Tall, thin, with abundant wavy grey hair and piercing dark eyes, Dr. Robert Heath looked like the image of a mad scientist many claimed him to be. Chairman of the Tulane psychiatry department since the late 1950s, he promoted the idea that mental illness was based an aberrant biochemistry and electrophysiology rather than any parental influences or early sexual traumas. This was a period when Freudian psychology still held strong sway in the field, and many of his contemporaries, including members of his own department, considered him to be a “kook.” I thought he was definitely eccentric, but found his ideas interesting. He was certainly a skilled surgeon, able to implant as many as forty electrodes in prisoner “volunteers” during a time before ethics commissions and Institutional Review Boards (IRB) rightly ended this kind of human experimentation. His early papers showed that stimulating a single electrode in a given part of the brain could produce profound behavior changes, which could be reversed by stimulation of a different area. Later development of potent antipsychotic drugs confirmed the biochemical nature of many “mental” illnesses.
As students, we spent a lot of time interviewing patients, placing them in the framework of then currently accepted psychiatric categories, and discussing treatment based on accepted norms. Like most people, I was (and am) intrigued by what makes people behave in certain ways, and how maladaptive behaviors may be altered. The concept that there is a science by which this understanding and alteration may be achieved was attractive to me, as well as others in my cohort.
What I discovered during my rotation, however, ran contrary to my expectations. Unlike on other services where my lack of knowledge and experience caused me to take a back seat in any therapeutic discussion, I found the concept and boundaries on the psych service so fuzzy and amorphous that I would often argue about diagnoses or treatment of some of our patients with my attending. Worse, it appeared to me as well as some of my classmates that my viewpoints and arguments had equal validity with my attending. Likely, I was wrong most of the time, but the lack of rigor in the field made it hard to see who was right.
Things came to a head when I was asked to interview a 16 year old girl who had been diagnosed with a form of schizophrenia based on her hearing voices, as well as exhibiting “odd” behaviors. By then, I had talked with enough other schizophrenic patients on the service that I was convinced that this young woman wasn’t anything like them, and persuaded one of the neurology staff to come and examine her with me. After doing a complete neurological exam, he could find nothing physically wrong with her, and was in the process of giving me a gentle lecture about medical student hubris and imagination when the girl had one of her “odd” spells in front of us. This was prior to availability of CT scans or MRI’s, and persuaded him to order a pneumoencephalogram (an X-ray taken of the brain after replacement of the cerebrospinal fluid by a gas) which showed a large temporal lobe tumor. My hardest task was to convince her to allow the surgeon to shave her head in order for the tumor to be removed. The problem was even more complicated by the fact that she was an orphan, and the person she was living with prior to hospitalization was not a relative or legal guardian. Eventually, she had her surgery, and as predicted, the voices completely disappeared, along with her “odd” behaviors, which were temporal lobe seizures. Had she been admitted to the neurology service rather than to psychiatry, the diagnoses likely would have occurred sooner. Once someone is given a label, psychiatric or otherwise, it is hard to shake it, as it seems to short circuit the thinking process of those providing care for them. The effect of labels on people and the need to be vigilant in avoiding bias in the absence of facts proved to be a very important part of my education. This experience, combined with the lack of clarity in the specialty, at least for me, convinced me that this was one I could scratch off my list of desirable residencies.