"Unique Opportunity" for the PCP (i.e., psychotherapy)

"Primary care practitioners have a unique opportunity to address the emotional needs of their patients, but regardless of their importance, these needs must be handled in a time-effective manner. The psychosocial aspect of patients' problems must be effectively addressed within the regular 10 or 15-minute medical visit. The therapeutic goal is to help patients reorganize some small aspect of their self-concept or behavior in a more comfortable, productive, or, at minimum, less destructive manner. The healing grows out of the established practitioner-patient relationship."

Stuart MR, Lieberman JA III. The Fifteen Minute Hour: Therapeutic Talk in Primary Care. United Kingdom, Oxon: Radcliffe Publishing Ltd.; 2008.

Very interesting thought. And I suppose, a good goal for someone like me who--if I ever become comfortable enough with it--would spend much more than 10 - 15 minutes on therapy with a patient.

Diagnosing One's Identity

I have started my psychiatry clerkship and I think I'm in love.

The staff is nice, funny, accommodating, kind. The physicians are crazy in their own way. The patients, well, the patients are all fascinating--there's something so complex about mental illnesses that makes it hard to reduce any one person to simply medicine alone.

And yet, with my patients, I feel like I keep reducing them to their diagnoses.

We are always told that patients are people--that we are treating them, not their illness. But with mental problems, the person is their illness because, well.... hmmm....

What is identity? It is the way we interact with our environment. It is our behavior. It is our thoughts, are consciousness. It is who we see ourselves as. It's what comes to your mind when you're asked to define yourself. Throughout college I told people I was "biracial, bisexual, and bipolar," because 1) I liked the way it sounded and 2) it seemed to partially capture the fact that my entire life I've seen myself as someone stuck in a huge gray area between the black and white poles of the various identities constructed by society. Definitively nothing, unquestionably everything: Elora Kathryn Apantaku.

But back to psychiatry and patients and their identities. I didn't realize how chronic most psychiatric disorders were. A lot of the older patients--in their fifties and sixties--a lot of them have been suffering from these illnesses--manic depression, major depression, schizophrenia--for decades. Their lives are so strongly influenced by their diseases... and although medication and therapy can help them stay out of the psych ward, their presence on the floor argues that they are doomed to continually function in a way that is maladaptive--either to their family, their friends, or to society.

The Barometric Mind

I woke up this morning around 5:30, very briefly--thirty seconds maybe--because it was raining, and although the sound of rain beating on my apartment's giant windows overlooking the South Loop is usually really calming, the water dripping through my roof, through my ceiling, and onto my already stained carpet is quite distressing. But I didn't stay awake because at this point, a stained carpet is very low on my list of worries.

I'm thinking about away rotations and my grades and how to make myself look good for residencies. Am I forgetting paperwork? Probably. Where should I go next year? Do I want to go to Maine? Stay with my sister? Or should I go somewhere I've never been before, working in a hospital in Mississippi all by myself. Do I want to do family medicine rotations or psychiatric ones? These are the things I've been worrying about, but I recognize that my worries are not really important, just bothersome.

The patients in the psych ward, now their worries are real. Your family can't tolerate your manic outbursts anymore so they have you admitted--you promise to adhere to your medications from now on, but your family doesn't trust you any longer so now you don't have a home. Where do you go? In this already stressed out health care system, you run a real risk of becoming homeless--or as the hospital I'm working at calls it: undomiciled. That's a worry. Or let's say you're psychotic. Then the voices can give you a whole new set of things to worry about: "you're going to die as soon as you leave here" they might tell you, or "you need to be back on heroin again--that's the only thing that can help you, this anti-psychotic sh*t isn't helping and you and I both know it."

I arrive to the inpatient psych floor at 9:30. One of my patients, on the spectrum of schizophrenic to bipolar, is standing in the hallway, leaning against a wall. She looks terrible. "Good morning Miss [HIPPA compliant], you look tired, did you sleep well?" She says no. I stand next to her for a good fifteen seconds, waiting for her to elaborate, but she does not, so I slowly walk away, looking back at her as if she'll suddenly want to tell me more. Later, when I follow the doctor around like her own personal shadow, we stop by to see my patient. "This morning the nurses said you were banging against the wall and screaming, why was that?" My patient answers back something about "the voices" which I was almost positive had been alleviated by her sudden acceptance of her anti-psychotic meds.

Another patient, depressive with psychotic features, also has a similar complaint. The medications had helped reduce the voices to whispers, muttering always, no longer commanding. But this morning, they woke her up again, yelling at her. She looks tired today--much more so than yesterday.

I am a scientist--but I am a bad one. For me, personal anecdotal evidence is much more powerful than studies that have thousands of patients arranged into double blind groups and blah blah blah.... This is why when I think of sickle cell disease--how my dad's a carrier, my mom's not, but yet all three of their daughters have the trait--I think that there's more than coincidence going on with how it's inherited--either magic or some genetic translocation oddities.

Which is why I know believe that weather can make you psychotic. Two patients woke up in the middle of the night, around the time I woke up freaking out about the rain, and were brought back to their presenting level of psychosis. Maybe the pressure drop affected the neurotransmitters as much as it affected the forecast.

Just a silly, crazy, insane thought.

.... Shelf!

Surprise! I have a giant subject exam next Wednesday! I'm terrified! Hence the exclamation points!

I'm terrified because it will be worth 20% of my final grade in my favorite class: Clinical Neuroscience. I had a feeling I'd like psychiatry even when I came to medical school, but it was never something I thought I'd seriously like.

I came in with a pledge to make medicine easier to understand for my patients. I fully believe I will have to see a lot of patients, but I want to make every single one of them feel in control of their health--by giving them the information and the support they need to make their own decisions.

This is why my final research project in college involved looking at the ways doctors communicate with their patients.

And psychiatry, I realize, sets itself up as the specialty that requires communication over everything else. Even with primary care--let's say family medicine, which is still my first love--you talk with the patient, and most of the time, talking is all you need. But you still approach a patient in primary care as an algorithm. History fills in some information, labs and tests fills in the rest. You shake it up, and you come up with a diagnosis. Or several diagnoses.

Psychiatry at the very start basically says: the only way you're going to get anything done is communication. There is no back up plan. You can't be that doctor who is really smart but also really distant--really bad at talking to people. I guess what I like most about psychiatry is that it really emphasizes medicine as an art form.

Regardless, I am now considering a double residency because hey--I'm young. But what I really want to do is qualify for an Honors Elective in Child Psychiatry. That was the most ... electrifying part of this course for me. Many of my friends, I realized, had these conditions. Most memorably, my best friend in elementary school had selective mutism. Which I always thought was interesting as a little kid, but now I understand it and I find it even more interesting.

Anyway, to qualify for the Honors elective I need an A in clinical neuroscience. And right now, without any extra credit, I have an 85%. SO FAR AND YET SO CLOSE. So, the next 6 days of my life will probably be panic, panic, panic.

Adding pain to misery, 50-55% of the exam is on "Central and Peripheral Nervous System" which is incredibly vague. Fortunately, the vagueness was removed by the course director who basically explained this chunk of questions as focusing on... you could easily guess it... my least favorite and, I am not exaggerating this when I say, my most personally antagonizing part of medical education... Neuroanatomy!

Trials and tribulations, right?

Here's to a weekend of staring at brains!

What Constitutes a Mental Illness?

Exciting news everyone! My previous post concerning personal ambivalence towards diagnosing, labeling, and medicating mental disorders has gained some validation. Below is the reading--from an actual publication--describing the "confusion" in dictating what constitutes mental illness.

BRAIN AND BEHAVIOR

Descriptive Psychopathology: The Signs and Symptoms of Behavioral Disorders by Nutan Atre Vaidya and Michael Alan Taylor:

The DSM conceptualizes a “disorder” as a condition that is clinically significant and that causes distress or disability. This definition fails because it is overinclusive, incorporating as disorders non-illness such as demoralization, jealousy and revenge, and criminality. By the definition, normal pregnancy might be considered a disorder. Others have argued that a more precise definition of illness is: a condition that causes harm and that derives from dysfunction. Harmful dysfunction involves “something going wrong with the functioning of some internal mechanism, so that the mechanism is not performing one of the functions for which it was „designed‟ by natural selection.”

This conceptualization works for most presently recognized psychiatric disorders, but may fall short for some of the personality disorders.

Confusion also arises from the fact that persons who appropriately receive classification labels are by definition deviant, but deviance has several fathers. Brain structural and physiological lesions (genetic and acquired), maturational variation, and indoctrination at odds with the cultural context cause deviation. Further roiling the conceptual waters is the fact that some deviation is advantageous (e.g. high intelligence, talent).