WILTIMS #307: Psych!

Today was my first day of my first clerkship of third year. A reminder to those who are rightfully confused about the various stages of traditional medical education in the US: third year consists of a series of 6-8 week clerkships where students work in a hospital or outpatient setting to learn about the different major areas of medicine. During these clerkships, the medical students get to join a medical team and actually take care of (very few) patients (under extra-super-duper supervision).

My first clerkship is in psychiatry and today we had an introductory meeting with the school-wide clerkship director. He is also the course director for the behavioural science course at the end of first year and it was fun to experience his unique teaching style again. Here are some highlights of his spiel:

• Unlike nearly every other specialty, the S in SOAP is most important part of the progress report for psychiatry. Usually in medicine, we are all about the objective. We want physical findings, vital signs, test results, etc. Our clinical judgement is just icing on the cake that ties together everything we discovered in the objective section. In psychiatry, however, nearly all you have is your clinical judgement, so it takes far greater importance.
• Psych is a field that treats the most vulnerable populations.
• Psych is useful to non-future psychiatrists for a few reasons. First, the vast majority of people with psychiatric conditions are treated on an ongoing basis by their primary care physicians. For example, regardless what specialty I go into, I will always be treating patients on antidepressants. Thus it would behoove me to know the basics of depression and its treatment. A second reason to pay attention to this clerkship is to be able to properly identify when a patient needs a psychiatry consult. I may not base my future career around patients with psychoses, but some of my patients will develop psychoses while being treated for something else under my care.
• The inpatient setting, regardless of the specialty, is like working on a submarine; if a problem arises, you need to take care of it yourself because there is nowhere else to punt the problem to.

TIL: Defining the problem for a psychiatric patient in a modified psychiatric progress note requires explaining the impairment, not the diagnosis. As I said a long time ago during behavioral science, hearing voices isn't a problem until it negatively impacts your life.

"mre" is an abbreviation for "most recent episode". An example usage is "Dx: bipolar d/o mre depression" which translates to "Diagnosis: bipolar disorder with the most recent episode being depression rather than mania".

PHQ-9 is one of a series of diagnostic tools for mood disorders. The number, in this case 9, indicated how many questions are used. PHQ-2, for example only uses two questions and thus has the tradeoff of being much quicker to administer, but is much less specific - leading to false positives and less useful results.