doc w/ Pen

journalist + medical student + artist

Tag: Psychiatry

On this day …

I don’t normally look at the “On this day” posts on Facebook. I don’t normally spend much time on Facebook at all. But today, on a whim, I did. This came up, a 5-year-old memory:

As did another post from a dear friend exactly a year later, which I’ve copied below. If I remember correctly, the first sentence, in quotation marks, is her quoting me; the second sentence is her reaction to my words:

“Holy shit. That is an acceptance letter.”
I LOVE YOU

Discussing the MCAT on this day in 2013, and a medical school acceptance letter on this day in 2014 …

I’ve come a long way since then. I’m now discussing medical school graduation (in 13 months!) and where I will apply for my psychiatry residency (in 5 months!).

Thanks to all of you who have helped make this possible, and to all of you who have followed me on the journey. I couldn’t have done it without you.

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Celebrate!

Every day, it gets a little more real. The fact that in just over a year, I’ll be a doctor.

Some moments, that timeline feels more concrete than others. Like today, when I logged in for the first time to my new best friend ERAS, the Electronic Residency Application Service.

I’m sure I will grow to loathe the purple, orange, and green color scheme of my ERAS dashboard, given how much time I will spend on this website. (And really? Purple, orange, and green? That’s a little much, isn’t it?)

But today, the colors seemed festive and celebratory. And so I am celebrating.

That’s right, I’m applying to RESIDENCY. Wow …

 

Picking among disciplines

“What do you want to be when you grow up?” It’s a common question throughout childhood. It comes from teachers and parents. It’s also a question we ask of ourselves. We dream into adulthood, trying on different career costumes, imagining what could be.

My own sense is that the question is in constant evolution. It can’t be definitively answered after high school, college, or even graduate school. Few people in this era complete a career with the same company. Each new promotion, each new employer, provide further clues into our professional identity.

When I decided to go to medical school after a career in journalism and publishing, I turned over a radically new leaf. I handed in my pen for a penlight, political sleuthing for a stethoscope.

Could I have imagined such a change in course when I first thought about my future? No.

As I approach the start of my fourth and final year of medical school, the original childhood question takes a far more specific turn: What kind of doctor do I want to be?

It’s pondered endlessly, ad nauseam, at times to the point of true nausea. As in childhood, my reply to the medical school version of the question has changed over time.

For as long as I can remember, I’ve made things with my hands, from beaded necklaces to stained glass windows to origami flower bouquets. So I initially pictured myself in a procedural specialty, something surgical, making the most of my manual dexterity. But I quickly realized that I much preferred waking patients to those under anesthesia. I also realized that the reporter in me craved stories, conversation.

In the context of my career history, filled with interviews and human contact, my chosen field — psychiatry — makes obvious sense. Admittedly it wasn’t the choice I’d imagined when I began medical school. In fact, it was among the fields I thought I wouldn’t choose.

But in a way, psychiatry chose me.

Before starting my psychiatry rotation, I’d rotated through obstetrics-gynecology and primary care (outpatient adult medicine). I’d loved aspects of each. In the ob-gyn segment, it was my two weeks on the labor and delivery service. Holding the hand of a mother-to-be, counting with her as she pushed out a new life. Talking, in between pushes, with her and whomever was there to support her (husband, partner, mother, sister, friend) about their hopes, dreams, and fears. During primary care, it was sensing the trust that patients put in their internist, who’d known many of them for years, knew their life stories and struggles as well as their medical diagnoses.

Not long into my psychiatry clerkship, I realized that in this one field, I could experience my favorite parts of my time in ob-gyn and primary care. I could talk about a patient’s hopes, dreams, and fears as well as develop ongoing relationships with them.

I could also use many of the skills I’d honed in my decade-long career before medical school. Psychiatry, like journalism, is about stories. It’s about developing quick rapport, asking the right questions, and being an active, empathetic listener. These skills are certainly not unique to psychiatry, but they are especially important in psychiatry, where a detail from the patient’s medical history, past hospitalizations, relationships, or living situation might be crucial to how you manage the person’s care. This background suddenly takes on immense importance because of the way past experiences shape mental health.

There is also an investigative aspect to psychiatry. One of the tasks frequently given to medical students on the psychiatry clerkship is to track down so-called “collateral” on a patient – to talk to a person’s medical doctor, therapist, psychiatrist, case worker, significant other, sibling, parent, or friend – to get a more complete picture of the person’s immediate situation. In psychiatry, as in journalism, you don’t rely on the story you get from one person. You approach information with healthy skepticism. And so you gather evidence from a number of sources and put the pieces together yourself.

Each field of medicine also has a vibe, a unique personality. Part of finding your place, I realized early on during my clerkship year, is finding your tribe. In psychiatry, I did. I found people whose personalities, interests, goals, sense of humor, wardrobe choices, and even favorite eyeliner color meshed with my own.

After completing my psychiatry clerkship, I was almost sure that I wanted to be a psychiatrist. After finishing other rotations, I’m entirely sure. Because the things I liked best about each of them also have a place in psychiatry. In neurology, my favorite patients were those whose illnesses blurred the lines between neurology and psychiatry. In surgery, I thrived under the tutelage of a particular trauma surgeon, one of the best educators I’ve ever met. He inspired me, on a daily basis, to learn and explore, to be curious. I’ve found mentors in psychiatry who do the same, and I find psychiatry’s subject matter inherently interesting in a way surgery concepts were not. In internal medicine, I liked the challenge of using artful communication skills to broach difficult subjects with patients and family members. I also felt at home in the role of being a comforter to those in distress.

While I’ve answered the next iteration in this serial question – “What do you want to be when you grow up?” – my future is by no means fully defined. First of all, where do I want to do my four-year psychiatry residency? And after that, do I want to do a fellowship for more advanced and focused training? Do I want to work with inpatients, outpatients, or a mix? What city do I want to practice in? I’ll find the answers to these questions and others, in time.

For now, I focus on what’s in front of me: finishing medical school, and finding the right place for me to become the best psychiatrist I can be.

 

Note: The original version of this essay appeared on the online magazine “The American.” You can read it here.

 

Running the mental gantlet

This essay was first published in the online magazine The American. You can see the original version here.

 

Learning about a patient is like digging into a demanding novel: plot and characters need fleshing out.

Running the mental gantlet

Some people compare starting a new clinical rotation in medical school – something you do every six or eight weeks for an entire year – to starting a new job. A job you’ve never done, and one you feel wholly unprepared for. I liken the experience to being dropped into the middle of a novel. Dialogue explodes around you. But the speech lacks context and you struggle to make any sense of the words. Characters fall in love, have sex, shoot each other, but you can’t always tell the good guys and bad guys apart. For heaven’s sake, you don’t even know where you are. Russia? Iowa? The moon?

That’s how I felt when I started my inpatient psychiatry rotation on a summer Monday last year. I arrived promptly on the unit at 8:20 a.m. as I’d been instructed. I knew the names of the attending, resident, and medical student I would be working with, but not their appearance or where I was expected to meet them. I sheepishly hung out with a kind, chatty nurse until the 8:30 a.m. team meeting – a meeting I had no idea I was supposed to attend until the friendly nurse told me. A dozen or so of us entered a room and sat or stood around a big table to discuss general issues – safety concerns, upcoming discharges, new admissions, staff absences, special activities.

After this combined meeting, we had another meeting just with my team to discuss more specific updates on our own patients. Since I was new, those present introduced themselves. Overwhelmed by it all, I promptly forgot most of their names and their roles.

I got slight comfort in telling myself I’d pick up the details after everything settled down.

I noticed that the woman running the meeting had two binders. One bore the name of my attending psychiatrist, the other the name of a different attending. Not all the patients were covered by my team, which made me wonder where exactly they wanted my focus.

As the meeting progressed, with notes and updates on specific patients, I noticed that my medical school colleague, who was sitting next to me, occasionally scribbled a few notes. “Should I be taking notes?” I wondered.

I didn’t want to be perceived as not paying attention, but I had no idea who these patients were, which ones (if any) were my responsibility, and which updates mattered.

One of these updates might consist of something like this: “On Saturday, Jane Doe took her medications. She spent most of the day with her family. She expressed her needs appropriately. She slept well.”

That sounds bland, but perhaps this was the first day Ms. Doe had agreed to take her medications. Perhaps sleeping well was a major improvement for her. I just didn’t know.

With patient names and behaviors swirling in my head, I did my best to keep the confusion at bay, reminding myself that this was my first day, my first hour. I couldn’t be expected to keep things straight. Not yet.

Then the team resident, my classmate, and I talked individually with patients in one of the unit’s small, private meeting rooms. The resident immediately launched into questions. Sleep? Appetite? Mood? Hallucinations or delusions? Medication side effects? Thoughts of hurting yourself or others?

Between patients, my classmate tried to give me a brief synopsis of the next patient: diagnosis, treatment plan.

With only that to go on, I struggled to make sense of the encounters. The journalist in me cried out for each patient’s fuller story. Understanding the past would help me understand their present, and their prognosis.

As the patients answered the resident’s questions, in my own mind the replies only provoked more questions. One patient made a vague reference to a brutal childhood trauma. Another hinted at magical powers. How could I not want to know more?

Making matters even more complicated I had little understanding of what my supervisors (the psychiatry resident and attending) expected of me for the next four weeks. The medical student told me what he’d been doing – interviewing two of our five patients one-on-one daily, and writing a progress note on each. But more concrete information was hard to find.

I finally went to the source, asking the resident what her expectations were. She told me to do essentially what my classmate was doing — pick a patient or two, spend some extra time with them, and write my own notes. I had figured as much, but now it was official.

I selected my patients and dug into their medical records, combing through the notes in each person’s electronic chart. I was back to reading the novel, starting at the beginning and working my way forward. I began with each patient’s presentation to the psychiatric emergency department. That gave me a sense of how they were when they first came to the hospital compared to how they were now. I then moved to the initial evaluation note from the psychiatric unit (where I was now working). These two comprehensive notes helped me understand each patient’s present psychiatric illness, as well as past psychiatric history, medical history, family situation, and other life factors. I also read what are called “collateral” notes. These are conversations between a medical practitioner (often a medical student) and someone else in the patient’s life — a spouse, friend, psychiatrist, therapist, or caseworker, for example. They provide an outsider perspective on how the patient’s current condition compares to their norm. Last, I read daily progress notes, finishing with the one written that morning. These brief and focused progress notes told the story of the patient’s day-by-day existence on the inpatient psychiatric unit. How they were eating, sleeping, behaving, and overall living while in the hospital. These daily updates clued me into whether someone’s delusions or insomnia had improved, for example, or whether they were tolerating an increased dose of a medication.

At the end of that first day, I was still in the middle of the novel, on page 200 or so. But I’d gone back and at least skimmed the first 199 pages. And with that background, I was now ready to move on to the next chapter: the next day.

Working in the psych ED

As many of you know, I write a monthly column for the online magazine The American. Here is my latest piece, describing my reactions to working in the psychiatric emergency department. You can see the original piece here.

 

“Repairing the mind”

Bless you,” one of our lecturers told me when she heard I’d asked to spend part of my six-week psychiatry rotation in the psychiatric emergency department (ED). I understand all too well why the psych ED is a place many people might want to avoid. Many patients in this locked unit are acutely and severely ill. One patient might come in talking about hanging himself, another of how how voices are commanding her to kill people. An ambulance might bring in someone found found running down the street in undergarments. A handful of these patients can turn aggressive or violent, yelling and threatening to harm the physicians and other staff.

Most can usually be talked down but some require sedation via an intramuscular injection — and in a few cases physical restraints. Safe to say there are few dull moments.

Before I discuss my own response to the psych ED, I want to talk about a tension that generally speaking exists in medicine. I’ll use hypotheticals to illustrate my point. Imagine a doctor sees a hospitalized patient afflicted with a rare, potentially fatal disease.

“Wow, what an interesting case,” the doctor tells a colleague when the patient is out of earshot. The colleague replies, “No kidding, I’ve never seen a case of that before. Let me know what the outcome is.”

This fascination with a rare, possibly incurable disease might seem cold-blooded to a non-medical observer. What kind of person would say something like that? But medicine is all about compartments. Doctors have compassion for their patients. They care for them to the best of their ability — applying empathy and professionalism. At the same time, they’re possessed with intellectual curiosity about the underlying processes of diseases. Probing pathophysiologic principles is part of the scientific method they’re trained in.

Though compassion and curiosity coexist quite peacefully, all this might sound callous to a casual observer uninterested in these medical compartments.

My years as a medical student have taught me that patients and their families are sensitive to remarks made in passing. Medical curiosity can seem unfeeling. As a result, I’m careful as to when and how I express it.

That preface in mind, let me move on to the psych ED, an assignment I found both medically and professionally exciting. The unvarnished truth is that patients need the service and the service needs a staff. The psych ED is a high-impact place with plenty of patients ill enough to pose an immediate threat either to themselves or others, or both. For a doctor, it’s a high wire act whose reward comes in the form of helping prevent a suicide or bringing someone down from a dangerous manic episode. Plenty of patients admittedly don’t want to be in the unit. Some refuse medication and protest their hospitalization. But even in such precarious situations, you’re still providing patients with short-term safety.

The psych ED encouraged me to use both my journalistic and my medical training. Skepticism is essential in any kind of psychiatric work. Some patients will lie and behave manipulatively. They’ll do whatever they can to get out of the hospital, or remain inside. Others will try to lie their way out of medication, or into it. Part of the history-taking process includes gathering what’s called “collateral information,” which involves calling around — psychiatrists, therapists, social workers, and internists — to verify a patient’s details. With permission, we’re also allowed to get in touch with family and friends to get the fullest possible portrait of the person, assess his condition and safety, and create the best treatment plan. The number of phone calls and the tracking process can revive old investigative journalist training. You doggedly hunt down clues, refusing to back down when one lead dries up. Persistence comes in handy.

As a medical student, I’ve spent a significant amount of time with patients themselves. Once a patient is safe and secure, students are often tasked with conducting the initial psychiatric evaluation. They then present their findings, assessment, and a proposed plan to the resident and attending, afterwards writing up a note about the encounter.

This sense of teamwork, of contributing to hourly and daily goals, is uplifting. In other clinical environments, my work was duplicated — often in front of me. I’m a student. Obviously, some of my moves require double-checking for safety reasons. That’s normal. But the duplication often left me feeling redundant.

In the psych ED, when I called the patient’s psychiatrist, I wrote a note about the conversation and then presented my findings. If I missed key information, I called the doctor back. My work wasn’t repeated. I felt more trusted, more competent. Having spent a decade working in publishing, I’ve missed both the trust and the sense of competence.

There have been many challenges. The psychiatric patient interview differs from a standard medical evaluation. In the case of suicidal patients, for example, it’s essential to ask whether they have access to a gun at home. That’s not a typical question in other disciplines.

It’s a delightful combination — to feel both challenged and effective on a daily basis. Most important, I feel like I’m making a difference in someone’s life.