Experiences and Impressions from Clinical School (Part 3: Clinical Patient Interactions)

Patients Concealing Anxiety and Depression

I’ve observed that a lot of the patients could openly talk about their physical medical conditions (and Diabetes), but are reluctant to talk about Depression or Anxiety. They might even “lie” about feeling happy and calm, which was contrary to the notes in the patient file which indicate a prescription for antidepressants and sometimes note “panic”, “sadness about [XXX incident] happening”. I’ve already memorized some facial expressions and certain body postures of NTs which typically imply certain feelings, so I try to observe the “upset” one in the patients when seeing them speak. I was told by a friend (who is NT and usually sees patients with me) that mental health and psychiatric conditions are often stigmatized by the majority of society and tend to get hidden away should it be regarded as a “personal failing” or a “mental weakness”, and that they chose to be depressed/anxious.

Furthermore we were taught in a tute that to perform a Depression screening, you have to ask questions which sound like they’re not related to Depression, but are actually factors of it, as many of the patients apparently don’t like to be confronted with the direct question “Are you depressed?”. Eg

“How has your sleep been recently?”

“How’s your appetite?”

“Are you looking forward to anything after leaving the hospital?”

“Do you still enjoy [YYY activity] these days?”

and in the worst case scenario, you may ask “Do you ever feel life isn’t worth living anymore?”

I find it disappointing that society at large seems to stigmatize mental health/Psychiatric conditions and perpetuates the pressure on people with Depression, Anxiety etc to hide how they truly feel and act cheerful and complacent just to keep up appearances and not “ruin the atmosphere”. I wouldn’t be surprised that such suppression of how one truly feels for fear of ostracism/”punishment” upon open expression would exacerbate their mental health conditions even more. It’s also possible that some people feel that Anxiety and Depression is something to be ashamed of and it’d hurt their pride if they revealed it and/or it'd affect how people viewed them, but I feel that society’s prejudice plays a factor into this impression. Apparently this phenomenon is even worse in Asian countries, where society is more hierarchical and conformist and there’s a greater lack of mental health and psychiatric services.

Other Notable Patient Encounters (fake names used)

“David” (dead son has undiagnosed Asperger Syndrome): David was in the hospital waiting for an operation. After asking him about his history of presenting complaints, I asked about his family. He said that he had a son who left the home and committed suicide at age 41. I told him that I’m sorry to hear about that, and asked if he happened to know why his son committed suicide. He then said that his son said he “couldn’t take it any longer” and that his son displayed all the clinical traits of Asperger Syndrome.

I told him that I had been diagnosed with Asperger Syndrome and asked him numerous questions regarding his son’s childhood and adolescent years (with his consent). His son had a mild speech delay, narrow interests, and would spend hours upon hours reciting scripts from Shakespeare at the age of 8, could do calendar calculation, hated eye contact and soft touch, and had difficulty forming reciprocal friendships with NTs. His son got bullied a lot at school, and even when sent to a boarding school where there was routine, got ostracized by other NT students. He also went to TAFE but dropped out due to not being able to tolerate the social atmosphere.

I explained to him that Asperger Syndrome was a relatively recent diagnosis (introduced in DSM-IV in 1994), and that the concept of an Autism Spectrum was very unheard of prior to the late 80’s/early 90’s, and that the clinical definition of Autism was much stricter prior to that time (predominantly classifying Classical/Kanner Autism), hence most people who now have Asperger Syndrome went undiagnosed throughout their childhood and young-middle adult years and deemed as “weirdos” or “nerds”, or they get misdiagnosed with Schizophrenia, Childhood Schizophrenia, Bipolar Disorder, Borderline Personality Disorder etc and get medicated/treated incorrectly, to further detriment of their cognitive functioning and emotional wellbeing. I told him that due to the huge lack of awareness of high-functioning Autism and Asperger Syndrome before that period, it wasn’t his fault nor his son’s fault regarding the tragic suicide, and that had his son been born much later (circa 1995), he would’ve easily received the Asperger Syndrome diagnosis by age 15 and received the appropriate support and accommodations at school.

David understood everything that I told him regarding this issue and didn’t say he was offended or upset about it. He understood that it was just bad luck that the condition wasn’t known then, and that to grow up and live as an adult with all these social stresses and being constantly pressured to put up a façade of “NT normality” even though that’s against his pure behaviour, difficulty with executive functioning, multiple phases of unemployment due to constant workplace bullying by intolerant NTs and not knowing what the cause was, would be traumatizing and lead to suicide.

For me, the death of David’s son was concerning as this was an example of the reputed “Middle Age Autistic Burnout” where an unsupported ASD individual is typically pressured on a daily basis at work (at a workplace with superiors who are unaware or intolerant towards ASDs), with “friends” or in public to be a “square peg in a round hole”, to fake their social skills and behaviour to primitively simulate an NT to avoid bullying, discrimination and getting fired for trivial issues not directly related to the work. It eventually becomes too cognitively exhausting and their coping mechanisms are eventually insufficient, so they reach an episode of severe depression and fatigue, and are no longer able to work in such oppressive/conformist environments anymore, and often quit their job, become really sick or very reclusive, or commit suicide. Sadly, modern research seems to be woefully inadequate in regards to studying the needs, prognosis and mental health of adults on the Autistic Spectrum.

Experiences and Impressions from Clinical School (Part 2: Clinical Patient Interactions)

I haven’t spoken to as many patients compared to medical students at the other Clinical Schools, but I feel that I’ve spoken to enough to make some primitive observations. I have had reasonably positive experiences with most of the patients that I’ve spoken to, in that they’ve never been aggressive to me or abused me, however the accuracy and clarity of what they say varies, so in terms of medical content for collecting data, the quality varies. This is probably why a few nurses tell me that some patients are “better historians” than others.

Lack of Insight or Denial

Some patients are rather lacking in insight into their medical conditions. While I understand that they’re not doctors or nurses or necessarily have a background education in health, I would’ve thought that they know about a few aggravating factors or physiological mechanisms regarding their condition as the doctors explain to them (in a more layman manner, less jargon). I’m not sure if this phenomenon is more prevalent within the public hospital system, though I suspect it is.

A classmate and I met a patient who was being hospitalized for an increased frequency of tonic-clonic seizures and was already diagnosed with epilepsy several years ago. After he asked her about her history of presenting complaints, he then proceeded to ask routine questions. When asked about alcohol consumption, she said she drinks a slab of beer (24 cans/stubbies) every weekend. When asked if she felt that the beer might’ve been the cause of more frequent seizures (alcohol usually lowers seizure thresholds), she said “Nah, the beer’s alright.”This was despite taking into consideration numerous psychosocial factors, the doctors already informed her in a polite manner suited to her preferences of the great risks associated with binge drinking for someone with epilepsy.

Another patient that I saw with a classmate said he was diagnosed with hypertension when asked about other active health problems, but he claims that it’s because he has successful children (one of them a doctor), and that he leads a happy life which causes it. At the time I found this very hard to believe, seeing that his son has a medical background, and the patient himself also taught Science (biology/chemistry/physics) for numerous years, so should’ve understood the basic physiology of blood pressure. I thought it didn’t make sense to have hypertension from having a happy life, unless he happened to be using psychostimulants or certain antidepressants (especially MAOIs) every day. He also said he was diagnosed with Type II Diabetes, and he was overweight. By Occam’s Razor, it seems implausible that happiness alone causes high blood pressure; on the contrary it’d be more likely to be constant stress, poor diet that’s high in sodium or obesity. I checked his patient files. No surprise, he was diagnosed with Depression as well and was prescribed an SSRI antidepressant. At the time, I was quite annoyed coz I felt that he was deceiving me, but I spoke to other people about this issue, and they suggested that he may be feeling happier instead primarily due to the antidepressants, which allow him to be more euthymic and appreciate what he has in life (family). While he might not have understood the mechanism of antidepressants in making him happier, I felt that it was most likely that he was in true denial of the real causes of his hypertension, seeing that the SSRI he was on wasn’t supposed to significantly increase blood pressure.

For other patients, when I ask them if they have any other medical conditions, they say no, but their patient files state that they have hypertension, Type II Diabetes or hypercholesterolaemia. How a patient didn’t regard Type II Diabetes as a medical condition is beyond me, but I’ve been told by other people that Type II Diabetes has existed in many patients for 1 or more decades that they’ve grown accustomed to it, and no longer regard it as abnormal. This is why from now on, I always ask “Do you have high blood pressure/Diabetes/high cholesterol?” after asking “Do you have any other medical conditions” and them responding “No”.

At the time I’ve been very tempted to confront these patients and point out their misinterpretations or reduced insight into aggravating factors, but was told that this is the job of the doctors and nurses to do, not the Medical students. Therefore I’ve restrained myself from doing so, which is frustrating for me internally, but I’ve gradually accepted it as part of life, and decided to focus on learning more about their medical issues by reading their patient files, as opposed to just getting bitter and angry about it.

Asking Open-Ended Questions

I initially had the tendency to ask direct, specific questions to patients, but have been told that this may make the patients (majority NT) feel that they’re being judged subtly. They explained to me how certain direct questions can make patients feel that you’re judging them, but I felt that these impressions were excessive and I had no intention of judging/denigrating them, and that the patients are just being whiny and overly sensitive. After all, many NTs obsess about appearances and “keeping up with the Joneses”.

However after the first few weeks of Clinicals, I’ve realized the importance of asking open-ended questions. I know that it goes against my Aspie-trait of automatically focusing on details, and I originally thought that asking open-ended questions would mean that I’m “selling out” to conform to NT standards like a sheep, but I’ve realized the systematic usefulness of asking open-ended questions, which is probably the only Aspie-friendly excuse (to me) for using it.

For example, when asking about someone’s cigarette use, by asking “Have you ever smoked cigarettes?” at the start allows you to step into the topic broadly. If the patient says yes, then you can ask if they’re still smoking, when they quit smoking (if they quit already), and how much they smoke/day. If I had asked “How many cigarettes do you usually smoke per day?” as my first question, then I may have missed out on their previous history of smoking had they said “None”.

Therefore it is more systematic and easier to remember for some topics if I ask them from a broad/open-ended--> detailed fashion. I can then remember the flowchart of questions for that topic in a specific order. The questions are also ordered in a way to provide the least offensiveness and “judgmental impression” that is experienced by NT patients, so in fact a flowchart of questions from broad/open-ended --> detailed “Hits two birds with one stone” in that it appeals to both NT and ASD mindsets. Most NT patients wouldn’t be offended if you told them that you’re going to be asking routine questions, and then asked them if they’ve ever smoked cigarettes. However they might’ve felt judged if you asked “How many cigarettes do you usually smoke per day?” at the very start coz they feel that you assume that they smoke cigarettes, and especially if they have some sort of cancer (especially lung cancer), that the cigarettes are a contributing factor to their medical condition, and that the question is too confronting as it addresses their “fault” in smoking, hence making them feel guilty/bad as well.

My example for smoking history is below (click on picture for enlarged version):

I was lucky in that I managed to follow this flowchart for smoking (and a similar one for alcohol) after a few weeks. It was initially surprising to me when I learnt about other sensitive psychosocial factors that can be mentioned/triggered when I perform the history for both.

Soon after I followed this flowchart, I spoke to 2 patients.

For 1 patient, when I asked an elderly woman “have you ever smoked cigarettes?”, she said she used to smoke when she lived with her husband, and then she quit to make her husband happy, and then she started again after her husband died, and she started crying.

I felt awkward and sorry for her. Admittedly I didn’t know the direct cause of her crying. I couldn’t tell if she was crying coz she started smoking again, or coz her husband died. An (NT) teacher who was sitting down and observing my interaction with her said that it was due to the latter (husband died), and that asking the smoking question reminded her of her husband’s death. I was so surprised that asking an open-ended question could’ve released so much info from her, but she may have been an exception due to specific familial circumstances that happened to have smoking intertwined with it.

I then remembered the ICM video about what to do when a patient cries: you’re supposed to stay quiet and maintain a pause for at least 10 seconds while handing a tissue box to them to take a tissue to wipe their tears. I did that, and the patient said thank you. The teacher then asked her if she was alright with continuing the conversation, and she said yes. And so the interview proceeded.

The other patient I spoke to on another day, I later asked “have you ever drank alcohol?” and she said “Never in my life!!!” She then said that she grew up in a household where her Dad was an alcoholic, and would be abusive to her, her siblings and her mum. She had a traumatic childhood and to this day never drank alcohol. She said that she finds it very upsetting and judgmental when other doctors ask her “How much alcohol do you drink?” because they automatically assumed that her liver cirrhosis was due to alcoholism and that it reminded her of her abusive Dad, when in reality there must’ve been some other aetiology to it. She was actually kinda upset that I asked that question, but the teacher (who watched my interaction again) did tell her that I stated it was a routine question and that it wasn’t meant to judge her. She later calmed down and proceeded with the interview.

I think after these 2 incidents, it really “hammered” it in that if I had asked the direct/detailed questions first instead of the open-ended ones (according to the flowchart), I would’ve gotten into deep shit or created a lot of friction/tension with the patients.

Experiences and Impressions from Clinical School (Part 1: Relatively Insufficient Patient Contact)

I may type my anecdotes and impressions of my Clinical School so far in a disjointed manner.

I have just completed my 1^st Block (Neurology/Ophthalmology/ENT) for Clinical School. In my previous entry regarding starting Clinical School, I said that the 2 weeks felt like it went for a really long time, perhaps due to the very stressful incident that occurred then (which I’m not allowed to further discuss for legal reasons), which seemed to slow down my perception of time, like undergoing massive Adrenaline rushes for several days or being under the influence of Cannabis. On the contrary, the remaining weeks of this block seemed to pass by rather quickly, and I’m feeling both stressed out and slightly relieved about it.

A Criticism of my Clinical School (--> Relatively Insufficient Patient Contact)

My impression is that each Block isn’t long enough, and that 6 weeks is definitely not enough time to see enough patients and learn the knowledge required to pass exams unless you spend the vast majority of your spare time outside Clinical School exhaustively studying and reviewing notes as compensation. This issue is exacerbated by the idiosyncrasies of my Clinical School, of which I was initially impressed by, but subsequently partially disappointed. It was supposedly the most didactic of all Clinical Schools (for Melbourne Uni MBBS), but it’s didactic in the “wrong” style.

For further explanation of being didactic in the “wrong” style, I mean that there’s technically more structure as there are more planned tutes and lectures throughout the week, but many of them are for topics that aren’t directly relevant to my current Block. While it’s true that many aspects of medicine crossover into each other (eg Pneumonia involves both Respiratory System and Infectious Diseases), the topics that are discussed are hard for me to apply on in terms of student-patient interactions, and don’t particularly benefit me in understanding the topics of my current block, ie “adding extra food to my plate” when I’m already overloaded with other stuff to learn.

For example, on Monday 7:30 AM, we always have a lecture relating to Orthopaedics and how different arm and leg fractures occur, and how it gets managed. Sure, this lecture would be beneficial to the students who are doing their Orthopaedics Block, but it’s not very helpful for students outside of that Block, and furthermore it’s even less helpful when they don’t even provide any preliminary anatomy lectures so everyone could at least have a general idea of what is going on. I think it’s asking too much of the medical students (outside of Orthopaedics Block) to study bone/joint/muscle anatomy when they’re really busy studying other things. I don’t gain much out of these lectures as I haven’t done the preparation beforehand, and I hate waking up really early to go to it (yes, lectures are compulsory to attend at my Clinical School). IMO they should only make the lecture compulsory for the students doing Orthopaedics, and only make “irrelevant lectures” compulsory for everyone if the medical condition is very common among Australian patients, eg Type II Diabetes.

Now, consider this and add in the following factors that are/aren’t intrinsic to my Clinical Hospital:

- “Irrelevant lectures” x 5 /week

- 1 or 2 “wishy-washy” tutes / week (ESPECIALLY the Empathic Practice ones which isn’t being examined on and doesn’t didactically teach polite bedside manners / professional etiquette)

- Often being unable to speak to a patient and/or do physical exams on them coz they just happen to be sleeping/with relatives or other doctors/away to undergo extra investigations/tired of speaking to medical students.

- Lectures/tutes/clinical visits often running overtime and being placed and spaced out on the timetable in an inconvenient fashion, occupying the “best times” to speak to a patient, and you often don’t have enough time in between to sufficiently interview them, if you even manage to get one in the first place.

- A curfew in which you’re not supposed to stay at the hospital after 6:30 PM (absolute latest) on weekdays, and not allowed to visit the hospital on the weekends or during holidays if you wanted extra patient contact. I understand that many patients are tired and want to rest on the weekend, but isn’t it possible to at least allow a 3 hour time-slot for students who want to visit the hospital on Saturday/Sunday as compensation for reduced spare time during weekdays? I didn’t think it’d be too overwhelming.

All of this results in SIGNIFICANTLY REDUCED OPPORTUNITIES FOR PATIENT CONTACT (COMPARED TO OTHER CLINICAL SCHOOLS) given the unpredictability of the ward setting and the nature of the patients, and is extra frustrating coz I’m compelled to go to lectures and tutes that don’t benefit me directly when I could be using that time to be in the library reading relevant books, or on the wards seeking/speaking to patients. Typically due to the circumstances, there are about 2 weekdays/week in which I don't speak to any patients at all. It feels a bit disorganized, and I feel like I’m being restrained, and I feel further anxiety and “injustice” due to the fact that we are required to log in a minimum amount of “long case quality” patient data by the end of Semester 9 but they didn’t provide a conducive environment for conveniently doing so .

It has reached the extent, where I feel like I need to spend every bit of spare time scavenging for the “good patients” who aren’t confused, have English as a 1^st language, aren’t sleeping or away for investigations, and are willing to talk to medical students. The number of “good patients” on the ward (out of around 30 Neuro patients) vary each week due to patients being admitted into the ward and being discharged later on, but there’s this drive in me to want to be the earliest student to speak to them for fear of them being “sick of speaking” to medical students later on. I apologize for my behaviour which may be perceived to be selfish and even “gunner-ish”, but I’ve noticed that if I don’t be proactive to a degree, the patients will just be “taken” by other medical students and it’ll be harder for me to get a suitable patient to speak to so I have good data to log in. It also doesn’t help that the total [students : ward patients] ratio is around [10 - 18 : 30] , which means that saturation of the “good patients” occurs pretty quickly during each week.

It feels like there’s an extra competition not directly mentioned by the Clinical staff, where you have to “fight” to get “good patients” to speak to. The closest game analogy I can make to this is MUSICAL CHAIRS but with some basic rule variations:

(Picture taken from http://photos1.fotosearch.com/bthumb/ARP/ARP113/Mus_Chr1.jpg)

- The music “plays” when everyone doing a certain Block is in a lecture/tute (compulsory).

- The music “stops” when there’s spare time so students can go onto the wards to seek/speak to patients.

- The chairs in one pile represent the “total” amount of willingness/tolerance that a patient has to speaking to medical students. This can range from 0 chairs for patients that are confused/in a coma, to perhaps 10 for patients that happen to be very chatty and in a good/optimistic mood (despite their medical condition).

- Students may work in pairs/triplets and speak to a patient while the other (1 or 2) student/s listen and write notes on what the patient is saying. Once a single chair is occupied (via student/s interviewing a patient), no other chairs may be occupied during that time.

- After a "significantly long" conversation with a patient has been completed, remove 1 chair. If several physical exams and systems reviews have been conducted, remove another chair.

- Total number of chairs may be replenished or reduced overnight depending on the progression of patient’s medical condition, and how much undisturbed time (by medical students) they have.

- Once number of chairs reach 0, patient is no longer accessible to students for conversations/physical exams.

- A “spare chair” for a specific patient as back-up may be provided for a medical student (even if main total is 0 chairs) if he previously engaged in a very engaging and enjoyable conversation with a patient and the patient thoroughly appreciated his company.

I have also created a few terms to describe the phenomena of this competition:

Stealing/Miss: When other medical students had conversations with a patient (especially a “good” one) and you were unable to speak to him because he has become “saturated” already.

Saturated/Depleted: When a patient has spoken to enough medical students up to his tolerated level, and can’t/no longer wishes to speak to any students anymore. Ie chairs --> 0.

Occupied: When a patient is currently being spoken to by a medical student, doctor, nurse etc.

Penetrating/"being popular": When a patient is being seen by multiple medical students throughout most/all spare time during the day. In most patients, their chairs would’ve decreased a lot by evening. "Penetrating" supposedly has an alternative meaning, so I would use "being popular" in public.

Quickie/Mini: A short conversation with a patient, lasting around 15 minutes or less, just to get a basic idea of his history of presenting complaint. A Quickie/Mini minimizes the chances of the conversation being considered “significantly long”, and thus minimizes the chances of 1 chair being deducted.The term "Quickie" has another meaning, so I tend to use "Mini" in public.

Kara (空): Empty, mainly in reference to an empty bed (ie patient isn’t there).

Ikki (一気): In one go, mainly in reference to having a long conversation with a patient covering the presenting complaint and general medical history, along with performing 1 or 2 physical exams with their consent.

Renzoku (連続): Continuous, mainly in reference to searching for a suitable patient to speak to, moving in a consecutive order around the ward.

Tenpai (聴牌): “Fishing”, when you conduct a significantly long conversation with a patient, and perhaps performing 1 physical exam as well, but you’re still missing out on a few medical details (that you forgot to ask or the patient doesn't remember), ie a small step away from having sufficient amount of patient data to log in.