Sunday, January 27, 2008

How To Clean your Brain, as told to me by a schizophrenic patient

Shortly after I decided to go into medicine, I knew the day would come when I would have to deal with a branch of medicine that both fascinates and intimidates me: psychiatry.

I'm not sure what it is about dealing with psychiatric patients that makes me so nervous. Perhaps it's how much I value my own cognitive abilities. Maybe it's the stories I've heard of patients in acute psychotic episodes, throwing furniture and yelling obscenities. Or it could be that every psychiatric ward I've ever been to or seen in movies sends chills down my spine.

But now that I've started my Clinical Skills unit on interviewing psychiatric patients, my naivety has resulted in a few surprises. I was blown away when I interviewed someone who has a severe form of a psychiatric condition, yet could still carry on a coherent conversation. I was also quite stunned after the patient told me about their ability to carry on conversations with squirrels in the park and according to their chart had to be tied down in four-point restraints on admission to the hospital, yet answered a number of Mental Status Exam questions testing insight, judgment and thought process as any normal person would.

Of course, the psychiatrist training us told us that there are a few exceptions to this.

For example, some patients will speak in what is termed Word Salad (ie. "I was running down the sidewalk, over the alleys in the supermarket. Sometimes the store is full of nuns, and sometimes the airplanes fly lower. But when I was younger, they threw me over the furnace and the time was singing."), and another patient he remembers didn't speak a single word in the interview, later revealing that he did so because he thought the psychiatrist could read his thoughts.

The patient I interviewed was a bit shy at the start but completely warmed up to me after a little bit. I was a bit nervous when the patient listed off their favourite weapons, stood up to demonstrate self-defence fighting techniques with intense enthusiasm, and then looked at me with hollow, peircing eyes and shouted "I'M GOING TO F------ KILL YOU!" (fortunately while recounting a conversation with somebody else, but it was still pretty intimidating!).

After getting a bit of history from the patient, I looked through the interviewing handbook we'd been given, and asked a couple questions from the "Anxiety" and "Depression" categories, but didn't get very far. Then I picked a question from the "Psychotic" category: "Do you have any abilities that other people don't?" and the patient lit up like a Christmas tree.

"Oh, definitely. I can clean out my brain."

"Really?" I replied, trying hard to stay professional and not crack a smile.

"Oh, yeah, I do it all the time."

"Could you tell me how you go about doing that?" I inquired.

"Sure, all you have to do is fill up the inside of your skull with water. Let it fill up slowly - not high enough that you'd drown, but close to the top." The patient held up hands to demonstrate the appropriate depth. "Then, all you do is shake it around a bit" - again I was given a demonstration of proper procedure - "and after that let it drain out, all through your nose and drool it through your mouth, all the way out until it reaches your navel."

After the interivew, I mentioned to the preceptor that I was stunned that given a demonstration like that, the patient could still answer a number of simple Mental Status Exam questions testing insight, judgement and comprehension correctly. "That's normal for someone with this disorder," said the psychiatrist. "Some of my patients with schizophrenia are incredibly high-functioning - they carry on normal lives with successful jobs - accounting, engineering for example." I wonder how many are doctors.

So that was my first psychiatric patient. I'll get to watch other students in my small group interview a number of other patients over this unit, and hopefully see a variety of pschiatric conditions. For me, however, after a few weeks' exposure to psychiatry, I've concluded that to me, psychiatry is a speciality just like pathology. While I'd never want to become a pathologist given the stigma, I have to admit that the more I learn about it, the more fascinated I am by it.

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Sunday, January 13, 2008

How a doctor might tell you that "you are dying."

Which is worse... telling a patient directly "you are going to die," or having them leave your office having no idea because you tried to phrase it gently?

While I haven't yet been trained in breaking bad news to patients, the answer to this seems like it may be fairly obvious.

In an
article published in the Journal of Clinical Oncology, author Scott Berry tackles this issue. Most interesting is a role-play situation in which physicians had to tell a patient they were dying; only one of eight oncologists used the word death. In the name of empathy and gentleness, perhaps the following statements veered too far into the realm of vague:

What the physicain said: Most people with this disease will have problems soon...Time could be very short—a few weeks to a few months. I think it is advisable to prepare for the worst and hope for the best.
What the physician meant: You are dying.

What the physicain said: Your time may be short.
What the physician meant: You are dying.

What the physicain said: If there were a hundred people in your situation, most of those people would have major problems within one month or so...let's consider that we are now at Labor Day. By the time we get to late September, early October, I would expect that you would be having major challenges or problems.
What the physician meant: You are dying.

What the physicain said: Certainly, it sounds like the disease is really threatening your life.
What the physician meant: You are dying.

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Friday, January 11, 2008

Rite of passage (or, Delicious Irony)

Every medical student comes to a point in their career where they must perform their first digital rectal exam (DRE).

Today, during a clinic rotation, was my turn.

In a delicious twist of irony that I think was lost on my preceptor, another physician in the office was having a going-away party which we visited directly after this little procedure.

In other words, within minutes of performing my first DRE I was celebrating my new-found skill with a slice of...

...wait for it...

...chocolate cake.

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Sunday, January 06, 2008

"I have never understood why medical schools have twenty year olds learning medicine."

While my age has been posted on this blog ever since it began over a year and a half ago, only recently have some commenters drawn attention to my age:

"Blogger, one question for you. How on earth did u get in to med school at 21? What was your life style like from high school through undergrad? " - anonymous
"I have never understood why medical schools have twenty year olds learning medicine. They have gone from high school to undergraduate to medical school and have absolutely no life experience. Of primary importance are the marks of the applicants; all else is secondary." - fossildoc
Before I begin I'd like to thank the many, many people who brighten my day every time they post a comment on this blog. Even if you don't agree with me (or my medical school's decision to accept me, perhaps, in an indirect sort of way?) offense taken. Keep 'em coming!!

It's interesting hearing this perspective when, first of all, I am by no means the youngest person in my class. Most medical schools publish statistics of their admissions class, which show that the average age is usually in the mid-twenties but the youngest person is often 20 years old on admission (and sometimes younger).

This is by no means the extreme, however. In some schools in Quebec, students are admitted to a five-year med program after only being out of high school for two years. And in the United Kingdom, students are admitted to a six-year med program straight out of high school.

Secondly, I sincerely agree with the fact that life experience is important. Personally, I took a year off and worked in a completely unrelated field and travelled between my undergrad degree and the start of medical school. I gained so much perspective in this year.

And not only is this my personal opinion, but many med school admissions committees would agree. If a spot comes down to two applicants who are equal on paper in terms of their academic qualifications, the applicant with more life experience will always be the one finding the thick envelope in their mailbox.

While fossildoc may have been right twenty years ago, and many schools retain a minimum mark cut-off, today it's no longer true that med schools admit students based primarily on their marks.

And as a result, the amount of life experience in my class alone means
the people in my class are all fascinating and there are so many whom I admire for various incredible reasons.

In addition to life experience though, medical adcoms look for something even more important: maturity. Maturity is an important factor in medical students and indeed physicians and you'd be hard pressed to find a school that admits someone whose immaturity compromises their professionalism.

Given all that, however, I can empathize with these readers who question how young medical school applicants are. I
submitted a forum post a while ago after being frustrated at the immaturity of some of my classmates:

"Most of the 3rd years in my class have demonstrated immaturity at one point or another, more so than the people who got in after 4 years or took some time off after graduating. By immaturity I mean anything from showing disrespect by talking loudly in lecture to uncontrollable giggling and crude comments during the genitalia examination clinical skills video. ... If it were up to me, based on what I have seen, I wouldn't allow 3rd years to get into medical school at all."
Needless to say I pissed off a lot of third-year applicants with that last statement, and in retrospect it was a bit extreme, but a) ruffling feathers on the interweb is fun and b) the number of mature young students compared to the number of immature young students - from my impression - is miniscule.

But while the ratio is low, the presence of a distinction demonstrates a point: the maturity of an individual cannot be inferred from their age. In other words, just because a student is young, doesn't mean they're immature. There are some students in my class who have stunned me when they revealed their age, because based on their maturity level, I would have guessed they were five years older than they actually are.

And that's the point I'm trying to make. Unfortunately I couldn't have said it as well as
worriedandwaiting, who summed this topic up really nicely in a statement on that pre-med forum, and with whose comment I'll close:

Are you a better doctor because you're 25 or because you're 35? That question has no correct answer. Age is not the factor. Who you are as a person is what matters. It is your life experiences that define you as a person, so try to maximize this opportunity to grow as an individual. As we all know, some 21 year olds already have a lifetime of experience, while some 30 year olds still think like teenagers. It all depends on the person.

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