Editor's Note: Jennifer Reckrey kept a weekly journal of her experiences during her intern year.
I had a few free minutes at the end of my clinic session this past Thursday morning, so I took over a walk-in patient from an overbooked colleague.
The patient was a large, muscular Salvadoran man in his early forties who had long-standing hypertension. He said that for the past three months, he'd been feeling tired and didn't have the energy to take his daily medications. Just a few months back, he'd finished a five-year prison sentence for armed robbery. Now he was living temporarily with his twenty-year-old daughter and her boyfriend, but he told me that he couldn't seem to get his feet back on the ground. Though he made a little money here and there as a freelance mechanic, he couldn't get steady work: no one wanted to employ a felon, and the job-placement program couldn't help him because of his mental illness.
"What mental illness?" I asked.
Looking more at the wall than at me, he described voices that he'd heard ever since he was a boy. Though the voices had started out as benign whispers, they'd eventually become angry and mean. They regularly told him to kill himself, and in the past he had tried. Sometimes they faded a bit, but in the last few months they'd been getting louder and more directive by the day. They told him not to take his pills. They told him that people on the street were out to get him and couldn't be trusted. They told him to jump in front of oncoming subway trains. And it was getting harder to ignore them, harder to say no.
He looked right at me: "But I don't want to die."
He was so earnest and insightful, yet also so needy and overwhelmed. Feeling instant empathy, I assured him that it was no wonder that he couldn't take his medications or find a job. And I promised to do what I could to help him get the voices under control.
But what? The routine protocol for patients suffering from command auditory hallucinations instructing suicide is immediate evaluation in a psychiatric ER. But he had a car-repair job lined up in Brooklyn that afternoon and was counting on the income to buy groceries. He'd survived with these voices for twenty years, and I didn't think it was necessary to get the police involved to force him to go to the ER right then. But he did need to get there soon. It was unlikely that he would be admitted to the hospital, but the ER was required by law to make sure that he had a follow-up appointment with a mental health worker within five days. And this was essential. A psych referral for a Medicaid patient in the Bronx can take weeks. Or more.
So with the help of the clinic social worker and my supervising physician, we made a plan. That afternoon he would do his job in Brooklyn and immediately afterward would bring my handwritten referral letter to the psychiatric ER so he could be evaluated.
The next day, both the social worker and I checked the hospital computer system: He hadn't gone to the ER. I called him, and he told me that he was still busy in Brooklyn but was feeling okay. He said he appreciated my call and would go to the ER soon. Three days later he hadn't gone to the hospital, and neither the social worker nor I could reach him by phone. She decided that we needed to call a community-based suicide intervention team to visit his last listed address and assess him again. He wasn't there. They said they will keep trying.
Since then, I've called him twice, and there's been no answer. I think of him often--of the resilience it takes to grow into an articulate and thoughtful man despite hearing a constant, disembodied voice telling you that you are worthless. And I find myself checking my workplace voicemail more often than usual, even when I'm not in clinic, hoping to hear that he's all right.
I stopped by the clinic social worker's basement office this week to see if she had heard from the suicidal, hallucinating patient we'd seen a few weeks back. She hadn't. The suicide intervention team had attempted several times to evaluate him at home, but he'd never been there. They'd spoken to his adult daughter, who'd told them he was in Brooklyn and doing fine. And so they had "closed the file."
I turned to leave, but the social worker stopped me. Turning from her desk, she asked softly, "Did you learn anything from this case?"
This is what she wanted to hear me say: When someone hears voices commanding him to kill himself, there is no room for negotiation. An immediate professional evaluation is both clinically and legally necessary to avoid situations like the one we were in right now.
But I couldn't bring myself to say it.
I have learned so much over these last months. When lab tests revealed that my patient's vague abdominal pain was actually severe pancreatitis, I learned to take every complaint seriously. When my uninsured patient stopped taking her seizure medication because it wasn't covered at her sliding-scale pharmacy, I learned that having one detail out of place can topple a whole treatment plan. But this was different. And much more difficult.
I hate that there are so few social services available to help poor people maintain their health, and that getting a life started again after incarceration is an almost insurmountable task. I hate that mental health care is so isolated from the rest of medicine, that even individuals who want help can lose months of their lives waiting for the referral to come through.
I want to swoop in and guide my patient through this complicated system. I also want to respect his decisions and honor the instinct for survival that has brought him this far. And I don't know how to reconcile these two desires. I still have so much more to learn.
About the author:
Jennifer Reckrey MD is a family medicine resident in New York City. "I started writing these reflections to keep in touch with friends and family. But the process of putting my experiences into words helped me to better understand and develop my own practice of medicine."