Intima

After the very short break, I started back at the hospital, assigned to the specialty I knew very little about. Colleagues had told me it was radically different than 'traditional' medicine and there was little I could do to prepare myself.

Some of my close colleagues didn't think much of Psychiatry, but I knew I had to take it seriously. The patients are vulnerable, and perhaps I am too. It seems to me the art of medicine can truly be elicited here as nothing is more important than establishing rapport and trust in an atmosphere riddled with vulnerability, distrust, doubt and much more. There are few organic (i.e. identifiable) causes of a patient's abnormalities and thus, clinical examination, laboratory investigation and radiological assessment are barely helpful except to rule out obvious, yet uncommon, identifiable causes of a patient's illness. Essentially, the only tool that is useful to organise and understand a patient's complaints is the history (i.e. interview).

I am currently assigned to the Department of Addiction Medicine, which is a subspecialty in its own right as the sub-population is highly unique. These are people banished from society due to their addictions and are incredibly distraught by previous experiences in their lives. Their sensitivity is striking and they pick up on the smallest notions of judgment, condescension and any hint of "I'm better than you, so let me help you." Not that I'm like that at all, but one has to be very conscious of their reactions and responses to the details these patients reveal. We must be empathic in moderation - going overboard may disrupt the rapport and showing little will destroy what structural support the initial impression a clinician gave the patient. This is a critical opportunity for us to practice people's skills and I'm sure we could all use a little of that.

The patients were somewhat uncomfortable and apprehensive. When I took notes, some of them were very concerned about what I was going to do with these notes and I found it difficult to explain that this information may be useful for their care. I'm not sure how they felt about that, but it was clear they weren't comfortable. I must get to a point where I can recall the majority of the history from memory, but that will take a very long time.

Growing up in the suburbs I did, drinking was a normal part of the playground. Young teenagers and their parents drank in the morning, afternoon and evening; sometimes well into the night. When there was no alcohol to buy, they resorted to drinking methylated spirits. Playing basketball around these people made me uncomfortable and the frequent bullying and glass bottle-throwing was not a nice gesture either. So I hated them - these people who drank until they couldn't stand, feeding their children and encouraging other children to join them. My hatred of alcohol use was amplified when I was old enough to realise that my father was a drinker. He had his nights of binge drinking, but what bothered me the most was the fighting. Then the late night self-talk he mumbled to himself, mostly profanity and the slamming of the china as he washed the dishes at peculiar hours. I enjoyed the odd drink of alcohol, but not to the extent that I was so drunk I was saying whatever came to mind and doing whatever I pleased.

High school exposed me to drug dealing in the bathrooms, marijuana use by my close friends and even cocaine in the final years. I didn't take drugs, but it was certainly popular. If I knew my friends better, I could have also known about their obsessive use of anti-depressants. And these memories have resurfaced in the last few days. Well, I guess that's slightly inaccurate: my father still drinks about 1-2 bottles of wine per night, every night for years. Every time I stay with my parents, I get angry and shut myself in my room, watching movies on my own or playing computer games until I was tired enough to sleep quickly when I went to bed.

I didn't like what was happening around me and it was easy for me to judge people. Thankfully I didn't have these thoughts and feelings when I started the rotation, and they haven't surfaced in the clinical setting as of yet. Every patient I have spoken to has mentioned sexual, physical, verbal or psychological abuse by either their spouses, children, parents or siblings so far. The very people that were supposed to be supporting them were the people destroying them.

Interestingly, all the patients I spoke to this week were self-admitted. I admired their courage and strength. They knew they couldn't survive any longer out in the world of pain, damage and abuse. At the same time, they wanted to get over the addictions they developed to numb the scarring and agony. Some of these people were disadvantaged since they were born, others had significant events that changed the course of their lives.

We as students, clinicians and professionals must be very careful to help these people through such a very delicate time in their lives and I hope we are able to make them feel safe, comfortable and eventually, create an atmosphere where they can speak to us about the things they like.

Our past will re-surface and we must be careful to maintain our own composure while remembering that it is the patient that is the strong one - they confessed, admitted and presented for help. We're still just coping within the barbed-wires of defences we have set up in our own minds.