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.

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