*Disclaimer: This post contains stories about actual patients. Any identifiable traits of said patients have been changed, and any non-pertinent details have been either changed or omitted. Whenever possible, permission was sought to write even the vague, altered descriptions below. As I am currently at a VA, all patients will be referred to as male, even if that is not the case, as a female patient would be relatively identifiable. If you suspect that I have overstepped my bounds and breached someone's confidentiality, please notify me immediately at CDMinNY@gmail.com*
There sure is a steep learning curve, but after making it to the end of the first week of my first clerkship, today felt good. Building off my semi-usefulness from yesterday, I think I actually brought something to a patient's care today that no one else on the team could bring.
This morning was crazy. The unit was packed with patients - some that had just arrived and needed to be processed for their inpatient stay and others who were being discharged and were itching to leave. On top of it all, the doctor I normally follow was taking the day off, so the med student burden was passed to another doctor who already was dealing with more than her fair share of work. She tried to have me interview one of the newly admitted patients with whom she was already pretty familiar, but the patient declined, as he has every right to do. So, I twiddled my thumbs a bit and tried to stay out of the way until an opportunity to be helpful presented itself, which it eventually did.
A patient I had been getting to know the past few days had been irritating the staff and other patients, rather uncharacteristically, last night. He was supposedly acting up again this morning and the nurses complained that something needed to be done to isolate him and hopefully calm him down. I'd talked to him one-on-one for over an hour the other day, so I actually knew him better than anyone. Since I felt pretty comfortable with him, and I honestly was curious and concerned about what had changed since I last spoke to him, I offered to go talk with him in a separate room and see what I could find out. The overworked doctor and case worker could not have looked more surprised or relieved. After all, I was killing two birds with one stone: distracting the problem patient and getting myself out of their hair.
We sat down in a secluded room and I asked him how he was doing. He definitely seemed a little off from yesterday and, as he explained his perspective of the past 24 hours, I learned why. In this environment you have to take everything a patient claims with a grain of salt, but I felt I could trust his narrative. I tried to get across that while I don't always agree with his methods of handling situations, that I was sympathetic to his perceived slights. And after a little more digging, it turned out that some of the things that had bugged the staff actually had very reasonable explanations.
One problem in particular involved his worry that because he wasn't quite as upbeat as he was in recent days, that the nursing staff would think he was slipping back into the depression that was part of why he was admitted in the first place. This is an especially dangerous line of thought, because anxiety about seeming depressed can make you more depressed in a sort of self-fulfilling spiral of negativity. I tried to reassure him that no one involved in his discharge planning was thinking along those lines and that, although he doesn't seem quite as chipper as the past couple days, after hitting the low of attempted suicide and the high of the initial rebound, it may take some time to see where his new baseline is.
I also reminded him that he's a fairly normal guy on an inpatient psych ward. When another patient seems to be pressing his buttons, he needs to remember that they are likely very sick. It can be very hard when you just want to keep to yourself but your ability to walk away from a situation is actively restricted, as it is at certain times of day in this unit.
By the end of our talk, I think we really connected and he seemed to feel a little better. I felt vindicated that the reports from staff that seemed so inconsistent with my understanding of him were clarified by hearing his side of the story. After we parted ways, I went back to the nurses station and explained his story. I was pleasantly surprised how willing the nurses were to accept the patient's explanation for things once I was able to advocate for him.
It's a nice reminder that the psychiatric population is one of the most vulnerable we deal with in medicine. They frequently get the terrible double whammy of behaving in ways that are hard to interpret from a normal perspective and being unable to advocate for themselves when those odd behaviors are inevitably misinterpreted. Our school leaders told us that this year we would be at the bottom of the totem pole, but that we would have the best chance of our careers to really advocate for our patients. Glad that prediction is already coming true.
TIL: At the VA, veterans only receive free care for conditions directly caused by their service. This gets a bit murky when the problem is psychiatric rather than physical. Obviously if you're shot in the leg while on active duty, then the injury was service related. But is it really the VA's responsibility if a veteran had psychiatric symptoms before their tour of service? What if there was an underlying condition but the service exacerbated it? In these instances, the VA has a complicated bureaucratic system for determining exactly how service related a condition is as a percentage. If a condition is determined to be more than 50% service-related, then it's treated free of charge. Less than that and your insurance kicks in, likely with some copay.
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