Looking back several years, my path toward psychiatry has preceded my familiarity with the field by many years. I have always been fascinated by the nature of human experience and in the untangling and interpretation of human stories, and have been a particularly voracious reader of fiction since childhood. As I matured, this same fascination with stories led me to pursue a degree in literature (in addition to my degree in genetics). In retrospect, I realize that many of my favorite poems and novels explored, if only implicitly, psychiatric issues and concepts. For example, T.S. Eliot’s classic poem “The Love Song of J. Alfred Prufrock” perfectly depicts a man utterly paralyzed by depression. Similarly, when I revisit the novel now, the slovenly, delusional protagonist of John Kennedy Toole’s “A Confederacy of Dunces” behaves like a disorganized schizophrenic– the same disease the author himself eventually developed.
My interest in mental health and the humanities continued during my preclinical medical school years, but it was not until my third-year psychiatry rotation that I found a new route for exploring this passion. What struck me immediately was the new depth of interactions and relationships between provider and patient: during my time on service I sat and spoke with patients at greater length than ever before. Each patient had their own complex narrative, and whatever psychiatric diagnosis we might suggest for them was deeply tangled inside that story– for example, the challenge of recognizing underlying depression in a chronic heroin user, or bipolar illness in a personality-disordered victim of domestic abuse. I came to recognize that even in diseases with a clear anatomic or pathologic basis, we could shape the outcomes of their mental condition only if we understood its context. More than during any other rotation, I learned that listening and talking– often the former more than the latter– were absolutely essential, and occasionally sufficient, for helping a person through a time of stress or illness. More modern approaches– pharmacological, surgical, and electroconvulsive– are of course vitally important to psychiatric practice today. These tools enable us to change the course of disease processes that, in an earlier time, sentenced many ill patients to anguished, foreshortened lives. However, at no point can mental illness– an illness of the mind– be separated from the mind itself, thus the essence of psychiatry ought to be the attempt to understand a suffering patient’s experience.
Psychiatry is, I think, unique in its recognition of this fundamental fact, and it was this realization that has shown me where my future lies. The field strikes me as a completely different and remarkable branch of medicine, combining the evidence and science of modern medicine with the rich history and humanistic quality of the arts. For example, one of my most enlightening experiences occurred early in the rotation with a patient who had been admitted the night before. During rounds we asked him to speak with us, and just in the few minutes it took for him to walk from the common room to his private room, I finally understood the full meaning of the term “psychomotor retardation.” Previously I had understood it only as meaning, “Depressed people move slowly”; and yet watching this young man walking down the hall, I could see in his face and his movements how difficult each step was, how utterly hopeless he felt, and just how disabling his illness had become. A few minutes later, when he spoke with us, I recognized that his words– his story– were filtered and dramatically distorted by his illness. As my time on the psychiatry service went on, I was able to see first-hand the faces of schizophrenia, drug addiction, domestic abuse, and intellectual disability, and my appreciation for the debilitating consequences of mental health problems only grew.
In the months since my psychiatry rotation, I have made it a point to explore mental health issues with my patients and colleagues on other services. For example, my most interesting patients during my pediatrics rotation were a series of teenagers who had attempted suicide, with whom I spent time discussing family life, friendships, and even religion. I realized that even among patients with no apparent psychiatric disease, simply taking a few minutes to discuss the disorienting and unpleasant experience of illness and hospitalization could be therapeutic. During my subinternship I worked to convince junior students that mental health should not be thought of as secondary in importance, that mental illnesses are as “real” as cancer and diabetes, and that a basic understanding of psychiatry is beneficial in any specialty.
In recent months I have also developed my understanding of basic psychiatric concepts through my own reading. In particular, I have tried to build an understanding of the unique vocabulary of the profession, as well as the essential neurobiological and theoretical basis of the mind and its perturbations. Psychiatry is unique for its rich and well-documented history; the writings of its most influential figures remain both relevant and widely available. I certainly cannot boast that I have mastered the works of such historic psychiatrists as Emil Kraepelin and Karl Jaspers, but I have at least attempted to familiarize myself with them, if only to understand the origins of our field. Each thing I read drives me to read further, to attempt to understand the remarkable, arguably inscrutable nature of the human mind and human experience. Although certainly my clinical experience at this point is limited, I cannot help but think that the question, “How can we treat depression?” is equally as important as, and indeed contingent upon, the fundamental question, “What is depression?”
One thing I particularly look forward to during my residency training is exploring these questions in real life with my colleagues, attending physicians and most importantly in the care of my patients. I hope to join a program characterized by a progressive, integrative attitude toward modern psychiatric research and practice. In that setting, I would be able to develop and refine my skills as physician and therapist, contribute to modern developments in the field, and above all provide sympathetic, high quality care under the guidance and supervision of like-minded clinicians.
I came to the field of psychiatry circuitously. For almost as long as I wanted to pursue medicine, I thought my future would be in surgery. At an early age, I remember visiting my mother’s laboratory, where she worked as a neuropathologist, and helping her dissect neurological tissue under the microscope. I would sit with her, mesmerized, gently teasing tissue off a monkey spinal cord with the delicate instruments, and imagining a future using similar tools to manipulate tissues and heal illnesses of the body. But while I believed that my future path was in surgery, I naturally gravitated toward the study of the human mind and behavior.
My father is a psychiatrist, and between him and my mother, the dynamic between the mind and brain were always topics of conversation at the dinner table. Partially because of their influence, and largely because of my own inclination and interest, I have always been driven to understand not only the “how” of thought processes and interpersonal interaction, but the “why”. Why do some minds create happiness, and others suffering, in the face of the same external circumstances? How do our internal states transform our external experiences? To what extent are these habits and predispositions fixed, and to what degree can they be reconstructed to improve our relationship with the external world and with ourselves?
When I entered college, instead of focusing on a basic science such as biology or chemistry like many of my pre-med colleagues, I was drawn to the study of psychology. It was here that I first began to investigate the more mysterious aspects of the human mind, and learned the ways the mind and brain can act unpredictably and destructively. I was fascinated by the complex psychopathologies of mental illness and motivated to understand the anatomical and biological basis of psychiatric disorders. I was struck by the realization that often our own mental processes, in trying to alleviate suffering, would instead create it.
When I graduated, I decided to further investigate these ideas in a research context. I joined the Department of Psychiatry at Stanford University and delved into the study of the relationship between stress, cortisol levels, APOE genotype and cognitive decline in older adults. I found the subject matter challenging and stimulating, and loved the excitement of discovering something new and contributing to the fund of knowledge available to all clinicians and practitioners. But when I entered medical school, I was drawn back toward the surgical specialties. I appreciated the technical aspects of surgery, the almost artistic nature of the field, and the dedicated, conscientious and disciplined nature of the surgeons. I focused on urology as a subspecialty, and directed the same interest that led me to pursue research at Stanford to a project at the USC/Norris Cancer Center investigating comparative pathological findings in men who underwent prostate biopsy and subsequent radical prostatectomy.
I began my third year surgery rotation excited to finally put into practice what I had studied from a theoretical perspective for so long. But instead of dreaming of spending time in the OR, I would look forward to clinic days, where I could sit across from patients about to have surgery, or recovering from a recent operation, and listen attentively as they told stories of fear, sadness and apprehension. I learned how underlying anxiety or distress could manifest as subtle physical complaints, such as pain or insomnia. I began to appreciate how mental states could influence a patient’s interpretation of his or her illness, and either aggravate or mitigate the suffering the patient felt in the face of the same degree of pain. I learned that by simply being attentive and mindful, I could demonstrate my empathy and concern, and show these patients they were not alone in the process.
Physicians in both surgery and psychiatry share a profoundly intimate role in the patient’s life. As a surgeon plunges into the body to heal with a scalpel, a psychiatrist plunges into the mind to heal with a few well-chosen words, an empathetic nod, or medications that modulate the neurochemistry of the brain. My subsequent third and fourth year psychiatry rotations have confirmed that my passion lies in alleviating suffering through reconstructing the mind, rather than in fixing the mechanics of the body. I look forward to developing the skills to transform both the mind and brain to serve my patients in a meaningful way, and am enthusiastic to combine my interest in clinical practice with my passion for academic research to create a fulfilling career in psychiatry.