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September 19, 2017

People : Voices



I haven't written about work for over a month because August was so busy, and it's hard to find words again. Honestly, it's been hard ever since I started my medical residency and got out of the routine, and now two years post-residency I've yet to feel that things flow when I want to write.  I can't really get at that voice, and I miss it.

In this work, other voices usually crowd out my own.  We have so many conversations with people living in realities different from our own that it takes awhile for me to settle back into where I am.  While it would be healing and healthy to disentangle myself from that web by writing it out, it's often hard to 1) reside in the worlds of others enough to understand them and 2) exit them enough to do them justice in writing.

But I think it's important to try regularly, for my own care and theirs.  Lately, I feel especially immersed in the voices of other people--patients who hear things that other people can't hear, feel things that are at odds with the reality the rest of us feel; patients whose depression crushes their capacity to speak altogether; patients whose anxiety render them unable to hear any soothing response to their run-on panic.

This past year I've been participating in a program designed to teach primary care providers some basic mental health care for patients with psychiatric disorders.  It's amazing, and stupid, how little training we get in medical school about how to communicate with people whose minds function differently from our own.  And the more time we spend in school, the more we get trapped in our own heads and the less actual life we experience.  Then we're thrown into practice, and find that often patients care less about hearing what we know, and more about sharing what they hear.

A woman in her late twenties comes in to clinic with chest pain.  The symptoms aren't consistent with a heart attack, which would be unusual in such a young person. When I ask her whether she is experiencing any specific stressors, she says, "Yes. I'm stressed because I'm worried that I have an aneurysm, because a voice told me that I will have an aneurysm on 9/11."

It can be challenging to compete with these voices, when they are so much closer, louder, and more familiar than mine. There are moments where I'm frustrated by this alternate view that eclipses mine--why can't I share what I've learned to reassure people; why don't they believe me?  And there are other times where I'm saddened by the immense fear that these phantom perspectives instill in people--how alone and scary is it to live in a place so misaligned with those around you?

Then there are the days when I think that these are glimpses into dimensions that we just can't experience.  One man asks me to test him for radioactive material, because he walked on the moon and wanted to be sure that he wasn't contaminated.  Sweetly, his main concern is that he might pass the radioactivity to others.  The same man tells me that our clinic has bad vibes, and that we should watch out for earthquakes.  The next day, we have an earthquake. It's subtle, I don't even feel it, but I believe that it happened because everyone says it did.  And I wonder what else exists outside my senses.

Sometimes these views for patients are so prominent, they close out the things that I can see, which includes myself. There's a muted response to my presence, and a shutting down of conventional senses.  One woman is so consumed by her mood that I can't find any way to connect.  She doesn't speak to me, she keeps her gaze down and doesn't look at me.  I ask her to look at me, and she doesn't move her eyes or face, and I try not to react as though she's refusing. I fall into the trap of telling her what to do in the guise of helping: "I want to help you, but I need you to talk to me," as if she has the same choice to speak as I do.  I then feel bad for making this assumption, and my guilt doesn't offer any new solutions.

At other times, people communicate things that are less directed towards me and more towards whatever else exists only for them.  In the middle of a fairly normal and routine conversation with a patient, I notice that she is becoming more and more irritable--fidgeting, sighing, shaking her head and rolling her eyes.  I ask whether something is bothering her.  She stands up and yells, "I hate this clinic, and you have such a bad attitude!"  She leaves the room before I respond, really before I absorb.  This doesn't hurt my personal feelings because I know it has nothing to do with me, but it hurts that general thing in us that wants to connect.  We occupy such disparate places, hear such different sounds.

Then I laugh, because the out of ordinary is almost always funny, a little ridiculous in its suspension of belief.  It makes me think of a line from a book I read recently: "It wasn't that happiness led to humor, but that humor could lead, perhaps to happiness--that an eye for the absurd could keep one active in one's despair, the opposite of depressed: static and passive." (Lillian Boxfish Takes a Walk by Kathleen Rooney).

The two things I aspire to in these moments are humor, and humility.

In all these situations I feel my presence shrinking, small in the face of what people experience in themselves and in their lives. There's so much potential for burnout in that, because we don't want our efforts to make us feel lesser. Because as people whose agency and work have been rewarded all our lives, we don't want to admit that we have much less control than we think and want.

But most often, I see this humbling questioning of ourselves as a huge reward of this job.  The goal and gift of this work is to feel small against the expanse of what people are and can be. There are few things that make me feel the weight of human-ness more than seeing how different people are, pushing the edges of the wide spectrum what we can experience, how little each individual can perceive but how much we collectively contain.  I feel lucky to witness such a range of feelings and voices.  For me the key to continuing, and to helping, is to treat these voices not as oppressive, but as expansive.  And if I feel pity for myself, to make sure that it's not pity for not being able to convince others of my perspective, but regret that my view is too narrow to see what they see.

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