Psychiatry (RETROSPECTIVE POST)

Psych (6 Weeks)

Our Psychiatry Rotation was done at the APU (Acute Psych Unit), which was in a separate building from the main Hospital. However our first Week included Lectures at another Hospital from an eminent Psychiatric Consultant. We also got to hear a Speech from a Schizophrenia Advocate about his Experiences with Schizophrenia and the Healthcare System which was a bit touching. I was internally amused that he also had Flat Affect, and I was able to detect the Parallel about how his Condition came to control his Life, and his ways to cope with it. Like ASD, Schizophrenia also comes as a Spectrum, although it’s typically much later onset, however at least they (along with ADHD) have the Convenience of official Medications to control any acute Symptoms. Even with Asperger Syndrome, you don’t stop thinking about it every day. You don’t want to define yourself by your Condition, but it affects the way you process Information and analyze Things that frequently you feel like an Alien or an Amateur Anthropologist on a foreign Planet.

I wonder if De-Institutionalization is the best thing for certain Psych Patients. Understandably there were significant Abuses in the massive Psychiatric Institutions in the past, which I think was also secondary to the Paternalistic Culture of Medicine, however I do see some Merit in that System. Currently, there apparently isn’t enough Funding to get all of the De-Institutionalized Psych Patients to adequately integrate into the Community, which to some Degree poses more harm to both the Patients and possibly the Public.

On a note, the recent and tragic Stabbing of Dr. Michael Wong (Neurosurgeon) at Western Hospital in Melbourne, by a Patient who was supposedly Psychotic and was a poor English-Speaker seemingly demonstrate Gaps in the Welfare of such Patients, who really should’ve been stabilized prior to being released.

Psychiatry was considered a “scary” Rotation by a lot of the Students, so very few from my knowledge went to the APU to clerk Patients, with the exception of supervised Clerking in Tutes by the Psych Registrars. I was warned that a lot of the Psych Patients in the APU were potentially aggressive or manipulative due to comorbid Personality Disorders (predominantly Cluster B), so I had to wear a Security Alarm when speaking to them. I ended up going through a lot of Patient Files to read their Medical Histories and learn how their Psychiatric Conditions have evolved, and how it was managed. I must say I found this very engaging, almost like reading an exciting Novel or Biography.

I did manage to speak to 2 Patients - a Woman with Bipolar Disorder and an Aspie Guy who was around my Age. 

I’m not allowed to disclose the presenting History due to Confidentiality Issues, but it was so fascinating / surreal to see a person display the Textbook Symptoms of a Medical Condition, especially a Psychiatric one. The Woman was still in a Hypomanic Phase, and looked elated and chatty. She stated that she hasn’t had much Sleep or Food to eat (due to low Appetite) recently, and told me a lot about her Personal Life, which whilst I didn’t mind at all due to the Open-ness, was apparently inappropriate to NTs as it was being “Overfamiliar”. She spoke rapidly but I was still able to follow her Train of Thoughts. In some ways it was actually easier for us to engage in Conversation as there were lots of different Topics to talk about. My perception was that it was easy to develop Rapport with her, to the Point where I actually gave her a small Present for her Birthday during her Admission. In Retrospect, I realized this was “Unprofessional” and was told by my Psychiatrist that such behaviour could distort the Professional Relationship, particularly as people in Hypomanic or Manic Phase are vulnerable to being exploited, plus the fact that she was only being “Overfriendly” coz she hasn’t been adequately medicated yet, and that the “Stabilized” her would have a higher Guard on par with most NTs. 

The Woman was fearful of the Aspie Guy coz he was being very noisy, which I presume was making sounds as a Stimming Activity. I found this amusing and sad as Aspies are usually quite “Soft” and “Innocent” if unprovoked (into Meltdowns) and would make very weak Enemies due to their intuitively reduced Theory of Mind and likely Executive Dysfunction to execute any malicious Plans whilst getting away with it very difficult if not impossible. I suppose she doesn’t know about his Diagnosis, and I wasn’t sure if I was allowed to tell her due to breaking Confidentiality, but I told her that he’s also experiencing Discomfort of another sort.

The Aspie Guy was actually a lot harder for me to talk to, which surprised me. I told him that I read his Personal History and was trying to explain that he’s not Alone, and that I have similar Symptoms and Experiences to him but have various Coping Mechanisms, and would be happy to teach him what I knew, but he seemed to be in Denial about his Diagnosis, sadly. It was actually quite frustrating for me at the time trying to reason with him coz I felt like I was looking into a Mirror of myself when I’m extremely grumpy, although I suppose in super-Meltdown mode as a Child, I couldn’t be reasoned with either.

I felt that I let him down coz as an Aspie, I was supposed to be empathetic towards his Experiences, and that I didn’t do “well” enough, in contrast to the Woman with Bipolar Disorder. In Retrospect however, I think he had overlapping Issues of Sleep Deprivation and Agitation over being in a new Environment filled with “Strangers” (other Psych Patients) that wouldn’t be conducive to Mental and Physical Rest. Certainly from my Sleep Problems in the past, I’ve done things that I never would’ve done if I was well-rested, plus I had impaired Cognition. I briefly discussed his Case with his Case Worker who actually agreed that the APU was NOT the appropriate Place for him to be managed, but there was a HUGE shortage of appropriate Facilities for ASD Adults in Strife to be referred to, which is why he was here for now. I hope his situation has improved by now...

It made me wonder how much I could decompensate in the future to the Point of needing a Psychiatric Admission myself... : S 

Nightmare

I just woke up from a vivid Dream (or rather a Nightmare).

I was in a Room gathering Notes for 2 other Medical Students until the Tutor came in and passed me a Note, which happened to be a Notification on me to the Medical Board.

The Complaint was from a male Patient who stated that whilst I was scrubbing in Theatre for his "Buttock Surgery" (I suspect this is for non-cosmetic Purposes, therefore General Surgery albeit unusual), I injured him too much with whatever Tools were used in the Operation (presumably Scalpels), and he has been permanently scarred and in pain. His Wife "Norm" was very distressed ever since. For some reason the Notification stated he was taking "Irmlodipine" (which I presume should be Amlodipine, spelling error in my dream!) but nothing else.
The male Patient said in the Notification that he was ready to contact the Medical Authorities and was willing hunt me down ASAP.

It was soon after that in which I woke up.

Holy shit, thank goodness that was just a Dream!!!

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I'm trying to reduce the stress of this Nightmare by openly discussing it via this Blog Entry.

As ridiculous as this Nightmare sounds, it particularly striked me as it mimicked my very real Experience of being notified to the Australian Medical Board (part of AHPRA) for unfair reasons during Med School. Whilst I got away with it in this instance, I recall being extremely stressed / anxious for 4+ months as I was worried that I'd be deregistered, wasting my (incompleted) Medical Education.

I wonder if this Nightmare was a reflection of my ongoing or subconscious Fear of being Sued or Notified by a Patient?

I wonder if I will have this constant fear while doing the actual Internship in 2015? Will I be able to sleep without having to resort to Benzodiazepines or Antihistamines?

I know classmates and Doctors who in the past think that maybe I shouldn't do Medicine due to the high-Stress Nature of the Profession, but I'm still willing to give it a go, just to see how I fare out. I may have Asperger Syndrome, but historically there were plenty of Aspies in Medicine with successful Careers due to very strong compensation mechanisms. Let's see if I can become one of them...

Paediatrics (Part 1/5, RETROSPECTIVE POST)

Following O&G was CAH (Child and Adolescent Health, ie Paediatrics). Of the 9 weeks, I spent about 6 weeks in total at the Paediatrics Department of my Clinical Hospital, and the 3 other weeks at RCH (Royal Children's Hospital) for lectures and a mini-attachment. Paediatrics was the first Clinical Rotation that I REALLY enjoyed and was enthusiastic about, of which there were multiple factors. I temporarily felt “ALIVE” and “SWITCHED ON” which was a huge contrast to my very low state the previous Semester. Another thing that made this Rotation memorable was that all the supervising Paediatricians knew about my AS and were amused by it given its relevance to Paediatrics. None of them were patronizing or treated me like a child. I didn't experience any repercussions in disclosure and knew in advance that it would be taken well.

The Paediatrics Department of my Clinical Hospital was very small compared to RCH, there were about 18 beds, and about 1/3 of them were for Eating Disorders. Being male and not a Paediatrician involved in their care, I was advised to avoid speaking to patients with Eating Disorders (all teenage girls). Most of the rare and complex cases would've been transferred to RCH, so the remaining Case-Mix at the Peripheral Hospitals (including this one) were very “Bread-and-Butter” - Pneumonia, Bronchiolitis, Gastroenteritis, Dehydration, with a bit of Epilepsy. Because there were so few Inpatient beds, I actually spent more time at the Paediatric ED which although had even fewer beds, but had much higher turnover, and hence more opportunities to practice Clerking and Physical Exams.

Like with Women's Health, we had a PBL (Problem-Based Learning) Tute each week at the Clinical Hospital and opportunities to attend Outpatients, along with morning Ward Rounds (including on the Weekends if we'd like).

PBLs were mostly on “Bread-and-Butter” cases. However there were two Tutes that stuck out in my mind, the first one regarding a fictional 4 year old boy who was being assessed for ASD / Fragile X Syndrome. Somewhere in the text it said that the boy had frequent “Tantrums”, particularly coz he wasn't able to communicate his ideas owing to his Speech Delay. I wasn't happy at the term “Tantrum” being used coz it brought the connotations of being naughty, rebellious, and/or manipulative (in reference to NT children, eg at the supermarket wanting something but not getting it), when he was anything but. 

In the Tute, I said I found the term offensive and misleading and that the more appropriate term for such an ASD child would be a “Meltdown” due to his current neurological deficits being unable to meet his personal needs, leading to massive frustration and vulnerability. And that the approach to his “Meltdown” (Education, Accommodations, minimize Sensory Overloads) would be completely different to that of a “Tantrum”, which we were taught to just “ignore the child until they stop whining, to give them the message that their Tantrum isn't working or acceptable”. I feared that parents would treat ASD children having Meltdowns inappropriately, which would just exacerbate the situation and cause more mental scarring. However the Tutor insisted that it was still a “Tantrum” in the literal sense, and was thus appropriate. This incident was very frustrating and ironic to me, given that ASD people like me supposedly take things more literally (relative Frontal Lobe deficits), and have an impaired ability to comprehend language pragmatics (including subtle connotations), and yet it was the Tutor (NT) who took it literally.

The second memorable Tute was about a Teenage girl who had several psychosocial issues to be addressed in conjunction with Epilepsy management, including Smoking, drinking Alcohol, teenage Sex and possible Depression. IIRC, in the passage regarding her Past History, that she “Tried Sexual Intercourse a few times last year but didn't enjoy it, so hasn't had it since.” This phrase was particularly interesting to me, coz it was only then I realized that sometimes, in order to dislike an activity, you have to give it a try first. I literally told the Tutor that “In order to know that she doesn't like Sex, she has to try it first,” in which he concurred. 

It may sound really obvious to others, but it helped influence my approach in life, that part of personal growth involves getting out of one's comfort zone (or narrow interests / repetitive activities) and experiencing new things temporarily, which would assist with developing one's perspective too instead of relying on preconceived notions or fear. I now see it as collecting more data to analyze. Sometimes there are strangers who I'm interested in speaking to, and whilst I used to be too anxious about approaching them at all, now I'm more forthcoming and curious, thinking it's “It's either I speak to them now, or never and continue to wonder what it's like if I had spoken to them”.

Long Case Exam

The long case exam is one of the exams that can occur during the clinical years of some medical courses, and is also a staple in postgraduate exams for certain specialties/fields (quite notably the barrier exams for BPT, Basic Physician Training in Australia which is usually 3 years' long before one applies for an Advanced Medical Specialty).

It typically involves a student/doctor candidate seeing a randomly allocated patient from a predetermined pool of hospital/outpatient patients who were deemed as "suitable long case material", relatively cognitively intact, and gave consent to participation. The candidate then has a limited time (on average ~ 1 hour) to interview the patient about their history of presenting complaint, hospital admission, past medical history, social history etc, and then perform the relevant physical examinations (documenting the findings), then formulating a summary, issues and management plan catering to that patient's "unique" presentation and needs. When the time runs out, the candidate then goes into another room to do an oral presentation in front of a few (often 2, maybe 3) examiners who are doctors themselves, regarding the patient's complete history, relevant findings, summary and management issues within a time limit (eg 15 minutes), which is then followed by answering questions from the examiners about detail clarification or about the discussed medical conditions.

My Medical Course has the long case exam as a hurdle, which means that you MUST pass this in order to pass the whole subject (as opposed to the Multiple Choice Exam where you're technically allowed to get < 50%, but still pass the whole subject if you compensate in other exams to get an overall mark of 50+%). I did my long case exam recently, and I was really anxious, for multiple reasons (same for many other med students too). While I have received reassurances from a few students in the year above (and a few doctors in lectures) that the long case exam at med school standard is not too harsh, and that the examiners want to pass you, I was still super freaked out. The long case exam was THE ONE that I was fearing my whole time this year (OSCEs and MCQs were less anxiety-provoking in comparison).

I can think of the following factors that contributed to me feeling like this:

            1. I didn't know what patient I was going to get for the long case exam (that's the point of the exam!).

            2. Due to other issues that made me extremely stressed this Semester, I didn't have sufficient alertness or mood throughout the Semester to thoroughly make notes on all the listed conditions (let alone the un-mentioned ones) in the Block/Rotation guides. So hypothetically, what am I supposed to do if the patient has a condition that I was supposed to know about?

            3. My AS means that I usually have a reduced verbal fluency (and increased difficulty with forming coherent sentences relative to NTs) when trying to talk/ask about things that I'm not familiar with and haven't rote-memorized or practiced a lot (which gets exacerbated by the previous point).

            4. My holidays before the next Semester were short, and I didn’t want to have it reduced by spending more time preparing for a resit exam should I fail. I was already tired from studying for the MCQ and OSCEs the week before, and really wanted to have more days to sleep and bum around.

I did my Long Case Exam outside of my home clinical school. I went into the listed room and registered my details while frantically reading my long case guidebook on the different core conditions. Sooner or later, it was my turn, and I had to leave my bag in the room, and carry my stethoscope, pen and paper and other testing tools into the ward.

The “administrator” guided me to the relevant ward, by then I was already having clammy hands and palpitations.  I waited outside the patient’s room while the “administrator” spoke to and prepared the patient for the 1 hour interview. The waiting felt like ages and for a short while I thought she was trying to mess with my mind by adding extra suspense by delaying me from starting it.

She came out later and said I could go in, with time starting now. I said “Ok thanks” and entered the room. It was a bit annoying coz there were a few other patients in the room with their relatives talking. I wasn’t sure if they were aware that I was doing a long case exam.

The long case patient I had was an elderly woman. I introduced myself and told her that I was doing an important exam with a time limit, so I’ll have to ask lots of questions and have to cut her off at times, with an apology. She said it was perfectly fine coz she had been a patient for numerous other candidates at other hospitals in the past.

I started by asking her name, age, address, past occupations, allergies, and comorbid conditions (name only). When it came to comorbid conditions, she talked a lot about each one and mentioned about some past operations. I then asked about those. This went on for about 20 minutes because she had the tendency to go off-track and I was too afraid to cut her off a lot at the time lest she get pissed off at me and refuse to cooperate. I think around this point, I asked her what medications she was on for each one, and she said she couldn’t remember. I then checked the folders on her bedside, but could only find one listing Vital Signs (the medications list got taken out!).

I was getting really freaked out coz they forgot to include the medication list. I asked her to push the “ASSIST” button to attract one of the nurse’s attention. I then remembered that I had to ask her about her presenting complaint (omg silly me, I should’ve asked that sooner), and then she went on about how she was experiencing a lot of pain etc several weeks ago. I was able to ask the relevant history questions and form a plausible story in my folder as she was talking. I decided to cut her off more times than before and ask numerous direct questions because I really wanted to hurry to the psychosocial history before starting physical exams.

By the time I finished the history of presenting complaint, there was about 20 minutes left. I rushed through the psychosocial history bit in about 10 minutes, asking her about her husband, 1^st-degree relatives (I had to cut her off again when she wanted to talk about her cousins and grandchildren in excessive detail), hobbies, diet, activities of daily living, and mood. Unfortunately I was absent-minded enough to not ask her about alcohol and smoking. She kept on talking about G-d and how he was so glorious to give her and her husband a long life, and I tried to “acknowledge that”.

After rushing through those questions and writing her comments, I checked my watch. There were 10 minutes left and I haven’t started my physical exams or formulated a summary and management plan yet. In my mind I was thinking “OMG OMG OMG OMG OMG OMG OMG OMG I’M SCREWED” .

The patient could tell that I was stressed out, and she said to me that if I continued on like this, that I wouldn’t live as long as her and that I’d get a heart attack. She said that I was one of the most stressed students that she has met so far. She may be right, but I didn’t want to argue with her, so I said “Thank you for your observations”.

I said to her that I had to do physical exams now and managed to do a very gross (basic) assessment of her Cardiovascular, Respiratory and GIT system before time was up. I said to her that I was sorry for being rushed and abrupt, but she said that she was happy to help students and that she wanted to make a contribution in the remaining years of her life. In my mind, I was thinking that I was going to fail my long case exam coz I didn’t write *anything* at the back of my folder for the summary and management plan.

The “administrator” came to pick me up, and I walked with her back into the hall to wait outside the examiner’s room. While walking, I felt like a lamb being led to the slaughter. During the 1 minute wait, I was profusely formulating management issues (the “topic titles”) but didn’t have time to further elaborate on it.

One of the 2 examiners opened the door to their room and let me in. I went in and started presenting my findings as they asked. I was afraid that I would muddle up my sentences when I spoke them, so I tried to speak in a relatively slow (compared to my “normal” speed when talking random stuff) rate, using simpler sentence structures that I could manage. I couldn’t tell if they thought that I was speaking too slowly/robotic.

I was halfway through presenting my physical findings when the timer buzzed, and it was question time. I didn’t have time to present my summary or management issues (which I didn’t exactly prepare for), so it was a double-edged sword, a possible blessing in disguise?! I knew that part of the marking criteria included the ability to formulate relevant treatment and referrals for the patient, but I technically didn’t mention any of that, so I feared I’d get a 0 in that section.

The 1^st examiner who was a medical doctor asked me various questions to clarify the patient’s history. I was able to answer most of them, except for the bit about smoking and alcohol. One of his questions was “Did she really say that her pain was 13/10?” That was what I said (based on what the patient said), and I thought he was trying to manipulate me and make me change my mind, but I said “Yes”.

The 2^nd examiner who was a surgeon asked me about physical signs, and I missed out on several vascular ones as I didn’t check all the pulses. He asked me about investigations, which I suggested a few, but not all of the relevant ones. It was embarrassing but educational when he stated the others that should’ve been ordered.

Question time ran out, and I was told to leave. It was strange, I no longer had palpitations, but there was huge unease. I had to wait several (“very long”) days to find out if I passed this exam or not, in which I did.

I got the lowest pass mark, but was still very relieved coz I didn’t have to do a resit, but I was still disappointed in myself based on the experience. Sure, this is an exam which can provoke anxiety, but so is the workplace where you might have to clerk several new admissions a day, and be expected to do so in a timely fashion. I understand that I’m still a student and expect to improve with time in terms of structure, asking in a systematic manner, and cutting off more frequently and strategically, but I predict I may get turned off it (in the very long term).

She was a kind woman who was willing to talk, but I still felt like an asshole for cutting her off a lot (relative to when I normally clerk patients on the wards, which is more relaxed and has more chit-chat). After what I’ve been through in the past, I don’t want to become a horrible asshole when I work, and I fear that such time pressures may give me the propensity to do so in my innate desire for efficiency and systemizing information (to reduce my being overwhelmed by details) instead of maintaining a balance, because systemizing and following an internal routine is when I am most productive (as an Aspie), especially if I enter hyperfocus mode.

I felt like I was objectifying the patient, and not taking into consideration all of the things that they value. My psychiatrist has told me of ways to redirect the discussion, and I’ll probably improve with more practice, but I still felt guilty and upset given her vulnerable state and my “exploitation” of her during the exam.

Superficially for now, if I pass the med course, I feel that I might be less suited for a general medical specialty, and would be better suited to a specialty with less patient contact such as Pathology. Less direct patient contact means that there’s more focus on the technical/procedural work itself, with most of the other communication with other doctors. I feel that if I manage to pass the med course and later on enter Pathology, I am statistically less likely to offend patients and let them complain about me. It's not that I hate patient contact, it's just that I fear I will perform a disservice to them if I were to work in my optimum Aspie style.

Let’s see what happens in the future…