By Brian Gross

I walk into the common room of the facility to find a man sitting in a chair hunched over a table. His face was covered by long strands of tangled white hair. He was intently scribbling notes into a book. I glimpsed at the notes to see wildly drawn symbols and disjointed sentences. His eyes were fixated on the writings. I tapped him on the shoulder, and he looked up and smiled. “Good morning”, he said. “Do you know who the maharaja is?” I stood there puzzled and told him I was not sure who that was. He then began to tell me about “his master, the maharaja” and all the teachings of peace and tranquility he instilled in himself. I listened intently, wondering the significance of this conversation. What did he want me to get out of this? Why is he talking about this person? The conversation continued until the point was exhausted, and yet he continued to state the same points repeatedly. It became clear that this “master” was an important figure in this person’s life. A point was reached when I could steer the conversation away from this topic. I thanked him for sharing about himself and introducing me to such an important person in his life. I then continued with the rest of the mental status exam.

When speaking with him he seemed calm and collected. His words came rapidly as he switched from one topic to the next, but he seemed level-headed. I then asked if I could read his notes. He agreed and handed me a pile of papers, strewn about in different directions. Swirling circles of green and red were superimposed on a backdrop of red numbers. Statements were scribbled in the margins reading “the green ball sits on the silver court”, “the children are being euthanized”, and a plethora of random legal statutes. It was clear that he was in the midst of psychosis. I finished my exam and told him I would see him again tomorrow. He thanked me for my time, and for listening and we went our separate ways. Me, back to the comfort of my apartment, and him back to his small one-window room.

When I got home, I thought about how a man who seemed manic yet collected, could internally be experiencing a psychotic break. How did he keep his internal thoughts from spilling out into his speech? I never would have guessed he was psychotic unless I asked to read his writings. How could I better understand his experience? With his psychosis, how could I build enough trust with this patient?

                                                            “The Maharaja”

I began to read up on the maharaja, his teachings, and practices. I learned more about meditation and yoga, and the peaceful tenants of the maharaja. The next day I arrived at the facility to once again find my patient hunched over his notebook, legal papers strewn about the table. I greet him and tell him I looked up his master. He smiled and began to talk about how much his teachings mean to him, how these tenants of peace and tranquility allow him to survive his “imprisonment”. We spent a little while talking about the teachings of the maharaja and the importance of meditation and yoga in the patient’s day to day life. I listened and learned. I discovered the needs of my patient, his interests, and his desires. This interaction with my patient seemed to change our relationship. I was no longer a student prodding and poking at him so that I could learn. We developed a partnership, one in which we began to understand each other and with this understanding, he began to trust me.

This partnership culminated on the last day in clinic. When I first met the patient, he was unmedicated and uninterested in treatment. While he was cooperative, he had little interest in following our recommendations. Begrudgingly, he began treatment in response to a court order, but we knew that he would require further pharmacological intervention for which he would have to provide informed consent. Instead of purely focusing on convincing him to start medication by discussing his symptoms and labs, I learned who he was as a person.

As we discussed further treatment options, I was shocked to hear the words uttered: “whatever you think is best for me”.  He explained that his acceptance was due to our connection, and I was honored to be given his trust. This experience will always serve as a reminder to learn about who my patients are as a whole. It reinforces the importance of learning about their lives, their passions, what made them the person they are today, and the person they hope to become. Despite the many pressures that the day-to-day work of medicine will bring, I hope I continue to remember the importance of listening to our patients, learning about them, and striving to build a strong therapeutic alliance built on partnership and trust.