Three Down, Seven to Go

Walking out of the last of three exams for mental health rotation today, I expected to feel the weight lifting off my chest like it did before. But no, that feeling never came; that sense of relief, of having accomplished something worth celebrating, never arrived. I had been looking forward to the end of exams for quite a few days, though. So maybe all the anticipation has made the moment rather anticlimactic.

Regardless, it's the beginning of another one-week break! Big plans are in store: a 100km trek through Fraser Island. Two months ago I went with my mate James and walked the southern portion of the Fraser Island Great Walk. The walk I have planned this time is a loop that takes in the northern portion of The Walk and a 25km stretch of Seventy-Five-Mile Beach. James is busy next week and no one else seems interested in doing the walk, maybe it's because of the distance covered, or maybe it's the -2 degrees centigrade overnight low on the forecast. Where are my hardy, outdoorsy friends when I need them? Looks like I will just have to do it solo, with a good thick book as my trusty companion.

I'll be off to Fraser on Sunday. Will write all about it when I get back.

What Exams?!

It's the weekend before another round of exams. And for the life of me, I just can't get motivated to study. So I do what I do best under these circumstances - procrastinate, something I have skillfully mastered after spending most of my life as a student. Cleaning, doing laundry, fixing up my bike, day-dreaming, reading about photography, going to the marina for coffee, making dinner, and blogging about procrastination - it's been a success! I have avoided looking at anything that has anything to do with psychiatry for a whole day.

Perhaps this is the manifestation of my ambivalence towards psychiatry. I'm ready for the rotation to end, not that I have any ill feelings about the specialty. To the contrary, I think it's a very important field without which medicine wouldn't be complete. From what I've seen, it's the only field in conventional Western medicine that treats its patients with a holistic approach, the whole biopsychosocial model med schools are so desperate to teach to the next generation of doctors. During this rotation, I have seen plenty of patients whose debilitating mental illnesses have been treated and managed well enough to allow them to initiate steps toward getting their lives back on track. So I don't think psychiatry is not "real" medicine, it's just that I don't think I can hack it.

Many people say, and I also believe, it takes someone with a certain personality to do psychiatry. By "certain personality," I don't mean crazy. Talking is of paramount importance in the field. Because there is no lab tests for most psychiatric illnesses, results from history-taking, or interviews, are the only information available to diagnose them. Conversational and interpersonal skills are essential for a successful interview. The ability to make people relaxed, to accurately read people's body language and their tone of voice, to ask questions in a way to solicit useful answers are all qualities in this "certain personality." A psychiatrist would have to be, in a way, manipulative to get the information he needs for an accurate diagnosis. I'm the first to admit that I'm not a great conversationalist. Sure, that's what the years of post-grad training program is for. But why train a monkey to walk on two legs when he's really good at swinging from branch to branch?

Another reason for psychiatry to be not my cup of tea is that I find its inadequacies frustrating. The mental health inpatient unit works in a somewhat revolving-door fashion. Patients present acutely, they are treated until they are well enough, then they are discharged, only to present again soon after with another acute episode that requires admission. Part of it is that psychiatric illnesses are chronic conditions, and part of it is a reflection of our social problems. Most of the patients reflect a cross section of society that is in many ways confounding their treatment: homelessness, neglect, abuse, self-harm, social isolation... Often times, psychiatry warps into social work, balancing the safety of the patient and the community against the need for an empty bed that will be filled by the next admission waiting in ED, knowing the patient will probably re-present acutely before his next outpatient appointment. In this regard I am impatient, I want instant gratification, I want tangible results now. I prefer surgery where the patient presents with a problem, a diagnosis is made, followed by surgery, the patient makes a recovery and is discharged; case closed. The idea of presentations that end with definite results, whether good or bad, appeals to me. That's something psychiatry tends to lack.

This rotation not only gave me new-found respect for psychiatrists, but also helped me put psychiatry lower on the list of possible future careers. Like they all say, it's not you, psychiatry, it's me.

And with that, I have killed the remainder of today. Good job.

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While ruminating on the topic of psychiatry, I cooked up tonight's dinner: vegetarian fettuccini topped with grilled haloumi and avocado.

Happy Fourth of July!

Fourth of July, just another day on the calendar over here. I showed up to the morning hand-over meeting where the staff gave a progress report on patients on the ward, sat in on ward rounds where patients were interviewed and their mental states assessed, and followed the psychiatrist on duty to outpatient clinic. During the consult with a patient with psychotic depression, the psychiatrist observed,

Oh, it's Independence Day.

Patient (in a flat monotone):
What's that?

Me (helpfully):
It was on this day in 1776 when the people living in America decided to become their own country; they didn't want to be British anymore. America used to be a British colony like Australia was.

Patient (realizing Fourth of July had nothing to do with him):

Oh.
(silence)
I still hear voices and I can't get them to stop.

And that was the only time Fourth of July was ever mentioned the whole day.

Happy Independence Day, everyone!

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Tonight's dinner: lamb and spinach lasagna

Zap!

I change into scrubs and walk into the operating theater. Around the operating table stand the anesthetist, the psychiatrist, and a couple of nurses, one of whom is holding a stopwatch in her hand. On the table the patient lies anxiously, straining her neck now and again to look around the room at all the difference faces. The nurse and I approach her to prep her for the procedure while the anesthetist starts the anesthesia. After half a dozen electrodes are placed on her head, the anesthesia starts to kick in; the patient goes limp, her head sinks into the pillow as if she has just lost interest in all the activities around her. The anesthetist asks, "Ready?" The pyschiatrist nods, then checks the settings on the machine. He makes sure everyone is clear of the table, then pushes a button. The patient's face contorts slightly; the nurse with the stopwatch starts the timing. The patient's body goes into a seizure. Because of the anesthetics, the only sign of the seizure are the rhythmic contractions of her feet. After about ten seconds, her seizure stops and the nurses turn her over to her side while the anesthetic starts to wear off and she starts to wake up.

And that is a session of electroconvolsive therapy, or ECT for short, a procedure used commonly to treat psychiatric illnesses ranging from depression to schizophrenia. If the ECT scene at the end of Requiem for a Dream leaves you reeling in horror, that's because the producers left out the flashing "DRAMATIZATION" sign at the bottom of the screen. The real thing, as I find out, is really boring.

Going Mental

Last week was the first week of mental health rotation. The mental health inpatient unit has fourteen beds and they've been full most of the time. Mental health service has come a long way since the days of Bedlam. The big institutions are all gone; no one gets committed anymore. What's left now are acute services and patients are discharged to the community. And then there are the rules. All the rules and regulations that ensure the proper treatment of patients while they are at their most vulnerable directly translates into mounds of paperwork. I know paperwork is an unavoidable part of medicine, but mental health definitely takes the cake in this aspect. The doctors are constantly writing in patients' charts and filling out forms.

I sat in on patient interviews all week. Listening to their stories and hallucinations, hearing them describe the way they perceived the world around them, I felt like a voyeur peering through a keyhole into their psyche. This catatonic patient who worried about every minute details of daily living, that floridly psychotic one having a complete breakdown, this one with delusions of grandeur who absolutely believed in his story, that schizophrenic one who was constantly arguing with the voices in her head - it was like watching a drama, a comedy, a tragedy, and a film noir all rolled into one. From day one, the med school has been teaching us to empathize with patients, to understand where they are coming from. But it looks like psychiatry wound have to take exception to that rule. The hardest part of psychiatry is probably learning to not empathize so much that we start to identify with the patient - in order to maintain insight into the patient's problems, but more importantly, for our own sanity.

It's going to be an interesting rotation.

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Tonight's dinner: chicken cacciatore on cous cous with silverbeet.