Freed from Expectations: A Lesson Between Documentation and Reality

Most medical students begin their clinical years (the portion of the training typically beginning during the third year which involves participating in clinical rotations and direct patient experience in the major medical specialties) at a community hospital, family clinic, or university health system. My school decides our clerkship sites through random lottery – so there isn’t much choice in where you go. In my first month as a third-year medical student, my rotation was at a forensic psychiatric hospital for patients sent by the judicial system for treatment of their mental illnesses. Naturally, I was terrified, as luck had suddenly thrown me into the fray of atypical patient care.

Upon arrival, I noticed barbed wire lining the perimeter of the building. I went through several security checks, and I watched guards secure each exit behind me. I felt the tension in my body rise – even before seeing my first patient. The resident I was paired with for this two-week rotation assured me that nothing bad would happen to me, but I still had my doubts. (Earlier she disclosed that she had to sign a note regarding a patient who broke down a door and punched another patient unprovoked, requiring 5-point restraints.) As she unlocked one of the monolithic gray doors that marked the end of each hallway, I tightened my mask closer to my face and stepped into the unit.

The first thing I noticed was the disproportionate number of people of color under our care. Largely Hispanic or African American, I noticed patients huddling on the floor, wandering the hallways, or sleeping in their beds. Psychiatrists, nurses, social workers, and I, the single medical student, entered the central room and huddled around a round table. They discussed current events in the unit and which patients needed labs or imaging. Despite being coached on how rounds work in our summer orientation, it was clear that the forensic hospital worked differently from my training. Our pace was quick and few words were spared as the patients were generally long-term residents who had no acute changes.

My resident asked me to practice pre-charting a patient for an interview later today. I picked out a patient randomly and located the paper chart, a phonebook-sized record that weighed at least 4 pounds. As I flipped through its heavy contents, I questioned how do I even interview an institutionalized patient?

The chart belonged to “Ray” (Note: names and identifying details have been changed to protect patient privacy), an Afro-Latino man, institutionalized under the penal code 1370, meaning that he was found incompetent to stand trial. Reviewing Ray’s chart, I was alarmed by his extensive number of incidents in the last year: restraints for randomly striking nurses and other patients, raging over the loss of his pen, trespassing into other rooms, and cornering smaller patients. Fear and doubt rushed through my head. What would I even say? How could I get information from this patient while maintaining my composure and safety? I completed my first rounds literally minutes ago, how was I ready for this?

Before we could interview Ray, the nurses notified us that he would be attending the FREE (Functional Rehabilitation and Educational Experience) program, meant to educate patients about the anatomy of the court system and ensure their competency to eventually stand trial. The resident encouraged me to attend FREE, so I followed Ray into a conference room in the unit. Today’s lesson centered on listening, especially in the courtroom setting. The instructor, Dr. Aguilar smiled brightly and greeted the five students attending her session. Next, she introduced an acronym guiding patients on how to listen: LEAP – Listen actively, Eliminate distractions, Ask questions, and Paraphrase/parrot. Patients were told to give examples for each part of LEAP and think of an image to associate with it in their mind.

To my surprise, Ray was one of the most active contributors of the lesson. His hands shot up each time Dr. Aguilar posed a question to the class. As the lesson progressed, Ray continued to actively participate and even began sharing memories from when he was in high school, explaining strategies he used to help him learn, remember material, and succeed in his classes. 

As Ray divulged more about his life beyond the state hospital, I questioned my initial perception of him. I let the notes on his chart and his accused crime influence my interactions with him. In my mind, I pictured an unstable and potentially dangerous person who I could not imagine reaching. Yet, here in this classroom, Ray was an avid student eager to learn and share his experiences about active listening. I wondered how much familial support Ray had in his life, as someone who had been plagued with mental illness and didn’t have access to mental healthcare prior to his imprisonment. I was curious to learn more about his upbringing and the social support he had, especially as a man of color.

The lesson concluded with a game of Simon Says to test the listening skills of the patients. Ray was eager to teach the rules to the other patients and volunteered to start the game. After playing multiple rounds, only two players remained, including Ray! Suddenly, deep in my heart, I rooted for him to win regardless of what life had set for him. My resident took on the role as the final Simon for the ultimate “speed round,” instructing the finalists to sit down, sit up, place their fingers on their nose, and raise their hands, all in quick succession. Finally, when she told the patients to sit down without a “Simon Says,” Ray listened and remained the last man standing, quite literally. He cheered and Dr. Aguilar congratulated him for being the best listener of the day. By God, if you could see his smile, you’d think Ray was the happiest man in the world at that moment.

Afterwards, in our official interview, Ray stated he had no issues to report, acting cooperatively and politely with us the entire time. Satisfied with the questioning, I left the unit reflecting on the drastically different reality from what I initially expected from my interactions with Ray.

Ultimately, one of the biggest lessons that I learned is to begin each patient encounter with an open mind. Reading Ray’s history before meeting him negatively skewed my views and guided my feelings towards fear and tension, when in reality, Ray was cooperative and forthcoming. If I let my prejudice and fears about Ray predominate the interview, I might not have been able to build a strong rapport with him. Important information could have been lost if I had let my feelings interfere with what was at stake: patient health.

Clinicians should be vigilant about the potential bias and prejudice in medical records, especially for patients of color, because they could bias future health interactions. For example, patients who are described as irritable by other physicians may actually be pleasant when speaking to you. Patient documentation is a useful indicator, but not an absolute predictor for each patient encounter. Healthcare providers should approach each visit with an open mind and allow patients to have the benefit of the doubt.

Despite being abruptly thrown into a chaotic environment in my first month as a third-year medical student, this rotation was a valuable learning experience in my journey to becoming a physician; it taught me about the importance of empathy and the complexities of mental health care, and the social determinants of health for people of color.

Ultimately, I found that learning can happen anywhere, whether it be in a community hospital, family clinic, university health system, or even in a state forensic psychiatric hospital.