MedMusings

I can say after being on two mental health rotations so far (my first was at a consumer non-government organisation for Medicine In Context last year), that I personally feel this is one of the most interesting fields which enables, rather, forces you to reflect about yourself in order to gain a better understanding of the patient experience of illness. This was illustrated through the concepts of transference and counter-transference, which were pervasive ideas I encountered and revisited multiple times throughout the nine weeks of my rotation.

I felt that it was one of the most challenging areas I’ve encountered, both as a medical professional and for the patient, because of the intertwining nature of mental illnesses and their impact on all areas of life – from education, accommodation, and occupation, to the establishment and maintenance of interpersonal relationships.  These are things which sometimes those without mental illness can take for granted.I felt rather helpless sometimes, despite the biological and psychotherapeutic options that were available.  Social constructs are not so easy to ‘fix’.  As such, treatment and management of the psychiatric illness is not possible without addressing all 3 factors – biological, psychological and social. And yet, there are factors which seem out of our control and which can complicate and perpetuate mental illness. This contributes to the chronic nature of mental illness, and recurrence is almost certain.

Those with childhood psychiatric disorders will almost definitely require lifelong treatment. They would require support from their family through the various stages of life, and these needs can change accordingly. Education and support for their family thus also need to be considered as part of the long-term management.

Talking to patients in psychiatry communicated to me the need for holistic assessment much more firmly. Many consultations felt very personal to me, and few fields allow you to delve so deeply into another’s psychology and sensitive areas of their personal life history.

‘Textbook learning’ (or these days, moreso digital learning) is something that I feel can never be replaced because there needs to be a way of obtaining fundamental principles of knowledge. However, particularly in psychiatry, it would have been a very poor and deficient experience if one could not appreciate the lessons you learn from just talking to people – be they patients, patient’s families or the members of the care team.

Being around psychiatrists, mental health nurses, allied health and case workers gave me a variety of different perspectives about mental health and illness, and as a whole, I was able to appreciate the integral role of each member in the team. I also was able to gain valuable insight into my own mental health from seeing how they coped with the emotional and psychological load that comes with being burdened with the life stresses of other people.

Psychiatry is not for everyone; however, there is no shortage of interesting characters. I don’t know, I’ve always been a bit of an internaliser and analysis is one of the things I like to do anyway. I like exploring my own, and other people’s psychology. And here, I for once was given the time and legitimate reason to do it without sounding like a complete creep, lol. I think this term just made me more aware of the scientific spin that you can put on it.

PS. ECT is boring. We arrived at hospital at 7.30am, got to the OR to be shown and explained: ‘This is a machine’. The procedure barely lasted 2 minutes, and 2 psychiatrists came bursting through the door simultaneously AFTER everything was over to ask if they were needed. Need I say more? You still have to get it checked off though!

I would talk about my blossoming relationship with Evange through all of this, but…you might throw up. LOL. What’s the feminine equivalent of a bromance? A man-date? Cos that’s not what we have/are.

Not even a little bit, not even at all.

(backdated to 12 Mar 2010)

On Wednesday, as part of my attachment, I attended the Eating Disorders Clinic at Browne St with Dr Hay.  I felt that the patients I saw were representative of the population, although Dr Hay did say that it would be skewed because it is a specialist clinic.

Patient A was an 18yo female who came with her mother, but was seen alone. An issue that came up, even before the consultation had begun, was my presence in the room. Although the patient had previously consented to having a medical student present, it came into light that her father was a practising consultant in the SSWAHS. In this case, maintaining patient confidentiality would be even more paramount. The patient was however, very obliging and had no issues with having me present, which I am grateful for. In keeping with what I have discussed before, I was aware of the beliefs that I myself brought with me. There were issues within the family dynamics that was a possible perpetuating factor in her condition. The fact that she came from a family of 3 sisters prompted me to reflect on my own family dynamics and how I could be impacting upon my own 2 sisters.

Patients B and C were also interesting as I was given a glimpse into the process involved in CBT (cognitive behavioural therapy) and also when hospitalisation is warranted for eating disorders.

Due to the vast numbers of patients visiting that day, I had plenty of alone time to talk to Dr Hay about…psychiatry. Haha, but as you do, conversation topics tend to drift off into areas you otherwise would not have had the opportunity to explore unless in a casual one. I learnt that as a medical student, she had done her elective in Manitoba, Canada. She talked of it fondly, and her recall was kind of amazing. I think it added a new dimension to her I hadn’t seen before.  It also somehow culminated in her buying me coffee, so…yay? LOL.

Patient C had the lowest BMI of any patient I have ever seen before (12.6) and had multi-system impairment (predominantly cardiac and renal). Despite this, I could see the inner struggle that she was having, coming to terms with the potential weight gain she would have in hospital. Dr Hay talked of the conflict she was experiencing inside herself – one side voicing the need to lose weight, and one side wanting to overcome the disease. It was clear which side was winning at the time in this patient, and that even with hospital care – it would be a long and difficult path ahead for her.

So at the request of some, I’ve decided to post up some of the entries I had to write as part of my reflective journal for the Mental Health attachment. Be warned: they may not be very stimulating, lol. However, it may give you some insight as to what you can expect if you’re doing it next!

To build on the last entry I wrote: (backdated to 16 Feb 2010)

I have often pondered the role of women in medicine, particularly what they each personally wish to aspire to. We all seem to recognise the balance that we will eventually have to establish maintain, especially between work commitments and family. Not infrequently, we wonder whether this balance is achieveable, or realistic. Sacrifice is something that we are forewarned about. ‘Are you *really* ready for this profession?’ is something we were constantly asked before medical school.

Hence, this registrar’s story was inspiring to me. I think you need a pleasant reminder once in a while, that things may be hard, but they’re still possible. It was like listening to a modern-day fairytale.

In continuation of what my experiences have been on this rotation though, I have still been seeing more patients come through Waratah House. However, the importance of social history has once again emerged in that I am being constantly reminded that history-taking is not a static process –patients with long-standing social issues will frequently require assistance from mental-health services (both community, and unfortunately, there are also readmissions to in-patient care). Their histories are always evolving.

A difference (among many) between the way the psychiatric ward is run and the way a medical ward would be run is that patients have intensive follow-up, and I have commonly seen symptomatic patients discharged. For example, Ms X was a patient diagnosed with chronic schizophrenia who had been abusing alcohol in order to help her sleep, but in the past had also multiple suicide attempts by overdosing on benzodiazepines. On discharge, she seemed euthymic and wanted to stop drinking. She was sleeping better, and had no suicidal ideation. On attending a meeting at Browne St (the community mental health centre) the week after, her caseworker reported that she had resumed drinking a bottle of white wine a day again to help her sleep, and would continue to do so unless she was given more sleeping tablets. The dilemma arises as she is known to stockpile and overdose on these. The solution was to try and encourage her to obtain weekly Webster packs.

Also, because of the association between one’s social environment and various psychiatric conditions such as schizophrenia, post-traumatic stress disorder and substance abuse, if there are ongoing social issues, the patient will be unlikely to fully ‘recover’. One instance of this that I witnessed was in a patient who had been in WH for two weeks, suffering from depression. He had seemed to be doing well, he was no longer suicidal and stated that his sleep and mood were slowly improving. Over the weekend, he had leave to be with his wife (coincidentally, it had also been Valentine’s Day that Sunday). When he came in with his wife the following Monday, she promptly stated ‘I want a divorce’. This will not only likely put him at greater risk of falling into further depression again, but he now has other social factors that need consideration such as future accommodation, deterioration of support networks and financial independence.

One patient encounter has stood out to me so far this week, because it is not something I was expecting and not something I have had to do very often (yet). A 48 yo man was brought to WH yesterday from PECC, with what seemed to be symptoms of a psychotic episode (auditory hallucinations, fear of persecution, paranoia). This man did not speak or understand any English, and an interpreter could not be booked for the day of his admission. Hence, I was asked to spend some time with him and take a full psychiatric history. I ended up speaking to him entirely in Vietnamese, and found him to be quite coherent and responsive. I was surprised at how much information I obtained, as I had been doubting whether I would be capable of conducting an interview in Vietnamese (considering I have no medical vocabulary in the language).

I went home that afternoon and told my parents what I had done at hospital that day (something I try to do as much as possible, because I don’t spend as much time at home these days), including this encounter. I realised that talking to him had reminded me of the time my own father was in hospital, and how isolating he had found the experience – not being able to communicate with anyone or understand much of what was going on.

A take-home message: “Countertransference exlains why therapists need to do their own therapy.”

While setting up for a Multi-disciplinary Team meeting, one of our registrars unexpectedly began to talk to us about her family, and in doing so, proceeded to reveal to us her own journey, her own story. We couldn’t have been more captivated by the things she had to say.

She asks me a question, and it is not a question I have not heard before. I have almost always wanted to be a doctor, since a child. I don’t know why, but I was always interested – even though thinking back, I can’t say I was highly influenced by anyone. It is a common preconception (particularly because of my background) that my parents would have had a large say in it – something along the lines of ‘doctor, lawyer or if you do really badly, pharmacist’. Strangely, my parents placed very little pressure on me – least of all regarding what I wanted to be when I grow up. I’m not sure how many people believe me when I tell them this. As for the registrar, she smiles approvingly, and reveals she had wanted to be a doctor since she was four. When she played, no one else could be the doctor – only her (everyone else had to be patients).

She eventually completed Medical School in Pakistan, got married and had become an O&G registrar on the verge of starting her own practice. It was around this time that she became pregnant with her first son.

Having to juggle commitments, she had to place her son under the care of a nanny at home. One day, while coming home from work, she found her 2 year old son asleep near the front gate, nanny by his side. She revealed that he had insisted on waiting until she came home. It was at this moment that she decided that she had to put her family first, and she stopped working to raise her son. She also had another son shortly after, and began to raise him also.

She soon came to the realisation (with the help of her husband) that she was becoming bored, and needed something for herself. She began working again as a GP, running her own practice. Once again, she would find herself giving this up for her family – one day, she found one of her sons in the medicines room: ‘Mamma, this candy is yucky!’

Her husband had then decided to emigrate to Australia, and she too followed. Shortly after, they had a daughter. It would be 10 years before she came back to Medicine, when her daughter started school. She passed all her examinations, and has currently been a Psychiatry Registrar for several years. As someone who had known almost her whole life she wanted to be a doctor, these ten years must have been one of the hardest times for her. But looking back, she does not regret a thing. Her friends may be consultants by now, but she never failed to be by her children’s side. She has a twenty-one year old son who will get up and make her breakfast, and phone calls worrying about her when she does night shifts.

She is currently finishing her thesis this year and will obtain a Masters degree. Aside from medicine, she also writes short stories and poems which have been published. When introducing herself, she reveals herself as a writer before a doctor. She urges us to find our own creative outlets.

Her voice lowers and she looks us straight in the eye when she tells us: ‘You will always be a doctor if you really want to be, but if you don’t know what your husband likes to eat, what your children like to eat, what sort of woman are you?’

And then the first patient enters; she gives us a last smile before efficiently and professionally following up the patient and updating his medications.

That night, E (my clinical partner) and I (rather uncharacteristically) dream of family.

I was just wondering if anyone else is bringing parents to the halfway dinner?

And if so, if they would be interested in sitting with my parents? LOL. They friendly, just don’t speak English too well.

…this sounds like one of those searching-for-a-friend ads.

Cardiology is going good. Haven’t done a night shift yet. My team is very efficient at discharging pts, lol. Need more cannulation practice. My Reg had 4 sugars in his coffee the other day. I accidentally (reflexively) typed LMAO instead of LMO in a patient’s discharge summary today.  Have people started having hospital dreams yet? xD Not that I have. 

I have no idea how to study from my hospital notes. All over the place. D: 

Miss your faces (except Shihui’s; I see your face plenty).

Some interesting pt encounters today:

Filipino man: had a massive AMI yesterday but is only visiting his family in Australia and has no health insurance. Every night he stays in hospital costs him $1200. He needs an angiogram which will cost him $10,000 and to have a bypass operation would cost about $30,000. When the family were told they could pay $50/wk in the meantime, they couldn’t even afford that. This isn’t even taking into consideration medications yet. His family face a huge decision: to bring him home with the very high likelihood he will have a recurrence without proper treatment, or to keep him in hospital and get him treatment while incurring a huge debt.

We asked one of our regulars (89 yo female) how she was this morning and she replied: “Last night I saw a ghost and I couldn’t go back to sleep.” Apparently, being on prednisone gives you hallucations. And yes, we still tried to do cardinal features (‘When did it come on?’, ‘How long did it last?’, ‘Where did you see it?’, etc.) LOL.

17 yo boy presents with hx of a seizure…and wait for it, “father attempted to rouse son by hitting him over the head (gently) and shaking his shoulders.” FAIL.

In my first 3 days, I’ve:
x heard an ejection systolic murmur over the aorta, radiating to the carotids (83 yo woman with aortic stenosis that has progressively worsened over several years)
x heard a diastolic murmur over the apex (mitral stenosis)
x auscultated a pt who had 2 prosthetic valves (mitral and aortic) put in. metallic-clicking sound.
x seen a stress test being done
x sat in on echocardiography
x tried to cannulate, been cannulated and finally did one successfully (albeit a little messily!)
x watched a patient get an ABG and cannula this morning. This afternoon, we watched this same patient get a pleural tap and ascitic tap – pleural tap took 3 goes and 2 people to get it, and ascitic tap…probably more than 5 tries by various people with a progressively larger needle (final one was a spinal tap needle), and they still couldn’t get it! Patient had lots of oedema and surgical scarring though, so it was hard. Felt kind of bad for him nonetheless.
x taken some histories, examinations
x wrote in patient notes with the SOAP system

Nonetheless, there’s still some quiet time (usually when the RMO or registrar is busy) and I’ve learnt how to blend into the wall. Victor seems really pro at everything.  xD

Main impressions so far:
x Lots of old patients!! Most of the patients I’ve seen are over 80 with so many comorbidities on top of their cardiac disease.
x Did not realise ward rounds went on for so long.
x Nurses are actually pretty nice, they helped me read medcharts and gave us people to cannulate, but then I haven’t been yelled at…yet.
x How crazy is Grand Rounds food?! And where on earth is Surgical Grand Rounds? Haha.
x Cardio Blue team seems M.I.A. LOL.

This patient we met today smoked 40/day. I’ve never SEEN such a massive pack of cigarettes. He calls it going out for “fresh air”.  ._.

TIREDDDD!

Perhaps I’ll leave with a quote:
“The young man knows the rules, but the old man knows the exceptions.”

Take care guys

xx

So because I’m a sheep, I shall add my tidbit tooo. =)

Today I (and three others) presented our project to 3 of the people at our community placement (a discussion of the sexual health issues in mental health, and how the service could address them). On Mondays, we walk down to a place nearby for lunch which makes these awesome focaccias (which I’ll sort of miss). For some unknown reason, we ventured into this Indian grocery store. It was weird because even though some of the packaging was in English, I still sometimes couldn’t figure out what it was I was looking at.

Okay. That wasn’t about my clinical experience at all. But…I think you’ll understand when you get to MiC. Sometimes you’ll wonder why you are where you are, and what you are doing there.

On a slightly cooler note, I HAS A CAR. =D