Families: August 29, 2005

Monday was a rather depressing day for the Psychiatry Consult & Liaison Service. We saw a number of patients in situations that were particularly difficult for us to bear.

*****

A 46-year old woman who is a slave to alcohol. Her family is intervening, and one of her sisters, a corporate lawyer, is laying down the law. She'll go as far as paying for her rehabilitation out-of-pocket. If that doesn't work, she's threatening to invoke Section 35, a Massachusetts action which will allow the state to forcefully commit a patient to drug rehabilitation.

Her family is in the hospital discussing options. Sadly, this family reminds me of another that I encountered when I spent a week at the Betty Ford Center Family Program. A successful sibling, out of desperation and frustration with his brother's alcoholism, personally paid for his brother to come to grips with his disease at Betty Ford. It may have worked for a time, but substance dependence is a relapsing, remitting disease, and the odds are that his brother went back to the bottle, and dragged his entire family with him down a deep, dark hole.

I don't have much hope that this woman's family will escape the same fate. Mitch notes that putting forth the effort is important to the family, just so they know that they tried everything. Her battle against alcoholism is going to strain this family for quite a while, and it's likely that they've already been through some very rough times.

*****

A 56-year old man who had a below-the-knee amputation (BKA) of his right leg five years ago. Obese, diabetic, wheelchair-bound. It's difficult to stay in shape when you're in a wheelchair. He's been so depressed and feeling guilty about his condition that he refuses to leave the home, afraid of looking like a freak to the outside world. His sedentary lifestyle has worsened his health, of course, and it's hard to prescribe any sort of physical activity, as his heart now has an ejection fraction of 15% (normal is around 55%). He's visiting a vascular surgeon because now his left leg is infected. Without the proper care, he'll lose his left leg, too.

This case is particularly painful because the patient is an articulate, intelligent, and insightful individual, and to see these feelings weigh upon him is difficult to observe. This is a man who has felt ill every day, every hour for the last five years. He has thoughts of suicide, but has decided that he can't do that to his family. Still, he is rapt with guilt, feeling he is a burden to his family. His family cares for him, of course, and would be devastated should he pass on.

*****

We said goodbye to Clive, who was absolutely giddy about finally leaving the hospital:

Mitch: Well, Clive, you look pretty happy.
Clive: Yeah....I'm going to stay at my mom's house for a while.
Mitch: Okay, well, take care. You remember this guy, don't you? (pointing at me)
Clive: ....Yeah.
Mitch: Do you remember his name?
Clive: ....Wong Sang Chang...hee hee...(never let it be said that schizophrenics can't have a sense of humor)
Mitch: Well, that's close, but his name's Mike.
Clive: ....Oh, right...(Clive shakes my hand)
Mikey: "Mike" is a little easier to remember, isn't it?

I'm going to miss Clive. Aside from his manic episodes, he's a really sweet 42-year old kid. He walks out with his parents. I'm touched by the commitment of his parents, who have cared for Clive all of his life. If they're tired, they don't show it at all. Clive's mom is an adorable little old lady (LOL) who has a shopping list of medications for Clive - but she's ready to take it all on.

*****

A 45-year old man with squamous cell carcinoma of the tongue. This tumor has grown to the point that it forces the front of his tongue to protrude out of his mouth. He can't eat, drink, or talk. He needs a trachea tube to breathe. Every couple minutes he has to wipe the drool bubbles collecting at his lip. A little less frequently, he has to clear the phlegm plug that is hanging from his trachea tube. Interviewing him is interesting, as he can only communicate with pen and paper. This takes a while. When he's not writing or suctioning the phlegm from his tube, he's staring at his tongue using a small mirror. He can't stop staring at his tongue. We think he has a form of obsessive-compulsive disorder (OCD).

I'm assuming due to the size of the tumor that the cancer was not detected early, and it's likely that it has metastasized to adjacent lymph nodes. This tumor is just going to keep on growing until it kills him. His care is complicated, and his family now refuse to let him live at home because they cannot help him deal with his disease. He'll most likely spend his last days at a specialized nursing facility.

*****

This is only my first rotation, so I am mindful that there will be gloomier days ahead. But...what a way to start the week.

Change

Mary

Consult services are called upon to answer specific questions, rather than perform full workups on patients. So, Psychiatry Consult would evaluate an AIDS patient for depression, or a surgery patient for delirium. Mary is a 35-year old Jamaican woman suffering from seizures, and is in the country on a medical visa. The question for us? Neurology wants us to determine whether Mary is faking her seizures to stay in the country. I'd rather that neuro phrased this question differently. You know - in a way that isn't so prejudicial. It shames me to admit it, but I find that I'm judging Mary differently than I would any other patient because of the immigration question.

I begin the interview, focusing on Mary's social history. We uncover a sad story, with Mary growing up in poverty, estranged from her mother and her siblings, her only support being her aunt, who lives in the United States. There is a history of sexual abuse, an abusive boyfriend, and her current boyfriend, who has multiple children from multiple other women. She knows that she needs to get out of this situation, but the opportunities are few and far between. In psychiatric lingo, Mary has quite a few "stressors" that may be factoring into her depression, to put it mildly.

Like many other depressed patients, Mary begins the interview with a slightly blunted affect, but as the talking goes on, her mood brightens a little bit as she is enjoying the attention. So what's the verdict? Mary's EEG doesn't show any abnormal activity during her seizures. To some, that could be damning evidence - however, it's not out of the realm of possibility that these pseudoseizures may be, in fact, real. Our impression, in the end: depression due to life stressors, and we make no judgment on her seizures.

I get to write up the consult and put it into Mary's chart. Mitch checks it over and praises the work. Raj, a fourth-year student doing his psychiatry consult elective, gives me a look of approval. Cool.

I check in on Mary three days later, and she greets me with a big smile.


Clive

Clive is still in the hospital because his surgery team is still concerned about his surgical incision. We see him walking the floor with a very slow gait. His limbs are trembling. When he speaks, he can't finish a thought. Clive thinks he's 'getting worse.' We're having trouble maintaining Clive's lithium blood levels within the therapeutic range. He's too sedated to bother the nurses, though, so they're not complaining.

We look up the symptoms of lithium toxicity: coarse tremor, stupor, ataxia, seizures, persistent headache, vomiting, slurred speech, confusion, incontinence, and arrhythmias. We'd noticed the tremor, stupor, and confusion, and we're concerned because prolonged elevated lithium levels may lead to irreversible neurological damage. Like me, Mitch has never seen lithium toxicity before. We're concerned.

Dr. Berg isn't convinced that this is lithium toxicity.
"Trust me," he says. "You'll know lithium toxicity when you see it."
"I'm seeing something" I think, "and I'm not liking it."
Of course, Dr. Berg is the chief, and he recommends that Clive be transferred to a rehabilitation center. Mitch and Dr. Berg exchange words. Dr. Berg agrees to hold Clive for at least another day for observation, and we alter some dosing to hopefully improve his condition.

I stop by to see Clive over the next couple days - his tremor improves slightly, and he remembers me. We talk for a few minutes. Later in the day, we hear reports of Clive giving grief to the nursing staff. Yep, looks like the Clive we know and love is back.


Herman

Herman's medical team acquiesces to his wife's wishes and restart his prednisone. His lungs still aren't clear, but his overall condition has deteriorated so rapidly that they're preparing Herman's family for the end. I'd heard that health care personnel tend to avoid the hospital rooms with dying patients. That's not true in this case. I want to go in the room to talk to Herman's wife, but some of the nurses are giving comfort to his family. I manage to peek in later, and give a smile and a wave to Mrs. Herman, who is sitting next to her sleeping husband.

Herman was transferred to another facility to spend his last days.

*******

So, in very little time, a student was starting to feel more confident about his place in the medical world; a previously gloomy patient was smiling at everyone walking into her room; an abnormally sedated patient got back to his slightly crabby old self; and another patient's family went from having hope to preparing for the end of his life.

It's striking how quickly things can change.

Culture Clash: Patients, August 19, 2005

Often, the patients that we meet give us cause to think about the way cultures (including our own) view psychiatric illnesses:

Ricky

One of our third-year classmates referred Ricky to Psychiatry because he suspected that Ricky is depressed. What we knew about Ricky before we walked into his room was the following: Ricky is 31; he was brought to the Emergency Department when he found that he couldn't walk; that he is HIV-positive with CD4 count of 7; and he has developed a B cell lymphoma that has appeared in the thoracic region of his spinal column. The CD4 count refers to helper T cells, which are important in fighting infection, but also one of the main targets of the HIV virus. A normal, healthy CD4 count is anywhere between 500 to 1500 cells per microliter. One of the graphs they show us in medical school is one that correlates the decreasing CD4 count with the appearance of certain opportunistic infections. Below a CD4 count of 200, the patient becomes susceptible to Pneumocystis pneumonia. Below 100, toxoplasmosis and cryptococcosis. Below 75, infection by the mycobacterium avium complex (MAC) is possible. Ricky has a CD4 count of 7. All of us are thinking end-stage HIV disease.

Sam performs the mental status examination. Ricky has a relatively flat affect, and his answers to questions reflect a poverty of speech. However, he's very cooperative, and performs well on the exam - alert, oriented, good attention span, intact memory. He admits to feeling a little depressed by his situation. Ricky believes that his disease is punishment for past mistakes he'd made in life. Ricky is feeling guilty for having AIDS.
Ricky had an "incident" months earlier, in which he heard voices telling him to hurt himself. He was able to resist the commands, and attributed the voices to some evil person performing voodoo on him.

Of course, we all know the answer to this expression is not:
"Oh, don't worry. Voodoo doesn't really exist. You're hearing voices because you're psychotic."

Rather, a better response would be something like:
"Have you heard those voices since they've given you the medicine?"
(I have to admit that while the analytic part of my brain requires empirical evidence to prove the existence of some force like voodoo, another part of me wishes that voodoo exists. Not that I'd want to use it on anybody, mind you, but only because there's this little juvenile part of me that wants to believe in "magic", which, obviously, is a gross oversimplification of what voodoo actually is, but I think you get my drift.)

Somehow, through his stoic expression, Ricky conveys optimism that he'll regain the ability to walk soon and lead a normal life. CD4 count of 7 echoes in our minds. End-stage disease. I hope, somehow, that number is wrong.


Sunita

Sunita is a relatively young woman in her thirties. She teaches at a local preschool, and lives at home with her husband, her children, and her in-laws. In the last few weeks, she has suffered several seizures of unknown origin. Obviously, seizures are debilitating, can be dangerous depending on the circumstances, and carry with them a certain stigma. She can't drive herself around the city anymore, and worries whether she'll be able to keep her job. She is very quickly losing her independence. Confounding the situation is her description of her support network. She has friends that offer support, but her immediate family seems to be less understanding - to them, there's "normal" and there's "stark raving mad." Did I mention she was living with her in-laws? The psychiatric consult team's evaluation? (All together now) Depression.

Choosing an anti-depressant medication is the easy part - all we have to do is make sure that it doesn't interfere with her anti-seizure meds. Much more difficult is finding a resource that is knowledgeable in dealing with some of the difficulties she's facing at home.


Clive

Clive's surgical wound is still infected, so his surgical team had informed him that he has to stay in the hospital for further observation. This led to him leaving his room, entering the stairwell, and yelling at the nursing staff. He claimed that he was experiencing visual hallucinations. The consult came in mid-morning:

Mikey: Should I follow up on Clive?
Mitch: Yeah, sure - why not? By the way, the nursing team had to calm him down after he was yelling and screaming in the stairwell. We'll meet you down there.
Mikey: ...

I walk into Clive's room and this time, he's fully alert. When he answers questions, though, sometimes you wonder if he's actually heard you. His expression never changes. He pauses for quite a while before he answers the question.

Mikey: Hey, Clive, how are you doing today?
Clive: ......Not good.......They're making me STAY!!
Mikey: Yes, I heard that. But it's okay - we're all just trying to help you.
Clive: ..............Are you scared of me?..........I'm not the violent type.....
Mikey: No, way.
Clive: .............I like you.
Mikey: I like you, too, Clive. You always shake my hand whenever we meet. We're buddies?
(Oh no. Long pause. It's like he's really thinking about it.)
Clive: .............Yeah..............yeah, we're buddies.
Mikey: Great. Can you tell me how you're doing now? I heard earlier that you might have been seeing things?
Clive: .............No..........no........
Mikey: Are you certain?
Clive: .............No.........that's over.......I just want to go home...
Mikey: I know. I'll talk with your surgical team to see what they have planned, okay?
Clive: ............okay..........

As usual, Clive shakes my hand at the end of the interview. As I leave, he calls out:
Clive: ..........Hey!...............How long are we buddies?
Mikey: As long as we know each other.
Clive: ..............oh.........okay...........

I run into Mitch and Sam. Mitch is openly amused. Apparently there's a hop to my step, and I'm talking faster than normal. "In my expert psychiatric opinion" says Mitch, "it looks like you've got a bit of adrenaline running through your system." I think I smile. It's like - whoa - I connected with a patient. And it feels pretty good.

Patients: August 18, 2005

Herman

Sam's patient. A more clear picture emerges as Sam and I learn more about Herman's medical history. Sometimes settling on the correct diagnosis takes a long time. Sometimes getting the correct diagnosis doesn't occur until it is too late to provide reversible treatment. And sometimes, getting the correct diagnosis results in hopelessness.

Five months ago, Herman was initially diagnosed with rheumatoid arthritis, an autoimmune disease involving both large and small joints. The pain is managed with non-steroidal anti-inflammatory drugs (NSAIDs). More severe cases may be treated with corticosteroids, which will suppress the patient's immune system with greater effect. This is what Herman was taking. It was a couple months later when the Rheumatology Department referred Herman to Hem/Onc for re-evaluation. More poking, more probing, and more tests led to a preliminary diagnosis of acute myelogenous leukemia (AML). Treatment includes chemotherapy, transfusions, antibiotics, and bone marrow transplant. I mentioned previously Herman's platelet level, which was so low that he couldn't brush his teeth or shave his beard. Surgery doesn't dare to touch him. To make matters worse, Herman's chest X-ray indicates that he has developed a fungal infection in his lungs due to his immunosuppressed state. It was decided that the best course of action was to wean Herman off the corticosteroid to help fight off the infection.

However, according to Herman's wife, as Herman came off the medication, his mental status became more unstable. His delirium has become increasingly more severe and his memory is starting to fail. To his family, Herman has become a shadow of his former self. Herman's wife refuses to let her son visit with Herman in this condition. She'll tell anybody who will listen: "Herman did so much better on the steroids. This isn't living. You don't know Herman - this isn't him. I want my Herman back."

Meanwhile, the raging fungal infection in his lungs hasn't resolved. Prognosis for AML depends on subtype, but in general, 70-80% of adults achieve complete remission. I'm not exactly sure why Herman's prognosis remains poor, but I surmise that the oncologists' reluctance to start chemotherapy is an indication of his compromised health. Herman's wife wants him back on steroids, thinking that the drugs will somehow normalize his mental status. Of course, there's no guarantee that this will happen, but the steroids will make fighting the infection much more difficult. She must know this, yet she continues to press. Has she given up? Does she just want a few more days with the Herman she knew before he passes on?

Why are the oncologists so reluctant to submit to the wife's orders? Physicians often have a hard time letting patients go, too. Physicians often equate losing a patient with failure. It's possible that it is much too early to throw in the towel, but it's certainly been a long five months for Herman's family, and they must be horrified at the possibility that they've already lost the Herman they knew.


Clive

Clive is a 41-year old male who just had an aortic aneurysm repaired. He is being held for observation because the surgical incision has become infected. Clive was diagnosed with schizophrenia in his late teens. A snapshot of schizophrenia:

• affects 1% of the population, usually diagnosed in the 20s for men and women
• positive symptoms: hallucinations, delusions, bizarre behavior (aggression/agitation, odd clothing, etc)
• negative symptoms: flat affect, alogia ("lack of words"), few friends or interests

Psychiatry Consult has been requested because Clive seems to be managing the health staff, rather than the staff managing Clive's health. I've noticed that a common theme with psychiatry consults is that the psychiatrist is called in to deal with patients that are annoying the heck out of the nurses. Whatever. I'm excited to meet my first schizophrenic patient.

Clive is lying in bed when we walk into his room. He's alert, oriented, and very cooperative despite having a flat affect (his stoic expression never wavers). He is keenly aware of his mental status, and is obviously experienced navigating his way through the hospital system. He recites his primary care physician's phone number from memory. At the end of the interview, Dr. Berg turns to the medical students.

Dr Berg: Okay, who wants to pick him up?
Sam hesitates. Not wanting to look reluctant, I volunteer to follow-up Clive. Later, I apologize to Sam, thinking I may have stolen the patient right from under his nose.
Sam: Nah, man - I wasn't sure what he meant. I thought he wanted one of us to lift him.
(Oh, Sam - such a literalist.)

I return to Clive's room in the afternoon to perform a more thorough mental status exam. It ends quickly.
Mikey: Hi, Clive - remember me? I'm part of the team taking care of you. Would you mind answering a few questions?
Clive: Well...do I have to?
Mikey: I'm not forcing you to do anything.
Clive: Well...okay.
Mikey: Great, thanks. So how are you feeling today?
Clive: Not well. Look, I've just taken a Klonopin and I'm not up for this. NOW GET OUT!
(Okay, I made up that last part).

Interview Anxiety

Mitch having called in sick, Dr. Berg is the only psychiatrist in the C&L office today. Dr. Berg is really too busy to deal with the students, but reserves some time for us in the morning. He recommends that Sam follow up on Herman, and instructs me to talk to a patient in the Surgical Intensive Care Unit (SICU).

Problem - I have no idea where the SICU is.
Mikey: Dr. Berg, where's the SICU?
Dr. Berg starts then stops. Then starts to stop. Then starts again.
Dr. Berg: Uh, never mind. Meet me back here at 10 o'clock.
Dr. Berg exits, stage right. Exits? More like sprints awaaaay.

Sam and I wander over to the hospital to check on Herman. Aw, Herman's sleeping. Should we wake him? Herman had reported trouble sleeping yesterday. And now he's sleeping like a baby. We let Herman sleep.

So now what? Two hours before our meeting with Dr. Berg. Sam suggests looking for the SICU ourselves. Wow - imagine that. Two Noobs taking the initiative. We ask around, a nurse kindly points us out to the SICU. The signs in front of the SICU are bright red 'AUTHORIZED PERSONNEL ONLY' notices, making us whither away from the entrance. Boldly, Sam walks up to the ID scanner and waves his ID in front of it and the SICU doors swing open.

Sweeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeet.

Even more surprisingly, Sam and I are walking freely around the SICU. No one gives us a second look. Hello, people. You've got two med students with the word 'NOOB' tattooed on their foreheads, and you're not stopping them?!?! No, of course not. Because we're Authorized Personnel, Baby!!!

We look around for my patient, Mr. Franks. Mr. Franks is a jolly soul who had undergone a coronary artery bypass graft (CABG) almost a week ago. Dr. Berg hadn't told me much, so I'm going to walk in there and figure things out. I assess his mental status (affect, orientation, memory, etc.), check on his family support, and discuss his plans for the future. Mr. Franks is 'okay.' OKAY?!?! What does that even mean? I conclude the interview. Sam cuts in to ask a few questions. Apparently, I forgot to ask about possible substance abuse. Crap.

Our meeting with Dr. Berg goes fairly well. We admit to hesitating to wake Herman up for an assessment:

Noobs: He was sleeping like a baby. We didn't want to wake him.
Dr. Berg: I'll make a note of that...Look. You have to realize how valuable your time is. Even though I know you don't think so right now.

We go in to check on Herman, who's awake now. His delirium has improved a little, although he's still slightly disoriented. It's easier to detect a little sadness now, and he mentions that he hasn't seen his son in almost a week.

We then visit Mr. Franks. Mr. Franks is on the potty, but Dr. Berg conducts the interview anyway. I think Dr. Berg could interview a patient during a hurricane with a flurry of bullets flying around him. Dr. Berg asks me if I want to update the chart and write the psychiatry consult note. I decline. I'm such a wimp.

I run into my friend John (who is in the middle of his surgery clerkship) in the SICU. We give each other 'the look.' That 'look' that two people share when they've been through something together. We got through graduate school, and now we're back in the thick of medical school. We're doing this, and we're wearing the respective "uniforms" (me in my tie, John in his scrubs). This feels awesome.

*******

Self-assessment: My interview skills are rusty. I find getting social history quite natural, but obtaining medical history from the patient takes a bit more concentration, and I've never been comfortable getting alcohol or illicit drug usage information from the patient.

And I need to be more aggressive. I missed an opportunity today in not writing the note. I'm going to set a goal with the service. By the end of the week, I know how to update the patient chart independently.

Discomfort Zone

I. The White Coat

The medical student's white coat serves multiple functions. Perhaps most importantly, it identifies the wearer as a trainee. The white lab coat is a status symbol of sorts, but the medical student version is short, barely reaching below my waist. Right now, though, it's mostly about function. The white coat has big pockets. I know I'm supposed to stuff things into these pockets, but I have no idea what. It's my first day, and I stuff the following into the various white coat receptacles: stethoscope, a "pocket-sized" quick reference to the DSM-IV (the Diagnostic and Stastical Manual of Mental Disorders), a pocket-sized Current Clinical Strategies in Psychiatry book, and my Palm Tungsten T3 PDA. My coat, once light as a feather, is now noticeably heavy.

Plus, it doesn't fit. I was measured for this white coat seven years ago when I was 20 pounds heavier. It's slightly oversized now, so I imagine I look a little like David Byrne in Stop Making Sense. Great. My poor fashion sense is going to do nothing to distract from my apparent cluelessness in the clinic.

I arrive at the designated meeting place twenty minutes early, fresh from the gym. It's August in Boston, meaning it's hot and humid. And I've nearly drenched my dress shirt in a combination of post-workout and humidity-induced sweat. I don't have nearly enough dress shirts in my closet. Guess I'm going to blow even more money on the wardrobe this weekend.

Anyway, I find the meeting room tucked away in a dark corner of campus, and find that most of the staff psychiatrists are away on vacation. The only faculty member present directs me to call the psychiatry resident, who is also starting his first day on the service. This should be a fun day for everyone. When I meet the resident, "Mitch", he informs me that psychiatry is a coatless service, so I can ditch my white coat.

II. Leaves Blowing in the Wind

Here's the structure of the next three weeks as I understand it: I'm working out of the Psychiatry Consult and Liaison Service. The staff of this office are responsible for evaluating and following patients on the medical, surgical, and neurological services of the hospital, so I'll be interacting with the 'in-patient' population for now. There is one other medical student here, "Sam." For both Sam and I, this is our very first experience working in a hospital. We were able to establish early on that we both have a steep learning curve - not only do we have to figure out what's going on in the Psychiatry Clerkship, but we also have to learn to work within the hospital system, which means we have learn to use the computer system which keeps track of patient records.

Mitch looks rather disheveled, as if he's been on call. He's got major baggage under his eyes, and he's coming down with a cold. It's his first day on the Consult Service, he's the only psychiatrist working this week, and now he's got two Noobs to take care of. Mitch is a trooper. For now, though, he's got some more patients to see, so he sends me and Sam back to the office for our informal introduction to the service.

In short, our responsibilities on the service are to learn about psychiatry, although our experience with the consult service will include significant exposure to elements that we'll encounter in our Internal Medicine Clerkship. Sam and I will take on patients and follow their progress, requiring us to strengthen our history-taking skills. Interviewing psychiatric patients should prove to be a challenging activity. Other than that, we serve at the whim of the psychiatry staff: performing chart biopsies, looking up papers, presenting cases, and whatever makes the resident's life easier.

III. Patient Zero

The first patient belongs to Sam. I was too gutless to volunteer for the interview, so I got chart biopsy duty (breaking down the patient's chart and presenting notable medical history, vitals, and social history as pertains to psychiatry). The patient, "Herman", is a Hematology/Oncology patient, who was diagnosed 6 months ago with an autoimmune disease. Follow-ups by the Hem/Onc service indicated that Herman may have an extremely rare condition known as macrophage activation syndrome (MAS). His first two bone marrow biopsies turned up normal, but the third apparently was all 'blasts' (basically, an abnormally high concentration of immature blood cells). His condition has led to hematological disturbances, including an elevated white blood cell count, decreased hemoglobin, decreased hematocrit, and decreased platelets. A normal platelet count would be anywhere between 150,000 - 350,000 per microliter. Platelets basically enable the body to respond to wounds by releasing substances that induce clot formation. Herman has a platelet lab value of '20' - he can't even use a toothbrush because he'll bleed out.

You can already guess as to why Psychiatry has been called to consult on Herman's case. Imagine being diagnosed with a condition such as MAS - what's the normal response? They call a decrease in the ability to function in response to medical news an adjustment disorder. Sam's interview with Herman reveals that Herman is feeling depressed and is having trouble sleeping. He has difficulty relating his residence and family support structure, but is orientated x 3 (knows who/where/when); he's been bouncing around between hospitals for the last five months - Herman just wants to go home. Mitch later asks some mental status questions to test Herman's memory and state of mind. As this happens, I look around Herman's hospital room and see a picture of Herman with his family. This finally seems to bring the gravity of Herman's situation home to me. An image of Herman and his family when their lives weren't turned upside-down.

Herman's chart reveals that he's on almost twenty medications: anti-depressants, anti-pain meds, antibiotics, etc. It's possible that the combination of fever and morphine (for his pain) has resulted in a substance-induced delirium. It's hard to diagnose depression in a patient with a masking delirium, which can often be confused with depression. We'll follow up on Herman more tomorrow. My guess is they'll treat the delirium and reassess for depression afterwards.

Mitch looks like he's going to keel over. He manages to give us tips on writing up a Psychiatric History. Dude - go home and go to bed. You've got three weeks to whip our butts into shape. Mitch eventually sends us home. I've got homework, and that is to find out why mirtazapine, an anti-depressant, has better sedative effects at lower doses.

Tomorrow: I get a patient of my very own. And my first patient interview in over five years. Okay, now I'm scared.

So It Begins

Psychiatry clerkship orientation today. In which we were told how we would be graded (clerkship performance: 75%, Shelf examination: 25%) and then reviewed the major psychiatric illnesses: major depression, schizophrenia, anxiety, personality disorders, and substance abuse.

In the review of the major psychiatric disorders, I learned some new things:

• How much it costs to keep a schizophrenic patient on Haldol ($30/month) versus the same patient on an atypical anti-psychotic ($500-$800/month)
• Of the effort to revoke the Nobel prize from Egas Moniz, who was awarded the prize for developing the frontal lobotomy. The frontal lobotomy became the treatment of choice for severe mental illness despite the fact that no controlled research established its clinical effectiveness. (But it also gave us One Flew Over the Cuckoo's Nest).
  
• Apparently electroconvulsive therapy (ECT) works. Not sure why.
• Schizophrenic patients LOVE nicotine. You can often recognize a schizophrenic patient by the yellow nicotine stains on their fingers. They like to remove the cigarette filters and burn their fingers as a result.
• Schizophrenics also like to get high off gasoline fumes. The poor gas station attendant near school apparently has to chase these people away from his pumps.

And some not-so-new things:

• I remember precious little from the pre-clinical years. Things like...oh, drugs, how to take a patient history, how to put on a tie.

My first official day in the clinic is tomorrow. Deep breaths.

*******

And thanks to Kinjo and Cathy who guest-posted every once in a while, during my thesis writing phase.

Title This

Announcement: Name Mikey's Blog Contest!!!

Well, soon the name of this blog will be old/outdated. Mikey's Lab Blog will no longer be relevant because Mikey will no longer be in the lab. Mikey will go from being one person's lackey to the lackey of a larger group of people: surgeons, internists, gynecologists, psychiatrists, and whatnot. The main subject matter will remain the same: ME. And I'm embarking on another upward journey, leaving the familiar realm of the research lab and entering the unfamiliar, scary world of clinical medicine. I'm starting from square one - I remember only a fraction of what I learned in the first two years of medical school, I haven't taken a history or performed a physical exam in over five years now. It should be an interesting time, I hope you find it entertaining.

However, I'm having trouble settling on a name for the blog. So, I'm taking suggestions for what this blog should be named. Some thoughts:

• Mikey's Med Student Blog: Simple, straight-to-the-point, but requires another name change after I graduate.
  
• Mikey's Fashion Blog: This will focus my blog around reviewing all the latest fashions in hospital wear. Advantage: Mikey models designer scrubs for the world to see. Disadvantage: Same.
• Mikey's Blog (Brought To You By Stratagene): Just kidding ;)
  
• Life with Mikey: Writings on life with yours truly by Hank the Surly Penguin.

Suggestions and votes may be submitted through the 'Comments' link of this post. Everyone gets one vote. Except for me - I get 5000 votes. The writer of the winning title gets the original 'Hank the Surly Penguin' sketch.

The Best Defense...

...is a good offense. Or so they tell me. I think I managed to defend without being offensive. I'm not sure - that didn't come through in my feedback. Here's what I remember about my Day of Defense.

Part I: The Dissertation Presentation

• Barb had an extremely kind (and rather extensive) introduction. I think she made me out to be a better graduate student/researcher than I actually am.
  
• Some faculty from the Department of Microbiology showed up - which surprised me, as I never thought they would be interested in hearing about my research. Quite frankly, I thought they detested me, for being a student in the Department of Pathology and for leaving the Immunology Training Program. I never actually thought I had the intelligence to hang out on the Microbiology floor.
  
• Outside of those on my Dissertation Committee, there were absolutely no faculty from my home Department of Pathology. Not one. Sad. This was not a surprise. When my first advisor left the institution, not one faculty member from the Department of Pathology inquired as to what my plans were, whether I needed funding, or offered any support of any kind. (In contrast, two professors from the Microbiology Department did check in with me during that period.) But that's okay, I won't miss the Pathology Department - you can't miss something that was never there for you in the first place.
  
• There was a very nice turnout of fellow students. You guys are awesome.
• I don't remember much from my actual presentation. I recall starting it, but I put it on cruise control after that. I do seem to remember thinking that I was talking to the screen quite a bit, and not the actual audience. Other than that, I got rather positive feedback from my committee, and Barb seemed to be very happy with my presentation.

Mikey shoulda threw in more dirty jokes. I might've stayed awake then. Didja see Andy's defense last week? That. Was. Genius.



Yeah, whatever. Anyway, Part II: The Oral Defense

• During this time, the committee discusses with the candidate any issues they might have with the experiments, dissertation, and the candidate's knowledge within the field of study.
• The Committee Chairperson allotted each member 20 minutes to question me.
• As expected, one committee member asked me a rather basic science question. It started off with me being asked the mechanism of histone acetylation. Then to which amino acid the acetyl group was attached. Then draw the amino acid. Now draw the acetyl group. And I messed it up. I got the hard part - I drew the correct side chain, but couldn't dig up from memory what a darn peptide bond looked like. This is simple high school-level chemistry, folks.
  

• The best exchange was between Cyrus and Greg:

Cyrus: Shall I ask Michael to draw the Krebs Cycle?
Greg (to Cyrus): Can you draw the Krebs Cycle?
Cyrus: No, but...I don't have to (evil grin).

• The rest of the defense went as expected. Some discussions went smoothly, other discussions were a little hairy.
• As usual, at the end they sent me outside while they discussed. Or snickered. Probably a mixture of both.
• Then Jackie, the Committee Chairperson, called me back in by calling me "Doctor."
• At the end, it was only me and the committee finalizing the language of my thesis abstract, and the committee signing all the required paperwork. Then handshakes and hugs.

Kinda anti-climactic, huh? Just like this post.

And..........?

I passed.

I'd write more about the experience, but I've got to go out and celebrate. Perhaps Hank will write something later.

Rehearsal, Part II

Woke up late this morning. I've got this plan to get back onto the exercise wagon, and it just hasn't happened. I'm more of a morning exercise person, as motivation to get to the gym decreases as the day goes on whether it's because of mental fatigue or the dread of fighting the evening gym crowd. Anyway, once I throw that plan away (again), I realize that I am really freaking nervous. I've got no appetite, but force down a cup of coffee. Ten minutes later, I'm both nervous and jittery. This does not feel good.

I incorporated more of John and Dr. R's suggestions into my slides, then went into school to rehearse the presentation with Barb this time. This second rehearsal was a little more smooth, and Barb's feedback was amazing. First things she recommended were some techniques to help me relax. She talked about visualization and some help breathing techniques before I actually say anything tomorrow. I never realized it until now, but Barb has a stake in my performance, too. I am, after all, an example of her ability to mentor younger people. Barb is generally pleased with my presentation, and points out things she liked in addition to slides that need some work. Her final piece of advice is to go home and read my Biochemistry textbook. Uh oh. I threw that thing away two weeks ago. I kept my undergraduate Biochem textbook and haven't used it in a decade. Now I'm supposed to read it? Argh. Apparently one of my committee members likes to ask the 'basic' science questions. Like 'draw this amino acid' or 'name the steps in forming the transcription initiation complex'. Blah.

The presentation felt good for the most part - there were a couple slides that got a little rough, but I can work those kinks out. I didn't feel as detached from the presentation as I did yesterday, so no "voices" in my head this time. Still, I'm pretty close to freaking out.

Why am I panicking? Hmm...let's lie down on the couch and think about this:

1. Well, it could be just simple fear of failure. Is it likely that I'm going to fail? Um, I don't think so. In fact, I'd be the first that I'd know of. So perhaps there's that fear of being the precedent-setting first ever candidate to fail on the eve of his dissertation defense.
2. I've always carried this feeling in the back of my mind that I'm an impostor, that I don't belong in graduate school, and I've been faking it all the way through. Yes, I know that's a little irrational thinking, but I know many other graduate students who have felt this way. There are several checkpoints in graduate education that enable the faculty to weed out the competent from the incompetent. Coursework would be one. The qualifying exam is one. The dissertation defense is the last. I have this picture of the oral defense being held in a dark room. My committee peels off this outer layer that is me and AHA! discovers this faker underneath.
3. I looked in my closet and have just now realized that I have nothing appropriate to wear to my defense tomorrow.
4. I can't come up with a '4'. I'm freaking out, can't you tell??? I need to go and rehearse some more and then read every single paper I ever referenced in my thesis.
   
5. People like to relax me by saying that the PhD candidate knows more about his or her area of research than anyone else in the room. I don't. I'm an impostor. Sigh.
   

Rehearsal, Part I

I just rehearsed my presentation this morning, with my classmate John and the former Pathology Department Chairperson, Dr. R, as my audience. Wow, I'm rusty. I was a little sleep deprived, but not so much as to explain my stumbling and bumbling through my slides. I certainly wasn't nervous - perhaps a tad anxious - but it's weird how my perspective changes whenever I do any sort of public speaking. It's as if there's part of my mind that's controlled and going through the talk (Florestan), and another part that's undergoing a panic attack (Eusebius):

Florestan: And here are some of the systemic effects of the cytokine IL-1β, but most notably, IL-1β is an endogenous pyrogen, acting on the hypothalamic-pituitary axis.
Eusebius: Good...good...now careful here...transition coming up. Don't blow it!
Florestan: Uhh...and this slide displays the role IL-1β plays in disease.
Eusebius: YOU BLEW IT!!! It's over! We're done for!
Florestan: ...it plays an important role in septic shock as shown here. More recently, IL-1β has been shown to be an important player in the pathogenesis of diabetes mellitus...
Eusebius: Okay, nice recovery, we've still got a chance...
Florestan: ...and perhaps multiple roles in cancer biology. Ummm......
Eusebius: Oh, No!!!!! Dead air! WE'VE GOT DEAD AIR DO YOU HEAR ME? This is like the 134th 'Um' in the talk and we're only on slide 7!

***
Later in the talk
***

Florestan: Now I'd like to explain how we performed the analysis of this chromatin immunoprecipitation assay. This slide is a representative graph of the output data from a quantitative PCR reaction and...uh...you can see we have three different samples...um..
Eusebius: I totally told you last night we needed an extra two slides to explain this. But did you listen to me?!?! NoooOOOooo...
Florestan: Would you shut up? I'm trying to talk here.
Eusebius: Don't tell me to shut up, you fool! You're the reason the talk is so weak.
Florestan: I can't concentrate with you whining all the time.
Eusebius: I wouldn't complain if you exhibited the slightest bit of competence.
Florestan: Shut up shut up SHUT UP!!!
Eusebius: You shut up! I'm taking over!
Florestan: You can't do it! You had your chance and that's why you've been relegated to the subconscious! Go awa--

John and Dr. R exchange glances.
Dr. R: Uh, Mike? Are you still with us?

*****

Yet somehow, I made it through the rehearsal talk. John and Dr. R both said that it was fine. I was conscious of several pauses, um's, uh's, and several awkward stops and starts. Both John and Dr. R made no mention of those and thought that the level of those aforementioned blips would be fine even for the actual talk on Thursday. It's weird how your mind distorts your perception when you're on the spot. So, I've come up with a theory:

Mikey's Theory of Relativity (Speaking)

The speaker perceives the pauses and interjections (such as 'uh' or 'um') to occur at a length or frequency 5 to 10 times greater than does the listener. Your speech isn't going as poorly as you think it is. Or so I hope.

*****

As painful as this rehearsal was, this was a great way to find out where the weak points are in the talk. I think I've found the right tone and approach for the presentation. Now if only I can come up with enough jokes to fill in for the paucity of data, I'm Golden.