Social Phobia

My step 2 studying attempts are progressing nicely (mostly thanks to habitrpg.com, which allows me to incentivize my daily study habits and my lengthy to-do list). 
My friends and I went out to dinner tonight and we mutually commiserated on how awful studying for huge tests is. But I really think studying for step 1 was worse. I have terrible flashbacks of skin flaking off of my face and my ears bleeding.
Step 2 is better if only because it is more interesting:

Did I know that I meet the criteria for having both social and specific phobias? No!

Although it makes sense. As much as I love talking to patients, I dread actually introducing myself to people. I frequently find that I yell at myself for missing an opportunity to talk to a stranger, or engage with a patient longer. Little things will bother me for the rest of the day, like when I missed an opportunity to say thank you to someone at the park who helped me figure out how to work the water fountain.

The treatment for social phobias is cognitive behavioral therapy (CBT) and SSRIs.

Cognitive behavioral therapy really fascinates me, but I think that's mostly because it's always listed as an efficacious treatment for many psychiatric disorders which I think is pretty counter-intuitive. Psychiatrists (they can prescribe you drugs because they are doctors) are thought of as superior to clinical psychologists (they can talk to you because they are Ph.D's), yet both medicating and therapy are equally effective for a lot of mood and anxiety disorders.

Regardless, I guess I could start trying to enforce CBT on myself. I could assess why I avoid talking to strangers and how that behavior is affecting my life. I could try to change it. I could slowly mold myself to become the person I've always wanted to be--gregarious, friendly, fun--using various tricks I've found on the internet or in self-help books.

On the other hand, I could just ask my psychiatrist to switch me to an SSRI.

Out of Bounds

I’ve never been a huge fan of babies. Toddlers are cute and "children are our future", but neonates are really boring. In comparison with other newborns of the mammalian order, human babies are completely useless. Utterly useless… 30 days in and they can only coo? And they don’t start speaking intelligible words for at least 270 days? Not impressed.

But several weeks ago, a patient on the floor was a five month old and she was puffy-cheeked, bright-eyed, and adorable. A complicated perinatal period had ensured that she would require intensive additional medical attention indefinitely, and now she was back in the hospital with r/o aspiration pneumonia after a two week reprieve at home.

At five months of age, she was operating at a one to two month old level. There was no social smile, no babbling of words, no raking grasp. But she was able to grip my pointer finger whenever I placed it near her palm, and I thought that was a good sign. I spent a lot of time with this baby. Partially because I was trying to figure out what milestones she had missed as a way of quizzing myself on infant behavior, but mostly because she was adorable.

And I never saw the parents. For an entire week I watched this baby--rotating her head to help her plagiocephaly; baby talking at her so she could hear words; setting her on her stomach for tummy time to develop motor skills; smiling into her face so she could see facial expressions. And I never once saw the parents.

I checked in her files to figure out her family story. Several young children at home, maybe they weren’t ignoring her. Maybe they weren’t bad parents.

But I still worried. It’s weird how attached one can be to a thing that never smiles. And I wanted to guarantee her safety. I wanted to tell people about my frustrations and my fears for how this baby might grow up. But who would I tell? And in a hospital full of sick kids, was this kid any more special than anyone else? 

Yes. Of course. She was my patient. I was her hospital guardian. Every minute of free time I had on the wards I'd gown up, put my gloves on, and hold her hand while I tried to get her to smile.

Miraculously, somehow, I finally met the parents. Or rather, the patient did. They were a flurry of excitement as they entered the room, mother and father and brother. And suddenly her face was being kissed and her mother was pulling out tiny matching outfits from a shopping bag for her to try on before she was discharged home.

I was fortunate this time. This baby was going to be a burden on this family--no question. But this family had a lot of something that I wish I had seen more of as a child: love. I no longer felt a need to voice my concerns. But I wonder how distant I’ll be able to keep myself the next time I see a patient in need of more than just medical care.

Dream Office #2

It would be nice if the first time you saw your doctor, the doctor took your vitals themselves. Traditionally nurses or other office workers take down your measurements, and while this is incredibly efficient, it probably makes people feel as if they are being processed.

Planning the Rest of Your Life

It happened when I was being active in the milieu, playing bananagrams with a handful of occupants admitted to the in-patient psych ward: two suicide attempts, one recurring major depressive disorder not responding to recent medication changes, and a non-psychotic manic depressive who in conversation appeared to be slightly more psychotic than the notes suggested. I was rather enjoying myself, realizing that I could spend hours talking to any one of these people. The etiology of mood disorders had always fascinated me, and now I was able to explore them by myself, at my leisure. 

And although these patients were very kind and open, they were growing frustrated with another patient--a schizoaffective--roaming the common area: she would not stop talking. It wasn't pressured speech--it was continuous speech. It was rambling, non-directed speech, spoken to the hospital at large, and it was spoken with an annoying twangy accent that could be described as an inner city uptown chicago accent--very short A's. 

The bananagram players began to mock her, not to her face, but they began to mimic her monologues as they spelled out intersecting words. Halfway through the game, one of my patients, a very irritable and consistently antagonizing schizophrenic, sat down at our table and tried to get on my nerves, insulting just about everything he could get his mind to focus on. The guise of bananagrams saved me because I appeared and actually was busy, trying to win a game. He left shortly and I felt relieved to once again be surrounded only by the moods. And I realized, painfully, that I could not go into psychiatry. I loved my mood disorder patients, but I couldn't tolerate the psychotic ones for more than a few minutes. And while I could eventually work solely outpatient and see only patients with predominantly mood disorders, psychiatry residency programs are four years long, so I'd be spending four years doing something I could kind of tolerate to do something I'd probably love for the rest of my life.

As a third year nearing the end of her clerkship rotations, I've been spending a disturbing amount of time freaking out--I suppose the correct term would be "having panic attacks"--about my future. But my debate between family medicine and psychiatry is far simpler than some of my friends considering even longer residency programs.

Take my good friend Annette. Everything about her screams surgeon: her steady, unshakable confidence, her ability to immediately befriend and then joke-around with just about anyone, her oversized-for-her-stature-hands. Surgeon! But if she was to become a surgeon, she would most likely want to go into something very specific: pediatric GI. Her internal debates, one would imagine, would go something like this: waste another five years of my life learning other types of surgeries to eventually get to begin doing fellowships in something I love. Five years. Five years of surgeries on adults. Five years where, yes, she would learn some very important things that would make her a better doctor, but also a lot of things that have no bearing on her future dreams.

I would consider anyone entering the medical field to be an expert at appreciating delayed gratification. But as my friends and I begin to plan out the rest of our lives, it sometimes seems like medicine is asking almost too much from us. 

Blasphemy, I know. I've already spent hundreds of hours preparing for tests that I promptly forgot all the answers to. I've delayed seeing my own physicians--sometimes for months--in order to never miss a day of clerkship. I've stopped exercising and my diet consists of, and I am not kidding, microwavable popcorn, cheese sticks, and diet coke. Medicine has already asked a lot of us.

For me, my choice is easy: I've always felt strongly about family medicine, and as it turns out, you see a lot of psych patients in primary care settings. Family medicine: where you see everything and the residency program is only three years. 

But for my friend Annette, her decision between surgery, pediatrics, and pediatric GI surgery has to take into account how much of her life she wants to live inside of a hospital. 

Stereotypes in Medicine

It’s unfortunate that I want to go into family medicine, because I think the stereotypes about family practitioners are often times nonsensical. But I suppose it’s also good that both of my parents are kind, friendly surgeons, so stereotypes about medicine’s specialties don’t really hold true for me and my family. 

So surgery often gets stereotyped as being full of jerks. And while I think there are a lot of surgeons who seem to have an unnecessary and occasionally dangerously elevated sense of self-worth, you find that in other specialties, too, so I don’t think it’s terribly accurate.

Internal medicine people are obnoxious. It’s like they’ve convinced themselves that what they are doing is interesting, even though they’re stuck in a hospital all day dealing with dying people.

I want to say people going into radiology, ophthalmology, and dermatology are all terrible people who are in it for the money instead of really helping people. But that’s not true. And everybody’s idea of help is different. I don’t know why they’re interested in their fields, but technically, someone’s got to do it.

Emergency Medicine is full of hipsters. I don’t know how this happened, but it’s pretty accurate. People who are hipsters, people with ADHD, and people who get bored easily. As for their personalities, they’ve got their jerks and their saints, too.

Psychiatrists are indeed crazy. But I think that’s because if you have a mental illness yourself, dealing with medical students and physicians in other fields gets incredibly taxing. If I hear one more person reduce major depression to a simple affair that people should be able to handle without medicine, I may start applying to psychiatry residencies right then and there.

Neurology is full of people who are more emotionally stable than psychiatrists, but are still very, very weird. But understandably so. Like more professional psychiatrists. Or just more stuffy.

I like pediatricians. But I wouldn’t say they’re the nicest people in the world. Kids are just more tolerable than most other patient populations, so it’s easier for them to look happier while they work. Whether they are or not, nobody knows.

Obstetricians and Gynecologists are exactly like surgeons. Who will occasionally smile at patients because their patients are neonates.

And that pretty much covers it. Does this effect what I want to go into? Not really. It just makes me louder about defending my choice to go into family medicine, which most people seem to think is incredibly boring, despite the fact that, to me at least, it seems almost as exciting as emergency medicine (when you remove trauma cases) while also including continuity of care.

And to me at least, being a doctor means being a family physician. All other fields just add complexity—necessary or not—to the medical field.