Psychiatry summary

I meant to write more last month when I was on my psychiatry rotation, so here’s a summary of those 6 weeks. Psychiatry felt a lot like being a camp counselor. It didn’t help that I didn’t wear my white coat, and instead had a long lanyard with my hospital ID, keys to the ward (it was a locked ward, you know), a pen, and a flash drive clipped onto it, and everything would jangle as I walked around on the psych unit. Oh, and I had a clipboard with notes in it, and one of my patients drew me pictures during an art therapy session, and I stuck the pictures in the outer window. Between the art groups, the recreational walks, and then interpersonal drama between patients, it was like camp for adults. Involuntary camp. With ID bracelets and big security guards watching your every move. But still, kind of like camp.

I had a patient who told me that the tv talked to him directly, that newscasters could see him through the tv, and then he confessed his masturbatory habits to me (it made me so uncomfortable that he, even through his social awkwardness and um, psychiatric psychosis, actually said to me, “I can tell I’ve made you uncomfortable, sorry,” and I was like, “UM… Yeah, okay, you’ve made me really uncomfortable, um… yeah.”). It was actually a hopeful story, because he responded really well to medications and psychotherapy, and was committed to continuing therapy, and had a family that was supportive, which are not things that other patients tend to have going for them. So, anyway, even though I had to sit through a really weird conversation about marijuana and masturbation, he ended up being one of my favorite patients on the rotation.

Only on a psych rotation can your patient tell you that he’s with the CIA and the Israeli government. Or, a patient can freak out on you and tell you she’s bisexual and wants you to hit on her. (That conversation, by the way, really did make me freak out until I told one of the nurses, and the nurse was like, “Oh honey, that’s just Janie* — she asks everybody that.” That was… oddly comforting.) I ended up liking psychiatry a lot more than I thought I would, as much as I feared I would, and now it’s on the short list of specialties that I would consider doing my residency in. Yikes. I have some issues with becoming a psychiatrist (mainly: the total lack of medical respect that other doctors give psychiatrists, and the idea of going to med school to become “just” a psychiatrist), even though pharmacological treatment of psychiatric diseases is a lot more medical/science based than I would have suspected AND treatment often involves the psychological and social aspects of patients and overlaps a lot with public health and public policy, and even law.

Psychiatry is just very exhausting, and moreso than in Internal Medicine or Ob/Gyn, you can’t always hold your patients accountable for their actions. Psychiatry can be even more paternalistic than Internal Medicine, given that the physician always has to maintain the therapeutic relationship and basically rise above any immature stunts or behavioral issues in order to preserve a good treatment relationship. And whatever the patient expresses is supposed to be encouraged so that we have an idea of what’s going on in their lives. And you know what, maybe I’m not a big enough person to rise above it and listen to some of my patients who cannot let shit go or stop being such whiners, and one day I would give in to the urge to yell, “OHMYGOD, WHATEVER, OKAY?” Maybe that’s one point for medicine — you don’t have to be exceedingly patient with people who just don’t get it, over and over. In Ob/Gyn, if your patient refuses to come in for pre-natal care, you don’t go find them and drag them into the hospital, and a lot of the time, the baby turns out okay anyway. In Internal Medicine, you try your best and at some point you can wash your hands of a competent adult patient, but in psychiatry, part of the reason these patients are in the hospital is because they literally are not allowed to make decisions for themselves and need people who won’t give up on them. So maybe what I’m saying is that I’d like to be a quitter. But then I think about how fun it was every day to go to work, to play mental chess with the overtly hostile patients, to talk with the cooperative patients who understood that psychiatric help is a type of healthcare need, to hang out with nurses who have seen and heard the craziest things, and I think maybe it’s worth it. And you know, the hours can’t be beat.

*Names changed to protect patients… and me.
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Excuse me, your issues are showing

The things that people say or the way people react can give you little clues about what their lives are like. Sure, it’s possible that our conclusions are totally untrue and come from baseless extrapolation, but I prefer to think of it as secret peepholes into other people’s issues. Here, have some vignettes:

1. In our pharmacology lecture one day, Professor P started talking about the mechanism of action of Viagra. This was probably our 2nd or 3rd time learning the mechanism of action of Viagra, since starting med school. For some “unknown” [sacasti-quotes] reason, the professors in med school really love talking about how Viagra works and why it’s awesome. But Professor P’s quote during lecture really was the best of the bunch. Paraphrased, he basically said something like [you have to think of this being said in a Tennesseean, Al Gore-esque accent]: “Now, as men get older, the reproductive equipment doesn’t work as well as it used to. And it’s not anybody’s fault, it just happens, and it’s perfectly natural and Viagra really gives those people that function back.” Of course, those of us sitting in the audience (well, those of us who are awake) are a bit taken aback, and kind of looking down at our notebooks thinking, Um, awk-ward…

2. Last week in a lecture on psychotherapy, Dr. D started telling us about what couples therapy is. He says, “You would not believe the number of couples who do not have sex.” We’re nodding our heads in understanding and writing notes. He continues, “You would. not. believe. They are in committed relationships and they are partners, but when the lights go out at night, [sound effect that basically means, “nothing”].” We’re still nodding our heads, and he says one last time, “So many people. So many.” Gotcha, Dr. D. A lot of people, even the people we would least suspect. Ahem.

3. This week, one of my patients slapped another patient in annoyance and anger. My patient is a 30-year-old, autistic and mildly mentally retarded man who doesn’t actually have a mental illness, just difficulty coping with his emotions and expressing his feelings. In a sequence of events that feels like gentle irony, I ended up being assigned to this patient to work with him on verbally expressing himself, and helping him deal with feeling emotions in a healthy manner. I KNOW, you guys are totally laughing at the idea of me doing that, right? It’s like the blind leading the blind, you guys. Anyway, we were doing just fine, until I started talking to him about the difference between an “acceptable touch” and an “unacceptable touch,” meaning that hitting people in unacceptable, but shaking hands or high fiving is acceptable. And my patient says that hugging is also an acceptable touch. My response was, “Sometimes we have to ask permission to hug, before we just give a hug.” He didn’t understand and kept asking, “But WHY?” Without really thinking (but definitely in mild tones, because this guy is so sensitive I have to be really careful), I said, “Well, not everybody likes being hugged.” And he gave me this sideline look and said, “I am gonna hug you one day.” I’m a dead woman walking, you guys.

Psych out!

This post comes to you from scenic suburbia. For my 6-week rotation in psychiatry, I have temporarily relocated and I’m living in a sublet at a friend’s apartment, about 10 minutes away from the psych hospital.

The psych hospital is a separate building from the main hospital. It has its own ER, and 3 floors with 1-2 units each (for a total of 5 units). Since each adult unit can hold about 22 people, and each child & adolescent unit can hold about 16 people, that means the capacity of the hospital is approximately 98 people (not counting the ER, where people can supposedly languish for up to 3 days while waiting for a bed). That’s a pretty impressive number of people.

I am on unit B2, which is an adult unit. For good or bad, we do not rotate through different floors or units during our 6 weeks. Instead, the unit you get assigned to is the unit you stay with the entire team. Similarly, the two attending physicians you get at the beginning are the same ones for all 6 weeks. One of my attending physicians is Dr. D, the same person who ran the Behavioral Science course from my first year, and he’s now the clerkship director for the psychiatry rotation. This is… a mixed bag. On the one hand, I specifically chose this hospital to do my rotation because I’d learned so much during my first year. On the other hand, I really didn’t want to actually be on Dr. D’s unit — he expects a lot from his students. I didn’t want to directly work on his team — I just wanted to be adjacent to the team, and reap the benefits by being at his lectures. I mean, on the first day, Dr. D asked us what the definitions of psychosis and delusion were! The nerve! I don’t remember things I learned over a year and a half ago! I barely remember Internal Medicine, and that was 3 weeks ago! And now he expects us to read and learn and answer questions, God, I am so put upon. (Ha, now you all are hoping I don’t become your doctor in the future.)

So, obviously, the bad parts of being on Dr. D’s team have to do with being forced to learn and work, which is anathema to other students’ experiences on other psychiatry teams. The good part is that I will learn a lot of psychiatry. Dr. D truly loves his job, and basically spends those 6 weeks trying to convert people to psychiatry. Dr. D himself started out at an obstetrician/gynecologist, and then realized that he’d rather do psychiatry.

One point in favor of psychiatry? On Friday morning, we went to court! We had some patients who took us to court, to petition for release because they were being held involuntarily in the psych ward. Not to be mean, but some of the best times come from when patients prepare statements or speak out of turn, because then the judge gets to see just how RIDICULOUSLY CRAZY they are. For real, one of our patients prepared a long statement that started off with, “I am with the Israeli government. I am also with the CIA. I am a lawyer, and I taught special education for [redacted] County for 7 years.” The judge interrupted and said, “Wait a minute… the Israeli government and the CIA?” The patient said, “Yes.” And the judge, bless his heart, replied, “Okay.” The patient’s request to be released was, thankfully, not granted. Court was really, really interesting. It’s not so much that I love lawyers or confusing law-speak (sorry, Erika, but I do not), but rather that this specialty of health care interacts so much with other parts of the world. You have judges and lawyers and social workers and doctors and patients and their families and the police who maybe were called to the scene, all working together to try to help the patient. It’s enormously gratifying to be part of this overall plan, and not just work in a vacuum of the hospital, where we release our patients after they are mostly better and hope they continue to heal. I suspect, though, that the recidivism (is that even the right term? probably not) of our sicker patients is very high, and that this chronicity of mental illness would start to bring me down over the years.