After spending a few weeks at home, I found myself in the upper west side of Manhattan, on Riverside Drive. I am here for a one-month long clinical fellowship in psychiatry at Metropolitan Hospital. You might be wondering to yourself, "Why are you living cross-town?" Well, my little sister is here doing an internship at Columbia University Medical Center, and we figured it would be more convenient for her, as this is her first time living in the city.
I lived along for the first week, as my sister was still in school when my fellowship started. Immediately upon moving in, I heard a clarinet a few windows down, in another apartment. There were 2 voices, playing a trio sonata by JS Bach. [http://youtu.be/EuvsgPSLxM0]
I had recognized it because a few years ago, when I had developed an interest in organ music (DON'T JUDGE ME). The piece had been arranged for a reed trio and was very well played. It definitely gave some solace in such a busy city.
The fugue is difficult to execute by one person - usually, it is more interesting to listen to with 3 voices expressing a main fugal theme, interwoven throughout a piece of music. Bach's most interesting fugues are composed for ensemble play, not usually for a single instrument. The piano is event difficult to play an extended fugal motif. Hence, the organ, with two hands and the feet to play, allows for multiple voices to occur with only a single executor of the instrument. What results is the statement and development of a fugue theme with three voices.
The word "fugue" has another meaning to it, outside of music. A "fugue state", within the realm of psychiatry, is a mental state in which a person assumes another identity (or loses all identity) and travels impulsively, with no aim or direction; at the end of this fugue, they have no recollection of what had happened nor any clue as to why they had travelled to some other place, some times very distant from the place of origin. Common words derived from "fugue" include fugitive and refugee.
I recently admitted a patient to the inpatient psychiatry ward who had experienced a fugue-like state. He had stated that he had been wandering the streets for the past 2 weeks, with no recollection of where he was before he started, where he had been, or what he had done as far as food and shelter was concerned. He "woke up" from his wandering on the street, claiming that his mind was rushing, and called EMS who transported him the to the ER. He was extremely agitated and only stated that "I need my medication refilled." He was extremely paranoid on the floor and believed that the staff on the floor were there to perform mind experiments on him.
What is interesting and devastating to the scientific study of the mind is that it is perhaps the least organic and tangible entity of the human. When someone mentions "depression", "mania", "paranoia", or "mood", within the realm of psychiatry, these are words that have implications on the health of the mind. However, though these terms are use medically within healthcare, they do not yield anything that is tangible - there is no direct blood test, imaging test, or physical exam that can be utilized to properly diagnose any of these terms. What a clinician must rely on is the patient interview and language of communication in order to make a diagnosis.
Now imagine trying to interview a patient who is actively psychotic or so depressed that s/he does not even want to talk. What more can the physician elicit as far as diagnostic information in order to formulate a treatment plan? More often than not, I have found myself trying to make sense of a whole slew of pieces of a story. Organized chaos. But this is fun, and perhaps only scratching the surface for other medical specialties, such as internal medicine. Piecing together a story and making sense of all of the aspects of a patient excites those who love a challenging deduction.
As I stepped onto the 1 train for my morning commute, I recognized an old classmate from my undergraduate philosophy class. We had a small chat, asked how things were, and what she was doing in Manhattan. Before we knew it, it was the stop at 96th street. We both exited, not giving a formal good bye, disappearing individually into the meandering of the crowd, a fugue of individuals, all playing a voice in a grand ensemble of the city.
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