Ms. Z was a remarkable patient.  A retired Marine Corps officer, she landed in an inpatient psychiatry unit after assaulting her ex-husband while he held their 3-year-old son in the ER.  During the fray, she also gave her mom a concussion.  As a nursing note put it, “The cops gave her a choice: psych or jail.”

I first interviewed Ms. Z in a steamy resident work room with windows bolted shut for safety.  She looked about my age. Out of the service for years, she had plump cheeks and a waddling gait.

I asked her what happened.  “That mother fucker triggered my mama bear instinct,” she said. “He knows exactly how to push my buttons.  All I want to do is protect my child.”  

“Self-Portrait in Second Year” by Scott Sorge, MS4“Self-Portrait from 2nd-Year” by Scott Sorge, MS4

Multiple witnesses described her ex-husband as in a defensive position, holding their son, never striking back. I asked for more information and she went on, but never mentioned hitting anyone. I moved on.  

“Can you tell me about growing up?” I asked, grasping.  

“It was really nice. I was born in Kindred Hospital in Sandusky, Ohio.  My dad’s a physician,” she said.

“Woah.  I was born in Kindred Hospital and grew up in the next town over,” I thought.  My parents are also physicians.  We grew up in neighboring small Ohio towns 400 miles from Philadelphia.

In other medical settings, I would have chimed in, but my attending had just stressed enforcing boundaries about 30 seconds before. It’s an area where med students like myself often fail, I was warned.  “It’s okay to share, but always consider if it’s therapeutic,” he advised.  

I resisted the urge to blurt out that we were born in the same hospital and went to rival high schools. Withholding this made me feel uneasy, like I was breaking a social norm.

Over the next few days, Ms. Z broke me down. She was demanding, intrusive, and insulting.  She complained of back pain, shoulder pain, wrist pain, ear pain, eye pain, and vaginal pain.  She flirted on the unit and bossed around a shy, psychotic patient.

Every morning, she cornered me with a new list of demands.  We addressed each complaint. I felt like I lived at her beck and call.

Ms. Z consistently exhibited self-destructive behavior but lacked insight into how her actions caused her problems. It was always someone else’s fault. “I’m always in control of what I do,” she said.  

Ms. Z desperately wanted to be a good mom, often repeating, “Being a mom is all I live for.  I don’t give a shit what else happens.”

“She burnt bridges with pretty much everyone who ever loved her,” her mom told us.

More than anything, I wanted her to see that she was sabotaging herself.  I let her tread on me in hopes I could hold up a “reality mirror” to show her that she was not a hapless victim of circumstance and that her actions had power.

My reality mirror was a little dusty.  I failed at enforcing boundaries.  I started off well enough by not telling her where I was from, but I became too eager to please.  On any other hospital floor, diligently addressing a patient’s complaints is good care.  In this case, though, I began to see that yielding to her demands perpetuated her warped boundaries.  

One morning, Ms. Z demanded to leave. In our final conversation, dread washed over me.  “She’s sick and can’t acknowledge it,” I thought, dazed by the complexity of consciousness.  

Again, I considered again telling her that we were born in the same hospital, grew up miles away, were the same age, and probably had mutual friends and had attended the same high school football games. It could build trust and help end on a positive note, I thought.  

I didn’t tell her.  I’m still not sure exactly why I kept this to myself, or whether it was for me or for her.  Did I need this one boundary to persist, a symbol of hope for my own future improvement?  Or did she?   

Christopher Magoon is a medical student at the Perelman School of Medicine currently on a research year out in China.  You can follow him at @cpdmagoon.