April 11, 2011

10 Lessons of Psychiatry

I met today with a small group of students who also just finished their psychiatry rotation to share some of our experiences and some of the emotions it brought up in us - a sort of "burn out prevention" group, as the psychologist facilitator said.

As we went around the room sharing our experiences, I realized my peers and I were stating the big lessons of psychiatry. They were funny, horrifying, profound, and maybe most importantly - cathartic. Here are some of the stories and their lessons:

(1) even if someone looks like or acts like someone you know, someone you love, that kid who teased you when you were in middle school - they're not. so don't treat them like they are. One medical student in my group talked about how one of her patients looked just like one of our friends in medical school - and how she found herself really concerned about him and even more disappointed that he had caused permanent brain damage with heroin use.

(2) after all this studying, including the boards, after which we finally feel like - come on, we must know almost everything. Now we're ready to save some lives! We're confronted with the cold truth of medicine: third year medical students don't really do that. often times, the whole medical system doesn't really do that. helplessness is one of the hardest lessons for people who have dedicated their lives to such a trying path in the hopes that at some point they'll feel, HELPFUL.

(3) sometimes the story is false, but the pain is real. and sometimes even the pain isn't real - but that just means you have to look for deeper problems. One medical student in my group talked about a patient he felt that he really connected with - they both had lost someone close to them recently and the medical student left the interview in tears, but full of hope that the patient would get better. Later, he found out that almost everything the patient had told him had been false. At first he felt angry and betrayed - but eventually, he told us, he felt sad for the patient and wondered what he gained by lying to a third year medical student; he thought perhaps the patient was ashamed of being depressed without knowing why so he created a reason.

(4) it's rarely, if ever, actually about you. even though it feels that way a lot. A few of us told stories about specific patients targeting us in various ways. For me, it was a very sad man with schizophrenia who always rambled aloud all the things he was thinking (as in "today for breakfast I had eggs then I drew a picture I feel like I might have to go to the bathroom I really don't like that picture on the wall) - and one day, he started rambling about me. I wasn't even sure if he knew I could hear him, but he started getting incredibly sexually preoccupied and it made me very uncomfortable. So much that I ended up closing off - not just around him, but around all patients, and even my friends. I think I went into survival/protection mode and just was afraid. Which made me feel like a horrible person - here I am being afraid of this man who is so sick - but I was afraid. Eventually, I sort of resolved it in my mind, but I have such guilt about the relief I felt when he was discharged and I knew I would never see him again.

(5) Humor is a mature defense mechanism. I keep meaning to write one more psych blogpost about defense mechanisms, because it's so important to understand them. But humor really is a mature defense mechanism, because it's taking a situation that could be personal and making it relatable for everyone without projecting the grief or fear you feel onto anyone else.

(6) Find your own outlets. Everyone talked about how critical it was to have friends and family they could talk to, blogs/journals to write in, workouts or books that they could escape into, or places to go that were nothing like where we worked. Even this session seemed to be a critical part of not burning out, of continuing to want to help people, of striving to be the best medical students - and people - we can be.

(7) Addiction is bigger than anyone realizes. This will forever make me wary of prescribing addictive substances to anyone. This will make me take a thorough addiction history on every patient where it seems even mildly appropriate. Maybe everyone. Because someone needs to ask those questions - and if it's not your doctor, who is it?

(8) Ask an unscripted question. I stole this one from Atul Gawande's 5 Rules, but it's a good one, and maybe the most important in psychiatry, when getting a context for a patient is sometimes all you're trying to get. Some of my most productive questions this rotation:

When you are psychotic, what does it feel like?

Who's your support network?

If you had to name your reasons to live, what would some of them be?

What's it like to raise pigs?

Why do you think alcohol is different for you?

(9) There's not always an answer. As scientists, we are trained to create hypotheses, collect data, and analyze it to find the most likely answer. With problems involving people or emotions, and especially both - there's not always a right answer. Sometimes we just have to hold experiences until an answer comes, or we feel okay about not having one.

(10) While I don't think it's likely I'll actually be a psychiatrist, I feel so honored to have had this experience. And so prepared by it for all the other rotations ahead of me. Mental health issues are everywhere and having a better understanding of them will no doubt help me to pick up on things I might have otherwise missed. A big thank you to everyone who taught me or supported me along the way.


A good question is never answered
it is not a bolt to be tightened into place
but a seed to be planted
to bear more seed
toward the hope of greening the landscape of idea.
-John Ciardi

No comments:

Post a Comment