WILTIMS #317: Swing and a miss

Ouch. If only to prove that I don't use this platform just to boost my ego: today's performance was less than stellar. I didn't do anything catastrophic, but I was quickly reminded that I am still very inexperienced and it's a good thing people are watching over me.

Bright and early on this miserably hot Monday morning, I was asked to begin the admissions interview on a new patient from over the weekend. I had heard the quick summary of his story during morning report, so I wasn't working off a blank slate. But those preliminary scribbles on the proverbial slate were not comforting.

This patient was very sick. I knew it was going to be a difficult interview, but I've interviewed difficult patients before. I was hoping that I could stumble through enough open-ended questions that we'd build a rapport and the conversation would gain some momentum. This is normally a skill of mine: turning a stumble into the first lunge of a steady jog.¹ Well, sometimes you just fall flat on your face and that's harder to recover from.

Case and point: (the details are totally changed but, as you'll see, it hardly matters)

Me: So Mr. A, can you tell me your understanding of why you're in the hospital?
Mr. A: Because I'm cuckoo!
[Mr. A smiles heartily as I falter]
Me: Um... Well, why specifically are you here? What happened in the past few days?
Mr. A: WellIgneh... [mumbles] ...'m the Emperor and had all those people killed. [laughs] Yep, I did.
[I make a funny face somewhere between concerned and hesitantly amused]

I know that this is new. He had said some pretty disturbed things over the weekend, but never an outright delusion. But is this a delusion? The way he's laughing, it seems like a joke. But given his history of psychoses, he might think it's real, for all we know. How does one respond to a delusion-joke hybrid?

[I look to my preceptor, pleadingly]
Me: Um... well...

And my advisor takes over, to my shame and relief.

I talked with my advisor afterwards and everything was fine, but it sucks when you just freeze up. I had never gotten just random disorganized thoughts back at me from these sorts of questions and so I didn't know where to go with the conversation. Usually you start with open-ended questions and see what the patient wants to talk about. Then as you get an idea of what the important concerns are, you steer the conversation to areas that weren't touched through the natural flow of conversation. Finally, you drill in on any specifics that were missed.

When a patient gives you nothing but fantasy, what do you do?

TIL: When the above happens, you throw out the normal interview format and go straight for specifics. This way you can keep them on track and see what they are even capable of when it comes to effective communication. If they begin to settle down, you can then return to the more open-ended interview style.

¹#humblebrag