Thoughts from John Elder Robison's "Switched On" Book re: his rTMS (repetitive Transcranial Magnetic Stimulation) Experiences

John Elder Robison (prominent adult ASD Advocate) wrote a Book earlier this Year called "Switched On" (www.amazon.com/Switched-Memoir-Change-Emotional-Awakening/dp/0812996895) regarding his Experiences from the rTMS Trials @ the Beth Israel Deaconess Medical Centre (Boston, Massachusetts) in 2008.

I was very privileged to take Part in the initial ASD rTMS Trial @ Monash Alfred Psychiatry Research Centre (MAPRC) in November 2010, and was therefore very interested to read a more detailed Account from John.

My old Blog Posts about my rTMS Experiences are below:
http://aamsio.blogspot.com.au/2011/07/my-experience-from-repetitive.html
http://aamsio.blogspot.com.au/2011/07/my-experience-from-repetitive_30.html

Recent ABC Coverage on rTMS:
http://www.abc.net.au/radionational/programs/lifematters/john-elder-robison:-switched-on/7322548
www.abc.net.au/radionational/programs/lifematters/transcranial-magnetic-stimulation-explained/7330468

I'm very grateful that Dr. Peter Enticott (of MAPRC) notified me about the Book, and I emailed him my initial Thoughts after reading John's Book, as attached below in raw un-edited (and "binge-typed") Form. I'm sure there are some other Thoughts / Opinions missing, but I might add them on into a future Blog Entry after reading it for the second Time during Annual Leave later on.
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I ordered a Copy of "Switched On" and read it about a Month ago, and very glad I read it. but didn't have Time to reply. I'll send you another Email after reading it the second Time during my Annual Leave later on, if there's Points that I forgot to include below.

I found it very painful (emotionally) to read @ Times, coz some of it reminisced with my Sentiments and Experiences.

I think his Account of his TMS Experiences were very well-written, and will provide much Discussion re: future Treatments for ASD Adults.

I feel like John Elder Robison gained a Lot more distinct Changes following the TMS, and he was able to present the Advantages and Disadvantages of becoming more emotionally labile and intuitive to other People's Feelings. It's like a Blindfold was temporarily removed from him, but since the Release, he won't be able to forget it. His Awareness has increased and provided more Stress, but also more Opportunities/Options to respond in Order to achieve a Resolution.
- I briefly felt very embarrassed when I read about his previous "social Faux Pas" coz I have done plenty prior to becoming more Aware post-Diagnosis.

And I could understand his Thoughts where he flips between seeing his AS as a Gift or a Curse. I did find it upsetting/painful when @ some Point he saw himself as "defective", probably coz it's Something I think about on a daily Basis @ Work. I feel like I have to use my Strengths (eg Attention to Detail and Hyperfocus) to (over)-compensate for my other Deficits in clinical Medicine. It's worked so far, but @ great mental Expense, which is why I'm trying to get into the Pathology Training Program ASAP (with minimal Patient Contact etc).

I can relate to John's "Release" by being able to tolerate Eye Contact after TMS, coz it always felt uncomfortable prior. So now, I know what it's like to look @ People in the Eye without flinching, and this has improved my "Ability" to "appropriately" communicate with Patients, other Hospital Staff, and People outside of Work.

The other Things that John Discusses re: understanding People's Feelings and reading facial Expressions is Something that I learnt manually from rote-Memorization and Experiences. I still have flat Affect most of the Time (not depressed), and I only naturally change facial Expression when I'm euphoric / very upset / very angry.

I think what makes Part of it painful is how both me and him are in the Minority of ASD Adults who have been privileged to receive some Form of Assistance / "Treatment", and even afterwards we are still having to work hard to maintain our Livelihoods coz we're in the statistical Minority, and Adult Society is currently unlikely to provide much Accommodations. There's so many other ASD Adults (diagnosed and undiagnosed) who are struggling with Employment / Bullying etc.

Another Thing which I found painful was as John Recounts his Experiences, I also looked back and saw how many wasted Opportunities I had, and all the Mistakes I made pre-Diagnosis. But Past is Past, you can only learn from those Experiences and move forward.

I still make Mistakes post-Diagnosis, but I'm very self-critical, and I think it contributes to my low self-Esteem post-Diagnosis, coz I know how vulnerable I am, and how Others (in and outside Medicine) could easily exploit me if they knew my Weaknesses. I don't feel Shame coz this was how I was born, and sometimes I wonder whether Life is worth Living, but I look @ how many Hurdles I've jumped over so far, and even if I "fall down" later on, I can still act as a Source of Inspiration for some ASD People.

A Point of Interest would be whether John's Experiences will influence the Direction that ASD Research takes as he is on the Autism Speaks Panel, eg towards Something more socially-oriented, rather than Something to improve short-Term / Working Memory or Verbal Fluency etc. Certainly the frontal Lobes are implicated in ASD / ADHD, so these Functions are inter-related, but I feel there's a Risk of Bias.

I think for John, his TMS Experience seems so intense, like "getting thrown into the deep End of the Pool", mystical and profound, almost psychadelic, but it came @ the Expense of making his "Ego" more prominent. Not in the "arrogant" Sense, but the improved Awareness of himself and other People seemed very difficult to take in @ the Time, but he was able to cope eventually.
- A Bit like how in the Bible, Adam and Eve ate the "Fruit of Knowledge" and suddenly realized they were naked.

- Once you see it, you can't "un-see" it.

Whereas for me, I was like "dipping my Feet into the Wading Pool". Concretely / Directly, I only benefited from improved Eye Contact, but it served as a Catalyst for understanding other Neurotypicals in general coz I can spend more Time looking @ their facial Expressions, processing their Speech and direct / implied Meanings, and less Time thinking about how I'm uncomfortable with their Eye Contact. I'm still very flat and "Swiss" although there have been Occasions where I'm close to breaking down emotionally.

I also resonate with John about the constant Anxiety about whether TMS or becoming more "socially aware" will impair one our special Interests and ASD-related Strengths.

For me, even after reading his Book, I wonder if the Reason why I have my Ambitions, Strengths and Special Interests (Mahjong, Accordion) is coz of my Deficits. For me, interacting with NTs in general costs more than it benefits, and while there are general Rules of Behaviour, there's still significant Heterogeneity. Whereas with a Board Game or learning a musical Instrument, the Rules are much stricter and clear-cut, and the Gains are easier achieve and therefore more rapidly gratifying.

- Temple Grandin's Comment @ the Back of the Book totally hit how I felt:

"Switched On is a mind-blowing book that will force you to ask deep questions about what is important in life. Would normalizing the brains of those who think differently reduce their motivation for great achievement?"

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In short, I've enjoyed reading John's TMS Account (as demonstrated by finishing the Book within 2 Days) to see how his Experiences and Opinions were similar / different to mine.

I think TMS has much Potential to help ASD Adults / Children, but it must be done in a Way to avoid totally converting them to NTs (not that it's possible with the current Technology anyway), and hopefully there'll be a Way to help preserve their Strengths whilst reducing their Weaknesses. I don't think it's a Zero-Sum Issue, but unfortunately I suspect this won't be 100% possible.

I think for ASD People, the possible Goals of TMS are very variable depending on Level of Function.

I do think that for non-verbal ASD Children / Adults, the core Goal of TMS should be to facilitate Speech Development coz that's crucial for independent Living, regardless of whether you have Friends or not.

Also, what I think can be done now is to help educate ASD Adults on how to "respond appropriately" if they happen to recognize a facial Expression or Feeling in another Person. So that Way, an ASD Adult who becomes more self-aware of others (via TMS or gradual Knowledge Acquisition) can feel less anxious / awkward about how to react, and just say what "needs to be said".

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 

Experiences and Impressions from Clinical School (Part 4: Clinical Patient Interactions)

“Ben” (BROCA'S DYSPHASIA): I met a patient called “Ben” who had Broca’s dysphasia. Broca’s dysphasia is the condition in which a person knows what they want to say, but can’t retrieve the words for it and/or express it in a coherent manner. This is typically due to a lesion (eg stroke) in the brain called Broca’s area, situated around the border of the frontal and temporal lobe in one hemisphere. That isn’t to say they necessarily have an intellectual disability, as many of them have preserved verbal and reading comprehension and cognition, especially if the lesion was purely isolated to Broca’s area. The condition can range from very severe (extremely little or no coherent expression) to a milder form which sounds “stilted” and/or “jerky” with circumlocution/substitution in the attempt to find the correct term.

I didn’t have a stroke and while I officially don’t have Broca’s dysphasia (*NB*), I could empathize for him in imagining it would be very frustrating and I automatically knew how to communicate to cater to his condition without having to ask anyone for assistance.

I asked numerous very direct questions so Ben only had to say “yes”, “no”, a number or a short phrase. It was very important to break the burden of what he wanted to say into smaller fragments, otherwise it would be too overwhelming for him. I also gave him extra time to try to express himself, and if I couldn’t fully get what he wanted to say, I then paraphrased it and asked him if that was what he meant. I also drew a few pictures and wrote some individual words on paper in the attempt to trigger his “correct” word.

It was very time consuming given the highly numerous very specific questions asked (instead of several broad questions) and patiently waiting for a reply and trying to clarify it, but I got most of my desired background info at the end.

When asked if he was very frustrated coz of this issue, he said “Of course!” and was shocked that such a phenomenon could occur. He wasn’t made upset or aggravated during the conversation, but appreciated the accommodations I made for him.

I felt very comfortable and relaxed speaking to him, partly because I could communicate in a way that benefitted both of us, but after the conversation a very disturbing epiphany hit me. It turned out that although he was one of the few patients I was intuitively very empathetic for, I was also comfortable in the sense that he wouldn’t be a threat to me verbally. I NEVER exploited or abused him and had his consent to speak to him and he said he wasn’t offended at all, but his condition in a sense was an “extrapolation “ of the expressive language difficulties faced by many people on the Autistic Spectrum, where they have trouble with verbal fluidity for complex things on the spot. This is one of the major factors that’d make them very vulnerable to being bullied, manipulated or framed by NTs (from my past experiences and experiences of other ASD adults) as they have difficulty immediately and eloquently arguing back in a coherent and emotionally pleasing manner (to the NTs) unless they have already memorized numerous sentences, studied advanced debating tactics in their spare time, or managed to incorporate the argument into a pre-designed algorithm in which they will give moderately programmed responses with some editing based on the context etc. IE A POWER IMBALANCE IN EXPRESSIVE FLUIDITY/VERBAL FLUENCY, WORDS ARE SO POTENT.

I felt guilty after this epiphany, because I thought I was gaining comfort from his newly acquired impairment, but later I decided not to feel guilty anymore as I had no malicious intentions, and would never take advantage of his vulnerable state. Other clinical staff shouldn’t feel guilty about Ben’s condition either, they’re all trying to help him with neurological investigations, treatments, monitoring and rehabilitation (including speech therapy). Likewise it would be excessive and unnecessary to feel guilty/remorseful for someone else’s condition that you didn’t cause and have absolutely no intention of maliciously exploiting even if you could technically detect a weakness, eg a patient having a broken leg, or a patient who has endured ototoxic side effects from certain medications. You can sympathize for what they’ve gone through, but to feel guilty about it is going too far imo.

NB: I also have difficulty explaining more complex thoughts on the spot in a smooth manner although it is much milder than the ones with the official diagnosis of Broca’s Dysphasia/Aphasia. This isn’t an anxiety issue, as it occurs to me even when I’m with people that I’m comfortable with. It’s like I have difficulty organizing the sentence structure, so I compensate by my very strong preference to speak in sequential blunter phrases so I’m less likely to “get lost in my words”. This may be a working memory/executive dysfunction issue. It was also comfortable as I had the innate preference for honesty anyway. Unfortunately during speech this can get interpreted by NTs as arrogance or rudeness, and could be deemed as being unempathetic to their ever so important emotional needs. An alternative is to laboriously/exhaustingly memorize the more verbose (yet “polite”) expressions by rote, as it is very unnatural for me to use these phrases.

Example: “If at any point in time you feel too tired or uncomfortable to continue, you are welcome to say stop.” ("polite")

INSTEAD OF

“If you want to stop talking, just say so any time.” ("rude")

The brute rote memorization still accomplishes the need to simulate verbal fluidity that sounds pleasing to them, even though it’s tiring. Fortunately this issue isn’t as obvious in writing and internet communications as there’s MUCH more time to form and edit what you want to say on the computer before submitting it, unlike speech where if you accidentally say something “rude” or have difficulty explaining things to patients in urgent situations, in which you’re screwed to some degree.

Very strangely Pubmed searches indicate rather few medical papers that discuss Broca’s area in relation to people with ASDs. It would be a major discovery if this is one of the several cortical areas implicated in the condition, which may contribute to noticeable verbal communication impairment in adults and teenagers who are more severe on the spectrum. I’d be extremely interested for more neurological investigations to be done on this area in ASD individuals so perhaps a treatment (if pathology was discovered) to address this specific issue may be developed.

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.