienced attendings and mentors, applying them like a salve when I don’t know what else to say. Sitting with another person in silence is often powerful enough, but when something needs to be said, I fall back on these inherited ideas. One of the mantras I often use, and what I said to my patient that day, is about hope: “When you’re down in this depression, you feel hopeless, and you can’t see the hope. It doesn’t mean there isn’t hope; just that you can’t see it.” I’ve watched that idea take root in patients who—despite their own beliefs in the moment—do get better, thus proving the point. Another favorite phrase: “With any luck at all, tomorrow will be better than today.” When you talk to someone on the worst day of their life, what else is there to say?

Today, my conversation with that woman seems like an eternity ago. Public discourse has been overtaken by coronavirus disease 2019 (COVID-19)—the journalism, reflections on the journalism, medical advice, debate about the medical advice, and the innumerable ways in which this worldwide strife has created pain: celebrations and long-awaited plans cancelled, weddings and funerals put on hold, isolation, loneliness, death, and, of course, the fear of death. Those feelings and any other permutations are valid; another phrase, “It’s OK to feel what you are feeling,” carries weight for me these days. I work in a hospital, so I add to the list the breathless fears about what’s going to happen in our local environment. The chronic uncertainty was wearing us thin even before we had begun to do here in Ohio what was already being done elsewhere: working extra shifts, intubating new patients, praying we don’t get sick ourselves.

Our work during COVID-19

Amidst this, my colleagues and I continue our work as psychiatrists, sitting with humans experiencing complex grief (a man whose wife died alone in a nursing home, because of visitor restrictions), confusion (delirium resulting from respiratory failure), and even psychosis (inability to access stabilizing medications coupled with crippling paranoia). These remain just as real and debilitating in a pandemic as they do in other times. In addition to pre-existing mental illnesses, for some individuals, the shared anxiety will progress to clinically significant disorders that may last even longer than the effects of the virus. The resulting complex symptoms could affect everything from home lives to interpersonal relationships to our local and global economies. These are not minor issues. Although often triaged aside in a disaster, our collective mental health remains in some ways more central than ever.

Modern psychiatry would not often use the word “love,” but that’s what I am trying to do—show love to the people who need it the most right now (which is all of us, really). This love takes strange shapes, and sometimes new forms, but it’s just about all I have to give. Like everyone else, I don’t have concrete answers for the grief and fear and panic. But I’m content to share the burden of pain, believing that burdens are lighter when shared. And I have a few words that, however little comfort they offer in the moment, are eventually proven true: Just because you can’t see the hope doesn’t mean it isn’t there. It’s OK to feel what you are feeling. With any luck at all, tomorrow will be better than today.

On the first day of my third postgraduate year, I sat at a table with my entire PGY-3 class and our attending physician. This was my first case discussion of the new academic year, and the attending was someone I hadn’t worked with previously. He was an older gentleman who primarily worked in private practice, but enjoyed teaching and maintained his academic affiliations. He started the discussion with a simple question: “Does anyone have a case they would like to discuss?”

The silence we were accustomed to as new interns on the first day of service fell over the group. Everyone seemed a bit apprehensive, as this attending was somewhat intimidating. He was educated at Hahnemann University Hospital, and classically trained in psychoanalysis. He had a wealth of research knowledge, and continued to publish in academic journals on a regular basis.

Finally, someone volunteered to present a case. The case involved a 45-year-old woman with a long history of depression. She had received multiple medication trials that did not result in remission. In fact, she had never experienced significant relief of any of her depressive symptoms. The case was clearly shaping up to look like treatment-resistant depression. The resident continued with the case and discussed the differential diagnosis and treatment plan. The treatment plan involved a combination of pharmacotherapy and psychotherapy—not much different from the previous treatments the patient had tried. I anxiously anticipated the response from the attending.

After listening attentively and taking a moment to gather his thoughts, the attending responded with one word: “Egregious.” He was blunt, and clearly viewed the case formulation and management of this patient as “basic.” It was clear to me that I, and the rest of my class, were missing something. It was something that was not going to come from a textbook or treatment algorithm. He was the first attending in some time who was challenging us to truly think.

A profound point

I ruminated on his surprising response for a moment, as the treatment plan presented was commonly seen on the inpatient unit. It was not an unreasonable approach, but it lacked depth and sophistication. However, no attending I worked with in the past ever called it “egregious.” Now I was intrigued, and honestly, it had been some time since I felt excited about a case discussion. The attending’s point was simple: our patients are suffering, and they are coming to us in their most vulnerable state seeking answers. When we make decisions based on FDA approvals and blindly follow treatment algorithms, we fail to see the vast untapped potential to help patients that resides outside of these strict guidelines. This is not to say there is no place for algorithm-based psychiatry and FDA-approved medications; in fact, many times these will be the cornerstones of treatment.

During the discussion, this attending proceeded to make another profound statement that I continue to remind myself of each day. He said, “What would be the point of these patients coming to see you if you are going to practice psychiatry like a primary care provider?” I had to agree with him on many levels, because these patients are suffering, and they are looking for hope. If we simply offer them the same standard treatments, they are likely to get the same poor results. Our patients are coming to us because we are experts in the field of psychiatry; we owe them the respect to think outside the box. As specialists, the most complicated and difficult-to-treat cases will be referred to us. We need to possess a deep understanding of all treatment options, and know where to go when your first, second, and third options fail to produce the desired result.

The attending offered his thoughts on the case, and discussed his approach to treating this patient. He explained the importance of not being afraid to try medications in doses above the FDA-approved maximums in select cases. He explained the robust research behind monoamine oxidase inhibitors (MAOIs), and how to safely prescribe them. He explained why tricyclic antidepressants may be a more effective choice for some patients.

Continue to: These were discussions...

These were discussions I never had the opportunity to have in the past. In many instances, the possibility of using an MAOI would be quickly dismissed by my attendings as “too dangerous” or “better options are available.” In this attending’s view, it wasn’t the danger of an adverse outcome we are facing, but the danger of missing potentially life-changing treatments for our patients. The attending concluded with, “It’s sad that many of you will graduate without starting a patient on an MAOI, without titrating a tricyclic antidepressant and monitoring blood levels, and without ever really thinking for yourself.” These were powerful words, and he was speaking a truth that deep down I already knew.

When I reflect on this discussion and my first 2 years of training, I realize the value in learning structured methods of treating patients. I am aware of the need to practice in a safe manner that does not put the patient at unnecessary risk. However, I also realize I am going to face difficult cases where many smart and capable clinicians have attempted treatment and failed to get the desired outcome. It’s essential that as specialists we learn to use all the tools available to us to treat patients. If we limit ourselves out of fear, or blindly follow algorithms, we miss important opportunities to act boldly to help patients in their darkest moments.

On the first day of my third postgraduate year, I sat at a table with my entire PGY-3 class and our attending physician. This was my first case discussion of the new academic year, and the attending was someone I hadn’t worked with previously. He was an older gentleman who primarily worked in private practice, but enjoyed teaching and maintained his academic affiliations. He started the discussion with a simple question: “Does anyone have a case they would like to discuss?”

The silence we were accustomed to as new interns on the first day of service fell over the group. Everyone seemed a bit apprehensive, as this attending was somewhat intimidating. He was educated at Hahnemann University Hospital, and classically trained in psychoanalysis. He had a wealth of research knowledge, and continued to publish in academic journals on a regular basis.

Finally, someone volunteered to present a case. The case involved a 45-year-old woman with a long history of depression. She had received multiple medication trials that did not result in remission. In fact, she had never experienced significant relief of any of her depressive symptoms. The case was clearly shaping up to look like treatment-resistant depression. The resident continued with the case and discussed the differential diagnosis and treatment plan. The treatment plan involved a combination of pharmacotherapy and psychotherapy—not much different from the previous treatments the patient had tried. I anxiously anticipated the response from the attending.

After listening attentively and taking a moment to gather his thoughts, the attending responded with one word: “Egregious.” He was blunt, and clearly viewed the case formulation and management of this patient as “basic.” It was clear to me that I, and the rest of my class, were missing something. It was something that was not going to come from a textbook or treatment algorithm. He was the first attending in some time who was challenging us to truly think.

A profound point

I ruminated on his surprising response for a moment, as the treatment plan presented was commonly seen on the inpatient unit. It was not an unreasonable approach, but it lacked depth and sophistication. However, no attending I worked with in the past ever called it “egregious.” Now I was intrigued, and honestly, it had been some time since I felt excited about a case discussion. The attending’s point was simple: our patients are suffering, and they are coming to us in their most vulnerable state seeking answers. When we make decisions based on FDA approvals and blindly follow treatment algorithms, we fail to see the vast untapped potential to help patients that resides outside of these strict guidelines. This is not to say there is no place for algorithm-based psychiatry and FDA-approved medications; in fact, many times these will be the cornerstones of treatment.

During the discussion, this attending proceeded to make another profound statement that I continue to remind myself of each day. He said, “What would be the point of these patients coming to see you if you are going to practice psychiatry like a primary care provider?” I had to agree with him on many levels, because these patients are suffering, and they are looking for hope. If we simply offer them the same standard treatments, they are likely to get the same poor results. Our patients are coming to us because we are experts in the field of psychiatry; we owe them the respect to think outside the box. As specialists, the most complicated and difficult-to-treat cases will be referred to us. We need to possess a deep understanding of all treatment options, and know where to go when your first, second, and third options fail to produce the desired result.

The attending offered his thoughts on the case, and discussed his approach to treating this patient. He explained the importance of not being afraid to try medications in doses above the FDA-approved maximums in select cases. He explained the robust research behind monoamine oxidase inhibitors (MAOIs), and how to safely prescribe them. He explained why tricyclic antidepressants may be a more effective choice for some patients.

Continue to: These were discussions...

These were discussions I never had the opportunity to have in the past. In many instances, the possibility of using an MAOI would be quickly dismissed by my attendings as “too dangerous” or “better options are available.” In this attending’s view, it wasn’t the danger of an adverse outcome we are facing, but the danger of missing potentially life-changing treatments for our patients. The attending concluded with, “It’s sad that many of you will graduate without starting a patient on an MAOI, without titrating a tricyclic antidepressant and monitoring blood levels, and without ever really thinking for yourself.” These were powerful words, and he was speaking a truth that deep down I already knew.

When I reflect on this discussion and my first 2 years of training, I realize the value in learning structured methods of treating patients. I am aware of the need to practice in a safe manner that does not put the patient at unnecessary risk. However, I also realize I am going to face difficult cases where many smart and capable clinicians have attempted treatment and failed to get the desired outcome. It’s essential that as specialists we learn to use all the tools available to us to treat patients. If we limit ourselves out of fear, or blindly follow algorithms, we miss important opportunities to act boldly to help patients in their darkest moments.

On the first day of my third postgraduate year, I sat at a table with my entire PGY-3 class and our attending physician. This was my first case discussion of the new academic year, and the attending was someone I hadn’t worked with previously. He was an older gentleman who primarily worked in private practice, but enjoyed teaching and maintained his academic affiliations. He started the discussion with a simple question: “Does anyone have a case they would like to discuss?”

The silence we were accustomed to as new interns on the first day of service fell over the group. Everyone seemed a bit apprehensive, as this attending was somewhat intimidating. He was educated at Hahnemann University Hospital, and classically trained in psychoanalysis. He had a wealth of research knowledge, and continued to publish in academic journals on a regular basis.

Finally, someone volunteered to present a case. The case involved a 45-year-old woman with a long history of depression. She had received multiple medication trials that did not result in remission. In fact, she had never experienced significant relief of any of her depressive symptoms. The case was clearly shaping up to look like treatment-resistant depression. The resident continued with the case and discussed the differential diagnosis and treatment plan. The treatment plan involved a combination of pharmacotherapy and psychotherapy—not much different from the previous treatments the patient had tried. I anxiously anticipated the response from the attending.

After listening attentively and taking a moment to gather his thoughts, the attending responded with one word: “Egregious.” He was blunt, and clearly viewed the case formulation and management of this patient as “basic.” It was clear to me that I, and the rest of my class, were missing something. It was something that was not going to come from a textbook or treatment algorithm. He was the first attending in some time who was challenging us to truly think.

A profound point

I ruminated on his surprising response for a moment, as the treatment plan presented was commonly seen on the inpatient unit. It was not an unreasonable approach, but it lacked depth and sophistication. However, no attending I worked with in the past ever called it “egregious.” Now I was intrigued, and honestly, it had been some time since I felt excited about a case discussion. The attending’s point was simple: our patients are suffering, and they are coming to us in their most vulnerable state seeking answers. When we make decisions based on FDA approvals and blindly follow treatment algorithms, we fail to see the vast untapped potential to help patients that resides outside of these strict guidelines. This is not to say there is no place for algorithm-based psychiatry and FDA-approved medications; in fact, many times these will be the cornerstones of treatment.

During the discussion, this attending proceeded to make another profound statement that I continue to remind myself of each day. He said, “What would be the point of these patients coming to see you if you are going to practice psychiatry like a primary care provider?” I had to agree with him on many levels, because these patients are suffering, and they are looking for hope. If we simply offer them the same standard treatments, they are likely to get the same poor results. Our patients are coming to us because we are experts in the field of psychiatry; we owe them the respect to think outside the box. As specialists, the most complicated and difficult-to-treat cases will be referred to us. We need to possess a deep understanding of all treatment options, and know where to go when your first, second, and third options fail to produce the desired result.

The attending offered his thoughts on the case, and discussed his approach to treating this patient. He explained the importance of not being afraid to try medications in doses above the FDA-approved maximums in select cases. He explained the robust research behind monoamine oxidase inhibitors (MAOIs), and how to safely prescribe them. He explained why tricyclic antidepressants may be a more effective choice for some patients.

Continue to: These were discussions...

These were discussions I never had the opportunity to have in the past. In many instances, the possibility of using an MAOI would be quickly dismissed by my attendings as “too dangerous” or “better options are available.” In this attending’s view, it wasn’t the danger of an adverse outcome we are facing, but the danger of missing potentially life-changing treatments for our patients. The attending concluded with, “It’s sad that many of you will graduate without starting a patient on an MAOI, without titrating a tricyclic antidepressant and monitoring blood levels, and without ever really thinking for yourself.” These were powerful words, and he was speaking a truth that deep down I already knew.

When I reflect on this discussion and my first 2 years of training, I realize the value in learning structured methods of treating patients. I am aware of the need to practice in a safe manner that does not put the patient at unnecessary risk. However, I also realize I am going to face difficult cases where many smart and capable clinicians have attempted treatment and failed to get the desired outcome. It’s essential that as specialists we learn to use all the tools available to us to treat patients. If we limit ourselves out of fear, or blindly follow algorithms, we miss important opportunities to act boldly to help patients in their darkest moments.