Tag Archives: education


Dr Shyam K Bhat MD is a
Psychiatrist and Integrative
Medicine specialist.

He is board certified in
Psychiatry, Internal
Medicine, and
Psychosomatic Medicine,
with additional certification
in clinical hypnosis

...READ MORE


Subscribe to this blog
Click to subscribe to Dr Shyam Bhat's blog and receive notifications of new posts by email.

ARCHIVES


Read a Random Post


My First Day


Dr. Venkatesh, Professor of Psychiatry and Head of the Department, had a thick mustache and a permanently disgruntled attitude.

“What is schizophrenia, I say?” he asked by way of greeting, as we stood in his small office, sweating in the Bangalore summer.

“Sir,” I ventured, “it’s a psychotic disorder in which there are delusions, hallucina-tions, and decreased functioning.” I’d read a few pages from the abridged version of Kaplan and Sadock—bought the book, in fact—and since this was the only subject where my interest exceeded that of my peers, I hoped this was my turn to shine.

Dr. Venkatesh looked at me as if I was unclean. “You fellows don’t study, only come here to enjoy,” he said, which was a bit unfair because, frankly, there was not much to do at Victoria Hospital by way of enjoyment. “Get out, all of you,” he said, with disgust. “Go and learn something, I say.”

We shuffled out of his office, our heads bowed. In those days, in most medical schools in India, humility and subservience were the preferred modes of relating to one’s teachers and seniors. Confidence was often interpreted as arrogance, an unforgiv-able sin, and could result in failing the rotation. The safe approach was to replace any trace of confidence with a profound, almost theatrical meekness—head down, voice high pitched and soft, and minimal eye contact.

The less one knew about the subject, the more humble one had to appear. Ignorance was permissible, as long as one was sufficiently humble. Years later, while working in the U.S., I would be surprised by the unabashed self-assurance of medical students in the West, who would wax eloquent even on occasions they did not know the answer to a question. “Well, I think the data is not clear on that. In my experience. . . .”

I would never have passed medical school with that attitude. As medical students, it was essential for us to understand the dynamics of each department—who to keep happy, who to avoid, and so on. In psychiatry, the word was that Dr. Venkatesh was only the ceremonial head. The man who was really in charge was Dr. Sreenivas, a PG in psychiatry. PG was short for postgraduate, the term used in India for resident physician.

Dr. Sreenivas met us in a dark classroom next door, which was also used as a conference room of sorts, and on occasion, an interview room.

We would have to sit here, he said, until we got some patients.

I was surprised that we would have to wait for patients. This was the government hospital—free health care for the poor—and consequently, clinics and wards were overflowing with patients. In the medicine clinic, for example, a physician would rou-tinely see more than 200 patients a day. Obviously, business was slower in the psychiatry department.

I sat on the edge of the front bench from where I could see the Skin and Venereal Disease Clinic, which was adjacent to the psychiatry clinic. I am not sure why exactly sexually transmitted diseases were clubbed together with dermatology, but there it was.

I passed time by trying to assign patients waiting in line to one or the other. Skin or VD?

There was a man with white patches on his face—leukoderma, probably. Skin. Behind him, in the queue, a woman with the obvious lesions of leprosy. Definitely, Skin.

Then a man without any obvious abnormalities. I noticed his hand straying towards his groin. VD, I decided.

Almost half an hour passed in this manner. Two of my classmates were playing makeshift cricket at the back of the room, using a rubber ball and a heavy book for a bat. From another corner of the room, I could hear the sound of loud snoring.

Finally, Dr. Sreenivas came back. “No, no, don’t get up,” he said, as a few of us scrambled to our feet. “We have an interesting case. Only one of you can come.”

It wasn’t as if there was a huge rush to the door. I vaguely remember 2 of us standing up, and then the other person volunteered to sit this one out.

She was in her mid-30s, I estimated, and like many of the patients who came here, she was from a nearby village. She sat on the chair and looked straight through us. The man sitting next to her—the husband—stood up when we entered the room.

“What to do, Sir? Please. You have to help,” he said, speaking in Tamil.

I could understand Tamil, but spoke very little of it. Luckily for me, Dr. Sreenivas only expected me to observe the interview. He proceeded to piece together the story from the husband.

The wife did not say much, other than, “I cannot see,” after which she began to mutter unintelligibly, staring into space.

They’d been married for about a year, the husband said, and their life had been perfectly ordinary until a few weeks before. One night, he came back from the arrack shop, where he’d had his customary 3 sachets of the country-made liquor. What was that? Yes, he did drink every day, but what of it?

When he came back that night, and sat down for dinner, the rice was cold. He hit his wife because she should know better. Yes, yes, he should not have done that, but he did not hit her very hard. “Anyway, I don’t hit her every day, but once in a while only.”

When he slapped her this time, instead of heating up the food as she would usually do, she closed her eyes and began to chant some slokas from the Gita. He was about to raise his hand again when she looked at him, held out her palm, and blessed him. God promise, he could smell some jasmine even though there were no flowers in the room. What was going on? And then, he realized that a devi had come inside her—she had become a goddess.

So, for the next 5 days, he treated her as the goddess she was. He cooked for her, he performed poojas every morning, worshipping this divine being who graced his house, and as for the arrack shop, why, he had forgotten the way only.

His story was interrupted by a mewling sound from her. He jumped, but Dr. Sreenivas patted his hand. “Don’t worry,” he said. She lapsed into silence, and the man continued.

So, everyday he cooked for her and became an exemplary husband. “After all, a devi has to be treated like a devi.” On the fifth or sixth day, he could not remember which, he went out to the arrack shop again. “Just one packet I had, Doctor.” When he came back and went to pay her homage, she suddenly shrieked and slapped him on his face. Hard. She then began to use words that only he and his friends would use, especially when the cricket team was not playing well. “She does not know such bad words, Doctor.” He was stunned. Then he realized that he had been tricked. It was not a devi that had entered her being, but a pishachi, a she-devil. She was possessed by an evil spirit.

He touched a small cut on his face and showed us the blood on his hands in classic Bollywood fashion. “Look at my face; see what the pishachi did. Anyway, I brought her here because my neighbor, who is being a teacher, said this might be mental problems.”

“This is not her problem, but yours,” Dr. Sreenivas said gravely.

“Why, Sir? Why you are saying that?” “See here, Mister,” Dr. Sreenivas replied. “There is a saying in Kannada, ‘When you treat a woman well, she is an angel. Treat her badly, she is a devil.’ ”

Later, as a nurse helped the lady out of the room, Dr. Sreenivas explained the case to me. “Classic possession case with hysterical blindness. She has a conversion disorder. Now what I will do is give her some diazepam, then suggest to her that the devil will leave her and that she will be able to see again.”

I was impressed that she could be cured so easily, but Dr. Sreenivas misinterpreted the expression on my face. “Yes, yes, I know the books say this needs psychotherapy and all that, but we don’t have the resources. Not to worry, she will be alright, and more importantly, it will cure the husband also. Hopefully, the fellow will be scared enough so he will behave himself.”

A few hours later, I saw the patient leaving the hospital with her husband. He trailed behind her, slightly bent, as if he were cowering before a devil, or perhaps, bowing before a goddess.


Days Like This


I feel terrible,” she said. “I can’t sleep, I cry all the time, and I don’t want to do anything around the house.”

Her symptoms seemed mind-numbingly mundane. I’d heard a dozen similar stories in the past week alone, probably thousands over the years, and I had to remind myself that for her, this was a singular experience.

She’d never felt anything like it.

I dictated my note in a practiced monotone. Hers might be a story of despair, or even of hope and healing, but the words were generic: depressed affect, speech soft, thought processes logical and goal directed. . . .

I asked myself: what happened to that sense of wonder and privilege I felt when I first started out in psychiatry? I questioned whether my colleagues ever had days like this. I looked at them as they worked: one was at her desk efficiently taking care of paperwork, and my other more senior colleague, with more than 20 patients to see that afternoon and onerous ad-ministrative responsibilities, sighed heavily as his pager went off again.

Even his legendary patience looked like it was wearing thin.

Outside, the sky was gray and overcast, a depressingly obvious meta-phor for my mood. Why, I asked myself, did I choose to become a psychiatrist?

Of course I’d been asked that question before—most of us have—

but I hadn’t thought about it for a while. It’s interesting how we rarely ex-amine the very choices that define us.

When I was in residency, in a combined internal medicine and psychiatry program, everybody approved of the internal medicine part of my training—that was acceptable, even commendable. But my friends and family thought psychiatry an unfortunate choice, although interesting in a morbid sort of way. To them, psychiatrists were like members of a secret society that dabbled in dark and unholy deeds. Psychiatry was a place everyone had heard of, but nobody wanted to visit.

In my final year of medical school, in Bangalore, I met a psychiatrist, my father’s acquaintance and occasional golf buddy, at a party.

“Think carefully before you do psychiatry,” my mother said, pointing discreetly at Dr. Muralidhar, who was standing by the buffet table serving himself pulao and chicken. “He has no social life because people don’t want to acknowledge that they know a psychiatrist. Only a few other doc-tors are his friends, but most people run away when they see him.”

My mother was given to hyperbole when she was trying to make a point, but this story of ostracism only increased my desire to become a psychiatrist. I watched Dr. M standing alone in a corner; to me, he was a noble figure, a Galileo, a Socrates, a Gandhi, a pioneer who pursued the truth despite formidable opposition. Later that evening, my fantasy was sullied a bit by the sight of Dr. M talking happily to a group of his friends, laughing and chatting, with no signs of the stigma that my mother had re-ferred to earlier.

When I joined medical school, a friend of my father’s, a prosperous businessman from Bombay, asked me, “So, what do you want to specialize in?”

“Psychiatry,” I replied.

He looked at me, his eyes widened, then he leaned back and laughed out loud. “Psychiatry!” he exclaimed, with a mixture of hilarity and disbelief, as if I’d just told him I wanted to become a Bollywood star. The conversation ended there. I didn’t ask him why he reacted that way. But I’d grown up in that milieu; I’d seen the movies, and read the books, and I knew what he was thinking—that a psychiatrist is someone who walks the halls of a dank, decrepit building, a large rusty ring with keys in one hand and a flickering candle in the other, as crazed inmates scream wretchedly inside their barred cells.

For many people of his generation, there was no such thing as a normal person with an illness of the mind. You could, for example, be an average person who just happens to have a bad heart, or an ordinary woman who just happens to have arthritis. But the moment you were afflicted by mental illness, your very core changed; it was as if a person who was psychotic was transformed into another species altogether, a species that was considered better left uncared for, unheeded, and unmentioned. And I fancied myself the protector, shielding this underdog from the derision of people like the businessman from Bombay.

I remember other incidents that might have sparked my interest in psychiatry.

A classmate in college, on the eve of his exams, was found dead, hanging from the stairs, a paper bag over his eyes, and a rag in his mouth.

“Why did he do that?” I asked a friend of his.

He shrugged. “He thought he was going to fail the exams.”

His death was ascribed to academic pressures, and his parents were blamed for pushing their son too hard. No one ever suggested that a mental illness may have been responsible for his death. The family left the city a few years later, never to be heard from again.

Then, there was a distant relative of mine, my mother’s uncle’s cousin or something like that. (His proximity to the family was always minimized.) The family secret was that the man would sometimes take his clothes off and run around naked in the village, much to the embarrassment of his family.

I was curious. “Why does he do this?”

My cousin shrugged. “He’s just like that,” she said. “Crazy.”

And then, there was the boy in my seventh grade class who was clearly unwell. Even as 12-year-olds, we knew that he was different from the rest of us. Jasdeep ate pieces of chalk with seeming relish, and then often, when the teacher looked away, he took a piece of glass and casually ran it across his forearm, taking pleasure in the reactions he got from us: amazement, disgust, fear, and fascination. None of us thought of telling the teacher. To us, Jasdeep was just being Jasdeep. Later in the school year he was caught cutting himself, and his parents were summoned for a meeting. I remember Jasdeep coming back to school the following day, subdued and sullen. His father had beaten him, he said. A week later, he started eating chalk again and cutting himself with a vengeance.

But my first vivid memory of anything psychiatric is from one summer evening in the late 1970s, when my parents inadvertently took me to see the famous movie about a girl with mental illness, I Never Promised You a Rose Garden. They thought the title was fairly innocuous.

I was 6 years old at the time, and the movie’s images burned into my consciousness like a primordial dream: a girl taken to a hospital by her concerned parents; savage men brandishing spears and riding unbridled horses across barren lands; and flashes of the girl cutting her wrist and periodically extinguishing cigarettes on her forearm.

After I asked my mother for the third time, “Why is she doing that?” my parents and I left the theater.

I spent the rest of the week wondering why the girl had seemed so upset, why she’d cried and why she’d hurt herself. In retrospect, those must have been difficult questions for my parents to answer. How does one explain mental illness to a child who is still coming to terms with the concept of normalcy?

As I thought about these incidents, I realized that although I was not exposed to more than one’s usual share of psychopathology, I always wanted an explanation for what I saw; psychiatry was a method of inquiry into the questions I’d always had. I realized that for me, as for many of us, psychiatry was not a dispassionate career choice, but a vocation.

I think we become psychiatrists because all our lives we have observed things on the periphery of our consciousness, things that we could not describe, or comprehend, or change, until we learned the language of psychiatry.

We did not choose our passion as much as it chose us. On days like this, when my work seems dull and exhausting, thankless or frustrating, when even someone’s misery seems commonplace and tiresome, I find it useful to remember why I am a psychiatrist. Remembering why comforts me, inspires me, and renews me.

I went in to see my next patient. There was nothing else I’d rather be doing.