A moment on my soapbox, if you will

One of the principal goals for the psychiatry clerkship is to learn how to interview patients with mental illness. It's difficult to ask someone if they are hallucinating or if they are thinking about killing themself. How do you ask those questions when someone thinks your Ed Norton?

For those of you who don't know (or don't remember), I worked for one year at a daytime homeless shelter in Tacoma, WA called Nativity House. Before I started, my biggest fear was working with the mentally ill - I thought of them as unpredictable at best, and violent at worst. I had no idea how I was supposed to talk to them. What I soon realized is that you talk to them like everyone else. Being a medical student on psychiatry isn't really that different from being a volunteer at Nativity House, only now I have to ask a whole new set of questions: do you see things other people don't? do you have any thoughts about hurting yourself? what's your mood like today? I ask in the same way I'd ask about someone's chest pain, because like chest pain, hallucinations and suicidal thoughts are symptoms of a medical problem.

The mentally ill fall into a problematic gap in our society. Unlike other people with serious, disabling, even life-threatening illness, they usually don't come to the doctor on their own. They often have to be brought to the hospital by ambulance or police car. Many people with mental illness, especially the homeless, have active delusions or hallucinations or they may have serious communication or social problems, yet to a certain extent, they are "functional". They find their way to shelters at night, to kitchens for meals, and navigate major cities and transportation systems. Could they find a job? Some could and many do, but the people I knew at Nativity House who were chronically unemployed I couldn't imagine anyone hiring. The problem is that most of the people with what I would call sub-acute mental illness won't go see a doctor, either out of fear, distrust, or most likely, they wouldn't know how. Many of them try to treat the voices, the fear, or the anxiety they experience with drugs. At this point, what most people see from the window of their bus or SUV is a drunk lunatic who probably smells and should just get a job.

It's ironic that many people don't consider mental illness in the same way as diabetes, heart disease, or other medical conditions. There is often just as much of a genetic component to mental illnesses as for other illnesses. It seems like common sense, but nobody chooses to have schizophrenia, or to get manic or be depressed.

You'll hear very few medical students say they want to go into psychiatry. Statistically, less than 2% of my medical school class will choose psychiatry as their specialty. I'm not sure why, but it just doesn't seem as doctorly to folks - they'd rather suture something. Even now, maybe some of you are wondering (be honest, even worrying?) if I'm interested in psychiatry. But I'm not going to tell you - I'd rather you just get used to the idea.