Pondering on: Psychiatry

"Psych is a good break, so schedule it in between two hard rotations like OB/GYN and Surgery."

That's the advice that sage MS-3s will give the wide-eyed MS-2s as they plan out their schedules for third year. I wondered why this was so and whether or not Psych deserved the "bad rap" that they got for being easygoing slackers.

The wonder vanished when I entered Psychiatry. As a disclaimer, I am not saying that Psychiatry residents are trying to avoid hard work or do as little as possible for their patients. After all, they are still doctors and ALL doctors are caring and they all work hard (at least all of the ones I've met so far have upheld this archetype.)

I noticed that there is a certain aura that Psychiatrists try to cultivate. It is a very crafty and carefully created sense of ... relaxation. Low stress. The level of care for our med-student well-being went far beyond what was necessary and it was almost laughable at times. Here's a true story of something that happened to one of my friends:

"You rounded on your patients instead of having lunch?!? WHAT?!? Go eat! Go to the dining hall. We don't really need you here for our afternoon psych rounds anyway."

I would almost feel bad about hanging out with the residents in my attempts to soak up psychiatry when they were sitting around idly. I think the record earliest time I ever got out was by noon. Granted, this was after rounds with three separate attendings/groups and we rounded on a lot of patients, but that is really early. And I wasn't done for the day; I still went to school to read about psychiatry.

In my opinion, the reason why the psych residents were so aggressive about being so relaxed has a lot to do with their patient base. I was on the consult-liaison service at a large hospital in my state. There are a lot of patients who were admitted to the hospital and had psych issues come up tangential to their main diagnoses. We were called in to see them for the psych issues. It wasn't necessarily because the medicine or surgical teams couldn't handle alcohol withdrawal syndrome or depression or schizophrenia. They didn't have time to take care of these problems.

THAT is the crux of the psychiatrist. Their niche comes from having this precious TIME to sit down and talk with patient for as long as it takes to make a connection and help them feel better.

Even if they have a ever-growing list of patients on the service, the no-stress attitude keeps them from glancing at their watch or the clock (and undoing a lot of patient rapport when the patient feels pressured to "wrap things up" or what have you.)

5 Tips for Telling Better Stories

And how to apply it to your case presentations. The majority of these pearls are things I've gleaned from simply writing FIVE History and Physicals on some of my patients in the Inpatient Medicine block... my preceptor is very particular. She was very thorough in with her criticism, but as a result, I really felt the difference in my thinking. I'd like to send these tips along to you.

1. Keep it simple.
* A strong assessment needs to occur in your head FIRST, in order to frame a simple story, simply. I've made a lot of short stories much longer with my med-student induced compulsion for all details regardless of relevance.

2. Openings and closings are very important.
* Like an abstract for a research article, the first sentence should be the last thing you write. This sentence should give away your entire story and make the listeners feel smart for figuring it out so swiftly.
* Similarly, for the listeners that zoned out the whole time, you need to piece the whole thing back together at the end.

3. Be mindful of your story’s spine.
Keep in mind that EVERYTHING you say must come from the Patient-First Perspective. What does that mean? You need to pay attention to everything they say!
* Don’t interrupt the patient! There have been studies that show doctors interrupt the pt after only 18-22 sec (on average) after asking "so tell me what brought you here to the ED/hospital/clinic." However, given the opportunity, patients will only talk for 90 sec (on average) and no more than 2 min uninterrupted... much shorter than it feels I'm sure with the most verbose patients.
* Giving patients the opportunity to frame their OWN story before you stuff them into a boxed diagnosis gives you the chance to uncover something brilliant. I always make a few good observations on my team's behalf whenever I remember this particular rule and give the patient some freedom at the beginning of the interview.

4. Make sure not to alienate your audience.
* Residents, attendings and consultants are very busy people, I've learned. It's best to figure out EVERYTHING that's important before you dive in and present your case. The whole reason why med students are required to ask everything in the history, perform everything in the physical exam and present everything in a systematic order is NOT to bore people to death, though that's a major side effect. It's because we're dumb. We don't know what is important yet.
* Basically, as a med student, you should revisit this fact and remember who you're talking to. Sure, for the purposes of displaying your full understanding and adherence to procedure you can recite a HUGE laundry list in your review of systems... but the attendings will cut you off. Cater your speech to them.

5. Tell the truth.
* In rounds, I've frequently joked and said "oh, just make something up, they won't know the difference" whenever someone asks a solid question that wasn't investigated further as a query to the patient, lab data not collected or study left unperformed. But really, this negates the whole point of the rounding exercise. A patient's wellbeing is at stake.


References
Hat tip to A Storied Career
Gordon, GH. Defining the Skills Underlying Communication Competence. Seminars in Medical Practice. Vol 5, No 3. Sept 2002.

McCain Hates Science and Math. (My Biased Opinion.)

I am OUTRAGED that McCain has cited several items in SCIENCE as "pork-barrel projects. Nothing pisses me off more about his campaign than his blatant ignorance about the importance of science.

"[Obama] voted for nearly a billion dollars in pork barrel earmark projects, including, by the way, $3 million for an overhead projector at a planetarium in Chicago, Illinois. My friends, do we need to spend that kind of money?"

MY friends, we spent $3 million of your money to study the DNA of bears in montana. Now, I don't know if that was a paternity issue or a criminal issue, (LAUGHTER)... but the point is, it was $3 million of your money. It was your money. And, you know, we laugh about it, but we cry - and we should cry because the Congress is supposed to be careful stewards of your tax dollars."

On Science Friday and in the Scientific American, the scientists speak out.

They insist that the [Bear DNA] study is not only worth every penny but that the $3-million price tag cited in the ad is, in a word, wrong.

In fact, Congress over the past five years has forked over a total of $4.8 million to study the genetic material of Montana's grizzly bears, according to Katherine Kendall, a research biologist at the U.S. Geological Survey (USGS).

“This is not pork barrel at all,” says Richard Mace, a research biologist with Montana Fish, Wildlife & Parks (FWP). “We have a federal law called the Endangered Species Act and [under this law] the federal government is supposed to help identify and conserve threatened species.”

The fact that he calls it a "$3 million dollar waste of money" instead of the higher price tag goes to show that he can't even do simple MATH to criticize a program. Not only that, but it's evident that this program IS a paternity issue. It's studying the ancestry of an endangered species! DUH.

On ScienceDebate2008, McCain replied to the top 14 pressing questions candidates should answer. Here's his take on science and education. Funny how his actions diverge from his words. Or maybe its just his words contradicting his other words. Hypocrisy!

• Eliminate wasteful earmarks in order to allocate funds for science and technology investments;
• Grow public understanding and popularity of mathematics and science by reforming mathematics and science education in schools;
• Basic research serves as the foundation for many new discoveries and represents a critical investment for the future of the country and the innovations that drive our economy and protect our people. I have supported significant increases in basic research at the National Science Foundation. I also called for a plan developed by our top scientists on how the funding should be utilized.

UGH. I'm soo annoyed by this... on top of everything else that he's said or done so far this election. I must admit, I liked him a lot more when he wasn't running for presidency and merely keeping up his national image on the Daily Show and other shows.

(edit: And apparently, I hate english. I corrected some of my glaring spelling and grammar errors. It's been a while since I've written anything in proper English! *shakes a mocking fist at 5am Medicine Notes*)


Palin chimes in with her bit.

"Where does a lot of that earmark money end up, anyway? [...] You've heard about, um, these -- some of these pet projects they really don't make a whole lot of sense, and sometimes these dollars they go to projects having little or nothing to do with the public good. Things like fruit fly research in Paris, France. I kid you not!"

Wow. I'm sure that "fruit fly research" is EXACTLY the sort of waste-of-money earmarking that you think it is... and it has no impact on autism research.

Pondering: on Medicine

I'm busy on the Medicine service right now. It's by far, my favorite rotation so far in my third year as a medical student -- and I've done a month of inpatient OB/GYN, Psychiatry, Surgery and Medicine so far!

Medicine contains enough of what I learned as a first and second year that I don't feel totally lost in a new world of procedures (uncomfortable bouts of standing and trying not to infect patients in GYN/Surg) or protracted interviews (with difficult formulations in psychiatry!) Inpatient Medicine adds on a whole new level of intensity in admitting patients from the Emergency Department and caring for patients in the Intensive Care Unit, transitioning them down to the Progressive Care Unit and then out into the world. Surgery does this as well, but the majority of my day was spent in the OR rather than the ER or on the wards. To be quite honest, my favorite days of surgery were on the days when our general surgeons weren't in the OR and I had time to round on my patients and figure out how to manage their problems.

That must make me totally IM in the Medicine vs Surgery battle...

Best of: OB/GYN on HPV

In Grand Rounds for OB/GYN, a lecturer talking about vaccinations for young women said something that I thought was totally hilarious. My vague recollection of the quote goes something like this:

A study showed that 32% (95% CI 22.5-44%)of men in a university setting (n=240) had detectable HPV DNA on their hands. (1) That's not necessarily saying anything about their sexual habits...

He went on to say "It just goes to show that HPV is more prevalent than people think. And it can easily spread through hand-shaking." This does raise the distinct possibility of the hand-genital route as well, suggested in an earlier article. (2)

As funny as I found this initial statement to be, it's a serious and sobering topic. Especially since we have the HPV vaccine that can prevent cervical cancer with about 70% coverage. (Not good enough, by Dino's standards.) According to this week's Morbity and Mortality Weekly Report, "an assessment of HPV4 coverage, which is reported for the first time, showed that "25.1% of adolescent females initiated [Gardasil], the vaccine series (>1 dose) in 2007." Yay!

The Health Science Report shares information about the transmission of HPV in general, which can happen through other routes than sexual contact.

A report in 1/08 from the Journal of Infectious Diseases suggests that young women have an increased risk for HPV infection when their first male partner was sexually experienced with a Hazard ratio of 8.5 (95%CI 3.1-23) for 3+ previous partners, 3.6 (95% CI 1-12) for 2 partners and just 0.4 for 1 previous partner (95% CI 0-3.3) with 1.0 Hazard ratio as the reference for first sexual partner. (3)

References
1. JM Partridge - JOURNAL OF INFECTIOUS DISEASES, 2007. Genital Human Papillomavirus Infection in Men: Incidence and Risk Factors in a Cohort of University Students.
2. C. Sonnex. Detection of human papillomavirus DNA on the fingers of patients with genital warts. Sex Transm Infect. 1999 October; 75(5): 317–319.
3. Winer RL. Risk of female human papillomavirus acquisition associated with first male sex partner. J Infect Dis. 2008 Jan 15;197(2):279-82.

"When should I start teaching my children about sex?"

Dr. Karen Rayne has an excellent answer to this question that touches on the underlying implicit emotional issues that are often ignored in our often explicit and graphic culture. Here is an abbreviated version of her typical answer:

When you “should” start teaching about sex doesn’t really matter - you DO start teaching about sex when your children are infants.
...
You teach them what a gentle touch feels like and what it is to be loved.
...
We teach them the names of their body parts, and the names of everyone else’s body parts too.
...
We teach our young children how to be a good friend, how to share, and how to reconcile arguments and disagreements graciously and with love.

This is a wonderful lesson for everyone to have -- I think there are many ADULTS who still haven't been had proper sex-education in this context.

Read more from Dr. Rayne @ Adolescent Sexuality