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Treating a Messiah

It was my very first day of psychiatry rotation in my family-medicine residency at the Baylor College of Medicine, Houston.

This rotation took place at the old Ben Taub Hospital with its unmistakable odor–a combination of drugs, detergents, illness and death. Even if I were taken there blindfolded, one sniff would tell me that I was at Ben Taub.

At any rate, having survived my first seven months of residency, I was feeling a little more confident in my abilities.

I was one of the two interns on the psych unit, and we were supervised by a third-year resident named John. Our attending, Dr. Old, was actually relatively young; and I’d heard that he was tough on residents.

“Stay prepared,” John told us. “He likes pimping us”—torturing residents with rapid-fire difficult questions. Dr. Old wanted us to give every psych patient routine lab tests, hoping to find a medical reason to transfer the patients to medicine ward, which enabled the psych physicians to assume a less demanding consulting role.

As luck would have it, I was assigned to take call that first night. At about 7 pm, John said, “I’m going to the sleeping room. Page me if you need to.”

In seven months of residency, I’d learned that it was ill advised to call the supervising resident–and absolutely off limits to call the attending. The ethos was that handling difficult cases on your own builds character, even if you’re a naïve, terrified first-year resident.

I sat and chatted with three psych nurses in the quiet nursing station. One crucial thing I’d learned in residency was that at the worst, most grueling times, the nurses could be your best friends and support, so I wanted to get to know them.

“It’s awfully quiet here,” I said to nurse Jane. “Is it normally this quiet?”

She glared at me. “Now you’ve jinxed it!” she said. “You’ll see what happens.”

She was right: Soon our small talk was interrupted by a commotion in the hallway outside. The door burst open, and two psych technicians dragged in a very large man, who was screaming nonstop. He looked about six-foot-four, red-eyed, muscular–and clearly enraged.

As the techs took him past us on their way to a patient solitary room, I made out his words:

“I am the messiah, I am the messiah! I will free you all!”

The techs slammed the door of his room, then walked away, clearly feeling that their job was done. Watching them go, I could hear the man shouting from behind the door. As I contemplated what to do, nurse Karen smiled sweetly.

“Aren’t you going to see this patient?” she asked. The other nurses were smiling too, obviously enjoying this new intern’s predicament.

“I’m thinking,” I said. I needed to calm the patient down; but I also needed to get his medical history and lab results before giving him any meds.

In those days, the Baylor residents had to draw patients’ blood themselves, label the tubes and hand-carry them to the lab. My first problem was how to approach this screaming messiah and draw his blood.

I debated calling John, but decided to try something first.

I gathered up the box with tubes, tourniquets, syringes, needles, Band-Aids and alcohol swabs and started toward the man’s room. In the nurses’ eyes, I saw alarm for my safety mingled with amusement at my plight.

I opened the door. The man sat at the edge of the bed. He looked smaller. Except for his bloodshot eyes, he looked calm and collected. Even though he believed that he was a messiah, I felt I could connect with him on a human level.

“Mr. Messiah, I am Dr. Ahmed,” I said. “How are you today?”

“What can I do for you?” he said.

“If you’ll allow me, I’d like to ask you a few questions.”

“That’s fine.”

“How are you feeling today?”

“Fine.”

“Any symptoms?”

“Yes, hearing voices.”

“Have you heard voices before?”

“Yes, for many years. But more voices this week.”

“Where are the voices coming from?”

“From my TV.”

“What do the voices say?”

“Many things.” He paused and seemed to withdraw into himself.

“Do you take any medicine?”

“Yes, for schizophrenia.”

“Have you been taking it?”

“No, not for two weeks. I ran out.”

“I have a very important request,” I said, trying to quell my anxiety. “I need some blood for a ritual here tonight. It would be great to get blood from a messiah. Would you kindly give me a few tubes of blood?”

He immediately extended his arm. To my delight, his veins were very prominent.

Swiftly, I put the tourniquet on his arm and drew several tubes of blood.

After thanking him, I walked out triumphantly to the waiting nurses. When I described how I got the blood, they laughed out loud.

“Did you get his urine?” one asked.

No, I didn’t. I forgot.

I picked up a urine cup and went back into the man’s room.

He looked at me. “What do you need, Doc?”

“Listen Mr. Messiah,” I said. “I believe you are a messiah; you believe you are a messiah, but the nurses do not believe you are one. If you give me some urine, I can prove to them that you are a messiah.”

He stood up and started to unzip his pants. Before he could take them down, I stopped him and walked him to the urinal, then returned to the nurses, carrying the sample.

About an hour later John walked in, and the nurses gleefully related how I’d obtained the patient’s blood and urine. Studying John’s serious, somewhat depressed demeanor, I found it hard to gauge his response.

John examined the man, suggested some injections and left without saying a word about the tactics I’d used.

I accompanied nurse Jane to the patient’s room, and she gave him the injection, which he accepted peaceably.

Pondering John’s silence, I started to worry that he didn’t approve of my handling of the patient. The internship year is stressful, and as an international medical graduate I felt especially apprehensive; I couldn’t afford to fail this rotation.

The next morning Dr. Old came in for rounds. As we approached Messiah’s bed, my heart started pounding. He was deeply asleep. I gave the morning report and the lab results, which showed multiple illicit drugs in his system. At this point, John recounted how I’d gotten the patient’s blood and urine.

I eyed Dr. Old anxiously, feeling a little guilty. He looked back at me.

“Brilliant! You’ve passed this rotation!” he said.

After rounds, I went back to see the patient again. He was still in a deep messianic slumber.

Silently, I offered him my apologies—and my gratitude. Thanks to him, I’d passed this rotation on the very first day. In my heart, I knew that a messiah wouldn’t hold it against me for deceiving him; he’d probably rather pray for my soul instead.

Over the next couple of days, I got to know the man a little more. With his medications working well, our conversations were fairly normal, even friendly. In the back of my mind, I worried that he’d ask me about the ritual that I’d mentioned, and whether I had proven that he was indeed a messiah. Much to my relief, he never did.

This experience confirmed for me that connecting respectfully with another person, whether human or messiah, is the most critical skill for a physician–and also that the art of medicine is a little harder to learn than the science of medicine.

Syed M. Ahmed is a professor emeritus of family and community medicine at the Medical College of Wisconsin (MCW), Milwaukee, where he was the inaugural associate provost and senior associate dean for community engagement. “I have written and published stories and poems in Bengali, but only a few in English. My lame excuse is that I don’t have enough time to write, as I am enjoying my retirement. I have a collection of ideas for stories like this one, based on thirty-plus years of clinical practice, waiting to be written.”

Comments

28 thoughts on “Treating a Messiah”

  1. Respectfully, lying to the patient is not ‘patient-centered-medicine’. ‘Accepting the patient’s beliefs’ is not what was done here; the patient was lied to and manipulated. Excerpt below:
    “Listen Mr. Messiah,” I said. “I believe you are a messiah; you believe you are a messiah, but the nurses do not believe you are one. If you give me some urine, I can prove to them that you are a messiah.”

    There is a lot of support here for not changing the patient’s reality and not disagreeing with them in order to create a therapeutic relationship, and again, I’d just like to reinforce that you can accomplish these things without making statements like the one above.

  2. Hello Dr. Ahmed,
    Thank you for this well-written patient care story.
    It is clear that blood and urine were necessary for the care of this patient and that collecting them was a right of passage for you.
    However, this section gave me pause: “Listen Mr. Messiah,” I said. “I believe you are a messiah; you believe you are a messiah, but the nurses do not believe you are one. If you give me some urine, I can prove to them that you are a messiah.”
    Is this embellishment or reality?
    Thank you for sharing this experience.

      1. In this case, ” reinforcing”- or simply accepting the patient’s beliefs was absolutely necessary.
        It was the only way to help him.
        This is what many of us call “patient-centered medicine.”
        These days , we need much more of it in the U.S.

        1. Dear Maggie

          Thanks for your astute comments. I fully agree with your comments. When a patient has “altered reality “ , trying to change that in the first meeting or early could be counter productive. Establishing a trusting relationship with a patient creates the platform for effective treatment. It’s not only necessary, it’s crucial.Meeting a patient where that person is respectful and creates the avenues for engaging with a patient. Over my lifetime, I learned that patients care for a caring physician more than they care for a super smart physician who does not know how to engage.
          Thanks again
          Syed

    1. I kept waiting to read how the author was (hopefully constructively) criticized for how he handled this. It seems to violate the ‘don’t argue but don’t reinforce’ recommendation that I have always read and been taught, but perhaps this wasn’t the case in the past.

    2. I was expecting to read that the author was criticized for handling it in that matter. I have always read and been taught, ‘don’t reinforce’ when it comes to delusions.

  3. Thanks for your beautiful story. This is true re: the art and science of nursing too. I used to work on a locked dementia unit. Patients would frequently say, “I want to go home”. If staff responded with things like, “you can’t go home”, “this is your home” or “here, have some ice-cream” you could see (often) how enraging it was. As if, being heard was somehow rooted in survival itself. I wondered if they could process on a deeper level that they were being ignored. It was much more effective to validate. “You want to go home! I hear you. Tell me about your home” or “You want to go home! Me too. Let’s get out of here…”.

    Now I teach communication and EQ (with medical improv) and believe these kinds of skills will help us in critical areas: patient safety, patient experience, workforce health, leadership, collaboration, culture, cost-effectiveness. Pretty much everything.

    1. Dear Beth
      Thanks for your kind comments.
      With your last sentence, you captured the value of effective communication, though in medical schools , we barely teach these critical skills.
      Thanks
      Syed

      1. Yes, medical schools really need to focus more on
        how to effectively communicate with patients.

        Years ago, this is what the most successful doctors
        knew how to do. (Sixty-five years ago, I was a pretty sick child, and our doctor, Dr. Collins, made home visits.
        He knew how to talk to me and to my parents.)

  4. This is a great story, extremely well told. My older brother (who passed last year) was hospitalized in an inpatient mental health facility for a year in the 1960s and on a bad day could have been your patient. I am always grateful for the wisdom and humanity of healers who take the time to focus on the human connection. Health care must be more than “outcomes,” “throughput” and “efficiency.” Please keep writing!

    1. Dear Tim
      Thanks for your comments. Yes, health care was always a business and more so now. The pressure to reach RVU’s and show some arbitrary outcomes has become the norm. Patient satisfaction is measured but the value of human connections with patients is not emphasized.

      Thanks again
      Syed

  5. As a psychologist I ran treatment units at a state hospital then the VA. While drawing blood was something then I honestly think a number of psychiatrists would have been unable to do…nurses did it all… your approach of accepting the patient where he or she is was always paramount. When I got to know a patient I told him or her that I believed that little green men were in the room but no-one else could see them, for example, in an attempt to accept and introduce another reality. It worked well as a nice balance.

    1. Dear Pris
      I agree with your comments, specifically need to “accept the patient where he or she is always paramount “.
      Thanks for your comments.
      Syed

  6. I loved your story! And, in trading it, I realized that accepting the patient on their own terms is the key to good care for all patients, whether they are psychotic or not. Your story reminded me of a patient in our clinic decades ago who was floridly psychotic and had a similar delusion, that he was the Messiah, and we decided to just listen and listen and listen and respond as though we fully believed him- just as you did, and see where it led. To our amazement, within a few minutes, he was telling us, in an indirect way, his story of severe trauma. I learned that day the power of listening and accepting without judgment.

    1. Dear Warren
      Thanks so much. I appreciate your comments.
      The power of listening and accepting without judgement are the key ingredients in engaging with others.
      Regards
      Syed

  7. What a change in times. The residents never drew the blood or got the urine even in more than 30 years back. It was nursing that did it always or sometimes the nurse aides who had skills. But as a psych nurse, I often used this similar tactic to work within the patient’s delusions to get them to cooperate. You did whatever you had to get the job done.

    1. Dear Roland

      Thanks for your comments.
      Depending on which hospital you rotate , residents did lab work too. Yes, nurses did labs. Residents also did whatever they had to do to get job done.

      Regards
      Syed

  8. Your writing style is good. Keep telling those stories. A few sentences every morning and who knows what the day will bring

  9. Helen Katharine Swearingen

    Thank you. Your revelation that meaningful medicine is based on the art of relationship and respect for the person comes before an application of the science of medicine.

    We have a daughter learning to live with her schizophrenia and we as her parents have undergone a steep learning curve on ways to listen with respect to impulses she has which we do not understand.

    There is no antipsychotic or cognitive therapies that can heal without treating any person with honor and respect.

    Thank you for sharing this experience and wonder.

    1. Dear Helen

      Thanks for sharing your personal story of your daughter . I wish her the best.
      As you said, treating any person with honor and respect makes all the difference.

      Regards
      Syed

  10. I love that you met the patient, the messiah, where he was. You didn’t attempt any “reality orientation,” rather, accepted his reality.

    1. Dear Judy
      Yes, “ reality orientation “ does not work and can do more harm .
      I appreciate your kind comments.
      Regards
      Syed

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