Saturday, September 18, 2010

As posted on Facebook

It's 11 PM on a beautiful Saturday night. The kids are both asleep. What are we doing? I'm working at home, writing my thesis, and Tim went back to the office to do work. We'll both be up way past our bedtimes, and not even for very fun reasons. When did we get so old?

Thursday, September 16, 2010

Sweet dreams?

My late night reading has consisted of schizophrenia diagnosis, subtypes, and treatment, substance abuse and mood disorders, and a bit on delusions and hallucinations. I'm sure that will make for some sweet dreams, if and when I ever get to bed.

These two weeks on the inpatient psych ward have been good and bad, for many reasons. First off, it means I am progressing in training, which is a huge relief. Second, it's gotten me back in touch with the patient experience, which I enjoy. Unfortunately, it's much more time consuming than I thought it would be. And I'm trying to finish a thesis and teach a class on top of doing my rotation. Today though, what's affecting me most is this: it makes me sad.

My biggest fear starting this rotation is that there would be a situation between me and a patient that would be uncomfortable or dangerous. This is taken care of in the unit I am on: the psych teams (usually consisting of some combination of an attending psychiatrist, nurse specialist, social worker, psychologist, pharmacy resident, medical student, and nurse) meet together in the conference rooms to see patients as a group. The patients are brought to the conference room--there isn't a one on one exam in their individual rooms. I really appreciate this, not just for the safety perspective, but because it is more efficient to have everyone hearing the same thing and divvying up the to-do list together.

So, my preparedness for threatening situations is not needed. While I overestimated on that account, I underestimated how much my personal feelings would really affect me. I'll give you two specific examples, though there are many more.

The first was a patient admitted last week. Due to HIPAA, I'm not going to give out specific information. I'll try to give you what we are given in case studies, to keep things legal. So, this patient was admitted for a suicide attempt. He has a long, tumultuous history with his wife, and he attempted suicide, which he later claimed he didn't take seriously but was doing just for attention. The underlying issue was that he was an alcoholic, in complete denial about how serious of an issue his drinking was, and he had no interest to work on his issues. He had been out of work for some time, he had anger issues (and a domestic violence charge in the past), and he fully believed that the anger/violence was due to his wife's provocation and not the alcohol that he drank every night. It was textbook alcoholic dysfunctional family--everything was swept under the rug, things were fine, it was a one time issue, and no, the preteen son had no idea what was going on.

My attending's response: yeah right. Of course the kid knows what is going on. Of course nothing is going to change. Even the way that the husband emotionally controlled the wife was apparent when she came in for a visit. The patient was pretty angry when the team said that his chance of being successful in therapy was slim to none unless he quit drinking. My attending was very up front about the fact that antidepressants don't work for alcoholics, and neither do sleeping pills. The alcohol has to clear the system, the brain has to reset, and that takes time. She (my attending) refuses to baby people through the process. She'll get them the recovery help they need, either inpatient or out, but she tells the patient it's their choice and their responsibility to take charge of the illness.

This alcoholic patient was assigned to another member of the team (though I saw the patient every day on rounds). I was relieved by that. I saw such a reflection of what my mom has gone through in the past--from the hospital ER he was seen in to the intensive outpatient program that he was looking into attending after discharge. It was almost an out of body experience to see that entire dynamic play out with people I had never met before. There have been other alcoholics staying on the ward, and the dynamic is so similar in each case. I really appreciate the opportunity to hear my attending's take on things--I really respect her. She's got a no-nonsense attitude, but she is also very empathic with her patients. It's a good life lesson. But it's still sad to see all of these patients and families battling the same demons--especially when it is a demon I know well.

The second example happened today. We have case conferences every week with a long-time, well-respected staff psychiatrist. Today, we went to see one of the other student's patients. He's diagnosed as a schizophrenic, but he has had an atypical progression. What drew us to the case was the extent of his bizarre delusions. I don't want to tell you all about them here, but even the psychiatrists with decades of experience have said that this man has some of the most bizarre and persistent delusions they have ever seen.

While it was a great learning tool to hear how this man described his illness (which he completely denies having), what came over me was this immense feeling of sadness. Here was this man, beyond middle age, describing a lonely life in which he had never had friends, never had a romantic relationship, and had lived as a loner his entire life. I just found myself feeling so bad for him. The medication isn't helping his delusions, and even when he's been "healthy" in the past, his OCD rituals for keeping his life feeling less chaotic completely consume him. He mentioned several times how his "brain was lonely." It just broke my heart. This man will probably never get better, never have those close personal relationships he longs for, and even if he could find someone willing to take on his illness, his delusions would likely prevent him from engaging in any sort of personal relationship. There's nothing we can do to cure him, and even managing him hasn't given him a "normal" life.

That is the toughest part of medicine for me. There are lots of specialties where we can't "fix" the patient. I accept that, and I understand that a lot of medicine is chronic disease. I also understand that we are all terminal--at some point, people die. I know I am going to need to toughen up and depersonalize better in order to make it through medicine.  But psychiatry seems tougher for me than the limited experience I've had in medicine. For the most part, medical patients can understand their diagnosis and what it takes to manage it. Not everyone chooses to be compliant, but at least they have the choice. Inpatient psychiatry is full of people with limited to no capacity to understand what their disease is, and noncompliance is rampant because the patient's can't understand what the medication is from. PS, having a stranger in a white coat feeding you pills and giving you shots is great fodder for paranoid delusions and hallucinations--not helpful!

It was also pointed out on the first day that this service really carries the psychiatric patients with the worst prognosis. It's a process: the veterans on the ward are here because they have no private insurance, usually because they couldn't work after being discharged, usually because they had a severe psychiatric problem that prevented them from working. Many are homeless, most have a concurrent drug abuse problem, and they have nowhere else to go. I've seen ex-convicts, homeless, an elderly man who lived in his son's crack house for years, suicidal patients, homicidal patients, and patients with severe delusions and hallucinations. And I'm only in week two.

There's a part of me that sees such potential for helping people in a field like this. But there's a bigger part of me that knows I would break down. So many of these people boomerang after being discharged. Meds are only good if you take them, and they aren't always that good even if you are compliant. Most of the people that come on the ward have been here before, and they will be back. The one patient I am seeing right now is on his/her fifth admission this year. That's a story for another day.

I feel very stupid on a daily basis, but I also feel like I'm learning a lot about how to be a doctor. Psychiatric issues are a huge comorbidity in the population. It's going to have to be something with which I am familiar. On a personal level, I have a big family history of psychiatric disease, and so does Tim, so it's also in my best interest to know what to watch for and how to deal with it (not prescribing meds to family members, don't worry!).

I'm just worried about how well I am going to deal with my clerkships. I started with psych because it is supposed to have the best schedule and be one of the "easier" rotations. I'm working like crazy. If this is what psych is like, God help me for surgery or OB/gyn....

The psych ward waits for no woman, so off to bed, with all of my reading material percolating in my subconscious. This should be an interesting night--assuming all of the kids/pets let me sleep long enough to actually hit a dream cycle.

Monday, September 06, 2010

New Beginnings

I'm sitting here, feeling nervous for my first day of school. And this is the second time I've felt this way in just over a week--I had similar jitters before I taught my first weekend college class of the semester. Those jitters went away as soon as I started teaching. I'm doubting my current jitters will evaporate when I slip on my white coat. If anything, I expect them to get worse.

I'm excited, nervous, anxious, worried, and feeling inferior. I had grand ambitions of reviewing all of my psych notes from med school (from back in 2003) before heading to the clinics tomorrow. Unfortunately, life didn't feel like cooperating today. Therefore, none of the things on my to-do list for the day (thesis, thank you notes, notes/assignments/lecture for Saturday's class, and reviewing for med school) got done today. I am hoping tomorrow will be mostly paperwork, and I'll have one more night to prepare.

In the course of getting things ready for tomorrow, I came across my clinical tutorial evaluation from my preceptor. He filled it out on 3-31-10; I just found it in my clinic bag. I gave him an envelope to seal it up. He told me that he wanted me to read it before I turned it in. I hadn't read it yet--I'm not sure why. I don't know what I was afraid of, but I read it tonight. It was extremely kind and thoughtful, and while I am not sure that I believe all of the praise that is in it, it has helped me remember that just being a good person and a hard worker are big parts of having a successful clinical experience. I will need to remember/learn the material at some point. But I'm telling myself it's ok to go back--it's been more than six years since I finished the second year of medical school and took my boards. And it's been five months since I last saw a patient. It's natural that I have some rust--I just have to shake it off and do my best. I hope that'll be enough to get me started.

It's been crazy that my first class was last Saturday, Josh started daycare last Monday, I'm starting clinics tomorrow, and Sophie is also starting Montessori tomorrow. That last one was a bit of a shock. Tim and I carpooled on Friday (my car was in the shop again--that's another story). We both dropped the kids off in the morning, and Sophie's AM teacher asked if the PM teacher had asked us about moving her up to the next classroom. We said no, and the teacher said that since the fall "classes" had just started in Montessori, Sophie would be better off starting ASAP. We were both a little surprised at this. We knew it would be coming--her infant room is for kids 18 mos-3 years, and she'll be three in October. But they transitioned her over a period of weeks when she moved from infants to toddlers. We were expecting the same with the move to Montessori.

When we picked Sophie up Friday evening, her PM teacher reaffirmed that starting Montessori could happen ASAP. Sophie's teacher said that it might help the behavior issues she's been having--her teacher seemed to think Sophie was bored, and that's why she misbehaved (and spent so much time in time-out). I was concerned that she might not be ready--as far as potty training goes, she's nowhere close--but Ms. Sue thought she'd be fine. We asked Sophie if she was ready for Montessori, and she said yes.

A few points of clarification. First, Sophie has spent a little time in Montessori--if Tim drops her off, she spends some time with the older kids for 15-20 minutes max until they can open up the toddler room for breakfast. She's liked the time she gets to color or play.  Second, I didn't even know what Montessori was when we first started her in day care. It was the only opening of the many places I called, and I figured we'd have time to decide if we liked the Montessori classroom. The infant/toddler rooms were pretty standard.

Guess what? Time's up. And while I've read about Montessori online (basically, mixed age groups and self-directed learning), I'm still not totally positive why it is better/worse than other things. And honestly, as long as it isn't totally traumatic, it'll be fine. Sophie is comfortable with the routine, comfortable with the teachers, and Josh is going there now. I think we've missed the window to move her. And barring disaster, she'll stay there until it's time to start school.

I just can't believe how many "firsts" we've had in the last week or so. It's been a crazy time. It will continue to be crazy for a long time, I am sure, but I am hoping we'll get some time to enjoy life soon. I really haven't had a weekend to just chill with my little family, and there are a lot of people that I've been meaning to catch up with and haven't had the opportunity yet. Maybe this fall, I can start to feel organized again! I'll try not to feel like a total failure on that front if it takes a bit longer than I'd like :)

Off to find the white coat and the other goodies I'll need. I'm not sure what I need to pack for tomorrow, but I guess I'll figure it out--just like how I am still figuring out the rest of my life on a daily basis.

Friday, September 03, 2010

Transitions

Today is my last day in the lab. Honestly, with everything I have been through, I really wasn't sure this day would ever come. I also didn't expect to feel sad.

Every job has their issues and quirks. My current lab is no different. But, compared to the hellhole I was in for three years in Dr. B's lab, this has been heaven. The recent scientific meeting I went to was a great note on which to end. I've always enjoyed meetings, because it reignites my scientific passion. I love hearing about what other people are doing, what new questions are being answered, and how people have decided to approach their questions. The time I've spent in M's lab has helped lessen the disdain I had for bench work and reminded me that science isn't what I loathe--it's the bureaucracy and politics involved in academic science. And PIs from hell--I loathe that too :) If only he wasn't still on my committee, life would be perfect!

I'm still not willing to say that I'd jump back to bench research as a career. That's a bit TBD, and I have a lot of clinical training ahead of me before I make any sort of career decision. But, if my time in Dr. B's lab had never happened, I definitely think I'd be considering bench research. I still don't love how much of the day to day work of a PI involved stupid politics, but maybe if I was in a different environment, that would be better.

I do love teaching--I had my first weekend college class for this semester, and I think it is going to be a good class. I'd love to find something that was a mix of clinical work and teaching, so I'll have to see what is around when I am finally done.

It's been a busy summer. I've fallen way behind on lots of things--and sorry, but blogging gets cut when time gets short--but it's been a good summer overall. The marathon last week was being at the meeting in Canada, getting home really late Thursday night, prepping like a madman Friday to clean the house/get ready for the party, teaching Saturday morning, having family dinner Saturday night, and then having Josh's baptism on Sunday. We had fewer people than we expected Sunday (only about 50 came), which caused a little bit of hard feelings (the no-shows were mostly on Tim's side, and he had seen them the day before at another cousin's party, but then they didn't come to ours...drama). But, we're over it, and everything went fine.

This week has been Josh's first week in daycare, which seems to be going well. It's at least been making him tired--he slept through the night for the first time last night! The monthly check is now more than the mortgage on our house (even with the buy-one-get-one-half-off deal they are giving us), but we've been preparing for it since we found out we were pregnant, so we are making it work. If my car would stop breaking down, things would be fine :) I just have to limp the car until I start residency in 2012--then we'll have enough extra to afford another car payment. Come on, car!

Really, we're planners, and we've been saving for emergencies for all 8 years of our marriage. A car repair is an emergency, as was the tree down/broken fence episode from the summer. I'd rather be putting into the emergency accounts instead of taking out, but I keep telling myself that's why we saved for the five years before we had kids. That planning is definitely paying off. We don't have anything extra at the end of the month, but we've budgeted, and we live within our means. My own personal mini-challenge for September is to see how little we can spend on groceries. With the stockpile of dry goods in the pantry, and the meat in the deep freezer, I am going to try to buy only the perishables (milk, eggs, produce, etc) we need to make meals. Tim's already spent a little on pop, which I guess can be his necessity for the month, but I'm going to try my best to not get tempted by the sale papers and only buy what I need. This will take more planning than I've been investing recently, but it'll be a good habit to start with me returning to med school.

I really haven't invested much mental energy into returning to med school. I have always thought that it was so far off. It's the practical things--things like the fact that Sophie ruined my last pair of dress pants, so unless I go shopping, I will have no pants for the first day in the clinics. I think I am going to go thrift shopping this weekend and see what I can find--I like to spend about $5 per pair of pants, so we'll see what I can do. I rocked Target clearance the last time I needed dress clothes, so I may try that too. So, there's the practical (clothes) that I have to plan for, and I should also revisit some of my med school notes to remember how to think. I'm starting with psychiatry, so I'm trying to ease into my rotations.

I still have to give my dissertation, which won't happen for a little while, but otherwise, I won't be in the lab again until probably fellowship. It's a really strange feeling. We'll see how much I miss it when I am gone!