nANIMOv

My first solo History & Physical on this voluntary inpatient psychiatric unit. I thought it went pretty well. The patient had been experiencing some questionable delusions and paranoia (I say questionable because they themselves were questioning whether or not what they were experiencing was based in reality), and I thought I did a decent job of making the patient feel heard without necessarily validating their delusions.

As frustrating as I find management of psychiatric illness, what I do find interesting about it is the challenge of working with patients, with people, similar to the challenge that draws me to primary care. A lot of people are reluctant to receive psych treatment because it’s either unknown territory or because they have been burned by psychiatric treatment in the past (side effects, refractory illness, mistreatment, etc). The challenge is: how do I reach this patient who is scared and closed-off for whatever reason, and get them to a place where they are able to be open minded to the possible of trying a new approach? How do I get this person to trust me despite having relatively good reason not to? This is where more of the “art” of medicine comes into play, and I think there is a lot of opportunity for that in psychiatry.

This was the longest day I spent in the hospital since starting in psych. It was a bit of a shock compared to what I had gotten used to, but nothing crazy. If anything it’s what probably more of what I expected. I feel like I’m learning a bit more, but also I feel like there’s more pressure that I am not prepared for. I have been growing in my confidence in talking with patients and management of some of the more “bread-and-butter” diagnoses, but as soon as they deviate from a classic clinical picture I sometimes get stumped. We’re getting there though. I think it’s going to be a good week.

The attending I’ve been working with this week has been very chill. He is working via telehealth and so I’ve mostly just been bringing patients into the room and essentially shadowing while he interviews them other than my occasional side/ clarifying questions.

Today I asked if I could take the lead on a new patient interview and he was happy to oblige. What was nice about this case was that he was able to observe me in real time. One of the things about other rotations is I’m often unsupervised when talking with patients so my attendings don’t really know what my interviewing is like. Talking to patients is one of the things I am relatively confident in and feel strong at, which lies perhaps in stark contrast to sometimes accurately convey the contents of those interviews in my presentations.

The patient I interview was a pretty interesting case filled with drama and intrigue. After it was over my attending had very encouraging words which felt good and a nice dose of affirmation among an otherwise poor performance by me on this rotation.

TTITF:
Decaf coffee, curly fries, sun showers

One of the gratifying things about inpatient psychiatry is seeing improvements in mood, more or less in real time. We’ve had patients who came in on the verge of suicide, who over the course of their stay seem like completely different people; smiling, laughing, hopeful.

The sad part is sometimes when patients come in for their discharge interview I can’t help but feel like there’s something hidden behind an almost-too bright smile and cheery mood.

It’s not that I don’t believe that they are doing better or that I don’t think that they are capable of getting “better.” I just know that if was somewhere I didn’t want to be for whatever reason, and I knew putting on a smile would help get me out, I could easily fake it as long as I needed to (speaking from experience). Hell, I’d put on a whole damn show.

My concern is not simply whether or not they are faking it, but more so the implications if that’s true. It means we failed. It means we were no better than all the others that came before proclaiming that we care and that we want to help, but we didn’t do enough, and they will think twice next time about coming to us for help.

This is all existing in my overthinking brain though. I’m somewhat assured by the fact that patients seem to do well after they leave. And many patients do voluntarily return if things take a turn for the worse. But is also in the setting of recognizing that our mental health systems are far from perfect and people deserve better than what we are currently offering.

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.