Fridays

Finally it is the last day of the work week. Fridays are something to look forward to for many reasons (the upcoming weekend is an obvious plus), but I also very much enjoy an afternoon in probably my most challenging clinic. Usually the mornings are filled with either Radiology lectures or our "Master Clinician" series (a case-based discussion with many of Asheville's finest physicians). This is followed by a few hours of studying/continuity, and then Psychiatry in the afternoon. Psychiatry has offered some of my most colorful and challenging patients, as well as the best opportunity to really get to know my patients as people. In our initial interview, we (the students) spend an hour listening to the patient's story and asking questions. Only then do we take about ten minutes to discuss the case with our preceptors, and then we all talk as a group for the remaining twenty. So the students actually spend way more time than the physician with each person. And, unlike the outpatient clinics where we may only have ten minutes, there is usually very little pressure to accomplish any "agenda." It is a much more relaxed setting.

However, I must admit that Psychiatry hasn't always been a "relaxing" clerkship for me. I have always strived to get out of my comfort zone, and Psych has offered the best opportunity to do that this year. This is a field I certainly had no experience with prior to our orientation in October. For the first few months, I was almost always nervous before meeting each new patient. I never knew the "chief complaint" before starting the interview, and so every encounter was a surprise. Would the patient be manic? Schizophrenic? Suicidal? Thus, it honestly took me longer than usual to get truly comfortable with asking the important questions... Have you ever attempted suicide? Have you ever thought about hurting yourself? Have you ever harmed someone else? Have you ever felt like you were ever physically or sexually harmed? I usually acknowledge the confidentially of the patient-physician relationship first, but I initially felt uneasy asking the hard questions.

One thing this experience has taught me is to keeping asking and asking until you have an answer. Psychiatry is the ultimate "tell me more about that" specialty. Once I got comfortable asking patients the tough questions, I realized that sometimes I was moving on without getting a true answer.

Have you ever thought about hurting yourself?
No, not really.

At the beginning of the year, I would move on. But, "No, not really," is not really an answer. Tell me more about that. As I delve further into that line of questioning, I realize that many times patients just don't want to answer outright. Maybe they are scared or uncomfortable. This may be the first time they've admitted such feelings. Often it requires gentle prodding to fully understand the situation. I have found that "No, not really," actually may mean, "I only think about hurting myself when I'm alone. Yes I live by myself, and yes I own a firearm." Continuing to ask questions, and geting the full picture, is something that I have had to work on throughout the year.

Psychiatry has also given me a crash course in crisis management. Numerous patients have called me contemplating suicide, a number of people have called for prescription refills (won't be for a few years!), and some patients have called just to talk. Taking a step back, these are the encounters that remind me what an honor it is to be a physician-in-training, and how great the responsibility of being a doctor will be. My Grandmother once told me, "With great power comes great responsibility." My Psychiatry patients remind me of this constantly.

With the danger of putting too many thoughts into one Post, I will just make "one quick little teaching point, only if you can stand it" about Radiology. This is a field that many medical students get zero medical training in, unless they choose it as an Elective. Fortunately, we have been lucky enough to receive biweekly imaging lectures throughout our longitudinal months. I have spent many half-days sitting in the Radiology reading-room, and I absolutely must do Radiology during a month in fourth year. I doubt I could make a career out of sitting in a dark room most of the day, but it is a field that is constantly expanding and becoming an integral feature of every specialty. So, I've tried my hand at images about once a month since October (hopefully with some improvement).

The other specialty I need to try fourth year is Nephrology. Third year has taught me that I know nothing about the Kidney, probably due to my absence throughout much of Physiology during 1st year. For that, I have Ronnie Milam to blame, and 5 Star Nerve to show for it.