Time

It is disappointing and humbling to wonder how much time gets wasted in the day. We spend a good deal of effort, energy, and thought on activities with very little yield in meaning or productivity. How much of one's time is spent reading news articles that have no lasting impact, surfing the web mindlessly, shopping for things one doesn't need, or writing blogs for the sake of doing so? We whittle our lives away on Facebook or driving a car or waiting for elevators. Some of these activities are necessary and some may be worthwhile even if their worth cannot be measured. But perhaps others, the things we do selfishly, the things we do without knowing why, those things, can and should be discarded.

This thought occurred to me as I was pre-rounding on patients, faithfully copying down lab values. Indeed, that itself should be questioned. What laboratory tests are relevant to psychiatry? Certainly, some are vital on the consult service such as B12 levels or TSH or RPR. Some may be occasionally relevant like WBC or electrolytes or liver function tests. But a lot of what I was looking up and copying down never got used and never contributed to patient care.

The Pareto or 80/20 rule states that for many events, 80% of the results come from 20% of the efforts. Most of what we do contributes very little to our productivity. Our best successes can be attributed to a small percentage of our time. This has been empirically shown in many arenas: most of the wear on our carpet occurs on a fraction of the surface area; most of the profits for a business come from a minority of customers; most of the money in a society concentrates within a limited number of people; most our time is spent with only a few of our friends. Not all of our time is equally useful; not all of our work is equally productive. This has been widely applied in business and quality management, but I think it could be used in everyday life.

We should accept that some of what we do will be "waste" and as long as the fleeting pleasures or necessity of doing those things justifies them, that's fine. But we should wean ourselves off other pursuits that just don't seem time-efficient. We should spend less time with useless pre-rounding, more time with the patient; less time with online social networking, more time talking to those we care about.

Image is Rene Magritte's "La Trahison des Images," owned by and exhibited at LACMA, shown under fair use, image from Wikipedia.

Unsung Heroes

I have found that the truly underestimated workhorses of the wards are the non-MDs. Everyone is aware that the whole system depends on nursing and that they provide a wealth of experience and knowledge when it comes to patient care. But I've also found that social workers are amazing people who track down lost family members, call other health care facilities, contact community resources to figure out where a patient goes when he leaves the hospital. We can handle the medical aspects, but we know nothing when it comes to social work stuff. Physical and occupational therapists, too, make a world of difference in the patient's lives. Indeed, not many people know the difference (PT deals with gross motor ability such as gait; OT deals with fine motor movements and activities of daily living). Doctors worry about what kind of infection is happening and what antibiotics are needed; patients worry about whether they need a walker or if they can go up stairs. Lastly, today we relied on an interpreter who did an exemplary job acting as a neutral intermediary. And I'm sure there are other key players (phlebotomists, even custodial staff) who nobody sees but make the hospital run smoothly.

Lesson Learned

Today's lesson: dispo / sign off on patients as soon as you can, or else you'll get swamped.

Freud and Psychodynamics

An interesting question is how much Freudian theory or psychodynamics we use. Psychodynamics is the study of conscious and unconscious forces that underlie human behavior. We don't use very much of that clinically as psychiatrists. However, one of my attendings is very interested in psychodynamic theory and likes to conjecture on unconscious motivation. For example, we saw a patient who was somewhat hostile to us. In his garbled history, he noted a past conflict with child protective services over the treatment of his daughter. The attending suggested that the patient's hostility could have stemmed partly from the resident being a woman at the approximate age of the daughter. This could have stirred unconscious emotions related to that conflict.

It is fascinating to conjecture on what possible strange forces affect our behavior without our knowing. What causes our emotional lability? Why do certain people affect us more than others? Can you rationally explain emotional outbursts or episodes of depression? How come some minor suggestions trigger such powerful responses? I probably should never admit this, but I do like pretending to psychoanalyze my own behavior and those around me.

What is a Consult?

I think one of the more valuable general things I've learned on this rotation is the nature of consult services. It's useful to know when to get a consult and what a consultant does. At least for psychiatry, we get consulted when patients on the general medical wards have mental status changes, suicidal or homicidal ideation, behavior issues, pre-existing psychiatric conditions, legal status problems (such as a psychiatric hold), or questions of informed consent. Consult services expect the consultee to ask a specific question. Sometimes this is general, frustrating, or inappropriate ("she has interesting behavior, go check it out for us"), but usually it gives us a place to start. We then see the patient and assess general psychiatric issues, focusing particularly on the consult question. This allows us to make a recommendation on what to do with the patient; the primary team can choose to accept or reject those recommendations.

Legal Aspects of Psychiatry

Interestingly, the domain of psychiatry includes a lot of legal medicine and ethics. On consult service, we are sometimes asked to assess a patient's capacity, whether they have the ability to make an informed consent decision. Ironically, psychiatry has the fewest procedures so we rarely consent patients ourselves (electroconvulsive therapy is one exception). But we are considered knowledgeable of a patient's ability to consent because we spend a fair amount of time assessing cognitive capacities.

Psychiatry can also place legal holds on patients (along with general physicians, law enforcement officers, and others). That is, we can detain a patient against their will if they meet certain criteria such as being a danger to self, danger to others, or gravely disabled due to mental illness. These "5150s" are an interesting example of how individual rights are subsumed by paternalism (preventing suicide, grave disability) and societal safety. While many people can initiate the 5150, usually only psychiatrists really pursue the longer term holds such as the 5250 or putting a patient on a conservatorship.

Because of this intersection between medicine and law, psychiatrists are often involved in hearings that take place in the hospital by the bedside. They act as expert witnesses to argue whether someone should be held against their will or given medications involuntarily. To me, this is a fascinating aspect of medicine I hadn't thought about before.

Poem: Affidavit

One of my favorite poems is "No Second Troy" by W.B. Yeats. The amount of ground he covers in this 12-line poem is breathtaking and his use of sound, syntax, and imagery is unparalleled. Here is the original Yeats poem and one I wrote in response.

No Second Troy
W.B. Yeats

WHY should I blame her that she filled my days
With misery, or that she would of late
Have taught to ignorant men most violent ways,
Or hurled the little streets upon the great,
Had they but courage equal to desire?
What could have made her peaceful with a mind
That nobleness made simple as a fire,
With beauty like a tightened bow, a kind
That is not natural in an age like this,
Being high and solitary and most stern?
Why, what could she have done being what she is?
Was there another Troy for her to burn?

-

Affidavit

I confess I craved a second Troy to burn.
Not for the tyranny or maritime seduction
or the heroes that arise when they recognize
duty as passion, but simply to know
Beauty commands. For why else would women
court clostridium but for the basilisk gaze
to hold reason enthralled, drive waterfalls off cliffs?
Little do they know my misery, the temptation I rein,
that I learned something from those little streets:
Nobility is not free will, and responsibility leashes
my splendor from destroying your jury of weakness.

Challenges in Psychiatry

Psychiatry is often viewed as a soft specialty; it's touchy-feely and its vital signs include such things as mood and whether someone is feeling suicidal. Our bread-and-butter is someone's family support or occupation or marital status or education. We ask where our patients grew up, how they got to San Francisco. We don't physically examine the patient. Our trade involves things the public knows (or thinks they know): depression, psychosis, paranoia.

But after two weeks of this rotation, I realize this is not an easy specialty at all. We deal with the hardest patients: the manipulative, the uncooperative, the narcissistic. We deal with the hardest people: victims of abuse, murderers, schizophrenics. We have few diagnostic tools; there's no brain scan or lab test that can diagnose bipolar disease. We have to carefully evaluate someone's history, behavior, speech, and thought process to decide whether to label someone with a potential stigma. We can't even count on our patients communicating coherently. We run the risk of asking a sensitive question that turns the patient against us. We are often emotionally drained by those we see. Our patients have chronic, progressive, debilitating diseases.

Watching a good psychiatric interview done by one of the attendings is an amazing experience. I really see the remarkable finesse, the careful wording, and the planned organization of the interview to ally the patient and convince him to share deeply personal aspects of his life such as history of trauma or the delusions no one else will believe. It takes as much skill as conducting a good physical exam to conduct a good interview with an uncooperative, psychotic, or suicidal patient. It's often very difficult to "put oneself in the patient's shoes" when they are threatening to hurt others or hallucinating or delirious.

A Day in the Life of Psych C/L

A paranoid and disorganized schizophrenic who does not recognize when others are in the room, constantly mumbling self-dialogue and flailing all four extremities. If you listen closely, you realize he's plagued by demons and spends his life trying to exorcise those foul spirits.

A man in his forties who crashed his motorcycle after an 80mph high speed chase, drunk and high on cocaine, now nearly completely paralyzed. A family who bands together despite previous estrangements to visit his beside in the ICU daily.

A woman in her 20s, pregnant in her second trimester, who has lost weight from 104 to 86lbs.

An HIV positive man, antagonistic towards those around him, completely convinced that parasites travel within his body, migrating between his ears, and crawling under his skin. In severe renal failure, he's been kicked out of enough dialysis sites that he has nowhere to go.

A man who tried to commit suicide with turpentine, alcohol, GHB, and cocaine, now saying that he wants a pen to stab himself in the heart. When asked about suicidal thoughts, he says "why? Will you try to stop me?"

A woman who is refusing a life-saving pacemaker because it is against her religious beliefs as a Christian Scientist. That's usually okay, but we were called to assess her capacity to refuse this treatment. To see if she understood what was going on, we asked her to explain a pacemaker and she said it is "an envelope that sees my heart."

Outpatient Psychiatry Clinic

We have an outpatient psych clinic for all eight weeks of the block (including through neurology) to promote continuity care and exposure to ambulatory psychiatric complaints. I think it's a great idea as inpatient psychiatry is skewed towards severity. The clinic also breaks up the long week. My clinic is at the Walden House, a non-profit substance abuse treatment center which has an amazing array of resources from education for clients to get a GED to computers to work on resumes for jobs to community groups fostering social support.

I really enjoy it; it feels like family medicine with the community setting, the types of patients, and the role I play. However, the patients are complex. The first patient I saw started crying about ten seconds into the interview. I talked to her for over an hour (which before psychiatry, I would not have thought possible) but got such insight into her childhood, social stressors, problems with the law, substance use. At the end of the interview, she told me she felt an incredible relief and thanked me for merely listening. Just yesterday, I met my first transgender patient (male to female) who was struggling with depression. She had a fascinating mental status exam and we had a great conversation.