It's now been about a week since I started work on my inpatient unit. I'd love to tell you an insightful and inspiring story about a patient I helped this week; that looks like it'll have to wait for the indefinite future. The truth is that like many inpatient services, medical or surgical, we can't fix long-standing problems. We're a service for short-term stabilization -- getting someone just to the point of not being suicidal, not being off-the-walls manic, not hallucinating too much. But, just like medical illness, psychiatric diagnoses don't exist in a vacuum. If you're just depressed, you probably won't get anywhere near true suicidality, because your family and friends will drag you in front of a doctor way before that. But, if you're depressed, AND you had a traumatic childhood that left you unable to cope with life stress, AND you use alcohol/drugs heavily to cope with your depression and life stress, AND you're not exactly highly educated/compensated because of the foregoing, AND maybe you've got some chronic health problems to deal with, then chances are that at some point, you're going to just plain lose it. (The polite medical word for this is "decompensate".)
When you do, you'll end up on a unit like mine. My job, as determined by your insurance company, the law, and general custom, is to patch up your psyche, whether it's by increasing or changing medications, getting you a bit of detoxification from your substance of choice, or just giving you a safe and quiet place to hide for a week. What I'd like to do is let you walk out of the doors a few weeks later as a complete and functional person. Unfortunately, I can't. This isn't just the limitations of the medications and my own developing psychotherapy skills; it's the limitations of the world. For 90% of my patients, what's wrong with them is partly in their brain, and partly in their world. Their entire living environment reinforces whatever bad coping strategies got them admitted in the first place. Moreover, those bad early experiences have been burning themselves into the allegorical neural pathways for decades. It's not biologically possible (to the best of our knowledge) to undo years of conditioning in a week, or even a month. The best I can do is boost up the brain chemicals, get some help from our social worker to tweak one or two environmental variables, and then send the person back to their environment with a list of suggestions. Sometimes, they follow them, and over many years, they get better. Sometimes, they don't. Frustratingly, I don't get to find out.
This is, of course, not to say that what I do is useless. Far from it. My short courses of treatment are the equivalent of duct tape and twine, but if you know what you're doing, duct tape can take you pretty far. Moreover, treatment is the difference between one suicide attempt, and a suicide attempt followed by another, and another, until the person finally "succeeds". What frustrates me a bit is the endless list of problems that must remain unfixed. Like all good little doctor-trainees, I've got a perfectionist streak a mile wide. It's very hard to leave valuable work undone, and even harder to look a patient in the eye and tell them that no, I'm just not going to help with that particular problem. I'm sure I'll get a lot more comfortable with that as the year goes on; I'm not as sure that this is a good thing.
Tuesday, June 30, 2009
Monday, June 22, 2009
Trepidation
Since most of my readers (at present) are not psychiatrists, I thought it'd be good to start with that perennial question, "So what do you do, exactly, as a psychiatrist?" Since the next four years are supposed to be a comprehensive preparation for independent practice, the answer is really "a little bit of everything". But, at least for the next year, the answer is "one month of ER, one month of medical consults, two months of inpatient pediatrics, two months of neurology, and six to seven months of acute inpatient psychiatry". (A month is 28 days, hence why we have thirteen of them.) Like most intern years, it's heavily focused on the inpatient (people coming in to a hospital, as opposed to being in a clinic) management of acute (seriously ill, potentially life-threatening, fixable in a relatively short timeframe) conditions. In my case, that starts with acute inpatient psychiatry at the main University of Washington hospital.
Most of you will be lucky enough never to see the inside of an inpatient psychiatric unit. In some ways, it's like the other inpatient medical units you may be familiar with. Patients see their resident (and med student, if they have one) in the early morning, get seen again by the whole team (including attending physician) in mid-morning, have medication adjustments, tests, etc. ordered in the late morning/early afternoon, and then spend the rest of the day hanging out while waiting for those orders to be implemented. On a given day, one or two people get discharged, and others come in to take their place; the residents spend their afternoons doing the basic intake exams and paperwork required to keep that machine running.
Psych units have two big differences that still leave me a little nervous (hence the title of the post). First, instead of a large team, psychiatric inpatient care generally means one attending, one junior resident (me), and maybe one med student. Everything else is nurses, therapists, patient care techs[1], social workers, and other extremely helpful support personnel. In practical terms, that means that for somewhere between eight and twelve patients, I'm where the buck stops. I certainly get guidance and supervision in diagnosing them and picking the right meds, but the goal is for me to take the lead and be the primary doctor[2].
On a medicine floor, I'm very comfortable in that role. Yes, I've been away from the wards for six months, but the basic treatment for heart attacks, pneumonia, COPD[3], and heart failure hasn't changed much. Plus, I've had those drilled into me on so many rotations that I think I can diagnose and manage the average case competently. Not excellently; I'm still at the "cookbook medicine" level, and if they've got multiple other diseases the algorithms start to break down. Nevertheless, competently. I don't feel like I'm there with psychiatric disorders. I've had a whopping two months of psychiatric training during medical school, of which the most recent was over a year ago. I do still have a gut feeling for the diagnostic axes, but the full criteria and drugs beyond the first-line obvious choices continue to elude me.
Ultimately, this is what every intern feels just before he/she starts (except the ones who are delusional about their own intellect; those guys end up killing people). It will pass, about the time I'm scheduled to rotate to another service. Moreover, it keeps me humble, which is a good thing. That doesn't make the butterflies stop flapping in my stomach.
[1] The artist formerly known as "orderly".
[2] In theory; different attendings are variable in the degree of autonomy allowed, and I'm sure I'll be on a short leash the first month or so.
[3] Chronic Obstructive Pulmonary Disease, fancy doctor talk for "done smoked too much and lungs have given up".
Most of you will be lucky enough never to see the inside of an inpatient psychiatric unit. In some ways, it's like the other inpatient medical units you may be familiar with. Patients see their resident (and med student, if they have one) in the early morning, get seen again by the whole team (including attending physician) in mid-morning, have medication adjustments, tests, etc. ordered in the late morning/early afternoon, and then spend the rest of the day hanging out while waiting for those orders to be implemented. On a given day, one or two people get discharged, and others come in to take their place; the residents spend their afternoons doing the basic intake exams and paperwork required to keep that machine running.
Psych units have two big differences that still leave me a little nervous (hence the title of the post). First, instead of a large team, psychiatric inpatient care generally means one attending, one junior resident (me), and maybe one med student. Everything else is nurses, therapists, patient care techs[1], social workers, and other extremely helpful support personnel. In practical terms, that means that for somewhere between eight and twelve patients, I'm where the buck stops. I certainly get guidance and supervision in diagnosing them and picking the right meds, but the goal is for me to take the lead and be the primary doctor[2].
On a medicine floor, I'm very comfortable in that role. Yes, I've been away from the wards for six months, but the basic treatment for heart attacks, pneumonia, COPD[3], and heart failure hasn't changed much. Plus, I've had those drilled into me on so many rotations that I think I can diagnose and manage the average case competently. Not excellently; I'm still at the "cookbook medicine" level, and if they've got multiple other diseases the algorithms start to break down. Nevertheless, competently. I don't feel like I'm there with psychiatric disorders. I've had a whopping two months of psychiatric training during medical school, of which the most recent was over a year ago. I do still have a gut feeling for the diagnostic axes, but the full criteria and drugs beyond the first-line obvious choices continue to elude me.
Ultimately, this is what every intern feels just before he/she starts (except the ones who are delusional about their own intellect; those guys end up killing people). It will pass, about the time I'm scheduled to rotate to another service. Moreover, it keeps me humble, which is a good thing. That doesn't make the butterflies stop flapping in my stomach.
[1] The artist formerly known as "orderly".
[2] In theory; different attendings are variable in the degree of autonomy allowed, and I'm sure I'll be on a short leash the first month or so.
[3] Chronic Obstructive Pulmonary Disease, fancy doctor talk for "done smoked too much and lungs have given up".
Wednesday, June 17, 2009
Beginnings
It's now half a week until I actually turn into a psychiatrist. Jennifer (my fiancee) and I arrived in Seattle on the 25th of May, found an apartment, had our stuff delivered on the 30th, and were finally unpacked by the 13th of June. We've had three weeks to explore Seattle and the University of Washington, and so far are greatly enjoying it here.
Despite it being a week till the start of clinical residency, I've been on payroll for two weeks in order to get a bit of a jump on research. This is a large (16-person) residency, with two spots set aside each year as "research track". That mostly matters in later years, when I start to get a little extra time that I can use for laboratory work instead of supplemental clinical training. However, waiting until then to actually start a research program would mean I'd waste a lot of time learning techniques. My hope is to use these first three weeks of June, plus little snippets of stolen time throughout intern year, to at least start climbing the learning curve and getting socialized to a lab. That also has the nice side effect of dipping me into the information stream of who's writing what grants, where the overall direction of the field is pointed, what projcts might start up soon, etc.
For these first three weeks, I'm hanging around with these folks, who might seem more appropriate for a neurologist or neurosurgeon than a psychiatrist. The trick is that their "Neurochip" technology might have some unrevealed applications in psychiatry. Without going into too much detail (although I want to talk more about this in a future post), there's growing interest in brain stimulation for medication-resistant disorders. It's a tricky field, because it raises the spectre of abuses committed during the lobotomy era. Nevertheless, given that we seem to have more problems with the medication armamentarium every year, it appears likely to grow.
My argument is that what's going wrong in a variety of mental disorders is feedback. Your normal regulation systems get out of whack, such that you're acting on impulses you normally wouldn't (mania), over-suppressing normal behaviors (depression), unable to regulate your fear responses (anxiety, PTSD), and so on. The whole point of the Neurochip is to establish new pathways (feedback loops) within the nervous system. Applied correctly, that's a powerful new tool for letting patients take some control of their own minds. It also might help resolve some very thorny ethical issues; more on that some other time. For now, I'm trying to learn as much as I can about the technology and experimental methods, so that I can plan preliminary experiments and get a little "proof of concept" going.
Despite it being a week till the start of clinical residency, I've been on payroll for two weeks in order to get a bit of a jump on research. This is a large (16-person) residency, with two spots set aside each year as "research track". That mostly matters in later years, when I start to get a little extra time that I can use for laboratory work instead of supplemental clinical training. However, waiting until then to actually start a research program would mean I'd waste a lot of time learning techniques. My hope is to use these first three weeks of June, plus little snippets of stolen time throughout intern year, to at least start climbing the learning curve and getting socialized to a lab. That also has the nice side effect of dipping me into the information stream of who's writing what grants, where the overall direction of the field is pointed, what projcts might start up soon, etc.
For these first three weeks, I'm hanging around with these folks, who might seem more appropriate for a neurologist or neurosurgeon than a psychiatrist. The trick is that their "Neurochip" technology might have some unrevealed applications in psychiatry. Without going into too much detail (although I want to talk more about this in a future post), there's growing interest in brain stimulation for medication-resistant disorders. It's a tricky field, because it raises the spectre of abuses committed during the lobotomy era. Nevertheless, given that we seem to have more problems with the medication armamentarium every year, it appears likely to grow.
My argument is that what's going wrong in a variety of mental disorders is feedback. Your normal regulation systems get out of whack, such that you're acting on impulses you normally wouldn't (mania), over-suppressing normal behaviors (depression), unable to regulate your fear responses (anxiety, PTSD), and so on. The whole point of the Neurochip is to establish new pathways (feedback loops) within the nervous system. Applied correctly, that's a powerful new tool for letting patients take some control of their own minds. It also might help resolve some very thorny ethical issues; more on that some other time. For now, I'm trying to learn as much as I can about the technology and experimental methods, so that I can plan preliminary experiments and get a little "proof of concept" going.
Monday, June 15, 2009
Introduction
This is meant to be my professional, "public facing" weblog. I'm still working out what purpose it's going to serve (besides narcissism), but I think a few goals are:
So, why "Robotic Psychiatrist"? For one thing, "robopsychiatrist" is a strange enough word that it wasn't already reserved. Beyond that, I'm a psychiatrist (or I will be), and I work with robots on occasion. I also hope I can bring some of my prior robotics/engineering training to bear on psychiatry. People certainly can't be debugged the same way software can, but psych in particular seems amenable to a systems approach. The neurobiology of the disorders I'll be treating is (in theory) more of a whole-brain disorder than the specific and easily localized syndromes of neurology. Equally, it takes a whole system to care for our patients. Everyone thinks about the drugs, but those are one small piece of a much bigger picture. Successful treatment of mental disorders means not just pushing pills, but also making sure the patient has good family/community support, that someone's managing/coordinating their care, that they have access to crisis services, and that their disease is understood in the context of their whole life. Thinking about how to put all those pieces together is the kind of problem I tend to enjoy and (sometimes) be good at, which I think is part of why I was attracted to the specialty in the first place.
Of course, the first year is mostly training in acute inpatient medicine/psychiatry, so most of that will be starting and tweaking meds, but I hope I'll have a chance in there to talk about the human side of the job and the patients.
- Keep my widespread network of friends and family at least vaguely informed about what I'm doing and why I'm doing it.
- Provide me a place for introspection, feedback, and general thinking about the process of learning to care for the mentally ill.
- Be yet another sympathetic (I hope) window into what mental illness can mean for individuals and families, and the complicated role of medical professionals in helping both of the above.
- Give me a place to talk about my research activities and future plans, both to help explain to people what the heck it is I do, and also to help me think more clearly about what those goals really are.
So, why "Robotic Psychiatrist"? For one thing, "robopsychiatrist" is a strange enough word that it wasn't already reserved. Beyond that, I'm a psychiatrist (or I will be), and I work with robots on occasion. I also hope I can bring some of my prior robotics/engineering training to bear on psychiatry. People certainly can't be debugged the same way software can, but psych in particular seems amenable to a systems approach. The neurobiology of the disorders I'll be treating is (in theory) more of a whole-brain disorder than the specific and easily localized syndromes of neurology. Equally, it takes a whole system to care for our patients. Everyone thinks about the drugs, but those are one small piece of a much bigger picture. Successful treatment of mental disorders means not just pushing pills, but also making sure the patient has good family/community support, that someone's managing/coordinating their care, that they have access to crisis services, and that their disease is understood in the context of their whole life. Thinking about how to put all those pieces together is the kind of problem I tend to enjoy and (sometimes) be good at, which I think is part of why I was attracted to the specialty in the first place.
Of course, the first year is mostly training in acute inpatient medicine/psychiatry, so most of that will be starting and tweaking meds, but I hope I'll have a chance in there to talk about the human side of the job and the patients.
Subscribe to:
Posts (Atom)