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.