16 October 2013

I'll catch you if you fall

My resident and I braced ourselves for the meeting ahead. It was not going to go well. The patient had been informed that he would be involuntarily committed to a mental hospital because we believed he was a danger to himself. The patient was quite upset and had angrily demanded a meeting. Now it was time to meet with the patient as well as his family to explain what was going on. Most of the hospital staff had already gone home.

My resident asked me to jot off a quick message to the attending physician, letting him know what was up. I sent a quick text message to the doctor's pager. We hurried to the patient's room.

After a lengthy, impassioned back-and-forth, things were not going where we wanted. The family and the patient fiercely disagreed with our plan, and they were becoming irritated. I scurried down the hallway towards the page phone so I could notify our attending.

When I got to the phone, I spotted my attending sitting comfortably at a computer in the distance. He was typing up patient notes. What a relief! I went over to him. "Just who I wanted to see!" I said. I brought the attending up to speed and directed him to the patient's room. The attending took over and did a fantastic job of calming down the situation.

What was our attending physician doing in that particular hallway of the hospital, of all places? After receiving my page, he had come up to our floor without telling us. I think it was intentional that he had positioned himself out of the way, where we couldn't see him.

He had trusted us to handle the meeting on our own, but was ready to help at the drop of a hat if we needed it. It was perfect.

07 October 2013

Class act

At a small group session with some classmates on my rotation, we began with a "check-in" where we discuss how we're doing. I said that I was getting sick and feeling out of energy. I came home to find a bag on my porch filled with flowers, several varieties of tea, and a very nice note. Another classmate sent me a message offering to help however she could. These acts of kindness put a huge smile on my face. It's the happiest I've felt since I started my rotation. I feel good about people, about humanity as a whole.

I don't think I deserve such nice classmates. But I feel blessed to have them. Hopefully I can repay the favor.

03 October 2013


If someone looks euphoric, can we say they are having a manic episode?

To practice psychiatry, one must become intimately familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM). This tome lays out the diagnostic criteria for various mental illnesses. It's helpful because it ensures that clinicians are speaking the same language with each other. For someone to be classified as having a manic episode, they have to exhibit a certain number of particular symptoms, such as decreased need for sleep, racing thoughts, or grandiosity. The diagnostic criteria also specify that the symptoms must last for a certain amount of time and in the absence of other potential causes such as drug intoxication.

For many years, the DSM-IV has been the bible of the field of mental health. After fierce debate and negotiations, a new edition came out earlier this year: DSM-5. On the whole, the changes strike me as improvements. For example, there now is a single entity, Autism Spectrum Disorder, that replaces the confusing and seemingly artifical amalgam of five autism-like diseases found in DSM-IV. Under the old criteria for anorexia nervosa, pubescent girls had to have problems with menstruation. This criterion did not seem useful and has been dropped in the newest DSM.

When we were taught psychiatry during our pre-clinical years, we were taught the DSM-IV. But during my clinical rotations now, my attending physicians request that we use DSM-5 criteria. I think this is good. Academic institutions rightfully pride themselves on abiding by best practices.

At the end of my psychiatry rotation, we have to take a national exam that substantially impacts our grade. This exam uses DSM-IV. Part of the reason (I presume) is that it takes years to write new test questions and test them for validity.

What results is an odd and sometimes frustrating contradiction. During the day, I get grilled on the new DSM-5 criteria. But at night when I study, I have to learn the minutae of the DSM-IV, carefully mulling over details that no longer matter.