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Medicine from the Heart

December 22, 2011

Dr. Barry Saver
(c) UMassMed Now

“Let Dr. Saver know that I’m in Worcester State Hospital.” That was one of the messages in my inbox. Perhaps strangely, it felt like a victory. One of my patients with chronic paranoid schizophrenia had called to let me know about his latest mental health hospitalization.

I remember learning about schizophrenia in medical school. Patients had flat affects, did not develop close emotional links to others, spoke in word salad and faced a progressive, downhill course marked by periodic decompensations from which there would be incomplete recovery. However, I remember sitting with a preceptor as a third year medical student in the outpatient psychiatry clinic as he interviewed a woman with chronic paranoid schizophrenia.

“Do you ever think that people on TV are talking directly to you?” 
“Why, yes, sometimes.” 
“That’s very common in schizophrenia. You know, in the old days, people always used to think Arthur Godfrey was talking directly to them on the radio.”

“Arthur Godfrey? Are you serious? I’m going to have to tell my kids about that!”

That didn’t quite fit with what I had been taught—she had a family, a sense of humor and at least a little insight into her disease.

Working in safety net settings, I have cared for a number of patients with a variety of severe mental illnesses throughout my career. It took me a while to unlearn more of the prejudices I had been taught in medical school—and those absorbed growing up in our society. I have learned not to be surprised when a patient with whom I have been having a perfectly normal conversation, and may have seen a number of times before, answers “Yes” when I ask if s/he hears voices when no one else is around. Sometimes, I am the first provider they have told, because nobody else asked.

I have learned that some people can understand that the voices are generated inside their brains, not in the outside world, or at least understand intellectually that people probably aren’t plotting against them. I had one patient whose case manager was upset because he had just run up a large phone bill calling France—“He can speak French!” The next visit, we had a very nice conversation in French; he was schizophrenic, yes, but quite bright and had majored in biochemistry prior to his first psychotic episode.

In my previous job, seeing patients in a family medicine clinic at the county hospital, I inherited many patients from the Psych ER—seen once or twice with psychotic symptoms, started on an expensive, atypical antipsychotic and then dumped to us with a note, “Diagnosis: Psychosis, NOS. Please continue [antipsychotic drug name].” If the person was uninsured and did not qualify for Medicaid or Medicare, the Psych ER would not get paid beyond two or three visits for “stabilization,” so these people were sent to us and refused further psychiatric appointments, although we also were not paid for their visits, either. We had to try to figure out possible diagnoses and guess if they needed to continue medications or not. I met a large number of people with psychotic symptoms but many without the personality deficits I had been taught characterized schizophrenia. Many were working and some had good family relationships.

Working at the FHCW, I feel lucky that we have good community mental health services and I can focus on providing primary care to my patients with severe mental illness. I have seen patients with schizophrenia stop drinking, stop using drugs and even, occasionally, stop smoking. I try to help them understand and manage obesity, diabetes, hypertension, and hyperlipidemia. I frequently hear about the pain of estrangement from family and the hunger for intimate relationships. I feel sad when one of my patients decompensates and is hospitalized—but I am truly touched when someone, in the midst of that chaos, feels connected enough to me to call and let me know.

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