nANIMOv

After spending a week in the Psych holding unit and now a few days in the voluntary psych unit of my hometown hospital, I will say the experience was a bit different from what I expected.

Before saying anything else I would like to say this: no doubt all the people who were there needed to be there for one reason or another, and the hospital is doing a good job (at least from my unqualified opinion) of treating patients effectively and compassionately. Many of the patients coming in have psychiatric issues despite being relatively well-off, having supportive families, and other strong protective factors. Of course many of them simultaneously have tragic and traumatic pasts which contribute to their risk, and we do what we can to set them up with the support and follow-up to help them reach their goals for their health, psychiatric goals, and lives as much as we can within the limits of our abilities (and healthcare system and personal/ professional boundaries).

Having come from my last rotation at the county hospital and is the street medicine symposium I can’t help but think about all the patients with complex medical and psychiatric needs that we aren’t seeing. Often times we aren’t seeing these patients because they don’t have the means or the capacity or the insight to come to the hospital when they are in crisis. Maybe they have been burned from the hospital for whatever reason. Maybe they have other social or financial barriers. It’s easy to have one’s perspective skewed by your immediate surrounding, and I’ve noticed that happening with myself recently. The people we are seeing, though perhaps no less in need, are often those who have means and those who have some form of existing support system (even if tenuous). They are like the WWII ships that came in with all the holes making the engineers think the places where the holes were are the places they need to fortify. And it’s easy to forget about the planes that didn’t make it back, and the damage they sustained which prevented their return.

I’m not saying it’s the responsibility of the hospital or of psychiatrist to round up and treat all the forgotten, “invisible” people suffering from psychiatric illness. I don’t know what the solution is here, I think more than anything this is a reminder to myself that medicine and healthcare, their benefits and their shortcomings aren’t confined to the walls of a hospital or clinic.

Today I had a patient with delusional misidentification syndrome. There are different types: Capgras syndrome, where someone familiar like a family member has been replaced by an nearly identical stranger; Fregoli syndrome, where someone thinks people they encounter throughout the day are actually the same person (often a enemy or persecutor) in disguise; phantom boarder syndrome, where a person believes that there is someone living in their house (but they never see this person). All of these sound like they would be very frightening to experience both as the patient and as a loved one. The patient I saw today had kinda a mix of Capgras and phantom boarder. She believed that her husband of 40 years was a family friend overstaying his welcome at her house. She claims she had been divorced for 10 years and this guy just showed up and refuses to leave. She has called the police multiple times to have him removed, but they aren’t able to do anything because according to his driver’s license, he lives there. It’s just a sad situation overall. For the wife because that must be so scary to think some strange man is invading your home. For this husband because this woman that he shared 40 years of his life with is acting like none of that existing and treating him like a stranger.

What’s even more heartbreaking is there isn’t really anything we can do to make the situation better. The patient’s condition is age related and there is no cure or super effective treatment for dementia so she will just continue to decline. The husband doesn’t want to send her away and he doesn’t want to cause her any torment, but he also shouldn’t have to move out of his own house.

One part of me says, it’s cases like this that make me not want to go into psychiatry. But at the same time I feel some guilt because I feel like then I’m running away from difficult situation, but the reality I’m not sure how much psychiatry is actually involved in cases like this besides “understanding” the pathology and etiology, maybe providing medications with limited efficacy to marginally help lessen the symptoms, and make recommendations to send the patient to a facility or consider home health depending on a variety of other circumstances and social factors.

Later in the day I was able to volunteer with Doctors Without Wall, this time at a park clinic. It was nice to be back and see the familiar faces. It was nice getting to hear about patients now with this new medical knowledge and actually have some thoughts on management in a setting where previously I played a very different role. Gets me a bit fired up.

TTITF: old friends, vegan donuts, extroverted strangers

I will say what does appeal to me about psychiatry is the lifestyle. I have never had stress levels this low during a rotation. I’m not sure if it translates to being an attending, but from what I know of the psych attendings I’ve had so far, it does. It has given me time to work on other projects and not be a shell of a human. Not sure if the work itself is what I want though. I love talking to patients and I think having the opportunity to walk along side a patient during particularly vulnerable moments is something really special to medicine and psychiatry especially.

One of the gratifying things about psychiatry is seeing dramatic positive changes in patients’ mood overnight after staying in the hospital (of course this is not the case for all the patients we work with). Two of the patients we saw yesterday who were in a pretty bad state mentally and emotionally yesterday were today doing much much better. They were smiling, talking about how much better they feel, the plans that they came up with. One of them yesterday was super resistant to any type of therapy and medication and today he was all about it. He said the experience he has had at this hospital has been very different to others he’s been to and now he’s talking about all these plans he has and this new outlook on life. He was even open to starting a new medication.

At the same time I’m kinda scared for patients like this because I feel like meds and therapy can only take us so far. We can’t necessarily change the situation or the environment these patients go back to when they leave; circumstances which may have contributed to them getting there in the first place.

Another rough one for the books. Some of the questions I definitely should have known the answers too. Being put on the spot is hard because even if somewhere deep down you know the answer it can be hard to generate based on how the question was asked or just because of sheer panic. It’s always impressive when I see other students able to generate answer off the top of their head or when physicians just spew of information like it’s second nature. That’s ultimately where I would like to be. As much as I dislike the memorization aspect of pharmacology, I do think mechanisms are cool and interesting. The hard part about psych pharmacology is that in a lot of cases we don’t exactly know why certain things work. We just accept them and/ or hypothesize based on our limited knowledge of the brain and how it works.

I find myself very badly just wanting to sit and talk with our patients. I’m not sure if that would make me a good or bad psychiatrist. On the one hand I think any situation that help patients feel more heard and supported is a good situation. On the other hand (1) am I the right person for that role and (2) is/ will the level of investment I’m imagining too much for my own wellbeing as a professional. In this rotation I’m looking to get exposure to more different psychiatry practice styles to see if there is anyone practicing in a way that I can see myself trying to emulate.

We changed things up a bit today thanks to the new schedule we received yesterday. Today I was on an ED/ consult service. It was a pretty sobering experience. There were a lot of suicide attempts, and a lot of young suicide attempts. On top of that I felt like my attending was kinda numb to it all, which I suppose in some ways I guess you have to be. It seemed like he was kinda numb to everything. The suicide, the psychosis, the volatility. I was mostly shadowing today and there were several times throughout the day were I felt like I should say something almost on behalf of the patient or out of my own guilt, but I held my tongue because who the fuck am I.

I also got pimped a lot on pharmacology which is one of my absolute worst subjects, which is saying something. I’m pretty sure I got every question wrong. Definitely the swift kick in the butt I needed to gear up a bit more (also I had the option yesterday to stay with the very chill attending that I was with the first 2 days).

Even though in terms of net experience today my needle moved further away from psychiatry, I will say I found a lot of value in talking to patients on my own and something I look forward to doing more of.

These first couple days have been a bit strange. It feels like no one has really known what to do with us. The clerkship director I guess has just been getting back from some time off and the inpatient attending who we have been working with just doesn’t seem familiar with having students work with her at this hospital. We made it work as best we can and the other student and I were able to do some learning today. Today I got collateral (supporting second-hand account of patient’s condition) from someone I had been curious to talk to. This person basically confirmed a lot of the story of patient himself, some of which sounded almost unreal, but the fact that they are real very much supports his diagnosis. We interviewed a lot of patients as a group today. I realize that I may not make a good psychiatrist because every time the patient talked about pain or a weird heart thing my instinct was to OPQRST them and break out my stethoscope.

Later we did get to speak with the director and get out schedules and kinda have some structure brought into the tumult that has been our lives the past 48 hours.

Also it’s burrito week in SB, and my classmate and I got the Super Cucas burrito. It was good. I still prefer their Cali burrito though. We also went to the farmer’s market which they hold INSIDE THE HOSPITAL COURTYARD. I got a pie.

After I got out the hospital I went to volunteer with my old street medicine org. It was really nice to be back. Sitting in the park talking to folks just made me think about how much I miss this work. In this setting and even in the hospital and in the clinic, I love talking to patients, whether its about medicine, their health, or just about how their birthday is coming up and they reserved a stage to play music and invited all their musical friends and they want everyone in the community to be there.

Then after that I got another burrito.

It seems almost a fitting juxtaposition that I attended the ISMS last week and I am now starting my psychiatry clerkship this week. At the conference there was a lot of discussion about how we as a society and especially as a medical community talk about mental illness and how the pervasive stigma towards mental illness impacts the care patients receive (I’ll post about this over the weekend). On my first day in the hospital I got just a small glimpse into the manifestation of that stigma and the inadequacies of our current systems as it exists in higher level psychiatric care.

Beyond that it was a good first experience in inpatient psychiatry. I think psychiatry is interesting in that the manifestations of mental illness are primarily behavioral, so I don’t expect them to present as concretely in real life as I do in a textbook. That said the patient I saw today had pretty textbook mania. It kinda makes you wonder sometimes if patients have done their research and are just intentionally saying the “right” things, but that’s maybe my implicit stigma and bias seeping out (’cause also why would someone fake mania). I’m looking forward to how the rest of this rotation is going to go.

This was my first time attending the International Street Medicine Symposium. I’ve been wanting to go since I first got involved in street medicine back in 2017. Overall it was a very inspiring and humbling experience. Being in the presence of all these amazing, compassionate people who are doing the work, for me highlighted how much more I could/ should be doing just based on the amount of work that needs to be done. From the talks throughout the conference there was a lot to think about and reflect on and it’s hard for me to articulate exactly what I learned. I wrote a lot of discombobulated notes in my journal since I was getting bombarded by ideas left and right and I need to organize them all into somewhat comprehensible thoughts.

I will say I have really missed actually working in the streets; working with the street team, talking to clients, listening to their stories.

There a ton of reflections from this experience that I will be hopefully fleshing out over the next week/ between my scheduled psychiatry clerkship programming (orientation is today).