Second Rotation: Psychiatry

Weird, wild, worried....these terms are familiar to anyone studying personality disorders and use these words to help generalize the clusters. These words also effectively describe the feelings experienced during the psychiatry rotation.

Psychiatry is a very unique beast in medicine and I was grateful for the unique experience that I had doing in-patient psychiatry with creative preceptor. My attending gave me more freedom than I could foresee during my third year of school. I was expected to interview new patients, diagnose and share my running differential with the patient, participate in treatment team meetings, and adjust a patient's medication. I was also expected to anticipate discharge and process discharges from the hospital.

That first week, like the first week of any new experience, was a whirlwind. From learning the process of inpatient psychiatry and the expectations from my preceptor, I also was pressured to review psychiatric diagnosis and treatment protocols because I felt personally responsible for the outcome of each patient more so than any patient experience previously. In hindsight, this thinking helped me secure a foundation of knowledge early in the rotation so that I could focus on active participation in medical management of patients.

Did I make mistakes? You bet I did. My preceptor was great at suggesting therapies during our many conversations, especially when I was upfront about knowledge gaps during the questions he would ask regarding medication dosages or alternative therapies. If my diagnosis was not completely correct, he was great at helping me with the paradigm necessary to arrive at the more correct diagnosis (or the only correct diagnosis if I was completely off-base). He also managed to slip in "you'd make a great psychiatrist" often during our debates about the patient's status or projected changes in mental status.

Most of us students are warned that our learning will be of the lowest priority to our attendings and that we will be treated as if we are constantly in the way. However, my experience in this rotation is that I was treated with more respect and autonomy than I felt as though I deserved at this point in my education. These six weeks did not only make me a strong student of psychiatry; this rotation made me confident in my abilities as a future doctor.

WEIRD:

Everywhere you look will show evidence of mental health problems: at the grocery store, other healthcare employees of the hospital, and sometimes when you think back on experiences with family members. Mental health is often ignored by many and culturally unacceptable to address by some, but it is pervasive and as integrated into our medical health as any other system (like the cardiovascular or GI systems).

One patient I met was someone who could not move: catatonia. It took a while before this patient was able to regain control of their body, and this case brought up questions I had not considered before when learning about catatonic features: do they still pee? do they shower? do they eat? Well, these answers are not easy as every case of catatonia is different and can present with different levels of inhibitions to personal care abilities. Hopefully these questions also address why catatonia is a reason to hospitalize a patient. Inhibition to your ability to take care of yourself is a reason to consider in-patient psychiatric treatment regardless of the diagnosis, and it was never something I was aware of in our hospitals until this rotation.

WILD:

Every day is different. That's a pervasive theme in medicine practiced in the hospital setting but psychiatry offers something very unique because of how our personalities and mental health are intertwined. One case that I will never forget was a patient I had come to expect to be in their psychosis unchanged by the third week of treatment. This patient was already being referred to a long-term state psychiatric hospital, but that process takes a long time and beds are limited so transfer of care is a process. This patient came in from years of living on the streets, as most schizophrenic patients without family end up doing, and was found by police in a scenario you could not believe if I tried. Anyway, this patient was very nice and had some level of knowing who they were but seemed to be stuck 20 years in the past.

Disorganized thoughts, auditory hallucinations, and paranoid delusions were components of every discussion we had. The moments of lucidity are the moments I will always cherish because those were the instances where I could connect with the original person who's mental health was destroying what was left of their brain. One day this patient started yelling at me, "Get away from me devil-worshipper! Be gone Satan." At first I was unsure if the patient was trying to mess with me, but I could tell within that moment that they were in pure terror and every raw emotion of fear that felt very real in that instance to the patient.

So what does someone do whenever they are afraid? Well, there is fight, flight, or freeze as our primal responses to fear and this patient sure did go with fight. Due to the patient's age and my agile nature (haha) I was not harmed in the patient's attempted assault because of their hallucinations. The only feeling I could walk away with was sad. I was sad because I knew that no amount of medicine given to this patient at this advanced stage of schizophrenia would give her anything close to a life that society would deem "normal." The only thing left is to keep the patient from being a harm to others in society while they spend their days going from hallucinations and delusions to drug-induced sleep because the treatment options at this stage are extremely sedating.

WORRIED:

Now this one is not new to me because of my history with child protective services. Just as I think back to children I have removed from the home or families were I intervened and helped connect them with services, there are patients that I will always think back to and wonder if they stayed with their treatment or if they are still making many trips to in-patient psych hospitalization.

Schizophrenia is an amazing disorder with a very interesting progression, as it is different for everyone in presentation and progression. I thoroughly enjoyed the patients who dealt with schizophrenia as they were some of the funniest, creative, and straightforward patients. Schizophrenia is a disorder that has been characterized as exhibiting "kindling", another example is seizure disorder. Basically, whenever a patient experiences a psychotic break or a seizure then the damage induced makes it easier for a patient to experience another episode sooner and one that results in more damage.

Knowing this makes anyone diagnosing a young patient very invested in the patient's ability to understand. When you have a patient come in for their first or second episode, and they are very young, then you are going to be more vigilant in ensure stabilizing the patient and helping them understand the concept of kindling so that they take ownership of their own treatment. One 18 year old patient that makes me worried is the one who came in after having multiple in-patient psychotic episodes when only diagnosed with schizophrenia one year prior. I could not understand how this patient was having a difficult time obtaining remission until I spoke with their parent over many conversations. Denial that your child has schizophrenia or any other mental health problem is a barrier to the patient being able to be stabilized early. I don't blame the parent for being in this state of denial, as it would be difficult for myself to believe anything was wrong with my children if I watched them live 16 perfectly normal and un-psychotic lives. To complicate matters more, the spirituality believed by this family has a holistic approach to medical and mental health which explained the lack of adherence to the medications prescribed. And because this wouldn't be complete if you weren't also talking about treatment-resistant schizophrenia, let's also add this onto the problem list for the patient because this patient did not start responding to medications until 7 days from diagnosis when most young patients show a day to two-day turnaround in psychosis.

I had to be very deliberate in my communication with this parent and patient. They both had to sincerely understand what the implications were moving forward with choosing against medications. How do you explain to a parent that the reason the schizophrenia is resistant to medications could be because of the four previous psychotic breaks not being treated once remission of symptoms was obtained? How do you explain to a parent that their child has schizophrenia when they are repeatedly in denial and insist that their child is "just a little depressed"? How do you explain to a parent that experimenting with various herbs and oils to treat psychosis is taking a gamble with their child's future ability to know self or others because of the toll each episode takes on the personality? Let's hope I got the point across with the time I invested into this family and the persistence I had because I would want someone to do the same for me should my child be going through this and I was reluctant to accept the diagnosis. However, this is one case which will always have me worried "What if I didn't do enough?"

So, I think I could do well in psychiatry and that maybe I could help affect the course of many lives. However, there were too many recurrent themes that I would see that reminded me of my Child Protective Services days. The compassion fatigue is real, and I cannot see myself entering a profession where I felt drained of all energy after four hours of work. Eight hours of work would make me feel like I needed a couple days off to recover and that doesn't bode well for someone who loves coming home to his family and enjoys doing things with them in his free time. Many times during psych I would daydream about the OB/GYN rotation and how I liked many more things in that rotation than this one. However, there were also a couple instances where I could see myself doing psychiatry right before I would question myself if I was having delusions. Mental health takes special people with compassion, and I might have that to offer medicine but I do not think my reason for entering a field should be because "I would be great at it." I want to match into a specialty that makes me excited to do it everyday, and doesn't leave me wondering about other specialties I could have chosen for myself.

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