A Tale of Two Cities

I am a senior resident at an academic hospital in Springfield, Ill. The setting is a typically busy afternoon at a clinic. I am waiting for Nurse Nancy to come out of the examination room and thinking that it would be better if patients did not stop at various checkpoints before being seen by a doctor. It cuts down on my time with them, and as a resident, I am still struggling with how to manage my time efficiently.

Nancy informs me that “Rajeev,” a 19-year-old Indian American man, is here for an evaluation as a new patient at the request of his parents. Rajeev stands up when I enter the room and shakes hands with me. He has sweaty hands. I start with some neutral questions, and he leans backward comfortably in a chair. “It all started after that accident,” he says. He tells me that 7 months ago he was driving with his parents when they were involved in an accident. “They have been following me since then. They even bugged my house and my cell phone.” Rajeev says, “My parents think that I have some psychiatric problem, the same kind that my dad had when he was young. He was treated with some shots. They don’t realize that they’re ‘out there.’”

Later in the interview, I talk to his father, who is a successful engineer. “Rajeev is anxious and does not go out. He has stopped going to college. He is getting worse day by day. He has difficulty sleeping at night.” “What about the accident?” I ask. He replies that it was a minor fender bender.

Rajeev declines to take any medications but is willing to try some “therapy” to help him cope with “the things on [his] mind.” Rajeev meets with his therapist for four sessions before deciding to control his symptoms on his own because his therapist advises him to take antipsychotic medications. Rajeev’s mother pleads, “Doctor, can you prescribe him some medication that I can mix in his food without his knowledge, or what about those shots that his father used to take?” I ask Rajeev to come in for a follow-up appointment the next day. When I see him, he sits at the edge of the chair. He is wearing a dirty sweatshirt, and his hair is unkempt. He smiles superficially, and beneath the smile, he seems anxious. He again declines to take any antipsychotic medications but mentions, “a sleeping pill might help.” Rajeev is perplexed: “I am worried that medication may give me a false sense of security.” I try to ease his anxiety by telling him that the medication will not affect his ability to defend himself should it come to that. “But, doctor, I am not psychotic. I think taking medication is not a good idea.” The thought of prescribing him a sedative antipsychotic crosses my mind, but I feel bound by respect for his autonomy and the need for informed consent.

Rajeev reminds me of “Sarasvati,” whom I saw in 1999. I was a resident at the All India Institute of Medical Sciences in New Delhi. New Delhi gets very hot in the summer, and I could almost see the thick, hot air as I walked toward the outpatient psychiatry department after having lunch. Sister Sheila was sitting in her room at the other end of hallway. This room was used for ECT twice a week. I went to pour some masala tea that she usually kept boiling. There were patients crowded in front of the interview rooms, some sitting on the floor. Somnath was busy issuing outpatient cards to the patients who were flocking to his window. “I will close the counter if you do not stand in your lines,” he would repeatedly shout in Hindi with a harsh Bihari accent. We clinicians all had our little “kingdoms”: Somnath at the counter, Sheila in the ECT room, and me in the resident room. Sheila put some extra cream in my tea, which she usually did when she needed a favor. She requested that I see her niece. “Sarasvati, my niece, seems to have gone crazy. She hears voices,” Sheila said. “She is 17 and attends Delhi Public School.”

Sarasvati came in, accompanied by her mother. She pleaded, “Dr. Sahib, please help. My daughter is not doing well in school. She was one of the top students, and now she does not even want to go to school. She talks to herself.” With tears in her eyes, she continued: “Her test scores have dropped.”

Sarasvati avoided eye contact for the most part and hid behind her mother. She muttered to herself and scanned the room as if she were in enemy territory. She said, “Those peons want to kill me; they even follow me to my house.” Sarasvati had refused to take the chlorpromazine tablets that her uncle, a medical assistant, had prescribed for her. Listening to the plea of her mother, I prescribed liquid risperidone to be mixed in her food. At Saravati’s follow-up visit 4 weeks later, she seemed much better and requested medications to help her combat the residual voices.

Sarasvati improved remarkably and later became a schoolteacher. I have no recollection of thinking about getting her consent to prescribe medications for her. Getting her well was the only goal of treatment. Five years is a long time, long enough for me to change my mind-set.

I do not prescribe any medications for Rajeev. However, I struggle with the decision. I keep wondering if I should place such a high value on his autonomy and let him deteriorate. Am I respecting his autonomy at the expense of the questionable validity of his informed consent?

I keep wondering if Rajeev, who has the best medical care in the world available to him, would be treated any better if he were at a different place. I have come a long way from New Delhi to Springfield, Ill., but I wonder if in some ways I have taken a few steps backward.