WILTIMS #326: To chat or not to chat

Something I've been struggling with for the past few weeks is how to interact with patients who appear to be just beyond the grasp of our help. If, while walking down the hall, a patient who is very confused starts talking to me, is it worth stopping to talk? It sounds cold to even think of dismissing their conversation, but that is the status quo, and I'm not sure that it's wrong.

Think about a patient in a coma. Research has shown that talking to the unconscious patient can be beneficial to their recovery time. However, that doesn't mean that it's something you need their doctor doing. On the other end of the spectrum, several psychiatric disorders are exclusively treated with counseling. This is exactly when you want the doctor taking time to talk to the patient.

The trick comes when you see a patient that is in the weird gray area of acute schizophrenia, for example. The main symptoms^* of this are hallucinations (sensing things that aren't there), delusions (thinking things that aren't true), and disorganization (thinking in an unusual way). In the midst of an acute decompensation, we talk with the patient, but nothing they say makes sense. We still meet with them regularly, but the conversation is rarely productive. As their treatment progresses (typically once the medications start to kick in), their thoughts begin to make more sense and our interactions are more useful, both to the patient and the treatment team.

But, let's come back to my initial example. You're walking down the hall, on the way to your office but with nothing pressing on your schedule, and a patient flags you down. You stop to see what he wants, but without any perceptible end-point, the patient launches into an extremely detailed story of a friend of his from 30 years ago. Moreover, the patient has a hard time both physically speaking and finding the right words, so his speech is significantly slurred and slowed. After 10 minutes of patiently listening in the middle of the hallway, the patient seamlessly transitions his story into one about aliens from outer space.

This can be useful information to know during an admissions interview when you don't know the patient or how their mind works. But when they've been on the unit for two months and the stories haven't changed in all that time, is it useful to listen? As a medical student, I have the freedom to spend a half hour talking to a patient, so I usually do. I get to see a glimpse of what and how they're thinking, even if what I see is sometimes just a disorganized mess. But on the third, fourth, or fifth time, I'm not sure it's helping anyone anymore. Maybe I should just stop every two or three times they flag me down or once a week. I don't know. A lifetime of interacting with mostly non-psychotic people has trained me to stop and listen when someone wants to talk. I'm not sure that I want to consciously make exceptions to that rule.

TIL: It can be a giant pain in the gluteus to get someone their street clothes on a psych unit, especially when their doctor doesn't know the system yet. The patient needs to be interviewed and determined that they are level three (I don't even know what that means yet (I'll get back to you)), then a nursing order must be made in the chart (not a doctor's note, as I learned painfully today, but a general text order), then a nurse or nursing assistant can go track down the patient's effects. If you bug everyone enough to somehow get all of that to happen, you earn an appreciative smile and a vigorous handshake. Worth it.

^*These are called positive symptoms, because they are additions to or exaggerations of normal processes. There are also negative symptoms (a loss or dampening of normal processes) but they aren't as relevant to this discussion.