Leap Day
Instead of giving you, my readers, another diatribe about the world of psychiatry, I’ve decided to use this holiday to do something different. During clerkship lectures I get so bored that I usually spend the hour surfing the web on my palm pilot. Unfortunately, the mental health building at my hospital does not get WiFi. Therefore, I’m stuck trying to find other ways to keep myself entertained/sane. I’ve taken to writing poetry and making little drawings on note cards. I want to post some of the haikus that I’ve been writing.
The MMSE:
Do you know the day, month, year?
Can you draw this shape?
Psychiatry (noun):
Real patients, fake physicians.
Why wear the white coat?
The shrink’s battle cry:
Here’s a script to Wellbutrin.
Take it with water.
Bankrupting the country through medical care
The Democrats are in full swing this election season with promises of healthcare for everyone. They make it seem as if a magical fairy will sprinkle greater access and shorter waiting times upon the entire country, all the while keeping our taxes at the same level. What they don’t bother to mention is that the true cost of health care—$2 trillion—rivals the federal budget. In essence, to pay for everything we would have to nearly double the tax rate just to keep things the way they are now. What politicians also fail to mention are the further economic consequences of going to a single-payer system. Consider all of the men and women currently employed by the multitude of insurance companies. The moment we enter a single-payer system all of those people are going to be unemployed. Such a massive wave of people losing their jobs will lead to an immediate decline in government revenues and an increased burden on the welfare system.
While Hillary Clinton is trying to convince us to use evidence-based medicine as a way of deciding which medications and procedures get reimbursed, I wonder what standard would be used to uncover which parts of medicine are truly evidence-based. Using such a system would mean that all sections of complementary and alternative medicine could not be paid for. Many common surgical procedures such as the Whipple would also have to disappear. And even some of our medications—we aren’t sure of the mechanism of action for some of them—would cease to exist. Further, given the ever changing nature of medicine, how quickly will the government respond to new evidence? Just this week an article came out in PLoS Medicine stating that antidepressants are ineffective in patients with mild or moderate depression. If we were to use Mrs. Clinton’s principles of evidence-based medicine, would physicians have to rate a person’s depression in order to get a prescription to Prozac covered?
Also, now that healthcare is now “free,” will there be any limit to the amount of services that a person can use? Can a person with a headache demand an MRI just to rule out the one in a million chance that there is an intracranial bleed? Will over-the-counter medications now be covered? How many ultrasounds will a pregnant woman be allowed to have? I foresee physicians’ offices getting overloaded with very minor complaints: everything from an ingrown toenail to sunburns. And why stop at primary care? So long as we’re getting everything for free, let’s not even bother with setting an appointment. Let’s just go straight to the emergency department for any complaint that we want to get seen that day. My own hospital has loads of uninsured patients showing up to use the department as fast access primary care. I can’t imagine the time delay that will occur once millions more start to take advantage of this system.
Probably the greatest bite in the ass is that the American Medical Association—the group that is supposed to be protecting doctors’ interests—is the very organization that is stabbing us in the back with regard to health insurance. The AMA has recently begun airing commercials called Voice for the Uninsured in an attempt to shame us for having medical coverage. When I was a first-year medical student, many of my classmates joined the AMA by signing on for the $40 annual fee. I didn’t sign on back then and I have no plans of joining now. Yet somehow, I continue to receive postcards from the AMA on an almost weekly basis urging me to sign up for their program.
The fake doctors
Recently I wrote about my disdain for psychiatrists who wear white coats. In no other field of medicine will you see such a shiny, immaculate white coat as those worn by psychiatrists. Many of the residents I know have coats with creases in them that are as sharp as the day they bought them. To this day, I’ve only seen one psychiatrist with the stain at any time on his white coat. He openly admits that the discoloration is to due some coffee spilled during break.
Psychiatrists run in fear from any medical issue that patients may present with. Slightly elevated blood pressure? Call an internist. Slightly elevated blood sugar? Call the internist. Slightly elevated cholesterol? You get the idea. The residents and attendings use a shotgun approach to ordering labs and when anything comes back abnormal, they run and hide behind other doctors like a terrified small child does when he hides behind his parents’ legs. Now I know they had to learn medicine during medical school. I know they had to pass STEP III to get licensed as physicians. But the overwhelming response from psychiatrists—when presented with medical issues—is, “Why concern ourselves with kidney function and other nonsense when there are other pressing issues at hand?” On two separate occasions I have witnessed residents state that metformin leads to hypoglycemia. Any first-year medical student knows that metformin, a drug used to manage diabetes, is employed as a first-line treatment precisely because it does not cause hypoglycemia. Yet here they are, these disgraces to the title M.D., making untrue statements about the side effects of a very popular medication.
Psychiatrists act as if they should not concern themselves with medical issues, yet then get offended when people say that they aren’t real doctors. In this rotation we employ a device known as the mental status exam (MSE) to check our patients’ functional abilities. I have heard more than one practitioner state that the MSE is the psychiatrist’s physical exam. To this day I have yet to see a note that links the MSE to the body in a similar fashion that a neurology note can link physical exam findings to lesions in the brain. They claim to be medical experts of the mind, yet are neither talented as physicians nor as therapists. I cannot think of a greater waste of education than that of psychiatry.
For every psychiatrist there is, one seat in medical school is given up so that a person can join the pseudoscience realm of Freud. Their expertise requires eight years of training (four years of medical school + four years of residency) that do not translate into meaningful results. At best, they are misunderstood practitioners of the id and super ego. At worst, they are directly leading to the current shortage of medical doctors.
Therapists, on the other hand, make a unique contribution to the world by promoting insight and new behaviors that can lead to a decline in depression, anxiety, substance abuse, and maladaptive work and social behaviors. Therapists require many years of training and experience to provide an unparalleled level of service to people who need them. I have no problem with therapists. Psychiatrists, however, are a drain to our society because they can neither serve as medical physicians nor are they skilled practitioners of psychotherapy. Our only hope is that Medicare and insurance companies continue to cut reimbursement rates for psychiatrists to the point that the field is abandoned altogether. Only then will be free of their tyranny.
You won’t believe the stuff I saw today (part 2)
In most areas of medicine, you will encounter fairly mundane diagnoses carried by ordinary people. For example, a primary care physician might see 30 patients in one day, 25 of whom came in for cholesterol checks, blood pressure checks, or sugar checks. In psychiatry, however, each day brings with it a chance to meet the nation’s greatest citizens. Just this past week I met the inventor of the Knight Rider car, three millionaires, and a four-star general in the Air Force who ensured me that his commitment to the hospital was a mistake and that everything would be okay if I would just contact the Pentagon for him.
While documentation is important in any medical field, I have learned the art of buffing a chart on this rotation. On every other clerkship we students diligently note all of the patient’s complaints, their disease history, and all the findings on the physical exam. We do not bend any of the patient’s information, nor do we editorialize to make the patients seem sicker or healthier than what is presented to us. On this rotation, for whatever reason, we try to make the patients seem as ill as possible. “Buffing” is the act of adding information to a chart that was not stated by the patient, not found in the physical exam, or simply untrue for the sole purpose of trying to sway the reader in a particular direction. An example in emergency medicine might be a patient who comes in with a complaint of shortness of breath. To get the person examined by a cardiologist, you might also say that the patient has chest pain once an abnormal EKG is discovered. Buffing is highly illegal but is practiced by many physicians to varying extremes.
In psychiatry we make buffing seem like it’s a perfectly acceptable part of medicine. On any given morning I might round on a patient who tells me that he no longer hears voices and has no thoughts of hurting himself or others. He might further state that he wishes to be discharged so that he can go back home and live his life. The nurse’s report might state that the patient has been perfectly cooperative throughout the previous day, that he has mostly kept to himself, and that he slept throughout the night without any intervention or extra medication given by the nursing staff. In a chart I will then state that the patient continues to respond to internal stimuli (meaning that he’s hearing voices), that he is isolated and withdrawn, and that he needs continuous 24-hour monitoring to ensure that he is not a danger to himself or others. This practice of buffing the charts is not only encouraged—but required—by my attending.
I doubt that we will ever be caught because the laws protecting mental health charts are different than those for dealing with medical charts. In regular medicine, a patient has access to all of the information in his chart. If you want to see what your doctor has been writing about you, simply call his office and ask that your chart be photocopied and delivered to you. Mental health notes, on the other hand, cannot be revealed to a patient due to the sensitive nature of what they contain. Therefore, we already have one of layer protection separating our buffed notes from the patient’s inquisitive eyes. Further, if a court order should ever force us to turn over our notes, a patient is going to have a hard time arguing against a physician that he was “responding to internal stimuli.” We’ve done such an amazing job of painting all of our patients as psychotic, antisocial murderers that I’m sure we could charge admission fees to lectures on how to buff a chart. As my attending admitted, “Anyone could qualify to be a patient here.”
Psychiatrists as shams
Apparently I’m not the only person who thinks that psychiatrists don’t know what they’re talking about. The following is a bill that passed through the New Mexico senate in 1995, only to be later vetoed by the governor:
When a psychologist or psychiatrist testifies during a defendant’s competency hearing, the psychologist or psychiatrist shall wear a cone-shaped hat that is not less than two feet tall. The surface of the hat shall be imprinted with stars and lightning bolts.
Additionally, a psychologist or psychiatrist shall be required to don a white beard that is not less than 18 inches in length, and shall punctuate crucial elements of his testimony by stabbing the air with a wand.
Whenever a psychologist or psychiatrist provides expert testimony regarding a defendant’s competency, the bailiff shall contemporaneously dim the courtroom lights and administer two strikes to a Chinese gong.
Everyone gets a diagnosis and a prescription
A necessary part of running a hospital involves the task of getting everything paid for. In the United States, we use a complex series of codes called ICD-9 to bill insurance companies based upon which disease is treated. In psychiatry, all patients are given a diagnosis based upon the DSM-IV (The Diagnostic and Statistical Manual), the handbook of the American Psychiatric Association. For those of you who are unaware, the DSM-IV reads like a checklist. A typical diagnosis falling under the heading of “major depressive disorder” will list a series of criteria defining the diagnosis based on everything from decreased sleep to loss of interest in hobbies. If a person meets these criteria, then he is considered depressed. The problem arises when the patient doesn’t necessarily fit all the conditions. For example, in major depressive disorder, there are four criteria which must be met. If a patient only meets three of them, he cannot be diagnosed with MDD—no matter how sad he feels.
On my ward, everyone gets a diagnosis and a prescription upon admission. As my attending once told us, “We need a diagnosis. Give me something to put down here.” We then proceeded to force a patient into a category known as “psychosis, not otherwise specified” or anything else that might get us paid. My attending uses a fudge factor to try to force anyone to a diagnosis. To qualify for the label of “psychosis,” a person must have either delusions or hallucinations. When we interview someone in the psychiatry office, the patient is often intrigued by all of the posters on the walls. He may begin looking around the room and reading whatever is posted. Our attending will then use this behavior as evidence of hallucinations by saying, “He’s looking for the voices.”
I’m starting to size up the people around me and trying to fit them into psychiatric categories. My first diagnosis is for my attending, who I’m sure has narcissistic personality disorder. He sits in a high-back leather executive chair during rounds, while the rest of us sit in plastic seats. He begins rounds each day by methodically counting all of the patients’ charts as well as all of the medical students and residents present. We then discuss the new patients of the day, most of whom have schizophrenia.
Schizophrenia is the most devastating disease known to man, with the loss of employment, little hope for education, difficulty in maintaining interpersonal relationships, and the general trend of a downward spiral to the point where the patient is no longer functional. Many schizophrenics are forced to go on disability and receive Social Security income from the government. Many other schizophrenics turn to alcohol and drug abuse as a coping mechanism. When we combine these two, we get patients who are purchasing drugs using tax payers’ money. As one man told us of his cocaine habit, I could hear a sucking sound coming from the Social Security Administration that paid for his expensive addiction.
There are many conditions which resemble schizophrenia: drugs, certain infections, and traumatic brain injury. These diseases can lead to a variety of hard to handle behavior as witnessed this past week when an HIV-positive woman came into the staff area of the psychiatric hospital and then urinated all over the floor. As one physician stated, “Who needs TV when there’s drama here?” True, I do see a lot of crazy stuff.
Letter to congress
Shortly after starting this blog I came up with 1-800-IDEA-MAN. My very first post was about letting fourth year medical students become PA’s once they have passed both Step I and Step II of the US Medical Licensing Exam. I decided to finally take some action on my idea by writing to my state’s representative and senator. Here is the letter that I sent to both of them.
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Dear ____________,
I am writing to you today as a resident of District __ with my concerns about ______ health care. I am currently in my third year of medical school at the University of _____ and have witnessed firsthand the lack of proper resources to provide for the well-being of our citizens.
Solving healthcare woes is not only a priority of mine, but has become a major topic in this election year. While there are many ideas tossed around about how to provide greater access to care—such as malpractice reform and socialized medicine—I want to share a novel solution.
Currently, there exists a group of physician extenders known as physician assistants who work as mid-level providers to offer primary care and emergency services to many people. Physician assistants go through two years of training: one year of clinical course work, and one year of hospital experience. They then take a licensing exam to become certified here in the state of ______ as PA’s. Since they are not allowed to carry their own malpractice insurance, nor are they allowed to write unrestricted prescriptions, PA’s work under the guidance of a physician.
Now let’s consider medical school. To become an M.D., students must go through two years of clinical course work and two years of hospital experience. Before graduating, they must take two parts of the United States Medical Licensing Exam series. Even then, they are not licensed to practice as full physicians here in this state until they have completed one year of residency and passed part three of the series.
I propose that medical students who have completed their third year of training and who have successfully passed both Step I and Step II of the US Medical Licensing Exam should be automatically qualified to practice as physician assistants here in the state of ______. There would be several benefits.
First, they would reduce the burden on current physicians. The American Medical Association names ______ as a crisis state because of its medical malpractice woes. Many doctors have left the state and many more are limiting their practice, resulting in reduced access to health care. By having more physician assistants available, state residents would have greater access to primary care.
Second, medical students would enjoy the benefits of holding a job while in their final year of training. At my own university, many medical students graduate with over $200,000 in debt as a result of high tuition costs. By generating some income, medical students will be able to offset a small part of the financial burden of achieving their dreams to become doctors.
I’m not suggesting that these medical students/physician assistants will replace primary care doctors. They will continue to work under the guidance of current licensed physicians. Given the hiring rate of PA’s, I think it’s such a plan would work smoothly without causing any disruption to the job market.
I would appreciate your feedback on my idea. My proposal is certainly not going to completely fix the problem of healthcare access, but it will alleviate some of the strain without causing a rise in taxes or a reduction in physician autonomy.
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Sincerely,
Half M.D.
You won’t believe the stuff I saw today
I started inpatient psychiatry this week, which is already turning out to be one of the most ridiculous clinical settings I’ve ever been in—for a variety of reasons. My very first patient of the day was a 40-year-old man who claimed that he was 10 1/2 months pregnant. He was fairly certain that he was going to give birth in the next two weeks, claiming that he was carrying 50 babies. He was very adamant that he was the mother of the children and that his cousin was the father, prompting my attending to say, “That’s the craziest fucking shit I’ve ever seen in my 20 years in psychiatry.”
I certainly expect odd behavior from my patients. However, I’m sorry to see that many of the psychiatry residents and attendings also exhibit severe personality flaws. Already in my second day, I’ve diagnosed my intern as being manic. He told us on the wards that he was a player, and then proceeded to hit on a social worker, two pharmacy students, and was even flirting with several of the committed patients. I’m pretty sure that he’s going to be one of those psychiatry residents who ends up marrying a patient.
He talks incessantly. He tells us that he’s such a wonderful teacher, and then proceeds to read to us from a PowerPoint slide. While the med students are diligently writing notes and filing them away in patients’ charts, he is idling his time by surfing Facebook.com and telling us, “This is such a hard rotation. I can’t believe the amount of work I have to put in.” I wonder how a person who lacks insight and judgment got put in charge of managing a dozen patients who also lack insight and judgment.
Probably the most offensive thing I’ve had to witness so far on this rotation is the dress code. Nothing seems more out of place that a psychiatrist who wears a white coat. As if they’re real doctors! The pockets are typically empty. There is never a stethoscope, a reflex hammer, penlight, or anything else that might make a person believe that psychiatrists practice any kind of real medicine. My service consults out for every medical problem: diabetes, hypertension, shin pain, and pregnant men. Then, the shrinks all get upset and offended when other specialties state that they aren’t real doctors.
But I think I may have found a woman for my intern. I was sitting in on an interview today when the patient stopped addressing my partner, turned to me, and said, “Hey handsome, if you give me 69, I give you 69. You can get me pregnant.” Seems like a perfect match to me.
Questions answered
I finally wrapped up pediatrics this weekend. Throughout the previous two months I’ve seen and done things I’ve never thought possible. I’ve also learned quite a bit about children, mostly in the form of questioning the bizarre behavior that I saw around me. I would like to take this opportunity to share some of those questions and their answers with my reading audience.
Question: When I was in the neonatal ICU I noticed that all of the doctors and nurses were wearing gloves when handling the infants. While I understand that hand washing is good for reducing the spread of infections, why are gloves also necessary?
Answer: the purpose of the gloves is not to reduce the spread of infection; it’s to prevent the scent on your hands from being transferred to the infant. If the mother smells the scent of another creature on her baby, she will immediately kill and eat her child. It happens all the time in nature. Since were trying to prevent this from ever occurring, it’s necessary that all doctors and nurses wear gloves when handling babies.
Question: What are our responsibilities on pediatrics? What happens when we don’t fulfill those responsibilities?
Answer: As Pandabear is fond of saying, you have no true responsibilities as a medical student. However, the university will certainly try to give you many pretend responsibilities. I had to take call every fourth night to admit patients and to help the residents with their work. On two separate occasions I had forgotten that I was on call, gone home, and taken a nap. Each time I woke up, realized that I was supposed to be in the hospital, and then ran back to the wards. On both occasions, despite being late by several hours, the residents took no notice of my absence. In one case, the resident even said, “I didn’t even know med students took call.” The good news is that I’m on the psychiatry as my next rotation. I figure that if I’m ever late, I’ll tell the patient, “You had better tell everyone that I was here at 2 p.m.” If he ever squeals and tells my attending that I showed up at six, I’ll reply, “He’s crazy! Obviously he doesn’t know what time I arrived.”
Question: I watched a doctor give a lecture via PowerPoint today. He seemed not to know how the computer worked. He had the presentation in “edit” mode and went through the entire lecture with the screen at only half size. Why is it that doctors don’t know much about technology?
Answer: Nothing scares me more than physicians who don’t understand computers. Doctors are supposed to be the best and brightest of our nation; however, many of them can’t figure out how to use a microwave if their life depended on it. I’m constantly amazed at how we have many medical advances such as lasers being used in surgery, molecular mapping of the human genome, and nano robots that can deliver drugs to pinpoint target. Despite all these advances in technology, many physicians are scared of using anything technologically-related. Many of the premeds who used to shun physics, math, and engineering courses as undergraduates eventually progressed into becoming physicians who also shun applied physics, applied mathematics, and applied engineering. I’m extremely annoyed that we continue to use paper-based charts for all of our patients. My hospital has tried to go into a quasi-computer method of charting patients. We use electronic medical records to house data such as x-rays and laboratory results. However, we continue to use paper charts for admission notes and record-keeping. Once the patient is discharged and returns to clinic a week later, we no longer have access to the paper charts. Therefore, we have no idea why the patient is coming for a follow-up appointment. And forget about the patient ever knowing why they’re there. Most of them will merely reply, “I got a letter in the mail telling me to show up today.”
Question: Why do pediatricians talk to everyone (including adults) like children?
Answer: Doctors only understand what they practice—and pediatricians are no exception. One of my many great annoyances from this past rotation—and believe me, there were a lot—included pediatricians to like to talk to me as if I were a five-year-old. Nothing is worse than having a resident who is younger than me adopt a high-pitched voice and then say, “Do you think you can get that done for us?” Lord, I can’t imagine what their consults are like.
Since I’m starting psychiatry tomorrow, I’m sure I’ll have lots of new stories to begin posting on this blog. I’m sure many of them will begin with, “You won’t believe the shit I saw today!”
Half MD.com 