While I am a medical student, the purpose of this blog is not (or at least it wasn’t when I envisioned it) to blog about my journey through med school. One of the first blogs I remember reading was called ‘Over my med body’ and it was a brilliant blog written by a (then) medical student. I’m sure there are blogs out there of med students telling their tales on the floors, but that’s not what I want to write about. I realize, however, that over the next couple years I will go through things that most people will never experience. I’m seeing things that people only hear about third hand or see dramatized on TV. Occasionally it might be fit that I share my experiences. Now is one of those times.
I’m currently on my Psychiatry rotation. I don’t wish to openly discuss the medical school I attend, but I’m currently doing a clerkship at a public hospital in one of the poorest cities in the country. In general, the people that we attend to are uninsured or underinsured. There are high rates of chronic disease such as diabetes and hypertension, infectious disease such as HIV and TB, and extensive drug use. Learning medicine in this kind of environment is learning medicine in the trenches- it is one hell of an education.
I’ll admit that I’ve always been a bit intimidated by psychiatry. I’m in awe of the brain, specifically its ability to control such complex tasks with the use of limited resources. When it comes to neurotransmitters, there really aren’t that many. The brain effectively controls all our thoughts and actions with an incredibly limited vocabulary (5 neurotransmitter “words”: GABA, glutamate, dopamine, serotonin, and acetylcholine). I’m amazed it works in the first place, and I’ll admit that I’ve long been apt to think “Glad you work- let’s leave well enough alone” when it comes to contemplating the brain. Of course, just because something is hard to study, doesn’t mean it shouldn’t be studied. Indeed, that’s the point a fellow MD/PhD student made to me when he tried to wipe the look of surprise off my face when he said he was going into psychiatry. We need more great minds in psychiatry- the specialty is lucky to have him!
If you’re interested in an evolutionary approach to psychiatry, you MUST check out Dr. Emily Dean’s fantastic blog (please do- it would be the least I could do to send a couple clicks to her blog when she refers so many to me!). There’s a lot to think about and talk about when it comes to an evolution-based approach to psychiatry, and while I think that good nutrition, good sleep, good exercise, and good stress-management are all important for good mental health, I’m going to leave the tricky stuff to Emily.
Now, after a lengthy preamble, I get to the crux of the matter- my insight from the floors.
As one might imagine, the inpatient psychiatric ward at a public hospital in a poverty and drug-stricken community is… intense. I’ll admit to being thrown a bit off kilter by the bustle and (apparent) mayhem on my first day on the floor. You know you’re in a bad way when a fully psychotic patient gives you a look and asks ‘Are you ok?’. Aren’t I meant to be asking that question? Just how pale and wide-eyed am I? Inpatient psyche in this setting is not your aunt’s depression, or your roommate’s mania (not to belittle these conditions). The people we see on the floor are there voluntarily or involuntarily for a variety of reasons, but most frequently for schizophrenia, suicidal ideations or attempts, debilitating anxiety and depression, and/or delusions (frequently a combination). These patients are fascinating, and heart breaking. Some have insight into their condition (they understand that they have a mental illness), but many do not. On this floor you see how obsession can drive you to depression, and then to attempts to take your own life. You can see how delusions lead people to circumstances where they are at risk of hurting themselves and others. You see paranoia that cripples a person. These descriptions do not do the patients justice, but I don’t think any description would. It is something that has to be seen to even start to understand, and I am very grateful I have that opportunity.
Seeing these situations first hand is eye-opening. As I said, the first day I found myself overwhelmed. The psyche ward is a very different experience than medical wards. On medical wards, most patients are confined to their bed. You might see the odd patient out wheeling their IV around, or being taken for a walk around the floor by a therapist, but the halls are generally restricted to nurses, students, doctors, and visitors. The psyche ward is very different. These patients are almost all able bodied, and being out and about is good for them- many reap benefits from the group activities and sessions. We don’t want these patients in bed, but having them all up and about makes for a very interesting dynamic. It can get loud, it can get rowdy, and if you don’t know the patients, it can get scary (it can get scary when you know them too).
As I said, the first day I was overwhelmed. I saw patients only with my resident and attending (though I did have a very long chat (a real education for me) with one of our patients about the different street drugs she had taken and the various routes of administration (I learned more in that 10 minute chat then I did in all the years of drug education)). The second day I was cautiously curious, occasionally going out on my own to talk to a patient or do a mini-mental status exam, then seeking refuge behind the Plexiglas and locked half-doors of the nurses’ station. By the third day I was visiting patients on my own, and checking in on them for updates before we rounded… I think that was the turning point.
Psychiatry, especially in this setting, is all about observation. A patient may tell you one thing, but what you observe can give you much more information. Also, getting ‘collateral’ from family members, admitting physician’s notes, and lab results is very useful. A patient may tell you that he was brought in by the police after he called to complain about his upstairs neighbors (who frequently steal his stuff) getting in an argument, but a family member may later tell you he lives in an attic apartment and has no possessions. Equally, someone may report visiting an outpatient clinic regularly, only to name a hospital that closed years ago. These patients aren’t lying- or at least they’re not trying to. This is their reality. An accurate history is important in understanding the full picture of a patient, but obtaining one from a psychotic patient is often impossible.
Mental illness is not cool. It isn’t popular or sexy. I’ve received countless requests to participate in or donate to all manner of ‘walk for the cure’ events for juvenile diabetes, cancer, heart disease… chances are you’ve donated to these things if you haven’t participated in them directly. It’s an easy sell- everyone knows someone with diabetes, heart disease, or cancer. This IS your aunt, your roommate, your neighbor, and your friend.
Maybe it’s just me, but I’ve never seen an event aimed at raising schizophrenia awareness. Chances are, you DON’T know someone with schizophrenia, though the prevalence is actually not that low (perhaps around 1 in 100). While we’ve made great progress at eliminating gender, racial, and sexual inequalities, there remains a great stigma around mental-health. The heart is a pump, the liver a processing plant… the brain is ‘us’ and a disorder that affects who we are, without other signs of disease, can be hard to comprehend and accept.
Sometimes in the world of evolutionary health and wellness we like to get lost in the utopian ideal that an evolutionary appropriate lifestyle will fix everything. Overweight? Type II diabetes? Acne? Infertility? We’ve got lifestyle-modifications for that. But there are very real and very devastating conditions out there that will not and cannot be fixed with a change of diet and exercise. I’ve found the last week of my education amazing on so many levels- the patients, the staff, the doctors, and the drugs… I am in awe. I’ll miss the ward (and I will be back), but I don’t think it’s where I want to practice in the long run. I am very happy, however, that bright minds are tackling these issues and that there are people dedicated to helping a population that is often unable to ask for help.