I’m Over Psychiatry 

Yup. It’s been one week. And yup. I’m already tired of my new rotation. I kind of knew I didn’t want to be a psychiatrist but this feeling of being underwhelmed seems to be a recurrent theme for me. I’m worried I’m not going to find any specialisation that I really enjoy. Sigh.

But anyway back to psychiatry. I’ll tell you why I’m already over it on here so I can decide whether it’s just me jumping the gun and disliking a run straight away after one week or whether I’m justified in my unimpressed-ness on this rotation.

So. Reasons I’m ready to fast-forward the next 6 weeks:

1. Taking a psychiatric history has a minimum duration of 1 hour. This includes patients who are already admitted and whose progress needs to be monitored. And this is by the consultant. Not just an entry level house officer.

2. The pauses within the history taking.

Doctor: So how has your mood been?

Patient: …………………………………………………….. Yeah

Doctor:……………………………………………………………………………………………………………………………………………. How are the medications?

Patient:………………………………………………………………………………………………………..*shrugs*

I mean, come on! I admire the psychiatrist and their patience but as the observer, I was dying. Of sleep.

3. The 50 million unnecessary labels for conditions.

  • schizophrenia
  • Schizoaffective
  • Schizoid
  • Schizofreniform

Omg. And you know what the funniest part is? There was a patient whose regular psychiatrist had diagnosed him with bipolar disorder and who was being treated with Lithium. At the Mason clinic, another psychiatrist spent 1.5 hours with the patient taking a history (while I was falling asleep in the corner) and concluded that the patient had Schizoaffective disorder instead. I asked what that was. Apparently it is a combination of schizophrenia, bipolar disorder, AND depression. The psychiatrist spent a further 15 minutes explaining to me how to distinguish between schizoaffective and plain old bipolar.

I then asked her what the management was for this. She replied: “Oh there’s not difference. We just need to change a lithium to Sodium Valproate because Lithium isn’t working for him. Otherwise it’s just treating the bipolar”

-_____________________-

I felt like I had been trolled. The treatment is no different, yet it has a scary name distinguished only by “affect”.

Why.

Just why.

4. There are only about 5 treatment options for all psychiatric illnesses. You’re either on an antipsychotic, an antidepressant, a mood stabiliser, given cognitive behavioural therapy, or electroconvulsive therapy. For literally EVERY psychiatric condition. And it does not cure them, unfortunately. So then why is there so much hoopla about the psychiatric history. One of my consultants actually asks patients such specific questions like “Do you see spirits rising up out of the ground?” and “Do you believe that any of us here are working for the secret service and spying on you to pull the thoughts from your head?”. I failed to see how this was relevant. Because he had asked these questions after the patient had described the nature of his delusions/hallucinations. What exactly was the psychiatrist intending to do with the specifics of his hallucinations once it had been established that he was having hallucinations? Was the treatment going to be any different? Nope. Were we going to help change or rid him of the hallucinations? Nope. Then why these leading questions that may have in fact put such hallucinatory ideas in the patient’s head?? For their entertainment?

I just don’t get it.

And those are the reasons why I’m over psychiatry. I just don’t think I have the patience to be a psychiatrist. I admire them though. Such patient people with great listening skills. The consultants are actually lovely people which is great. But yeah I’m not really cut out for psychiatry I don’t think. I think psychiatry is really interesting and I’ll probably enjoy seeing a psych patient in ED (where it’ll be a short history with a quick referral. xD) but that’s about it.

Well. 1 week down. 5 to go. Hopefully it gets better. Or goes by quickly. Whichever. 

Forensic Psychiatry 

Day 1 of psychiatry. The first day of rotations are always really lame because it’s a new place with new people and there’s the awkward tour where you’re trying to remember everything you see but all the hallways look the same and you gotta introduce yourself 15 times to everyone you walk past, and and sigh.

Plus on the first day there’s never much to do. You just pretend to do some study or look mildly interested while thinking about the 6 weeks to come and the daunting assignments/assessments that need completing.

Today was no different in that respect. But this placement is very interesting for me. As the title suggests, I’ve been placed in forensic psychiatry. Where mental health meets the law. I’m in a relatively small practice known as Mason clinic in Auckland. It’s an extremely high security clinic for offenders with mental illnesses.

Apparently this is a scary place. When you google Mason clinic, some of the phrases that come up include “where the mentally insane killers are protected in the most secure mental clinic in Auckland” and that it is “home to some of the country’s most dangerous offenders”.

During orientation, the first thing the students received were these:

 
The rectangular thing on the left is a “personal alarm”. It is essentially a distress call that will have staff running your way in “about 10 seconds” in case you’re being attacked or held hostage or something. In addition, all hallways have reflective glass near doorways so you may see if someone is tracking behind you. Every door is swipe and fingerprint protected. I was also given a heavy iron key that opens certain doors in the high security areas. Oh and no lanyards as they pose a significant safety risk in case someone wanted to strangle you. No messing about in this place.

I knew I was placed in Mason clinic. The idea didn’t scare me much. But some of my colleagues were clearly spooked and were discussing ways to hide their ID cards and thinking up fake names to give to patients during history taking sessions. Oh and we’re also not allowed to carry out patient interviews alone. Always have a staff member present for your own safety.

Psychiatry has such a stigma. It’s kind of borderline funny for me. We always having teaching that tells us to position ourselves in the room with a psychiatry patient such that we are close to the door and can run away if any problems arise. Yes, I know,  safety first and all that but still. From the patient’s point of view, won’t that make them feel suspicious and as though we’re scared of them? Honestly these bulky personal alarms. I’m worried the patients will see them and think that we find them a significant threat. This is the 21st century people! Can’t we get smaller, more discreet alarms? How am I supposed to build rapport with a patient if I’m walking in going “yeah watch yourself pal, I’ve got an alarm and I’m not afraid to use it”. 

It can’t be easy having a mental illness as it is. But then with the added feeling that you’re a danger to others? That kind of thing might distress some people I think. 

But hey. They’ve been using these things for ages, so I might be the only one who thinks it might be weird for patients. I also wonder if they’ve ever had issues with patients with paranoid schizophrenia thinking that we’re using these personal alarms to spy on them or something. 

Okay now I’m just pushing it.

Oh and someone’s personal alarm went off today. It was a false alarm, but we’re supposed to treat every alarm call as genuine and go running. I’m so scared I’m going to accidentally set mine off. Eugh. They’re just too big and bulky. 

Well that’s day 1. I think psychiatry is going to be really challenging for me. We’ve had next to no teaching at all on this subject in the last 4 years. Except yesterday when a couple of psychiatrists attempted to conduct a crash course in psychiatry. Which was extremely overwhelming. Did you know that there’s a DSM 5 now?! These DSM people need to stop and take a breather. The criteria keeps getting thicker and thicker. And to be honest I feel like it’s including more and more normal people characteristics to diagnose a person with mental illness. 

It makes me question my own sanity. Sigh. This should be interesting. 

Mindfulness Painting 

I’ve just had a two week break after my GP rotation and before the final two rotations of the year. Those being psychiatry (starting tomorrow) and my selective in Melbourne (more on this soon. Watch this space) 

The two weeks went by way too quickly for my liking and I had a lot to do. Catching up on sleep was a main project of course. But so was my portfolio (that I am yet to complete), an essay, a pathology assignment, and studying for my progress test. 

There’s always room for procrastination though! So I thought I’d do some painting. To pick up an old hobby of mine using some blank canvas I’ve had lying around. Well, actually my mum said if I didn’t use the canvas right now she was going to chuck it out. But it was something I had been wanting to do. 

Have you heard of mindfulness colouring? I didn’t know this was a thing until I was a couple of years into med school and some of the med students were using this as a stress-buster. For those of you who don’t know what mindfulness colouring is, it’s a book of pictures you can colour in. But not like the ones you had when you were 4 years old with the zoo animals that had a maximum of 6 spaces you could colour in. These are elaborate drawings of sceneries and kaleidoscope type patterns, and even the Mona Lisa. With over 100 tiny spaces to colour in with different colours. Apparently working through these teeny-weeny spaces is supposed to be equivalent to practising mindfulness. Personally I’d rather just eat some chocolate or something. But apparently it works for people. 

Anyway, back to painting. I had a relatively small canvas so I thought I’d try a more intricate painting with different parts and textures. I’m no artist. I use standard acrylic paints with a pallet I’ve had since age 5. It took a whole two weeks but I think it turned out pretty okay and I think I understand mindfulness colouring a bit more. Very relaxing and very rewarding in the end. 

Et Voila! Mindfulness Painting. Again, I’m not the best artist so in case you were wondering, that’s a peacock. The face doesn’t look very natural and the feathers are a bit all over the place but I think overall it looks okay! It took a very long time to get the feathers right and every line in, but it was fun. Therapeutic actually. 

Well, onward to psychiatry! 

That Which Disturbs Silence

Some days I wish I was born both mute and deaf.

Not to trivialise or insult anyone who is mute or deaf. But some days I wonder what it would be like to be born and never hear awful things being said. And as such never being capable of saying anything awful? 

Some things can’t be unheard. What would it be like to not hear terrible, harsh sounds being spoken about yourself or others. What would it be like not to be scared beyond belief of what you might open your mouth and say that sets something horrible in motion? 

I’ve complained about silence. But some days, I wish nothing more in the world. 

There was a movie about a fictitious illness that spreads by talking. So everyone in a village had to be mute for a certain period of time. Really interesting movie. Everyone would be forced to only convey what needs to be conveyed. You can’t yell at or insult another person or express your anger through speech. You can’t attempt to destroy another person with your words. Wouldn’t that be nice.

I’ve had a long day. Not a great one, and so these were the thoughts going through my head during an important med school test. Sigh. 

It did get better though. While I was standing in the rain getting drenched waiting for someone, all I could hear was the rain. 

And that’s when Buddha’s words came to me.  

Words to live by. 

Portfolio And Poetry

All medical students have to write a portfolio every year up to and including their 5th year. It’s a compilation of experiences that demonstrate your learning in 5 domains. Professionalism, ethics and law, health and well-being, cultural competence, and learning and teaching (which no one really gets. Something about doctors also being teachers?). It’s supposed to be an exercise in reflective writing and can be used for future employment if required.

I HATE this exercise.

Not only because it takes so damn long to write the required 2 entries for each topic in a reflective way that truly shows your “growth” over the last 6 months (let’s face it, you have to exaggerate. Because one person can only be so culturally competent). But also because for the last 3 years, I’ve slaved away trying to write this thing and I only ever get “pass” as opposed to the “distinction grade”. And the worst part is, the supposed “feedback” to help me improve for my next portfolio has always been from some lazy person, in the form of “Excellent reflection!”, “Good work!!” or my personal favourite, “I can see you really thought about this”.

……………. Then why the heck didn’t I get distinction?!

But anyway. It doesn’t stop me from spending the amount of time I do every year writing it. In fact this year I seem to be spending more time on each entry. But since this is our last year of doing these portfolio thingies, my friend and I decided to add some poetry into the entries. We heard from others that they are generally well-received. Plus they take much less time.

Now, I’m no poet. I think this is mainly because I’m not very good at conveying a lot of things in a concise manner (you know that from my blog anyway. xD). But I thought I’d give it a go.

This is a topic I am actually quite passionate about. Motivational interviewing. Telling patients simply to change their health behaviours (diet, exercise etc) without really understanding the challenges they face. I’ve mentioned this before on this blog, but I’ve actually seen how useless some people can be at advising patient about supposed “lifestyle changes”. So without further ado, here is a poem about patient perspective on lifestyle advice.

The Doctor says I’m fat
He says I eat too much
He says my blood sugar is too high
He says I need to go on a diet
He just doesn’t understand
I work all night
The grocery shop is half an hour away
And the KFC is just up the road
I know he wants to help
But the Doctor just doesn’t understand

The Doctor says I’m stressed
She says my blood pressure is too high
She says I might have a stroke
She says I need to take time off to relax
She just doesn’t understand
I work 2 jobs on contract
I have 3 kids
I am a single parent
I don’t have time to relax
I know she wants to help
But the Doctor just doesn’t understand

The Doctor says I drink too much
He says my liver is failing
He says if I don’t stop
I’ll die
He just doesn’t understand
My parents used to drink everyday
My mates drink at parties
My partner drinks with me
I don’t know how to stop
I know he wants to help
But the Doctor just doesn’t understand

The Doctor says I’ve been smoking too long
She says my cough isn’t going away
She says if I don’t quit
My cancer will kill me
She just doesn’t understand
I started smoking in school
I tried to quit
But I got horribly sick
People in my family smoke
All my mates smoke
I tried to quit
But it didn’t work
I know she wants to help
But the Doctor just doesn’t understand

The Doctor said I need to change my diet
He said I need to quit
He said I need to relax
He said he knows how difficult it is to change
He said we’d do it together
He said he won’t push me too hard
He said he’s been there
I know he wants to help

The Doctor really understands

Like I said, I’m not a poet. None of that even rhymes. But I think it kinda shows what I feel doctors are doing and what they should be doing. And it’s my first poem so it’s made it to this blog so I can remember it even after it’s marked by these silly portfolio people.

But hey, 1 entry down, 10 to go.

Better get back to it!

 

3 Eyes

I have 3 sets of eyes.

My own eyes, which are blurry most of the time and riddled with astigmatism.

My glasses which are quite old and do NOT give me a bookish look, but rather make me look like a clueless 2-year-old (much like Chuckie from rugrats ^^)

And my contacts which are hella expensive and have just become useless (my current pair anyway.)

2 days ago I developed an itchy, sticky, watery Eye (just the left one) with a foreign body sensation in it also. This was around the morning time on my last day at the GP practice. Which was not a good look because patients kept asking me if I was okay or if I was tired (as I kept rubbing my eye like a sleepy 3-year-old)

Embarrassing. But I am a well-read med student who had recently come off an ophthalmology rotation. I thus concluded the most likely, plausible, rational diagnosis for my eye.

Omg I have acanthamoeba keratitis!! I panicked for a bit because this is a disease that contact lens wearers get and you could lose your vision in one eye completely and I had seen a victim of acanthamoeba keratitis and it did NOT look pretty.

Fortunately, my GP calmed me down and said it’s very unlikely to be acanthamoeba keratitis and it’s more probable that there was some debris on my contact lens that had damaged it. And was thus causing said itchy/ watery/ irritating eye. But just to be sure, I had to get rid of them.

Unfortunately, I usually get a 3 month stock of lenses from my optometrist, and those were my last pair of the 3 month stock. Which means I have order new ones and rely on NZ post to bring them to me. Which essentially means I have to go 2 weeks without contacts. Not. Fun.

I don’t really hate my glasses or anything, but they do get frustrating sometimes. Like when I want to wear sunglasses, I have to awkwardly place them on top of my glasses (because I do not have the fancy photo-chromatic glasses). Or when it rains and suddenly I’ve got underwater vision (which is not a good thing by the way). Or when I have a nap-attack, I can’t just flop on my bed or couch unless I want a bruise on the bridge of my nose. Just so inconvenient.

First world problems, I know. And normally I wouldn’t complain, but I’m in a complaining mood at the moment. So it just must be done.

My eye is fine now from not wearing my contacts for the last 2 days. Which is good. But I’m still 2 weeks from getting a new pair.

I should just have laser eye surgery. But my mommy said no because she’s worried I will develop cataracts at the age of 40 from it. Apparently she read this somewhere. Does anyone out there know someone who has had laser eye surgery and is past the age of 40 who does not have cataracts? I want to know if I can prove my mum wrong and get my eyes zapped. And I’m too lazy to read the literature.

3 pairs of eyes are just so inconvenient.

Special 

On my last week of GP rotation, I am required to do a mini-cex. A GP consult with a supervising GP present. Everyone gets 2 tries at this.

My first try was not the best. My GP said I needed to improve in my second.

I studied as best as I could, going through notes I had made nearly 3 years ago now on history and examination. Which was beyond difficult. 

But it paid off. My GP awarded me a high grade for my mini-cex. She went so far as to tell me that I’m very on to it and I’ll make a great doctor.

Now, I don’t particularly handle compliments well. Mostly because I don’t receive them too often. I don’t usually get praise for being smart or on to it or at a high level with my clinical knowledge. I basically just work as hard as I can trying not to waste the opportunity given to me. And I have a sneaking suspicion my GP just has a soft spot for me. But it was lovely to hear anyway.

In that moment, I wanted to believe her. I wanted to believe that I can be someone who is “on to it” and “a great doctor” someday. 

Lately I’ve had trouble believing I’m anything other than an all around mess. So when someone suggests I can be better, I go through many levels of not really believing them and then kind of thinking maybe it’s okay to believe it. I liked being an “onto it” person. It’s not a feeling I often experience. 

Made me feel special. ^^

Who Is The Word?

So today, while on my GP run, I was just organising the store cupboard when the nurse asked me to come see a patient who didn’t have a appointment but had chest pain that was of concern to him and his mother.

Rehearsing SOCRATES for chest pain and the protocol for referral to hospital for heart attack in my head, I went to see the patient. This man was 48 and otherwise well. He presented a history that sounded like reflux/indigestion/heart burn/GORD (GERD for Americans).  I arrived at this conclusion because he described a pain radiating up his oesophagus, typically in the morning, with an acid taste in his mouth, and that the pain is relieved on burping. He has had this chest pain for 3-4 years and occasionally had tummy pain.

But this guy was anxious. He was terrified that this was coming from his heart. He had a family history of heart disease on his dad’s side who had passed away from a heart attack at the age of 60. He broke down at the clinic. I reassured him as best as I could that this pain did not sound cardiac and considering his risk factors, it is unlikely to be a heart attack. He had however, not completed any blood tests given to him in the past so technically, I was unaware of his cholesterol status, etc. I told him that the doctor would probably prescribe him omeprazole, and check his H. Pylori status, and order any blood tests to establish his CVD risk for future.

Anyway! He was super anxious and the nurse suggested that we carry out an ecg just incase. To ease his anxiety. She also thought that the history sounded much like reflux. So we hooked him up to an ecg machine and printed an ecg.

And that’s when the problem began. His ecg showed T inversions in lead 1 and what looked like ST depression (I couldn’t actually remember the exact number of squares the wave had to be below to confirm ST depression, but it looked like it to me anyway) in the rhythm strip. There was also evidence of Left ventricular hypertrophy (peaked R waves). Uh oh. Not good. Ran to the GP and showed her the ecg for a second opinion. She said the ecg definitely showed both these things and the patient needed an urgent troponin. She THEN asked me what his history was. I explained that it sounded like a history for reflux and his ecg abnormalities may be an incidental finding.

So the GP took her own history and the patient ended up being referred to hospital. What was interesting, was that the referral stated the findings as “chest pain + ecg changes”. And there didn’t seem to be much detail about the nature of the chest pain. Nothing about the acid taste or the burping relieving the pain.

Eugh.

The patient was discharged later that day. Diagnosis? Chest pain secondary to reflux. Omeprazole charted. Out-patient H. Pylori testing ordered. LVH changes on ecg noted; Echo clear, NAD. No evidence of significant hypertrophy. There was no mention of ST depressions.

I’ve been in hospital. In ED. And I could just see the registrars on acutes rolling their eyes or face-palming at this referral once the history was taken. And the further frustration of the house officer that would be required to type out the discharge summary within 3 hours of the patient arriving in ED.

The funny thing is, this is the second time this has happened while I’ve been on this run. I thought a patient had Bell’s palsy, my GP referred her to hospital for a possible stroke when her only symptom was a droopy lip and a BP of 180/100. Which is fair enough because the high BP means you can’t risk not sending her to hospital. But she was discharged with a diagnosis of Bell’s palsy and antivirals the same day.

What is the discrepancy here? Perhaps because I haven’t known these patients for years as my GP has, I don’t have any preset notions for diagnoses? A colleague presented a case on a discussion board about confirmation bias because the doctor had known the patient for a long time, and hence knows what their most likely diagnosis would be. I wonder if that is what pushed the GP to refer this patient to hospital where the doctors would make a diagnosis based on the patient they see then and there.

But then who’s right? I think one of the peculiar things about medicine as a field is how much variation there can be between doctors and how they practice the same medicine they all learnt. One doctor says stroke, another says oh please just take some prednisone. One doctor says it’s just reflux, another says omg it’s a heart attack! Go to hospital asap!! I mean, who’s practising the best medicine? Does it matter as long as the patient is okay? But then you hear stories of how a patient goes through a bunch of doctors who tell them they’re fine, but then one doctor provides the correct diagnosis that all the others missed. What happens then? Are the other doctors incompetent? I doubt it. Because I’m sure there were other cases that they would have diagnosed brilliantly.

So then, who is the Word?

It’s not like I didn’t know this before, but I’ve just been put in the middle of it I think. And it makes me a little insecure about what type of doctor I will become. Because obviously everyone wants to be that guy at the end of line that picked up on the right diagnosis, because obviously he’s the ‘best’ doctor. But is he? Really? Maybe he just got lucky. Lucky in a sense, anyway.

Thoughts?

Satisfaction

 Just finished my poster on this GP run. Apparently all students are required to contribute to their GP clinic in some way during their 4 weeks. This does NOT include cleaning and organising, apparently. Which stinks because I’ve done a HECK of a lot of that.

My GP asked me instead to educate the nurses at the rest home she manages. I was required to make a poster about the top mortality and morbidity causes in a rest home and how nurses can prevent these. And it was not easy. Apparently not many people are very aware of these issues and as such, research papers in this area were surprisingly scarce. 

But I did not give up. And so 3 weeks, long hours of googling, (specifically, google scholar-ing, Pubmed-ing and Medline-ing), challenging my computer’s RAM, and frantically digging up my poster making skills later, 

Voila! Isn’t it poifect? 

poster

It seems to have more info than an average poster. But my GP did say she liked how colourful it was and approved it (albeit with small edits) and this is the final draft! Onward to A3 printing and laminating. 

After which time it will be plastered on a wall in a hallway of the rest home where nurses will walk past it barely reading the whole thing. Because come on. I don’t believe it’s going to change much at the rest home, but hey. I tried!

The best part however, is the pure satisfaction I get from closing the -what seems like- millions of tabs I had open of the various website I took bits of info from and compiled together first on Word, then on pdf, then finally on PowerPoint. 

My goodness. My screen has never looked so cluttered. So happy the little X on the top right hand corner of the screen can be highlighted and clicked on! 

desktop 2
Farewell to these websites and thank you for helping put together this poster for whatever it’s worth on a wall somewhere in a small rest home. 

Ahh. The satisfaction of completion. 

Now I can get back to cramming for my mini-cex tomorrow. Since I pretty much screwed up the last one, tomorrow had better go well. But I haven’t been studying much due to this poster. Eugh. May some  odds be ever in my favour! 

Rain In Winter

I’ve been going on about June and winter a lot haven’t I? Well I enjoy season changes. And yet another thing that is great about July (as it is as of today)/winter are the intense rainy days that define winter of course.

Winter in New Zealand for everyone else in the world, means snow. And snow is amazing in New Zealand. Even a little bit of snow = days of excitement.

But I live in Auckland. To many people (myself included to a certain extent) is pretty useless. It’s just a city. There’s nothing you can say “omg Auckland has the best _____”. When friends come from overseas and ask me what there is to do in Auckland, they usually receive a very long “….ummmm” from me. Then some vague comments about the skytower and a beach. I mostly advise them to visit cities outside of Auckland where there is more charm.

But there is in fact two things that Auckland is famous notorious for.

  1. The weather
  2. The traffic

The latter I absolutely hate. Traffic in Auckland has the potential to turn what is usually a 15 minute drive, into up to 1.5 hours. Not exaggerating in the slightest.

The former, however, is something that never fails to stun me.

Today was a rainy/windy/cold day. It was the perfect day to stay indoors leaning against a window and listen to the forceful patter of rain on my window and the howling of the wind

The wind is howling like this swirling storm insi- yeah no. Let’s not go there. xD 

And incredibly, some time later, the rain would stop completely. Such that there’s complete silence outside. Then a soft wind with cloudy skies. As though threatening to open again to let the rain pour. I love this interim. Going for a walk in this climate is one of my most favourite things to do. And I did just that. Admiring the effect the rain has on everything. It seems to make everything softer. Trees, flowers, road, everything has a dewy hue that is much easier on the eyes. 

This is something you’d only get in Auckland. My old chemistry teacher once told someone that “if you don’t like the weather in Auckland, leave for two hours and come back”. Because that’s how quickly it changes. 

And in winter, it’s the best thing ever. I’ve developed a fondness for walking in the rain. And the wind, and the cloudy-ness. 

I would have liked to attach a photo to this post, but I love my camera too much to risk it in the rain. Maybe I shall attach one later, taken while indoors. 

For now, I have to complete a monster assignment for this GP run and studying for my test. While listening to the rain of course. It’s doing wonders in keeping me company and calming me down while I stress over this. 

Ahh. Rain.