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Introspection   |    
The Picnic
Edward Rynearson, M.D.
Am J Psychiatry 2009;166:855-856. doi:10.1176/appi.ajp.2009.09030379
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In 1966, St. Elizabeths Hospital in Washington, D.C., was still a mammoth federal psychiatric facility housing nearly 7,000 chronic psychiatric inpatients. Psychiatrists staffed the hospital, but a separate medical service from the U.S. Public Health Service provided medical care. As a newly graduated medical intern, I was now “in charge” of the medical care of 800 women patients in one of its seven divisions for 2 years.

Walking through the five antiquated wards was like being sucked into a partial vacuum. As each heavy metal door unlocked, I was drawn in by the mass of women patients rushing forward to greet and touch me. With the door of the nursing office safely closed behind me, I was given a report on who needed medical attention, charts neatly stacked for my review, bulging and hopelessly disorganized.

All these women patients looked and sounded the same to me—deranged, toothless, in light green cotton dresses and white tennis shoes. I felt overwhelmed. This was a place that cried out for order, so I suggested that we have weekly community meetings on each of the five wards, that clinics be organized for diabetic, hypertensive, and cardiac patients, and that I spend each afternoon reviewing charts and completing physicals on at least four patients.

With scheduled clinics and patient reviews, I turned the key and pushed against the doors each morning anticipating the discovery of some undiagnosed disease I would find and cure. And there were a few, but treatment did not bring much change. After a year I began to lose confidence, but the staff seemed emboldened by the reorganization.

“You are the first doctor to sit down with every patient to get to know them. No one has ever made the time to do that. Look what you discovered with Mabel.”

Mabel’s hair was snow white and drawn into a sparse ponytail she smoothed with tremulous hands. I noticed that she was missing her right thumb and fine scratches covered her hands. Her back was so curled that she barely came to my waist as we stood together, and firmly grasping my hand, she rasped, “Come on, big fella, let’s go to my room and have some fun.”

We all smiled at this frail little lady behaving like a temptress with her young doctor.

Months later, when Mabel was scheduled for a medical review and physical exam, the record room sent me her original chart. No one had reviewed her complete medical record since Dr. Walter Freeman, a neurologist at St. Elizabeths, had performed a prefrontal lobotomy on Mabel in 1947. According to her admission workup she had worked as a prostitute in Chicago before moving to Washington, D.C., and she had an admission diagnosis of paranoid psychosis associated with neurosyphilis that had been inadequately treated with injections of mercury until Dr. Freeman treated her syphilis with penicillin in 1946.

Some months later we discovered why Mabel’s hands were covered with scratches. I was making rounds late one night, and as I walked beside the heavily screened porch of Mabel’s ward, she was hand-feeding a large black cat through the screen. As she grabbed the cat, it scratched her hands before disappearing underneath the porch.

We found not one but many cats under that porch, and at our community meeting the next morning I suggested that we make room for the cats on the ward.

As the cats passed between us, providing a more vital focus for our community meeting, Mildred, an immense black woman who had been mute the year that I had known her, timidly asked, “Could we have a picnic?”

A week later we slowly negotiated the wide path to the picnic tables at the edge of the Anacostia River. The younger patients joined in pushing wheelchairs or steadying the older. As we gathered around the tables to eat our peanut butter and jelly sandwiches, I felt a mixture of triumph and pride in our expedition, so I stood and proposed a toast with my remaining Kool-Aid. I thanked Mildred for initiating the idea, and the nurses and attendants for all of their work in arranging the trip. Finally I raised my paper cup toward my patients, uniformed in their green cotton dresses and white tennis shoes, but now I knew each of them: “Most of all, I want to thank each of you for making this trip....”

I had to stop. My voice cracked and my eyes glistened in that moment of connecting with them as my companions as well as my patients. Suspended in silence, I looked into each of them and wordlessly gave thanks—for they had changed me more than I had changed them in the 2 years I had been their doctor.

The supervisor rescued me from my meltdown. She held up her Polaroid camera and announced that she wanted to start a ward scrapbook, and she arranged us around a table, asking me to hold her cane while she took our picture. Peering over the camera, she directed all of us to smile. After snapping the camera, she pulled out the film and we clustered around her to await its gestation. The backing peeled away, and the picture passed among us.

I am standing at the edge, steadying one of the patients with one hand and holding the cane in my other. Stooped and staring women circle around a picnic table on the shore of a dark river with the dome of the Capitol shining in the distance—their smiles awkward and commanded. In the center of the picture is Mildred, who has brought us here and sits Buddha-like while holding a black cat in her lap, and Mabel, sitting next to her, reaches for the cat.

Address correspondence and reprint requests to Dr. Rynearson, Virginia Mason Medical Center, 1100 9th Ave., Seattle, WA 98111; edward@rynearson.com (e-mail). Introspection accepted for publication April 2009 (doi: 10.1176/appi.ajp.2009.09030379).




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