A Raisin Brings the Sun

It was a cold Saturday afternoon in December of 2005 when I received a call from Walter Nathanson (pseudonym), the medical director of a safety-net institution that was recruiting for a chair of psychiatry. This venerable institution, well known for its teaching, research, and clinical care, had fallen on hard times. The Department of Psychiatry needed a new chair. I was intrigued, and a few days later, I met Dr. Nathanson in his office to discuss the position.

It was late one evening, a week before Christmas. The hospital was strangely quiet and lacked any gaiety. The corridors were empty and poorly illuminated to save power. Even though the building was impressive, it lacked regular maintenance, and it showed. Dr. Nathanson described at length the problems faced by the hospital and the Department of Psychiatry. Similar to many other safety-net institutions in America, it was unable to meet its obligations due to changes sweeping the field. Dr. Nathanson mentioned several maladies of the department, and I made special note of the lack of regular and effective communication among various disciplines that made up the behavioral health team. Instead of discouraging me, the conversations with the medical director had the opposite effect. He arranged meetings where the staff was instructed to be open and hold nothing back. I found the staff to be bright, dedicated, and articulate but demoralized and deeply frustrated by the lack of resources, increasing clinical demands, and absence of any reward system. After this process, we agreed that the department had the potential to be turned around. I submitted my plan of action to the hospital. The hospital fully supported it, and thus began my long and arduous journey as a leader of a large department in a safety-net institution.

One of the early initiatives we introduced was to organize a daily “Morning Report” to improve communication among all disciplines. This consisted of a one-hour mandatory meeting in which the staff discussed new admissions, discharges, consults, investigations, and administrative issues. Even though the hospital was located in one of the richest counties in the nation, the social safety net was full of holes. The initial reservations of the team about the Morning Report disappeared when we received plaudits from regulatory agencies. They described the Morning Report as a best practice to improve clinical care and encouraged us to share it with others.

The staff responded to this and other initiatives with great enthusiasm, and improved clinical care was the result. The institutional leaders identified the Department of Psychiatry as the flagship department of the institution.

With the passage of time, institutions change, sometimes for the worse. Our department was no exception. By the early 2010s, the impact of the Great Recession began to affect the hospital finances. Disasters, such as Hurricane Sandy and the building heroin epidemic, also took their toll. In addition, the need to manage highly complex cases without adequate resources; a demanding local, state, and federal regulatory climate; a highly litigious clientele; and a rapidly changing health care delivery system created enormous strain. Consequently, even the most dedicated physicians of the department suffered from burnout, which led to several departures. Staff members who chose to stay felt increasing pressure to care for a greater number of patients and to deal with the consequent problems that came with doing so.

The attendance at the Morning Report started to become erratic. Sharp differences among attending physicians became more frequent. Pervasive feelings of ineffectiveness and helplessness started to spread like cancer. One of our responses to this crisis of spirit and morale was to introduce a mindfulness practice session to follow the Morning Report every Wednesday, or at least once a week. Such was the situation within the department when an incident occurred.

The Incident

One Wednesday in early spring of 2016, Dr. Connors, a psychiatrist in the department who is an expert on mindfulness practices, opened the session by stating that he would try a different approach that morning—called mindful eating. He proceeded to explain how one can practice mindfulness to reduce stress in all aspects of life: while taking a walk, studying for a test, eating a meal, or drinking a cup of coffee. Dr. Connors pulled out of his pocket four packets of raisins for sharing with each person in the room. His instructions were specific: to examine the raisin’s texture, size, color, translucency, and irregular surface. He further instructed the group to take a raisin, roll it on the tongue, and then bite into it. He suggested that we think no other thoughts during the exercise and concentrate on the experience of eating that raisin. We followed his instructions. I enjoyed the raisin, and because I was hungry, I ate a few more.

As the exercise ended, Dr. Connors instructed the participants to open their eyes and resume their day. The quiet of the room slowly gave way to the sounds of people shifting in their chairs, collecting their belongings, and getting ready to leave. Some yawned; others stretched their arms and smiled with either skepticism or satisfaction. However, Dr. Irfan, another psychiatrist, still had his eyes closed and head tilted back. Soon, he started to snore, which we initially found amusing. However, his breathing became erratic, and his head fell further back. Our initial amusement quickly turned to dread and disbelief. He was not just experiencing “postmindfulness bliss”—he was becoming critically ill. We were unable to arouse him despite vigorous shaking. Was he about to go into cardiac arrest? Was he having a stroke? A syncopal attack? In that moment the diagnosis did not matter. The imperative was to save a colleague whose life suddenly seemed to be ebbing away. Someone urgently shouted to call the rapid response team.

The attending physicians and residents arranged a flat surface, moved Dr. Irfan from his chair, opened his collar, and laid him down with his body turned to the side. The response team arrived and started working to revive him. He came through, and everyone sighed with relief, but soon after that, he became unconscious again. In the next few seconds, which felt like ages, Dr. Irfan started to breathe normally. He opened his eyes and gave us a weak smile. As a physician who prized his privacy, Dr. Irfan was embarrassed and kept reassuring us that he was fine. The outcome could have been far worse. However, the irony of observing such a frightening experience after a mindfulness exercise was not lost on us.

Outside the room, patients’ families began to arrive because visiting hours had started for the day. Visitors were curious and asked each other what had caused all this commotion. Even as the response team left the unit with a protesting Dr. Irfan, I invited the Morning Report attendees to debrief as they would after a traumatic event. The first to talk was a nurse, Ms. Adams, who told the group that Dr. Irfan, whose inpatient unit had the most violent and challenging patients, had been under much stress and had asked his nursing colleagues to check his blood pressure on a few occasions. Dr. Jones, who recently had cardiac surgery, felt that Dr. Irfan was too busy to take care of himself, and he hoped this incident would be transformative. Mr. Peters, a social worker, was relieved that the experience did not end in a disaster, and he wanted the mindfulness practice to continue.

Others talked about the potential for physical violence in managing disturbed patients as well as legal threats and escalating regulatory pressures, all of which contributed to their struggle to find a balance between work and private life. Many thought that the episode with Dr. Irfan would force them to take better care of themselves. Ms. Samuels, a nurse who recently had given birth to a baby boy, talked about needing time to care for her baby and followed through with taking the planned family leave after the incident.

Finally, some members of the team, with whom I shared the manuscript of this column, saw value in our sharing the harrowing experience with others outside the hospital and encouraged me to submit the paper for publication. Ms. James, a social worker, had tears in her eyes and said, “We feel so alone and misunderstood. I am sorry I could not contain myself.” Dr. Edwards, a psychiatrist, read the draft and asked me if he could share the paper with his wife “so she would better understand my work day and why I do not want to talk or seem moody sometimes when I come home.”

Epilogue

Thus, a potential disaster turned quite fortuitously into an opportunity to increase cohesiveness throughout the department. The mindfulness exercise paradoxically highlighted the dormant conflicts in a department that was effectively functioning by all measures. The near-death experience of a colleague galvanized the staff toward greater commitment to their personal care and improved the not-too-salubrious climate in the department. The negative feelings associated with staff departures in the past few months were greatly alleviated when the department was able to recruit top talent to fill the vacancies. The Morning Report had become more focused and task oriented, without destructive emotional outbursts. Even though it was premature to declare that the crisis was over, there was relief that we crossed a major hurdle—one among many for this department, with its long and checkered history.

Well after the incident had passed, I noticed Dr. Irfan sitting in his usual chair before the daily Morning Report started, and he was looking slimmer and pensive. He was alert, focused, and jovial as usual. I asked him how he felt, and he answered with a smile that he was feeling much better. Both his blood pressure and cholesterol came down significantly after receiving medical attention. He also said that the mindfulness practice had benefited him, despite his scary experience.

Finally, I learned the efficacy of mindfully eating a raisin; never underestimate what good a small raisin can do for you!