Wednesday, September 15, 2010

Pa-pa-pa-poker face

Just got done with rotation number one, psychiatry. In-patient. Lock-down floor. Veteran's hospital. It is a shame some rotations are not longer than 4 weeks. I felt like I was just getting the hang of things when it was time to leave. It is interesting what specialties medical schools choose to make a requirement and which ones they do not. Four weeks is not long enough for someone to decide they want to do something for the rest of their life in my opinion. Some thoughts:

-The employees of the hospital dubbed their electronic health record, "the best in the world" and I am surprised if that is as good as it gets. It is my first run-in with an EHR, but I had many suggestions for improving it. While it may improve time when compared to paper charts, it is by no means fast. It still took time to gather the information needed to be caught up on the patients' current care, diseases, medications, labs, vitals and any other pertinent information. I know most of it has to do with the fact that it is my first rotation and I have no idea what I am doing. What I did like was that we could see any visit the patient made to any VA hospital in the country. That was clutch.

-The hours were nice. Essentially 8-4:30 every day, but the call for residents was every 4-5 days which isn't the greatest. I still had to get there early to navigate the EHR so the hours for me seemed longer than they should. Still, the hours were very nice and precise. I foolishly tried to meet with a secretary to get some papers filled out at 4:15 on a Friday. Struggled to find someone who could tell me, "Don't ever try to get anything done at 4:00 on a Friday." Thanks chief.

-I was blessed with an amazing attending, and wonderful resident and an awesome staff to work with. Everyone was very laid back and helpful. My resident was constantly making sure I was not overwhelmed or stressed out which I appreciated but never crossed the line to treating me like a baby. In med school we constantly hear the horror stories of attendings who are rude and residents who make you feel like a piece of crap. Not this rotation. Call me "weak" or "soft," but I know I will not do well in certain situations with certain personalities. Sorry for all the residents who have a resentment towards students, puppies and laughing children because somewhere along the way you got a massive chip on your shoulder. I am convinced that residents and attendings can be pleasant, thoughtful and respectful and still be wonderful teachers and mentors. The snide comments, standoffish teaching approach and temper tantrums will never help me. For instance, a resident on another team was constantly grouchy, passive aggressive, and rude to everyone, especially his students. I was helping one of his students navigate the EHR, the floor, the procedures, etc. during his first day and after five minutes the resident privately asked me if his student was getting it yet in the most condescending tone. Getting it yet? Getting what yet exactly? Yeah buddy, he has the whole "doctor" thing mastered in five minutes. He actually just left to apply for Harvard faculty. I am willing to give people the benefit of the doubt a few times, but at some point you cross the line from "bad day syndrome" (my new addition to the DSM-IV) to "I want to kick you down stairs" jerk.

-I loath gunners. Direct quote from another student: "When the attending was asking me questions, I thought it was because she didn't know the answer." Seriously? You really thought that the attending uses medical students as her wikipedia medical reference. The trained and licensed physician wanted you to enlighten her on medical practice protocols during your first rotation. The more and more time goes on I realize most gunners just flat out don't get it. He doesn't understand what just came out of his mouth enough to understand how absurd it is. This same student also decided it would be a good idea during rounds to point out that another student forgot to check his patient's labs. My hat goes off to the attending who corrected this guy by simply stating "It is bad form to take over another student's patients and correct them. Nobody likes it." There needs to be more attendings like that. This guy is a nice guy, it is almost as if he doesn't think through actions and things that come out of his mouth. Glad he wasn't on my team.

-There were underlying themes to mental illness. This by no means is a attempt at politics or judgement, but the patterns are clear. Combat experience, drugs, broken families and abuse jack people up. All political and religious beliefs aside, I have a huge appreciation for the sacrifice military men and women make for us. The illnesses that can come from a result of serving not only mess the servicemen up, but can destroy their family's lives as well. I was saddened at many of the people's lives as a result of their service commitment.

-The human mind is so sensitive. There is so much unknown about mental illness and the brain and I am amazed at seeing some of the sicknesses first hand. Reading about schizophrenia is one thing, but seeing a person believe people are going to try and kill him to the point his heart is racing is eye-opening to say the least. Hearing voices that are so real to them that if they cover their ears, the volume of the voices diminishes. I feel like there is such a fine line between our brains and the brains of the mentally-ill. I often wondered if someone were to really listen for voices (I mean really listen and try to convince yourself you can hear them) what might happen. Or if something really bad/traumatic were to happen to me, would my coping mechanisms be enough to keep me sane?

-There were really odd situations. Like the guy who kept peeing himself and attempted to play the dementia card, and the stroke victim card at the same time. Was he demented, was he a stroke victim, we couldn't figure out what he was trying to have us believe. After extensive metabolic tests which came back negative we did physical exams and mental aptitude tests. Once the tests came back severely different in the matter of 4 hours, we were pretty sure he was faking it. Why? I have no idea. Maybe he doesn't want to go home. I have no idea but were were extremely confident nothing urgent was wrong with him so we discharged him. There were many people who came to the floor to avoid being homeless and facing legal issues. Utter the magic phrase = "New England Clam Chowder" "I want to kill myself" and you are in. The cycle of people coming in at the middle of the month when they run out of money and then miraculously getting better near the first of the month when their disability/service check/welfare check was due to be delivered was like clockwork.

-Another odd situation was a gentleman who had antisocial personality disorder. My attending stated he would pass a lie detector test because he legitimately doesn't have feelings of remorse. He could look you in the eye and lie to you and have no problem with it ever. This same gentleman was caught selling drugs from the patient floor on the ward. Nice.

-I had to figure out techniques for not laughing. Pretty much worked on my poker face for a month. It is seriously hard to do in certain situations. I did not want to be unprofessional or insensitive, but at times it was really hard to not laugh as some things patients said and did. How do you not laugh when advising a grown man that masturbating on the ward is probably not a proactive approach to get himself discharged. And dude, I know you were not "dry" down there so don't try to play it off that you were "moisturizing." As close as I came to laughing at times, I never cracked. I was also accused of the following:

  • Having a second wife and three current girlfriends. After all, the patient's lawyers had been following me for the past 6 months.
  • Changing my name repeatedly
  • Having a small device to make the patient fall over when she was talking to me. She had my attending search my pockets.
  • Putting thoughts into a patients' head
  • Starting rumors that a female patient had a penis. Seriously how do you not laugh when a conversation goes like this:

Me: "Good morning Ms. X, how are you feeling today."

Ms. X: "Not good, you started a rumor I have a penis and I don't!"

I had to learn to anticipate odd comments so they wouldn't come as such a surprise and at times had to bite the inside of my mouth so I wouldn't smile. Worked pretty well.

Overall it was a perfect first rotation. I got comfortable interviewing real patients and had plenty of time to do interviews. By not being in a office setting I didn't feel the need to rush through patients. I can't say that I am sold on psychiatry. I felt at times there was not enough procedural action. It was a very interesting field, but I am not sure it would be the best fit for me as a career.

Next rotation: Family Medicine

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