For the past five weeks, I've gotten a very in depth look at the sort of psychiatry practiced on a locked, inpatient psychiatric unit. This is the best place to see the most dramatic diagnoses that most medical students will never get a chance to see again in their education or careers. But the vast majority of psychiatrists don't practice in this setting. So if you're trying to educate us on not just the rare diagnoses but on this potential career in general, we need to get off the unit for a while. The past two days I got to see a couple of these other settings.
Yesterday, I got to take a mini field trip across the VA's medical campus to the long term geriatric care building. Ironically, the first patient we saw was actually crazier than any of the patients on my usual inpatient unit! Conveniently, this was the perfect case to demonstrate the difficulties of dealing with psychiatric symptoms in elderly patients. There are three things that can cause these symptoms: dementia from old age, delirium from an acute medical problem, and psychosis from a chronic psychiatric condition. The trick is figuring out which of the three are in play at any given moment.
ThursdayIL: Dementia is chronic, progressive, gets worse before bed each day, and is characterized by confabulation (making up answers to questions you don't know the answer to). Delirium is acute, waxing and waning irrespective of the time of day, and frequently presents with hallucinations and altered mental status. Psychosis is a really general term and can refer to many types of symptoms. The big ones are hallucinations, delusions and cognitive changes. As you can see, there is a decent amount of overlap that makes this differentiation difficult.
Today, I traveled another half hour north to another VA hospital that is less psychiatrically focused. Here, the chief psychiatrist primarily does consults on medical patients who have developed psychiatric symptoms during their treatment for other conditions. The other common reason for a consult is to determine the decision making capacity of a patient, either to accept/refuse treatment or to make decisions at home (like how to spent money or whether to drive a car).
FridayIL: The four attributes that you must document to determine a patient's capacity to make a medical decision are understanding (Can they describe the procedure/test/treatment?), appreciation (Can they explain what the expected outcomes/side effects are?), rationality (Do they have a rational way of making the decision?), and communication (Can they articulate a consistent choice?). Note that the rationality requirement does not require that their logic be popular or even reasonable, just that it's rational. For example, "because my obscure religious cult does not allow it" is totally fine. But if the rationalization involves a clear delusion, e.g. "President Obama told me not to through the chip that aliens implanted in my brain", then that's not ok.
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