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. . .