Few fields of medicine are as unique and exciting at psychiatry. Where else are you going to find a 34-year-old man talking to his penis and telling it secrets? At the end of your shift you will come home wanting nothing more than to tell all of your friends and neighbors about all of the interesting people you’ve met throughout the day. Don’t go breaking HIPPA and other codes of decency just yet. There are several important rules of etiquette that apply more so to psychiatry than to any other specialty.
First off, never say that a patient is “crazy,” “bizarre,” or even “psychotic.” These terms stigmatize mental disease and place blame on the patient for a neurochemical disorder that could just as easily affect any one of us. Instead used terms like “inappropriate behavior” or better yet, cite specific examples of things that the patient does, such as “responding to internal stimuli.”
Second, never say that a psychiatry resident is “crazy,” “bizarre,” or “psychotic.” For whatever reason, the strangest people in medical school generally end up as shrinks. And as the book Mount Misery tells us, psychiatrists will specialize in their defects. There are many stigmas against the field both within medicine and among the lay public. And you certainly don’t need to contribute to them.
Television shows such as Dr. Phil leave us believing that anyone can treat mental disease and has turned us into a nation of armchair therapists. Encroachment on the field by social workers, life counselors, and a variety of psychologists who use any title such as “school psychologist” make the specialty seem easy to enter.
Among other physicians, psychiatrists are seen as being helpless to treat medical conditions. I wanted to apologize to our consultants every time we had to call them because our residents could not manage blood pressures of 150/90. Whenever a patient attempted suicide by cutting his wrist and then presenting to the psychiatric hospital, he was immediately deferred to another physician to suture the wound closed. The other specialists were generally greatly annoyed that anyone with a title of “M.D.” could be unable to manage mild hypertension or mildly elevated blood sugars.
What you need to know to succeed on your clerkship:
1. Drugs, drugs, drugs. With the exception of electroconvulsive therapy, there are no procedures to master in this rotation (as if you’ll even see ECT during this rotation). The sole method of treating mental disease amongst psychiatrists is to use an armory of medication in the hopes that the various neurotransmitters are put back into proper balance. I suggest that you either find or make a list of various psychotropic medications, their mechanisms of action, their indications for use, and the side effects specific to each drug. Such a list of drug names would not be very long, but should contain a detailed amount of information. For example, clozapine is a very effective medication against schizophrenia. However, its most dangerous side effect is agranulocytosis. I can guarantee you that you will be asked about this drug at least once.
2. DSM criteria for diagnosis. In psychiatry, the majority of diagnoses are made solely upon history. There is no physical exam, and anyone who tells you otherwise is lying to himself. There are however a battery of paper-based scoring test that are used in the management of a patient’s condition. Rarely are labs ordered. If they are, look to order electrolytes, a thyroid panel, vitamin B1, vitamin B12, urine toxicology screen, and an RPR to test for syphilis.
Several months ago I posted my stories about psychiatry on this website. They generated quite a bit of discussion amongst my readers. Here are my previous posts. I hope that they can create new conversations amongst all of you.
You won’t believe the stuff I saw today
Everyone gets a diagnosis and a prescription
Psychiatrists as shams
You won’t believe the stuff I saw today (part 2)
The fake doctors
How’s that for a can of whoop ass?
You won’t believe the stuff I saw today (part 3)
You won’t believe the stuff I saw today (part 4)
I’m sitting here at Tino’s restaurant wondering how much longer my food is going to take. I’ve been here for at least 20 minutes already and no one has taken my order. A waitress has passed by me twice without giving me my meal. In fact, she’s avoiding eye contact because she knows it’s her job and she just doesn’t want to do it.
I had to start coming here because my old restaurant, Great Papa’s, has become too expensive. I can no longer afford my prior chef. He kept raising his rates citing nonsense like overhead and food poisoning insurance. I’m pretty sure that he just wants more money so he can join a country club. We all know how greedy chefs are.
Christ, how long is this going to take? Is he out playing golf somewhere? Just where is my chef? My waitress mentioned something about a kitchen fire. My last chef tried to use the emergency excuse whenever he wanted free time to surf the Internet, too.
Doesn’t he know that food is a basic right? I can’t go on if these meals become too expensive. Why does he keep raising the rates? There needs to be some kind of intervention. A system where food can be given to the good citizens of this nation so that we can eat and know that our bellies will not starve. On top of that, I need everything on the menu, right now, and for free. And I don’t care how many times they tell me that the food won’t mix well together. Don’t let laziness be an excuse.
I don’t trust the chefs and chef assistants anyway. They’re always making mistakes. There needs to be more oversight of their assistants, the food prepares. Lord knows I don’t want them messing up my food. Just last week my friend Joanna got food poisoning from eating the shrimp. She stayed up the whole night vomiting. That crazy ER doctor that she went to see tried to pawn it off on my friend by saying she was throwing up because she had been drinking too much whiskey. I’m pretty sure that the doctor was in cahoots with the chef.
I recently began working on a calculator for biostatistics and evidenced-based medicine. While there are certainly valid complaints about the field—I’ll let others be the complainers—EBM has pulled medicine out of the dark ages into a more scientific discipline. To help with calculations regarding diagnostic procedures, I’ve put together this Excel chart that can give sensitivity, specificity, predictive values, likelihood ratios, 95% confidence intervals, and a graph of the pre-test vs post-test probabilities.
Simply enter the appropriate information into the 2×2 table and the program will take care of the rest. If you wish to print the form, only print the first page. The rest of the chart contains a series of calculations.
In the future I plan to continually add to the EBM calculator to include exposures.
Hello, my name is Ted Newley, and I am running for Congress as a representative of the Enchanted Forest. I want to represent all woodland creatures such as elves and dwarves. In short, I want your vote. I’m a reformer among reformers and I think that I can do the best job for the Forest. Let me share with you my platform.
I have big plans for the little citizens of this area. My major goal is to reform health care with the following actions:
1. Extend Medicare’s drug plan to include magical potions. Far too long western medicine has come in with its mass-produced medicines that do nothing but cause rashes and diarrhea. I would force the federal government to open up its coffers to the healing power of the eye of newt and wing of bat.
2. Allow benefits for trips to gypsies and fairies. American physicians may have many years of training, but they still don’t know how to properly predict the future or heal a broken heart. Through the power of tarot cards and palm reading, a soothsayer can accurately tell you when you’re going to die. Further, there is no pain like that from a broken heart. A fairy should be able to enchant your heart and find your one true love. Once you have that, there is not much more that can harm you.
3. During the Great Depression the chant was “a chicken in every pot.” I advocate for pot of gold at the end of every rainbow. We need to ensure that healthcare provides a holistic healing for the patient. What better way to do that and to provide the necessary funds for getting a taxi ride, hiring a babysitter, and purchasing pet food?
If you agree with me on my plans for the future, vote for me this November. You can meet me in person on October 8. Food will be supplied by the Keeblers.
The public seems to have this dual perception of physicians as if we are the smartest, yet stupidest people in existence. For instance, there is a certain infallibility that doctors are expected to have when it comes to medical care. You didn’t diagnose a rare presentation of a disease? You’re going to get sued. You failed to order a CAT scan on a person with a chief complaint of “mild headache,” yet has no fever, no neck stiffness, no focal neurological findings, and is perfectly awake and oriented, only to later find out that the person has a hemorrhage? Time to hand in your license. That non-smoking, white collar worker has a cough and you didn’t bother to check for mesothelioma? I want you to meet my two friends Cohen and Cohen.
At the same time, however, the public has a perception that physicians are easily swayed by marketing gimmicks. Somehow if a drug rep gives me a free pen with the word Seroquel written on the side, I’m going to start prescribing the product to everyone that has a chief complaint of “feeling happy.” Those shining members of ethical practice known as Congress have decided that come January, drug reps can no longer supply free gifts to doctors. The thought is that physicians are too easily swayed by the cheap gifts given out by drug reps. Meals are still fair game because “they can be educational.” Textbooks, on the other hand, are no longer allowed because they are considered big ticket items. Somehow, a fancy dinner that costs $100 is considered more appropriate than a book with the same price.
How do doctors to get this dual reputation of being the most educated yet easily persuaded members of society? And where am I going to start getting my pens?