Tag Archives: Am J Psychiatry

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


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


Read a Random Post

How Many Psychiatrists Does It Take?

The dinner was excellent: gently seared tuna and succulent crab cakes. The symposium was not as enjoyable, but still, this was a good start to my stay in Philadelphia. I had flown in that morning for the annual meeting of the American Psychiatric Association, my first experience at such a large conference. My room for the week was at a decidedly seedy motel in Bucks County, about an hour away from the city. I looked at my watch. There was still some time before the last train back, so I decided to spend some more time at this hotel, one of Philadelphia’s finest. I walked toward the bar, situated in the center of a high-ceilinged lobby with shimmering chandeliers. An ingenious waterfall with thin sheets of water cascaded onto pebbles, making a pleasant sound.

I settled into one corner of the bar and ordered a cocktail, soaking in the ambience. Most days, this was probably an oasis of jazz music and soft murmurs, but tonight it was teeming with other psychiatrists. Like me, they had bags with the conference logo displayed prominently and badges. Unlike me, most of them were in groups engaged in animated conversation. I entertained myself by listening in on some of the discussion.

“The schizophrenia update was excellent. It’s going to definitely change my practice.”

“I am not so sure about the applicability of that data in the real world.”

“What’s your experience with…”

Just then, a man walked into the lobby, carefully taking the few steps to the bar. He sat down on a sofa next to me, and I could smell him from where I was sitting: sweat, urine, and stale cigarettes. His shirt was wet even though it hadn’t been raining, and he rubbed his unshaven face and looked around at the crowd, torn jeans sagging below a corpulent belly. He began mumbling to himself, and although I briefly entertained the idea that he might be an eccentric colleague, a fellow psychiatrist who had forsaken formal attire in favor of something more unconventional, he looked so destitute and beaten that it was obvious he was one of the many mentally ill and homeless people I had seen in the city. Drugs, alcoholism, a major mental illness, social drift, and here he was, rummaging through the torn plastic bag he was carrying.

It struck me as incredibly ironic that this should happen, that someone who was mentally ill should walk into a roomful of psychiatrists. By now, the bar personnel were staring at the man and whispering among themselves. One of them finally went to the man.

“Do you need anything?” The man shook his head and mumbled, “No.”

“This bar is for guests only, sir,” the waiter said.

The man ignored him and just looked away, saying something under his breath.

I found myself troubled by his presence, uncomfortable because I felt obliged to do something, and yet I held back, unsure of what I could do for the man. I wondered if my colleagues were similarly conflicted. They certainly seemed to have noticed him. I saw groups of other conference attendees pause and cast furtive but trained eyes on the man. The buzz of conversation around the bar slowed, and the soft strains of piano and the gentle splash of a waterfall could be heard again.

Then security guards appeared from either side of the lobby. With their suits and earpieces, they looked like they’d just taken time off from a presidential entourage. The man sank back into the sofa, but when they said, “Sir, you have to leave,” he collected his belongings and rose to his feet without a struggle.

I sat there, sipping my cold martini, and convinced myself that there was little that anyone could do. The options were limited; psychiatric practice itself was inadequate, making interventions in situations like these impossible. I mean, we could hardly administer medications or perform psychotherapy right there in the room. What were we supposed to do? Now, if a man with chest pain walked into a congregation of cardiologists, that would be another story. There would be a scramble of cardiologists rushing to help the man—to administer advice, to recommend hospitalization, or, if the need arose, to start cardiopulmonary resuscitation. How bizarre if instead of helping the man with chest pain, the cardiologists ignored him and continued to discuss the latest data in their field. Or worse still, what if they felt uncomfortable—even embarrassed—that a man with chest pain had stumbled into a cardiology meeting? What if they just did not know what to do?

The man stood and looked around, eyes drifting from one side of the room to the other, and it seemed that he was seeking help. But I continued to sip my drink, and like every other psychiatrist in the room, I avoided eye contact with the man. He shambled off, making his way through the lobby, and pushed the double glass doors and went out into the cool Philadelphia night.

The room seemed to lighten when he left. Glasses clinked, laughter and merriment drowned out the music once again, and conversations about the latest treatments of mental illnesses resumed in full earnest.

Delusions of Life

The gray-haired Irishman walks around the wards quietly, avoiding eye contact. He touches the walls, as if to reassure himself of the world around him. He says very little, and the little that he says I find difficult to understand. I have been in England for only a month, and I assume it is his Irish brogue that I find difficult to follow. The consultant psychiatrist I am working with tells me otherwise. “It’s the antipsychotics he’s taking,” he says on rounds. “He has major depression with psychotic features. Nihilistic delusions, thinks he is going to die.” Dr. Anwar speaks in clipped Oxford tones, tinged with a trace of Southeast Asian inflection. I find myself modulating my own Indian accent when we talk. “What about ECT?” I ask.

“Refused it,” he says. “Until he changes his mind, we’ve to keep plodding on. I just increased his olanzapine and reboxetine.” He pauses and presses the intercom for the nurse. “Betty, can you send Tim in now, please. We’re ready to see him.” This manner of rounds is new to me. We wait here, like judges in a courtroom, while patients are summoned like penitent prisoners, so that we may examine and interrogate them. I know the real reason for this method is to protect the patients’ privacy since they have roommates, but I can’t help wondering if patients feel like we pass sentences for crimes of depression, psychosis, or attempted suicide.

Betty leads Tim into the room and seats him on a chair that faces a grimy window. Outside, the Birmingham landscape appears bleaker than usual. Smoke rises from steel mills in the north to join nimbus clouds in the sky. Birmingham is a city in flux, attempting to shed its industrial past, and old Gothic houses lie side by side with modern town homes. It is early afternoon but dark enough inside the room that the fluorescent lamps are switched on. Dr. Anwar and I sit opposite Tim, a small low table stained with coffee rings between us.

“How are you, Tim?” Dr. Anwar asks in the gentle manner that he reserves for patients and also (I know this because I have heard him on the phone) for his wife.

Tim does not say anything for a while. It is quiet and all I can hear is the incessant patter of rain against glass. Finally, Tim looks at Dr. Anwar for a brief moment before staring at the floor again. “Feeling all right, Doctor,” he says. “But not for long, I reckon.”

“How’s that?”

“My heart’s going to give out soon.”

Dr. Anwar has been down this path before. He sighs and says, “Your heart is fine, Tim. We got it checked out by the cardiologist. Your blood pressure is fine, your cholesterol is excellent, and you are the only patient we have here who does not smoke.”

“It’s going to give out,” Tim repeats. He stands. “Can I go now?” he asks, but he leaves before Dr. Anwar can reply.

A few days later, the morning starts as any other. A customary cup of tea with the nursing staff during a report from the night shift and then rounds. By noon, we are finished, and I have a quick lunch at the cafeteria. There’s a special on the fish and chips, but then, there’s been a special on that all week.

Things are quiet today, and I even have some time to play snooker in the doctor’s lounge, usually the domain of the dermatology trainees. Back in the ward, I am finishing up some notes before I leave to catch the train home, when suddenly there is a shout and then an overheard page: “Cardiac arrest in ward 10. Cardiac arrest in ward 10.” It takes me a moment to realize that this is ward 10. I rush outside in panic. A man has col lapsed in the corner of the hallway next to a television set showing the 5:00 news. Betty and another nurse are already there, administering cardiopulmonary resuscitation. I recognize the gray beard and the white hair.

The crash team arrives and hooks up a monitor. They administer medications, intubate him, press on his chest, inflate his lungs, and shock him several times. I look at the monitor—ventricular fibrillation and then asystole. His heart has stopped. After 20 minutes, they call it off. The medical resident, a balding Asian man, shakes his head. “No use, not a flicker. We did what we could.” He pauses. “So what kind of psych problem did he have, anyway?”

“He was psychotic,” I say. “Thought his heart would stop.”

“I don’t understand,” he says.

“Neither do I,” I tell him. “Neither do I.”