Short doctor

I've now in the second week of my psychiatry rotation at Harborview. The other day I was walking down the hall when I passed one of the patients on the ward with bipolar disorder. As we walked by each other, having never met, he mumbled under his breath, "short doctor". So goes life on psychiatry.

I've been assigned to one of the "care teams", which includes an attending psychiatrist, a resident in psychiatry, many nurses, a social worker, and of course me at the bottom. There are three psych wards at Harborview and my team works on 5-Center, which is referred to as the intensive care unit, meaning we accept the sickest patients. The rooms are small and have only a small bed bolted to the floor in the center of the room. There is no other furniture or a tv. Each room has a window. Many of our patients come to us from the Psychiatric Emergency Room, which adjoins the main ER, and almost all of them are admitted against their will on a 72 hour hold. Some come to us in restraints, though most don't require them for long. My job as a student is to learn about psychiatric disorders, what medications are used to treat them and what side-effects they have, how to interview a psychiatric patient, and how to assess their mental status (the physical exam in psychiatry). The only difficulty for me is that many of my patients are extremely difficult to interview.

Here are a few examples of the patient's I have seen. My first patient was a middle-aged man who flew to Seattle from the midwest so he could check into a hotel room, get drunk, and kill himself (he survived). Another patient was admitted for post-partum depression with psychosis. When she was admitted she was actively hallucinating, was convinced that she had been cursed by an evil demon, and was acutely suicidal. Schizophrenia and bipolar disorder are the most common diagnoses on 5-center.

So here's how a typical day works. I arrive at the hospital at about 7:30 and look on the computer to see if we've admitted any new patients. We get a report from nursing at around 8:15 to tell us what happened overnight with our patients, and then for the next couple hours, we go around interviewing our patients. Because I am the student, this is primarily my responsibility, and as I said, it can be challenging. Sometime you should try interviewing a woman with schizophrenia and diabetes who is convinced that you are rigging the glucose meter, that the attending and resident are really judges, and that she was once a famous singer until someone removed her "vocal muscle". After the interviews are over, we write daily notes and orders on our patients and make phone calls. In the afternoons, there is often formal teaching.

The incredible thing is, most of our patients improve with medication. Recalcitrant patients who were in restraints or refused to talk to us roam the halls or talk to me (even if they can't answer my questions). The engineering student with bipolar disorder that I mentioned before eventually improved, was transferred to one of the less acute wards, and wanted to start his PhD program (this was probably too optimistic). But most of the conditions that bring patients to our ward are chronic, severe, medical conditions. Improvement is relative. Some patients might live a moderately functional life (e.g. they can work) if they are compliant with the medications which they will take for the rest of their life; some patients won't be compliant, will relapse, and be back in the hospital. The former singer I mentioned has been involuntarily committed to the hospital 25 times.

It's too bad that many of these illness aren't considered as "real" as other forms of illness. For example, schizophrenia is a devastating psychiatric disorder which often involves hallucations, delusions, disorganized thoughts, catatonia, and so-called "negative symptoms" such as inactivity, flat affect, or refusal to speak. It affects 1-2% of people, and there is no variation in prevalence by country, race, or sex. It has been described as early as the 15th century b.c. Incredibly, it accounts for 25% of hospital days in the U.S. (most schizophrenics require extensive hospitalization to stabilize them, and many relapse), and the cost of care for schizophrenics is 2% of the GDP! Yet in some states, most notably Idaho and Wyoming, treatment for schizophrenia is not covered like other medical conditions - so called mental health parity - but that issue will have to wait for next time. . .

Idaho Medical School?

Dan Popkey wrote an excellent piece in the Idaho Statesman today about Governor Butch Otter's push for a medical school in Idaho. Like the students interviewed in the article, I think it makes no sense to consider a 1 billion dollar medical school when the state has been reluctant to add spots for Idaho students at UW and Utah. The state could educate just as many students per year at those schools, and have them graduate from well-established programs that are among the best in the country. In any case, here's the link to the article:

http://www.idahostatesman.com/newsupdates/story/142583.html

Getting you up to date

So what have I been up to this summer?

After school ended in May, I spent three weeks studying for the national board exam all medical students take after the second year. You'll be happy to know (as I was) that I passed. Then it was time for a few weeks off.


Mt. Rainier
Two friends from school, John and Tom, and I set out to summit Rainier via the Inter-Emmons route, but unfortunately we did not summit. We made two attempts, and on our second we were foiled by white-out conditions and high winds at 12000 feet (that's me in the orange, on our first attempt). All in all it was worth the sore muscles and blackened toes, and I learned a lot about mountaineering, including how fast a well-worn bootpath can disappear in 50 mph winds. Hopefully we'll get another chance.

Road Trip
Two days after coming home from from Mt Rainier, Diana and I left for a road trip through Idaho and Oregon. We went to my parent's new cabin near Lowman, where we enjoyed the new place, cooled off in the South Fork of the Payette, scouted out winter ski slopes, identified the resident hummingbirds, and ate some great home cooking.
From there it was on to Boise for a night with Diana's parents, and then off to LaGrande to see Diana's grandmother, aunt and uncle, and cousins. We set off some fireworks and managed to keep our limbs. We stopped through Bend, OR the next day where we visited the Deschutes Brewery, camped on the shores of Suttle Lake, and then climbed Black Butte the next day.
After that it was on to Portland to see Jason and meet his new fiance Linda. They showed us a great time and were excellent tour guides, but after that it was back to Seattle and back to work and school.

Pediatrics
This was my first rotation and although I didn't think I was that interested in peds, it turned out to be a great rotation. It was 6 wks long and I spend the first three outpatient at a clinic at Harborview (the public hospital here), and then the second three weeks inpatient at Children's Hospital. The wonderful thing about pediatrics is that every kid is different, and that every age of kid is different. Each age comes with new abilities, new problems (try looking in a two year old's ears), and different diagnoses. Children also also resilient and make doctors (and medical students) look good by getting better so fast in response to even minor treatments. I found that parents could sometimes be difficult to deal with, and especially in the outpatient setting, much of a pediatrician's time is spent reassuring parents that their kids behavior, or their ears, or their spitting up, or their poop, is normal. In the end, I enjoyed peds and I can see why many people choose it as their specialty.

Scooter!
And how could I forget to tell you that Diana and I bought a scooter? It's flippin' sweet. It gets 100 mpg and solves all my parking problems. Check it out:

Good intentions

As with much of what goes on in my house, this was Diana's idea. I told her I needed some kind of project to work on, and this is what she suggested. She knows me well, because before I started my third year rotations, I openly committed myself to do some journaling about what happened. How many time have I journaled in the last 7 weeks? Zero. Plus, with my brother Lee sending out occasional manifestos from Afghanistan, I had to do something to keep up.
Hopefully this blog will keep me honest, keep my friends and family informed (turns out I'm not always so good at that either), and be occasionally entertaining. We'll see.