Psych

I've been relaxing with my family over the holidays, so no new medical updates. Overall, Psych wasn't a bad rotation. I would get to the hospital at 7:20 AM and return home before 4 PM. In between I would spend most of my time talking to alcohol/drug addicts. Crazy people on Thursdays. Once I had a psychotic patient who told me "I'm a werewolf. Please don't be afraid. I'm not a bad wolf. I'm a good wolf." This was a teenager admitted a week after the release of "New Moon." Coincidence?¹ If this was a shelf question and the the patient continued to talk about werewolves, would you...

A. Neither affirm nor deny the delusion, but gently redirect the interview
B. Ask the patient if vampires sparkle in daylight, to further categorize the mythology behind the patient's delusion
C. Assess lycanthropy status by pressing sterling silver against the patient's skin and monitoring for severe contact dermatitis
D. Reveal that you are a member of the undead and the patient's sworn enemy to test his resolve
E. Recognize that your werewolf/vampire jokes are a coping mechanism for dealing with the pain of watching a young life torn apart by mental illness

...?

I had a tense half-second when the patient I'm describing made a sudden movement that made me think he was going to bite me, but he did not. (I thought up more werewolf jokes to process that one too.)

However, the only time I was genuinely afraid of a patient was with a short, elderly woman who hated black people. I don't know how much of it was mental illness or her underlying personality, but after five minutes on the genetic superiority of the 'German race' (her race?) and the depravity of 'Africans' I was actually nauseated. This woman's care was managed on an outpatient basis. I am glad I am not her physician, because as I fall asleep I still occasionally think of her out there, setting someone's house on fire.


1. Ayche RC, et al. Twilight series makes people literally crazy: case study of first break schizophrenia in a teenage male. N Engl J Med 2010 Jan 7; 362(1)

Rough Introductions

The introduction to Harrison's is eleven chapters long. I'm currently bogged down in "Principles of Clinical Pharmacology" with only a couple pages to go.

Speaking of being bogged down... tomorrow is my last day of clinical duties on Psychiatry. Only today did I discover that I can access past psychiatric discharge summaries in our hospital's secondary electronic medical record system. Students are unable to access these records in the primary system, due to privacy concerns. Yes, our hospital uses two systems. And paper charts. It is completely streamlined and never results in medical errors or lapses in judgment like placing privacy controls on one system and not the other.

Pages Read: 37/2754

Holy Pronoun Fail, Batman!

Case Files is a popular review series for third year clerkships. The chapters in the books are numbered by case and not titled, so you must read the opening case presentation and formulate a diagnosis before reading the chapter and learning more in-depth about the central topic. Generally, Case Files is awesome for studying on the wards, when you might have five or ten minutes available every so often to squeeze in a little review. However, I was irritated by the last case I read in Psychiatry. The case is (spoiler alert!) Gender Identity Disorder, an issue all of itself, and it opens, "A 26-year-old chromosomal male dressed as a woman comes to see a psychiatrist as part of the workup required before he is allowed to have the sex change operation he desires." Really? Did the author honestly use the word "he" twice in the opening sentence? The entire case is written using male pronouns. Just to be clear, it later includes the sentence "He considers himself a 'straight woman' and has never seen himself as a gay man."

If they ever allow me to be an real doctor, I hope I have the basic decency to refer to my patients using pronouns consistent with their expressed wishes. I wonder how pervasive the use of inappropriate pronouns is in medical records? I have not yet had a transgendered patient that I was aware of, so I have not experienced this first hand.

Harrison's Principles of Internal Medicine

Last night I decided I want to read all of Harrison's before I graduate medical school. Is this unreasonable? Is 8 pgs/day an unsustainable goal? We shall see! I think this could provide me with some much needed structure in my study habits.

I am half-way through my third year and I do not know what I am going to be. My plan was always Medicine and an ID Fellowship, but I started thinking about Pathology and threw everything out of whack.

Reading the intro to Harrison's reminded me why I was so interested in ID. In 2001, 56 million people died worldwide. Of those, 20% were children under the age of 5 who died of acute respiratory infections, measles, diarrhea, malaria, and HIV/AIDS. Our world is not yet what it should be.

Pages Read: 18/2754

Forensics

As you may have inferred, if you are a med student or former med student reader (ha ha... I think people read this!), I have been absent from this blog as the stress of studying for Step 1 took its toll. But I have emerged victorious! Or at least, I passed. WHOOO RAH! I think my score is solid, especially since I don't want to be any kind of surgeon or read films all day or spend the rest of my life dealing with people's disgusting skin.

Boy, do I hate skin conditions. Just the word "papule" is upsetting.

And speaking of things I won't spend the rest of my life doing, I am currently on forensics. Pathology as a whole I have not ruled out, but forensics? Absolutely not. Why? Because insects are waiting for you to die, and they will eat you. I cannot unlearn this. It will haunt me till, and especially on, my dying day. Thanks, forensics.

Physical Diagnosis

This semester we are continuing with the physical diagnosis format from last semester. Every student is assigned to a preceptor along with another student or two. We have five assigned afternoons to go into the hospital, find a patient, perform a complete interview and physical, and meet with the other student(s) and preceptor to present this patient. For me, last semester was a disaster. Though my preceptor was friendly, she gave little instruction or feedback, and the overall experience has left me anxious about my lack of knowledge in performing a physical. I think some schools give their students the chance to learn physical diagnosis on standardized patients. We learned to interview with standardized patients, but we were expected to learn the physical exam by practicing on one another. This was not especially helpful. Our school has also recently built a center for simulated exams on dummies, but as of yet my class has not been given the chance to make good use of it. Given the widespread dissatisfaction with this part of our curriculum, I wonder how other med schools have integrated clinical exam skills into the first two years.

My new preceptor seems like he will be expecting more from us, so I am hopeful I will be more prepared for third year by the end of this session. At the very least, I hope to not miss anything this semester as glaringly obvious as I did last--purple hands. Yes, indeed, the patient's hands were purple. But even omitting inspection of the hands was a vast improvement over my first patient of the year, who I was too afraid to touch. He was an actual hospitalized sick person! I could hurt him! I suppose if we can manage to somewhat bungle our way through the physical exam by third year they've accomplished something.

Ayche's 12 Step Program to Gunning - Step 12

Step 12 - Don't Actually Be a Gunner

Every student should do his or her best to learn the material, but actual "gunning" takes the emphasis off of patient care and puts it squarely on the ego of Hot-Shot Med Student. I attend a medical school that has switched to a Pass/Fail system. It seems many schools are switching to a non-grade grading scale to encourage cooperative learning. I do not know how successful these are at other schools, but at my school they still dole out "Honors" for the top 10% and keep GPAs so students can qualify for AOA (the medical honor society). It makes me wonder, what's the point?

We are all in this together, right? While there is nothing wrong with being a good student, it is at least as important to do what you can to help out your classmates. This view is antithetical to true gunning. I have much more respect for a classmate with average grades who sends the class a brief email concerning an important piece of information the professor remembered when asked a question after lecture, compared to a 4.0 student who in the same situation would keep the information to himself. If my class were a venn diagram, the circles of "knows the most" and "shares knowledge" only slightly overlap. Why? Gunning.