The greatest difficulty I've had during my psychiatry sub-internship is deciding when to take away someone's personal freedom by placing them on a mental health hold (MHH) or a short-term certification (STC). My attending told me at the beginning of the rotation, "I want you to make decisions about your patients. We'll do what you want, so long as you can explain why you're doing it and you have your head screwed on straight."
This responsibility hit home a few weeks ago when I knocked on my attending's office door to talk with him about a patient. I was uncertain about whether to place this patient on a STC. My attending sat back in his chair and listened while I explored both sides of the argument.
On the one hand...
This is a middle-aged guy with an unclear history of psychosis who's experiencing paranoid delusions to the extent that he has isolated himself from the entire world, including his family. He has a history of attempting suicide, and there is evidence of increasingly bizarre and disorganized thoughts. According to the police who originally placed him on a MHH, the patient's apartment was a disaster. Charcoal briquettes were placed around the periphery of each room, bed and couch and lamps were turned upside down, curtains were turned inside out, and two pennies were placed in strange places like in the refrigerator and in the shower. This is a man who could certainly benefit from continued hospitalization and treatment.
On the other hand...
The patient does not want to stay in the hospital, does not want treatment, and does not believe he has a mental illness. He shows no depressive symptoms and denies wanting to hurt himself or other people. He sure has some bizarre and paranoid thoughts, and doesn't have a job, but he pulls in a Social Security disability check each month and is able to clothe and feed himself. He may or may not meet legal criteria for being "gravely disabled," which would justify holding him on a STC.
When I finished, my attending leaned forward, looked at me intently, and asked, "So, what are you going to do?" I understood what he was doing: pushing me to make a tough decision and stick by it. This is part of my education, the process of becoming a doctor.
"I don't know, that's why I came to you for advice."
"Do you think this patient is mentally ill and needs treatment?"
"Yes."
"Do you believe that he is a danger to himself or others?"
"No."
"Do you believe that he is gravely disabled?"
"Possibly."
My attending then advised me to remember that my primary responsibility is to my patients. As long as I believe that I am following the law, I should do what I think is necessary to take proper care of my patients and let the judge decide if our actions should be upheld.
"So, what are you going to do?" my attending asked again, this time with an amused smirk.
"I'm going to cert him."
Although he never explicitly said so, it was clear to me that my attending thought that we should keep this patient on a STC. I made the decision, though, based on my gut feeling that my patient was indeed gravely disabled and would benefit from treatment.
The patient stayed for another week with nominal improvement of his paranoia and disorganization. He agreed to keep taking medications after he left the hospital. That was something.
Everything about this patient's case was ambiguous to me. Did I really help him by keeping him in the hospital against his will? Was I justified in holding him on a STC? Was he really gravely disabled? Sometimes there are no clear answers, and I just have to make a decision that seems best at the time. I feel better knowing that I would make the same decision again if I had to do it over.
Showing posts with label Psychiatric Care. Show all posts
Showing posts with label Psychiatric Care. Show all posts
Sunday, May 27, 2012
Monday, May 21, 2012
The legal side of psychiatry
Most of the inpatient psychiatry patients I have seen were admitted voluntarily. But some patients can be held involuntarily if they meet certain criteria: 1) They pose a threat to themselves, 2) They pose a threat to others, and 3) They have grave disability. Those first two are self-explanatory; "grave disability" just means that a patient's psychiatric illness impairs his or her ability to properly care for themselves. Think food, clothes, and shelter.
A mental health hold (MHH) is the shortest involuntary hold at 72 hours. Its purpose is to further evaluate a patient's mental state according to the above three criteria. There are important legal implications of the MHH. Most importantly, since the purpose of the MHH is fact-finding, the psychiatrist is allowed to obtain medical records from other institutions, and talk with the patient's friends and family, without the patient's consent. This means that if a patient is initially admitted on a MHH then switches to voluntary status, the psychiatrist is no longer able to get that information if the patient doesn't agree to it. I saw this happen a few times.
Short-term certification, which lasts for 3 months, is the next step of involuntary hospitalization. By the end of a 72 hour of a MHH, the psychiatrist must convince a judge that short-term certification is necessary, again demonstrating that the patient poses a threat to himself or others or has grave disability. Long-term certification lasts an additional 6 months and also has to be argued before a judge to be granted.
Lastly, there are involuntary medications (i-meds), which are exactly what they sound like. Typically, a patient flies out of control after refusing voluntary medications, emergency medications (e-meds) are given to control the patient in the short-term, then the case is brought before a judge to grant power to administer i-meds. Concern for the physical safety of fellow patients and staff is often cited as justification for requesting i-meds.
The gravity of depriving a person of freedom is not lost on me.
Going to court
One particularly memorable patient took his case to court. Among other problems, this patient had delusions of grandeur that led to increasingly serious run-ins with the law.
The patient was shackled and escorted to the courthouse by a sheriff, while the rest of us piled into a government-issued van for a field trip. The intern would be testifying, a first for him. He practiced his testimony on the ride over, and the attending prepared him for what to expect. "The public defender is going to try to discredit you as an expert witness. Don't worry: It's not personal, and the judge will likely rule in your favor."
That's exactly what happened. My intern became a newly-minted "expert" with the privilege of providing testimony related to the matter of placing our patient on a short-term certification. He stood at the podium with his hands clasped tightly behind him, so tightly in fact that his fingertips were white. His back was straight, his shoulders squared, his head held high, and in that pose he answered questions thoroughly but succinctly in a clear and certain voice. I was very impressed.
After some back-and-forth questioning from the public defender and city attorney, the patient/defendant had the opportunity to address the court. It turned out that our patient sealed his own fate with a diatribe that clearly demonstrated to the judge that he poses a threat to himself and suffers grave disability. We won short-term certification and the ability to administer involuntary medications.
Observing the legal process in action was fascinating, a valuable component of my psychiatry education.
Update: This patient is now doing fairly well. My intern writes:
A mental health hold (MHH) is the shortest involuntary hold at 72 hours. Its purpose is to further evaluate a patient's mental state according to the above three criteria. There are important legal implications of the MHH. Most importantly, since the purpose of the MHH is fact-finding, the psychiatrist is allowed to obtain medical records from other institutions, and talk with the patient's friends and family, without the patient's consent. This means that if a patient is initially admitted on a MHH then switches to voluntary status, the psychiatrist is no longer able to get that information if the patient doesn't agree to it. I saw this happen a few times.
Short-term certification, which lasts for 3 months, is the next step of involuntary hospitalization. By the end of a 72 hour of a MHH, the psychiatrist must convince a judge that short-term certification is necessary, again demonstrating that the patient poses a threat to himself or others or has grave disability. Long-term certification lasts an additional 6 months and also has to be argued before a judge to be granted.
Lastly, there are involuntary medications (i-meds), which are exactly what they sound like. Typically, a patient flies out of control after refusing voluntary medications, emergency medications (e-meds) are given to control the patient in the short-term, then the case is brought before a judge to grant power to administer i-meds. Concern for the physical safety of fellow patients and staff is often cited as justification for requesting i-meds.
The gravity of depriving a person of freedom is not lost on me.
Going to court
One particularly memorable patient took his case to court. Among other problems, this patient had delusions of grandeur that led to increasingly serious run-ins with the law.
The patient was shackled and escorted to the courthouse by a sheriff, while the rest of us piled into a government-issued van for a field trip. The intern would be testifying, a first for him. He practiced his testimony on the ride over, and the attending prepared him for what to expect. "The public defender is going to try to discredit you as an expert witness. Don't worry: It's not personal, and the judge will likely rule in your favor."
That's exactly what happened. My intern became a newly-minted "expert" with the privilege of providing testimony related to the matter of placing our patient on a short-term certification. He stood at the podium with his hands clasped tightly behind him, so tightly in fact that his fingertips were white. His back was straight, his shoulders squared, his head held high, and in that pose he answered questions thoroughly but succinctly in a clear and certain voice. I was very impressed.
After some back-and-forth questioning from the public defender and city attorney, the patient/defendant had the opportunity to address the court. It turned out that our patient sealed his own fate with a diatribe that clearly demonstrated to the judge that he poses a threat to himself and suffers grave disability. We won short-term certification and the ability to administer involuntary medications.
Observing the legal process in action was fascinating, a valuable component of my psychiatry education.
Update: This patient is now doing fairly well. My intern writes:
The patient became less and less resistant to medications as he become more linear and logical. He never quite thanked us for forcing medication on him, but he did start saying positive things about the way he was thinking. Before he left, he actually became quite socially appropriate, responding to social cues, which previously he had not been able to do. He started telling jokes, some pretty funny and some bizarre. But he would occasionally follow a bizarre comment with reality testing saying, "Does that sound crazy?" and then laugh it off. At discharge, he was nervous to go home and thought it was happening too fast. Last I checked, he was making his outpatient appointments. His home visits have found him pleasant; he has been very welcoming to his case worker and showing off how clean and organized his apartment is, as well as new writings he has been working on.
Sunday, May 20, 2012
Acting intern
Two weeks into my psychiatry sub-internship at Denver Health, and I'm having a blast. I was right in guessing that Denver Health would be a great place for a psychiatry sub-internship, given that it is a county hospital and a safety net for indigent and socioeconomically disadvantaged people.
The psychiatry inpatient service is capped at 12 patients, 6 patients for each of the two interns covering the service. On the first day, my attending told me that he wants me to build up to seeing 6 patients by the end of the month. This is consistent with the purpose of a sub-internship to prepare medical students for being an intern.
I'll get a chance to do exactly that this coming week. For the first part of next week, my attending will be away at a conference, and one of my interns will be out taking Step 3. The doctor who is covering for my attending spent some time with the team on Friday to help smooth the transition on Monday.
"You take three patients, and I'll take three patients," he said.
"What?" I said it without thinking, and it may have come out somewhat indignantly.
The new attending looked a bit surprised. He sat back in his chair, smirked, and asked me, "How many patients have you been carrying?"
I told him that I had been carrying 5-6 patients this past week. "Good! Then you can take your own team." He went over to the white board at the nurse's station, where all the patients are listed according to which resident is taking care of them. He erased my intern's name and wrote in my name. "Make sure to bring your pager on Monday. The nurses are going to be paging you when they have questions about your patients."
This promises to be an interesting week.
The psychiatry inpatient service is capped at 12 patients, 6 patients for each of the two interns covering the service. On the first day, my attending told me that he wants me to build up to seeing 6 patients by the end of the month. This is consistent with the purpose of a sub-internship to prepare medical students for being an intern.
I'll get a chance to do exactly that this coming week. For the first part of next week, my attending will be away at a conference, and one of my interns will be out taking Step 3. The doctor who is covering for my attending spent some time with the team on Friday to help smooth the transition on Monday.
"You take three patients, and I'll take three patients," he said.
"What?" I said it without thinking, and it may have come out somewhat indignantly.
The new attending looked a bit surprised. He sat back in his chair, smirked, and asked me, "How many patients have you been carrying?"
I told him that I had been carrying 5-6 patients this past week. "Good! Then you can take your own team." He went over to the white board at the nurse's station, where all the patients are listed according to which resident is taking care of them. He erased my intern's name and wrote in my name. "Make sure to bring your pager on Monday. The nurses are going to be paging you when they have questions about your patients."
This promises to be an interesting week.
Thursday, February 16, 2012
Abdominal pain in a child
Of all kids coming to the emergency department complaining of abdominal pain, plain old constipation is to blame 70% of the time. Just such a kid came into the ED, but it turned out to be much more interesting than constipation.
Talking to Mom, I found out that the girl had been having stomach pains intermittently for over a year, that she could be fine one minute but doubled up in pain the next. These episodes came in clusters, were not associated with school, and were separated by months with the last episode happening several weeks ago. She was indeed previously worked up extensively for her abdominal pain ruling out things like appendicitis, pancreatitis, and celiac disease. In fact, an abdominal x-ray a few weeks ago even ruled out constipation.
The little girl last had a bowel movement earlier in the day, and Mom noted it to be soft without excessive straining required to defecate. She also had two bowel movements the previous day. None of this was pointing toward constipation as the cause of this girl's abdominal pain.
My patient was difficult to talk to. She would hardly look at me. Even when I asked her simple questions like "What's your favorite color?" she would look over to Mom, who professed that her daughter was normally very talkative. Mom was also difficult to talk to: she couldn't get words out of her mouth fast enough, she went off on tangents before eventually answering my questions, and she spent a lot of time unloading all her worries about what might be causing her daughter's abdominal pain.
Within a few minutes of entering the room, and without even touching my patient on exam, I was already pretty confident about my diagnosis. This could be delicate and require some tact.
"Are there any significant psychiatric problems in the family?"
Jackpot. Mom described symptoms in herself highly suggestive of no less than three psychiatric diagnoses, all of them undiagnosed and untreated. She also said that the kid's father is on medications for two psychiatric disorders. Further delving into the social history revealed significant turmoil at home, including an absent father and other significant stressors.
After a thorough exam, I explained to Mom that I ruled out the scary stuff that could be causing her kid's tummy pain. I said that the clinical picture doesn't really fit a physical cause and that I thought it was more likely that her daughter's stress or anxiety might be behind her symptoms.
Brace for impact....
But to my surprise, Mom accepted what I had to say: "You know, that makes so much sense. No one has ever suggested that before!" Encouraged, I then explained to her that it is very common for children to convert emotional or psychological stress into physical symptoms and that this is called conversion disorder.
In hindsight, this child in fact didn't have conversion disorder because the diagnostic criteria for conversion disorder require another non-pain neurologic symptom, which this girl did not have. She probably met diagnostic criteria for chronic pain disorder with psychological factors, the treatment of which is psychotherapy and antidepressants.
I explained to Mom that it is really important that her daughter receive prompt treatment for this problem to decrease the chances of her developing other psychiatric problems such as an anxiety disorder. For what it's worth, she said she would follow up with her daughter's primary care physician for a referral to a child psychiatrist. I really hope that actually happens.
Talking to Mom, I found out that the girl had been having stomach pains intermittently for over a year, that she could be fine one minute but doubled up in pain the next. These episodes came in clusters, were not associated with school, and were separated by months with the last episode happening several weeks ago. She was indeed previously worked up extensively for her abdominal pain ruling out things like appendicitis, pancreatitis, and celiac disease. In fact, an abdominal x-ray a few weeks ago even ruled out constipation.
The little girl last had a bowel movement earlier in the day, and Mom noted it to be soft without excessive straining required to defecate. She also had two bowel movements the previous day. None of this was pointing toward constipation as the cause of this girl's abdominal pain.
My patient was difficult to talk to. She would hardly look at me. Even when I asked her simple questions like "What's your favorite color?" she would look over to Mom, who professed that her daughter was normally very talkative. Mom was also difficult to talk to: she couldn't get words out of her mouth fast enough, she went off on tangents before eventually answering my questions, and she spent a lot of time unloading all her worries about what might be causing her daughter's abdominal pain.
Within a few minutes of entering the room, and without even touching my patient on exam, I was already pretty confident about my diagnosis. This could be delicate and require some tact.
"Are there any significant psychiatric problems in the family?"
Jackpot. Mom described symptoms in herself highly suggestive of no less than three psychiatric diagnoses, all of them undiagnosed and untreated. She also said that the kid's father is on medications for two psychiatric disorders. Further delving into the social history revealed significant turmoil at home, including an absent father and other significant stressors.
After a thorough exam, I explained to Mom that I ruled out the scary stuff that could be causing her kid's tummy pain. I said that the clinical picture doesn't really fit a physical cause and that I thought it was more likely that her daughter's stress or anxiety might be behind her symptoms.
Brace for impact....
But to my surprise, Mom accepted what I had to say: "You know, that makes so much sense. No one has ever suggested that before!" Encouraged, I then explained to her that it is very common for children to convert emotional or psychological stress into physical symptoms and that this is called conversion disorder.
In hindsight, this child in fact didn't have conversion disorder because the diagnostic criteria for conversion disorder require another non-pain neurologic symptom, which this girl did not have. She probably met diagnostic criteria for chronic pain disorder with psychological factors, the treatment of which is psychotherapy and antidepressants.
I explained to Mom that it is really important that her daughter receive prompt treatment for this problem to decrease the chances of her developing other psychiatric problems such as an anxiety disorder. For what it's worth, she said she would follow up with her daughter's primary care physician for a referral to a child psychiatrist. I really hope that actually happens.
Friday, January 27, 2012
Recidivism in psychiatric patients
It has been a running joke with one of my residents, my optimism when it comes to the chances that my patients will actually make meaningful changes in their lives. Out of curiosity, and as a sort of exercise, we sat down together and reviewed the charts of my patients from earlier in the month. My meth addict patient? Missed his follow-up appointments. My alcoholic patients? They all missed their appointments. My borderline patient with anger issues and family problems? "Oh, look," my resident chuckled, "He made his optometry appointment but missed his psychiatrist and family therapy appointments! That's interesting..."
She wasn't so much rubbing it in my face as making her point that, as a psychiatrist, you can't expect your patients to change any more than they are ready to change. It's easy to get discouraged and jaded, she said, the more of yourself you invest in their recovery. Her eyes widened for a flash, a microexpression. I think she got worried that I might judge her as jaded and cynical. But I understood what she meant. It was natural for me to want to single-handedly fix my patients' self-destructive behaviors, but the game was already lost the moment my motivation exceeded my patients' motivation for change.
She wasn't so much rubbing it in my face as making her point that, as a psychiatrist, you can't expect your patients to change any more than they are ready to change. It's easy to get discouraged and jaded, she said, the more of yourself you invest in their recovery. Her eyes widened for a flash, a microexpression. I think she got worried that I might judge her as jaded and cynical. But I understood what she meant. It was natural for me to want to single-handedly fix my patients' self-destructive behaviors, but the game was already lost the moment my motivation exceeded my patients' motivation for change.
Sunday, January 15, 2012
Time for lunch
To my surprise, psychiatrists take an hour out of their day to eat lunch. Even psychiatry residents do this. Fairly regularly, too. On my first day of the clerkship, the residents and medical students all walked a few blocks to a local deli. We actually ate at the restaurant instead of taking the sandwiches back to the hospital and working through lunch or eating at a noon conference. The thought crossed my mind that this luxury might just be an anomaly.
But it continued. One day last week, I had to write two notes and talk with a patient, so I decided to work on the notes through lunch. My resident was apologetic: "I'm so sorry you're not taking a lunch break!"
Working so hard through the third year of medical school, I've almost forgotten how relaxing and refreshing a lunch break can be. It's social; it's fun; it's what normal people do out in the real world.
But it continued. One day last week, I had to write two notes and talk with a patient, so I decided to work on the notes through lunch. My resident was apologetic: "I'm so sorry you're not taking a lunch break!"
Working so hard through the third year of medical school, I've almost forgotten how relaxing and refreshing a lunch break can be. It's social; it's fun; it's what normal people do out in the real world.
Friday, January 13, 2012
The psychiatry schedule
My psychiatry rotation at the VA is by far the most relaxed schedule I've had in my third year. I get in before 8am so I have enough time to read notes on my patients from the day before. No pre-rounds and no rounds. We have a brief meeting with the social workers at 8am, then table rounds with nurses afterward.
After rounds, the daily schedule is remarkably unstructured. Sometimes we have a new patient and do the intake interview together as a group. Usually, though, we medical students are left to our own devices. I use the time to go talk with my patients, take care of patient-related tasks, and write notes. I actually have a lot of fun writing psychiatry notes, probably because we're expected to be verbose and because the subjective portion of the note is simply recounting a conversation, most of which are rather interesting.
Writing notes usually takes me until early to mid afternoon, depending on whether we admitted a new patient or not. Both my attending and residents have repeated that we should go home when we're finished with our clinical duties, but both my classmates and I tend to stick around until 5-6pm, studying Psychiatry Case Files together, until the residents call it a night.
Part of the reason I finish so early is because I'm only carrying two patients. This is due to unfortunate timing of construction that necessitated closing one of the two psychiatry floors, truncating the bed count from 36 down to 22. That means fewer patients for everybody.
We don't work weekends. On top of that, there are two national holidays (New Year's and MLK Day) during this rotation, which the VA hospital patriotically observes by closing. All of this means that my psychiatry experience is more limited than I would have liked.
After rounds, the daily schedule is remarkably unstructured. Sometimes we have a new patient and do the intake interview together as a group. Usually, though, we medical students are left to our own devices. I use the time to go talk with my patients, take care of patient-related tasks, and write notes. I actually have a lot of fun writing psychiatry notes, probably because we're expected to be verbose and because the subjective portion of the note is simply recounting a conversation, most of which are rather interesting.
Writing notes usually takes me until early to mid afternoon, depending on whether we admitted a new patient or not. Both my attending and residents have repeated that we should go home when we're finished with our clinical duties, but both my classmates and I tend to stick around until 5-6pm, studying Psychiatry Case Files together, until the residents call it a night.
Part of the reason I finish so early is because I'm only carrying two patients. This is due to unfortunate timing of construction that necessitated closing one of the two psychiatry floors, truncating the bed count from 36 down to 22. That means fewer patients for everybody.
We don't work weekends. On top of that, there are two national holidays (New Year's and MLK Day) during this rotation, which the VA hospital patriotically observes by closing. All of this means that my psychiatry experience is more limited than I would have liked.
Thursday, January 12, 2012
Security on the psychiatry ward
I was leaving the psychiatry ward earlier today when I turned around and saw an older gentleman wearing a veteran's cap and street clothes, wanting to exit through the locked doors with me. I only had an instant to react: "Are you supposed to be leaving this floor?" He looked up at me with some surprise: "Oh, yes." Should I believe him? Before I decided to not let him through, a nurse who overheard this exchange yelled down the hall that it was okay for him to leave. He turned out to be the janitor leaving after his shift. I felt embarrassed and apologized, but the veteran took it in stride and said he was glad I'm being careful. The nurse also told me later that day that I did the right thing. There are few better ways to fail the psychiatry clerkship than letting a psychiatric patient escape!
Sunday, January 8, 2012
Electroconvulsive therapy
I was introduced to electroconvulsive therapy (ECT) on just the second day of my psychiatry rotation. ECT was first developed in 1938. Although no one really knows how it works, the idea is that by inducing a controlled tonic-clonic seizure with electrical current, we can "reset" the brain's pathological function, whether that's by interrupting connections between different brain regions or altering the balance of neurotransmitters. It's a lot of hand-waving.
Regardless, ECT works; in fact, it works much better than any pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs), with a 95% effectiveness. When used in depression, ECT has a recurrence rate of 50%, which is comparable to SSRIs. 100,000 people in the U.S. and 1,000,000 worldwide undergo ECT yearly, mostly for depression with psychotic features but also for schizophrenia; my attending thinks that ECT is underused.
With that background, I met my patient: an older veteran suffering from such severe recurrent depression with psychotic features that it led him to attempt suicide. He had already undergone four ECT sessions. On the morning of his fifth session, he was so nervous that he was visibly shaking. A friend held both of his hands and prayed briefly with him before we led the veteran through two locked doors and into the elevators down to the minor procedure suite. He walked bravely, as calmly as he could manage, because he knew that this treatment was necessary.
Once he was lying on the procedure table, we placed blood pressure cuffs around both his ankles and inflated them so they would act as tourniquets to block the drugs from reaching his feet. The anesthesiologist sedated him, paralyzed him, placed a tongue guard in his mouth, and began breathing for him with a bag valve mask. Then, my attending poured gel onto two 1.5-inch diameter metal plates and secured those plates on the patient's temples with a rubber strap. The metal plates were connected to the machine that delivers a prescribed electric shock. A baseline electroencephalogram (EEG) was obtained, then the shock was delivered by simply pushing a button.
Suddenly, his toes curled and the arches of his feet flexed continually for the duration of the 8-second stimulus. I looked up at his face and was surprised to see a contorted grimace: clenched jaw and eyes shut tight. A few seconds after the stimulus ended, his feet began contracting and relaxing indicating that he was in the middle of the tonic-clonic seizure that is the goal of ECT. The foot twitching lasted about 20 seconds. The spike-wave squiggly lines coming out of the electroencephalography machine, indicating a seizure, flattened to baseline after 50 seconds indicating that the central seizure had stopped. Then the anesthesiologist woke him up. It was over.
From start to finish, the whole thing took less than a half-hour. This patient's ECT bore no resemblance to the dramatic convulsions and screaming that most people associate with ECT, thanks to Jack Nicholson's unnerving performance in One Flew Over the Cuckoo's Nest.
The addition of anesthesia to ECT protocol in the late 1960's (notably before this movie was released in 1975) has made ECT a much more humane experience. Paralytic drugs prevent the thrashing around, and some anesthetic agents can cause retrograde memory loss so the patient doesn't even remember the procedure. ECT itself can also cause retrograde memory loss as a side effect.
My patient remembered the anxiety leading up to his ECT treatment but not much else about it. We interviewed him briefly a few hours after his ECT session, and I was shocked (pun intended) by the transformation. He was freshly showered and was wearing a freshly ironed shirt that his friend brought from home; he was much more expressive and interactive, he wasn't hearing voices, he didn't have suicidal thoughts, and he said that he was actually feeling good. Despite the dramatic nature of ECT and its negative portrayal in the arts and media, it's hard to ignore such striking success.
Regardless, ECT works; in fact, it works much better than any pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs), with a 95% effectiveness. When used in depression, ECT has a recurrence rate of 50%, which is comparable to SSRIs. 100,000 people in the U.S. and 1,000,000 worldwide undergo ECT yearly, mostly for depression with psychotic features but also for schizophrenia; my attending thinks that ECT is underused.
With that background, I met my patient: an older veteran suffering from such severe recurrent depression with psychotic features that it led him to attempt suicide. He had already undergone four ECT sessions. On the morning of his fifth session, he was so nervous that he was visibly shaking. A friend held both of his hands and prayed briefly with him before we led the veteran through two locked doors and into the elevators down to the minor procedure suite. He walked bravely, as calmly as he could manage, because he knew that this treatment was necessary.
Image taken from the blog of actress Carrie Fischer, who has shared her experiences with ECT for bipolar disorder. (http://carriefisher.com)
Once he was lying on the procedure table, we placed blood pressure cuffs around both his ankles and inflated them so they would act as tourniquets to block the drugs from reaching his feet. The anesthesiologist sedated him, paralyzed him, placed a tongue guard in his mouth, and began breathing for him with a bag valve mask. Then, my attending poured gel onto two 1.5-inch diameter metal plates and secured those plates on the patient's temples with a rubber strap. The metal plates were connected to the machine that delivers a prescribed electric shock. A baseline electroencephalogram (EEG) was obtained, then the shock was delivered by simply pushing a button.
Suddenly, his toes curled and the arches of his feet flexed continually for the duration of the 8-second stimulus. I looked up at his face and was surprised to see a contorted grimace: clenched jaw and eyes shut tight. A few seconds after the stimulus ended, his feet began contracting and relaxing indicating that he was in the middle of the tonic-clonic seizure that is the goal of ECT. The foot twitching lasted about 20 seconds. The spike-wave squiggly lines coming out of the electroencephalography machine, indicating a seizure, flattened to baseline after 50 seconds indicating that the central seizure had stopped. Then the anesthesiologist woke him up. It was over.
From start to finish, the whole thing took less than a half-hour. This patient's ECT bore no resemblance to the dramatic convulsions and screaming that most people associate with ECT, thanks to Jack Nicholson's unnerving performance in One Flew Over the Cuckoo's Nest.
The addition of anesthesia to ECT protocol in the late 1960's (notably before this movie was released in 1975) has made ECT a much more humane experience. Paralytic drugs prevent the thrashing around, and some anesthetic agents can cause retrograde memory loss so the patient doesn't even remember the procedure. ECT itself can also cause retrograde memory loss as a side effect.
My patient remembered the anxiety leading up to his ECT treatment but not much else about it. We interviewed him briefly a few hours after his ECT session, and I was shocked (pun intended) by the transformation. He was freshly showered and was wearing a freshly ironed shirt that his friend brought from home; he was much more expressive and interactive, he wasn't hearing voices, he didn't have suicidal thoughts, and he said that he was actually feeling good. Despite the dramatic nature of ECT and its negative portrayal in the arts and media, it's hard to ignore such striking success.
Wednesday, January 4, 2012
Introduction to my psychiatry work environment
I am doing my psychiatry rotation at the Denver VA Medical Center, which has a 36-bed inpatient psychiatry unit. The psychiatry patients are cared for by three separate teams, two of which take medical students. My team is composed of one attending psychiatrist, two psychiatry residents, and one classmate.
The psychiatry ward is locked down, as one might imagine. You have to pass through two locked doors and walk by a security station to get into and out of the psychiatry ward. Plus, the security badges that unlock the doors only do so for a quick half-second before locking again, making escape by someone unfamiliar with this timing that much more difficult.
Once on the floor, there's a ten-foot stretch of hallway before reaching a taped red line on the white linoleum. Patients aren't allowed to walk beyond that line unchaperoned. Similar red lines are in front of doorways and serve to keep patients out of restricted areas. It's remarkable how well the red line works and how rule-driven these veterans are, in general.
Everything is designed so that it can't be used as a weapon. Drinking fountains have no spigot head, sinks have no faucet, chairs have no legs and are so heavy that they can't be picked but instead have to be scooted around the room. Doorknobs are not knobs, rather semicircles practically flush with the door with indentations for grips.
A wide array of patients stared at my attending, two classmates, and me as we walked down the hallway during our orientation. Some were poorly groomed; others were clean-cut. Some were wearing government-issued pajamas, a bath robe, and hospital socks; others wore street clothes and were actually sharply dressed for the setting.
An unfamiliar face in the psychiatry ward is the object of curiosity. Several patients stared at us three medical students with an unsettling vacant gaze that all of them seemed to share. One "happily demented" veteran, hunched over and pushing a walker, a smile on his face, approached us just to strike up a friendly conversation.
Another veteran, younger, balder, and unhealthily skinny, sidled behind the group and when he was noticed blurted out in one breath, "What do you know about perpetual consciousness? It's like a circle running around and around and around in your mind not stopping, which is ironic because," and he moved his finger in a circle by his head, then whispered, "it makes you look crazy." I felt uncomfortable. How do you respond to something like that? My classmates felt equally awkward. One of them decided to reply in the only way he knew how: "Hi, my name is John," offering a handshake.
This interaction made me understand that my biggest challenge for the upcoming psychiatry rotation will be to set aside my feelings of discomfort, and other negative emotions elicited by my patients' unusual affect and behavior, to make sure that they don't get in the way of my ability to understand and empathize with my patients. Easier said than done.
The psychiatry ward is locked down, as one might imagine. You have to pass through two locked doors and walk by a security station to get into and out of the psychiatry ward. Plus, the security badges that unlock the doors only do so for a quick half-second before locking again, making escape by someone unfamiliar with this timing that much more difficult.
Once on the floor, there's a ten-foot stretch of hallway before reaching a taped red line on the white linoleum. Patients aren't allowed to walk beyond that line unchaperoned. Similar red lines are in front of doorways and serve to keep patients out of restricted areas. It's remarkable how well the red line works and how rule-driven these veterans are, in general.
Everything is designed so that it can't be used as a weapon. Drinking fountains have no spigot head, sinks have no faucet, chairs have no legs and are so heavy that they can't be picked but instead have to be scooted around the room. Doorknobs are not knobs, rather semicircles practically flush with the door with indentations for grips.
A wide array of patients stared at my attending, two classmates, and me as we walked down the hallway during our orientation. Some were poorly groomed; others were clean-cut. Some were wearing government-issued pajamas, a bath robe, and hospital socks; others wore street clothes and were actually sharply dressed for the setting.
An unfamiliar face in the psychiatry ward is the object of curiosity. Several patients stared at us three medical students with an unsettling vacant gaze that all of them seemed to share. One "happily demented" veteran, hunched over and pushing a walker, a smile on his face, approached us just to strike up a friendly conversation.
Another veteran, younger, balder, and unhealthily skinny, sidled behind the group and when he was noticed blurted out in one breath, "What do you know about perpetual consciousness? It's like a circle running around and around and around in your mind not stopping, which is ironic because," and he moved his finger in a circle by his head, then whispered, "it makes you look crazy." I felt uncomfortable. How do you respond to something like that? My classmates felt equally awkward. One of them decided to reply in the only way he knew how: "Hi, my name is John," offering a handshake.
This interaction made me understand that my biggest challenge for the upcoming psychiatry rotation will be to set aside my feelings of discomfort, and other negative emotions elicited by my patients' unusual affect and behavior, to make sure that they don't get in the way of my ability to understand and empathize with my patients. Easier said than done.
Sunday, January 2, 2011
Psychiatry shelf exam
We were required to take the psychiatry shelf at the end of the Fall semester. This was the culmination of the psychiatry thread that was integrated into the CVPR, Neuro, and DEMS blocks. Shelf exams are standardized national exams in a particular medical specialty (e.g. psychiatry, OB/GYN, etc...) that are usually taken after a third-year or fourth-year clinical rotation.
It's fairly unusual for second-year students to take a shelf-exam. I haven't heard of other medical schools requiring second-year students to take a shelf-exam. The reasoning of our course directors, I think, was to provide us with a sneak peek into what kinds of tests we'll be taking once we start clinical rotations. Maybe they also wanted to give us a reason to start studying psychiatry for Step 1.
"Shelf exam" sounds kind of scary, but it was actually very low-pressure because the test doesn't contribute at all to our grade or academic record. There are no negative consequences from bombing this test, but someone who does well could be eligible for some sort of scholarship.
To prepare for the psychiatry shelf exam, I just read through Psychiatry Blueprints and did practice questions, both at the back of this book and through USMLE World Qbank. I found this to be sufficient preparation.
It's fairly unusual for second-year students to take a shelf-exam. I haven't heard of other medical schools requiring second-year students to take a shelf-exam. The reasoning of our course directors, I think, was to provide us with a sneak peek into what kinds of tests we'll be taking once we start clinical rotations. Maybe they also wanted to give us a reason to start studying psychiatry for Step 1.
"Shelf exam" sounds kind of scary, but it was actually very low-pressure because the test doesn't contribute at all to our grade or academic record. There are no negative consequences from bombing this test, but someone who does well could be eligible for some sort of scholarship.
To prepare for the psychiatry shelf exam, I just read through Psychiatry Blueprints and did practice questions, both at the back of this book and through USMLE World Qbank. I found this to be sufficient preparation.
Saturday, November 6, 2010
Alcoholics Anonymous, Part 2
The Alcoholics Anonymous meeting I went to this afternoon was pretty much what I expected it would be: a bunch of people sharing the ways in which alcohol has destroyed their lives and seeking strength in others in the group to remain sober. The setting: a community center basement that looked like an Elk's lodge from the 1970's with fake wood panel walls covered by yellowed posters of motivational phrases like "Live and let live." Everyone in the group was in their 50's or 60's and looked like they had lived hard lives.
The group was led by a sweet lady, a Betty White look-alike. I never would have guessed that she's a recovered alcoholic. She started the meeting by asking if anyone wanted to share anything with the group. When no one said anything, she shared her own thoughts: basically that she is grateful that God brought her to Alcoholics Anonymous, grateful for the people who she has met through AA, because otherwise she is sure she would be dead.
Then other people shared. Each person opened by saying "My name is John Doe, and I'm an alcoholic." Or a recovering alcoholic, or a recovered alcoholic. Everyone then said "Hi, John Doe!" And when that person was done sharing, everyone said "Thank you, John Doe!" Just like in the movies.
Most everyone had similar I-would-be-dead-now-if-not-for-AA stories except one woman who must be in her 40's but looked at least a couple decades older. She told us how she's stuck on Step 4, how she just can't seem to get the pen on the paper. She had been in and out of AA over the years but is determined to make it through all 12 steps this time. I watched her as she spoke. I could see the desperation in her eyes; I could feel her sincere and desperate desire to quit drinking in the way she spoke and held herself. But I also saw fear and hopelessness that can easily lead her back to drink.
I don't know how her story will play out, but I did recognize how valuable Alcoholics Anonymous is to her efforts to stay sober. She has a clearly defined goal right now: to make a searching and fearless moral inventory of herself. Beyond that, she has a pathway to recovery laid out before her, providing her with goals to work toward. But I don't know whether she has a good sponsor. It's my impression that a good sponsor is key to a lasting recovery.
Eventually, the group leader asked if I wanted to introduce myself and share anything. I told the group that this was my first AA meeting; before I could finish my sentence, everyone was clapping! I went on to say that I was there not as an alcoholic but as a medical student with the purpose of learning more about Alcoholics Anonymous. Everyone was very welcoming.
The meeting wrapped up with everyone in the group holding hands in a circle and saying a prayer. It's a good thing that I was prepared for the spiritual aspect of AA because it would have caught me off guard otherwise. Multiple people in the group said that the two most important things in their life are God and sobriety and that they wouldn't have sobriety if it weren't for God. Interestingly, these same people also commented on how they were initially uncomfortable with the spirituality that is so integral to Alcoholics Anonymous. I can see how spirituality is a double-edged sword: while a person's relationship with God can be a powerful modifier of behavior, the idea of God can be off-putting to many people for a variety of reasons.
Overall, I think it was valuable to actually experience an AA meeting. I now have a better appreciation of both the strengths and limitations of Alcoholics Anonymous.
The group was led by a sweet lady, a Betty White look-alike. I never would have guessed that she's a recovered alcoholic. She started the meeting by asking if anyone wanted to share anything with the group. When no one said anything, she shared her own thoughts: basically that she is grateful that God brought her to Alcoholics Anonymous, grateful for the people who she has met through AA, because otherwise she is sure she would be dead.
Then other people shared. Each person opened by saying "My name is John Doe, and I'm an alcoholic." Or a recovering alcoholic, or a recovered alcoholic. Everyone then said "Hi, John Doe!" And when that person was done sharing, everyone said "Thank you, John Doe!" Just like in the movies.
Most everyone had similar I-would-be-dead-now-if-not-for-AA stories except one woman who must be in her 40's but looked at least a couple decades older. She told us how she's stuck on Step 4, how she just can't seem to get the pen on the paper. She had been in and out of AA over the years but is determined to make it through all 12 steps this time. I watched her as she spoke. I could see the desperation in her eyes; I could feel her sincere and desperate desire to quit drinking in the way she spoke and held herself. But I also saw fear and hopelessness that can easily lead her back to drink.
I don't know how her story will play out, but I did recognize how valuable Alcoholics Anonymous is to her efforts to stay sober. She has a clearly defined goal right now: to make a searching and fearless moral inventory of herself. Beyond that, she has a pathway to recovery laid out before her, providing her with goals to work toward. But I don't know whether she has a good sponsor. It's my impression that a good sponsor is key to a lasting recovery.
Eventually, the group leader asked if I wanted to introduce myself and share anything. I told the group that this was my first AA meeting; before I could finish my sentence, everyone was clapping! I went on to say that I was there not as an alcoholic but as a medical student with the purpose of learning more about Alcoholics Anonymous. Everyone was very welcoming.
The meeting wrapped up with everyone in the group holding hands in a circle and saying a prayer. It's a good thing that I was prepared for the spiritual aspect of AA because it would have caught me off guard otherwise. Multiple people in the group said that the two most important things in their life are God and sobriety and that they wouldn't have sobriety if it weren't for God. Interestingly, these same people also commented on how they were initially uncomfortable with the spirituality that is so integral to Alcoholics Anonymous. I can see how spirituality is a double-edged sword: while a person's relationship with God can be a powerful modifier of behavior, the idea of God can be off-putting to many people for a variety of reasons.
Overall, I think it was valuable to actually experience an AA meeting. I now have a better appreciation of both the strengths and limitations of Alcoholics Anonymous.
Alcoholics Anonymous, Part 1
Alcoholics Anonymous partnered with our psychiatry and ethics programs last month to educate our class about the organization: what it is and is not, its history, and its mission. I knew very little about AA except from what I've seen in movies and TV shows (admittedly not the best sources). For example, I was surprised that AA is entirely apolitical, making no contributions to candidates and taking no stances on propositions or legislation. I was also surprised by the spiritual (not religious) character of AA, as is apparent in their iconic Twelve Steps:
In addition to this informational lecture, we were also given an assignment to attend an AA meeting. The idea is that we should have a good understanding of what AA is all about if we will be referring our patients to AA. For example, AA may not be so great for a staunch atheist.
I will be attending my first AA meeting this afternoon. It was surprisingly very easy to find a meeting. I found the Denver Area Central Committee of Alcoholics Anonymous website simply by googling "Denver alcoholics anonymous," then I clicked on the "meetings" tab. There are dozens of meetings every day around the Denver metro area, each one with its own flavor.
I have mixed feelings about attending an AA meeting. On the one hand, I'm very curious about what it will be like and the kinds of people I will meet. On the other hand, I wonder whether my presence will make some people there feel uncomfortable. Apparently it's common for health care professionals to sit in on open meetings to learn more about AA. Listening to some of my classmates talk about their experiences at AA meetings, I realize that it's a crapshoot as to what my meeting will be like. In fact, we were taught that we should instruct our patients to attend multiple meetings until they find the one that's right for them. So, I basically have no idea what to expect from my AA meeting this afternoon, and I'm going into it with an open mind.
1. We admitted we were powerless over alcohol — that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
In addition to this informational lecture, we were also given an assignment to attend an AA meeting. The idea is that we should have a good understanding of what AA is all about if we will be referring our patients to AA. For example, AA may not be so great for a staunch atheist.
I will be attending my first AA meeting this afternoon. It was surprisingly very easy to find a meeting. I found the Denver Area Central Committee of Alcoholics Anonymous website simply by googling "Denver alcoholics anonymous," then I clicked on the "meetings" tab. There are dozens of meetings every day around the Denver metro area, each one with its own flavor.
I have mixed feelings about attending an AA meeting. On the one hand, I'm very curious about what it will be like and the kinds of people I will meet. On the other hand, I wonder whether my presence will make some people there feel uncomfortable. Apparently it's common for health care professionals to sit in on open meetings to learn more about AA. Listening to some of my classmates talk about their experiences at AA meetings, I realize that it's a crapshoot as to what my meeting will be like. In fact, we were taught that we should instruct our patients to attend multiple meetings until they find the one that's right for them. So, I basically have no idea what to expect from my AA meeting this afternoon, and I'm going into it with an open mind.
Wednesday, September 29, 2010
Psychiatry thread
“Psychiatry and neurology are inextricably linked. Psychiatry is neurology that we just don’t know yet.” -- Dr. Filley
The psychiatry thread started last semester during the CVPR block (cardiovascular, pulmonary, renal) and consisted of three brief lectures spaced throughout the block. Each lecture was then followed by an interview with a psychiatric patient. We split up into groups of eight students, each group led by a couple psychiatrists and/or psychologists who facilitated the interview and learning experience. One of the eight students then conducted the patient interview in front of everyone else.
At our level of training and experience (i.e. none), interviewing a patient by itself is enough to get the adrenaline flowing. But being observed and evaluated by both professors and our fellow classmates makes the experience that much more anxiety-provoking. I conducted an interview last semester with a patient who suffered from anxiety and depression related to a serious cardiovascular illness.
The psychiatry thread has continued into the neuroscience block. Each week, we cover a different condition or disorder. So far, we have interviewed patients with PTSD, autism, Parkinson's disease, chronic pain, bipolar disorder, and schizophrenia. Next week we're interviewing someone who is dealing with a substance use disorder.
I'm having a lot of fun with psychiatry. I have always been interested in the brain - how it works, and also what exactly goes wrong when it's not working so well. Learning about neurologic and psychiatric disorders in the classroom is good and all, but I really value this more clinically-oriented exposure to psychiatry. First, application of knowledge is always rewarding. Second, this psychiatry thread has encouraged me to appreciate on a personal level the impact that these diseases or disorders have on the individual.
I may or may not become a psychiatrist, but I have heard several times that every physician - regardless of specialty - practices psychiatry on some level.
Friday, March 12, 2010
Medical hypnosis
I have always been fascinated by the brain and its mysteries, so this semester I took advantage of a medical hypnosis elective. It was just two classes, each two hours long, and really only served as a very brief introduction to the role of hypnosis in medicine.
What is hypnosis?
"A good date is a mutual hypnotic state."
Hypnosis is a special state of mind that is brought about by intensely focusing on something and is characterized by a sort of dissociation from self. Have you ever been driving home and, once you arrived, realized that you didn't remember how you got there because you had been driving on "autopilot?" You focused on the road and allowed your mind to relax into whatever thoughts it pleased so that you lost all sense of time, and your body mindlessly performed the motor tasks necessary to get you home. That's a hypnotic state: a combination of intense focus and relaxation that somehow lends a person more open to suggestion.
Inducing a state of hypnosis involves both of these elements, focus and relaxation. The instructor demonstrated this by hypnotizing the class, the five of us. He had us imagine a "safe space" in our mind and asked us to explore every little detail of it. I noticed that the suggestion was vague and open to interpretation. This is called a "lead and follow" technique: the operator (hypnotist) leads the patient in a given direction then follows where the patient's mind goes. The effect is to reinforce imagination as reality to induce a deeper hypnotic trance. Four out of the 5 of us experienced a hypnotic state. Some people are inherently more easily hypnotized, and some people are less so.
Being the hypnotist
Next, the instructor invited us to practice on each other. Sitting down with my classmate in front of me, ready to do and feel and imagine what I suggested, I had a much clearer understanding that only experience can teach of what it means to hold such strong control over another person's mind. The sensation was exhilarating and a bit unsettling. I quickly learned that not only my words themselves but how I spoke mattered greatly. So, despite the adrenaline pumping through my body, I was careful to speak in a calm and measured manner, slowly, so the full impact of my words could be absorbed.
I discovered that I am good at hypnosis! I induced a hypnotic state in my classmate quite easily, but I didn't know what to do with it. This was partly due to my inexperience as an operator, but it's also because there was no real purpose to the session other than to practice inducing a hypnotic state.
Hypnosis and medicine
Hypnosis is not just used in psychiatry, which is what I'm sure most people believe. The instructor pointed out that pain is a particularly good inducer of a hypnotic state because nothing better focuses one's attention than pain. In fact, a patient with pain is often in a hyper-suggestible state of mind. Then the doctor walks in the room wearing a white coat and/or stethoscope, which are both symbols associated with the promise of alleviating that pain. I have myself witnessed such a hyper-suggestible state in my own patients, for instance when a man in excruciating pain from a fractured rib allowed me to touch him in exactly the spot that hurt the most.
The meat-and-bones of this elective was first recognizing this unique psychological state that we'll see in many of our patients, and second to learn techniques to take advantage of it to better serve our patients. My favorite example was using a pinwheel to distract a child from pain (e.g. a splinter, a scrape, getting a shot). I wish I had had this trick up my sleeve last semester when I was giving children shots at Warren Village. Asking the kid to blow on the pinwheel first offers the child something else besides pain to focus on. More than that, though, there are physiological benefits to breathing deeply to blow on the pinwheel, and the pseudo-trance is strengthened by the immediate effect of watching the pinwheel twirl.
My first hypnosis patient
Some time after I finished the hypnosis elective, a classmate of mine was trying to study but couldn't concentrate because she was so tired. "I can hypnotize you to make you concentrate better," I suggested, half joking. But she said yes, and I got myself my first hypnosis patient. I hypnotized her easily enough and suggested that when she woke up she would feel energized to study more and a sharpness of mind so that she would understand and remember the material better. For what it's worth, she reported to me the next day that she was able to finish out the night studying, and she's sure that otherwise she would have fallen asleep in her books.
I'm eager to keep practicing hypnosis. Any volunteers?
What is hypnosis?
"A good date is a mutual hypnotic state."
Hypnosis is a special state of mind that is brought about by intensely focusing on something and is characterized by a sort of dissociation from self. Have you ever been driving home and, once you arrived, realized that you didn't remember how you got there because you had been driving on "autopilot?" You focused on the road and allowed your mind to relax into whatever thoughts it pleased so that you lost all sense of time, and your body mindlessly performed the motor tasks necessary to get you home. That's a hypnotic state: a combination of intense focus and relaxation that somehow lends a person more open to suggestion.
Inducing a state of hypnosis involves both of these elements, focus and relaxation. The instructor demonstrated this by hypnotizing the class, the five of us. He had us imagine a "safe space" in our mind and asked us to explore every little detail of it. I noticed that the suggestion was vague and open to interpretation. This is called a "lead and follow" technique: the operator (hypnotist) leads the patient in a given direction then follows where the patient's mind goes. The effect is to reinforce imagination as reality to induce a deeper hypnotic trance. Four out of the 5 of us experienced a hypnotic state. Some people are inherently more easily hypnotized, and some people are less so.
Being the hypnotist
Next, the instructor invited us to practice on each other. Sitting down with my classmate in front of me, ready to do and feel and imagine what I suggested, I had a much clearer understanding that only experience can teach of what it means to hold such strong control over another person's mind. The sensation was exhilarating and a bit unsettling. I quickly learned that not only my words themselves but how I spoke mattered greatly. So, despite the adrenaline pumping through my body, I was careful to speak in a calm and measured manner, slowly, so the full impact of my words could be absorbed.
I discovered that I am good at hypnosis! I induced a hypnotic state in my classmate quite easily, but I didn't know what to do with it. This was partly due to my inexperience as an operator, but it's also because there was no real purpose to the session other than to practice inducing a hypnotic state.
Hypnosis and medicine
Hypnosis is not just used in psychiatry, which is what I'm sure most people believe. The instructor pointed out that pain is a particularly good inducer of a hypnotic state because nothing better focuses one's attention than pain. In fact, a patient with pain is often in a hyper-suggestible state of mind. Then the doctor walks in the room wearing a white coat and/or stethoscope, which are both symbols associated with the promise of alleviating that pain. I have myself witnessed such a hyper-suggestible state in my own patients, for instance when a man in excruciating pain from a fractured rib allowed me to touch him in exactly the spot that hurt the most.
The meat-and-bones of this elective was first recognizing this unique psychological state that we'll see in many of our patients, and second to learn techniques to take advantage of it to better serve our patients. My favorite example was using a pinwheel to distract a child from pain (e.g. a splinter, a scrape, getting a shot). I wish I had had this trick up my sleeve last semester when I was giving children shots at Warren Village. Asking the kid to blow on the pinwheel first offers the child something else besides pain to focus on. More than that, though, there are physiological benefits to breathing deeply to blow on the pinwheel, and the pseudo-trance is strengthened by the immediate effect of watching the pinwheel twirl.
My first hypnosis patient
Some time after I finished the hypnosis elective, a classmate of mine was trying to study but couldn't concentrate because she was so tired. "I can hypnotize you to make you concentrate better," I suggested, half joking. But she said yes, and I got myself my first hypnosis patient. I hypnotized her easily enough and suggested that when she woke up she would feel energized to study more and a sharpness of mind so that she would understand and remember the material better. For what it's worth, she reported to me the next day that she was able to finish out the night studying, and she's sure that otherwise she would have fallen asleep in her books.
I'm eager to keep practicing hypnosis. Any volunteers?
Subscribe to:
Posts (Atom)