When to believe my patient: Cynicism versus gullibility

During one of my medicine rotations this past year, I picked up a patient who had been admitted the previous night for abdominal pain. This was a middle-aged guy who had been in and out of the Emergency Department more than 7 times over the past few months for the same problem. A thorough chart review showed that he had the million-dollar work-up several times over, including half a dozen abdominal CT scans, and absolutely no biological cause was found to explain his symptoms.

Importantly, he also had a distant history of IV heroin abuse. On admission the night before, he said that he slipped up once a few months prior but swore he hadn't used since then. The admitting intern handed him off to me as a "drug-seeker with functional abdominal pain."

Talking briefly with my patient before rounds, I just didn't get the sense that he was drug-seeking. My resident was more cynical; he called me naive, but he also gave me leeway to do with my patient as I saw fit.

After rounds that morning, I spent a little more time with my patient. "What exactly happened a few months ago that caused you to use heroin again?" I discovered that his wife had committed a violent suicide and that he had found her. He blamed himself for her death. This was a revelation to me. Incredibly, my patient felt that he had put this traumatic event behind him, despite never going through any grieving process. He didn't draw any connection between his wife's suicide and his current abdominal pain, even though his pain began at around the same time.

I gently suggested to him that perhaps his abdominal pain was a result of that psychological trauma. He resisted that idea because, to him, it implied that he was "crazy" or making it up, and the pain felt so real to him. I asked him to just consider it and told him that I would return later in the afternoon to talk more.

During our next conversation later that afternoon, he was surprisingly receptive to the possibility of a psychogenic cause of his abdominal pain. "In all of my hospital visits, not a single doctor has suggested that, but it makes sense." He was in unbearable pain even then, so I suggested that we try a simple breathing relaxation technique. After five minutes of this, we got his pain down to a manageable level, and he seemed bolstered by the improvement. At this point, I was practically convinced that his abdominal pain was psychogenic in nature.

We were treating his abdominal pain with narcotics, which is a poor choice of medication because it can actually cause constipation and exacerbate abdominal pain. I suggested that, overnight, he first try the relaxation technique that I had taught him and only ask for oxycodone if he really needed it. This was the real test: How much pain medication would he ask for? When I came back the next morning, I found that he decreased his oxycodone from 10 mg every two hours to 5 mg every eight hours. This was objective evidence that my patient was not drug-seeking and supported a diagnosis of pain disorder.

My resident and attending were both surprised, to say the least. The management of drug-seeking patients is truly difficult, especially at a safety net hospital that predominantly serves a socioeconomically disadvantaged population with a high proportion of drug addicts. I grant that I am naive and perhaps too trusting when it comes to handling these patients. But I also see that if I hadn't at least been open to believing my patient's story, that he was in fact not drug-seeking, I would have failed to properly identify the underlying cause of this man's abdominal pain. This hospital visit would have been just as unproductive and wasteful as the previous 7 admissions. Most importantly, his abdominal pain would have persisted, with inappropriate medical treatment, and his need for counseling would have continued to go unrecognized.

Before discharging my patient, we started him on an antidepressant and gave him a list of psychiatrists who he could see on an outpatient basis. He had already made an appointment with an outpatient psychiatrist before leaving the hospital.

He was tearful when we said goodbye, thanking me for genuinely helping him after many frustrating hospital visits. Then he handed me a folded piece of paper, a letter addressed to my attending, who later shared it with me and quoted it verbatim in my evaluation:

I have been in and out of the hospital the last few months. No reasons were found for my problem until I was assigned Mr. O. He was able to help me in such a way that I am able to function again. He spent a good deal of time talking to me about my medical and personal life. He personally has brought back faith and recovery for me. He spent his personal time explaining ways to help with pain. I wanted to tell you that I am grateful for all his council, medical advice and help.

Silence

A few months ago, near the beginning of the interview season, I started feeling self-conscious about what I was writing in my blog. Knowing that this is a public space, and that it is entirely possible that residency program directors may find this blog and associate it with me, I felt constrained in describing my thoughts, feelings, and opinions about the residency application process and specific programs. So I stopped writing entirely. This reaction may have been extreme, but it was also the safest and easiest. As a result, though, my family, friends, and other regular readers have missed out on a significant segment of my medical school experience. For this I apologize. I continue to write, without publishing to this blog. After Match Day on March 15th, I will start publishing back-dated posts about my residency application and interview experiences. Until then, I may write on topics that will not directly impact the Match process.

Med/psych externship at Tulane

I arranged a second med/psych externship at Tulane University and started this past Monday. My main goal for this externship is to experience med/psych in a completely new environment. I want a broader perspective of med/psych, something with which to compare my experiences at UC Davis. I also obviously want to learn as much as possible about Tulane in general and its med/psych program in particular.

I've never been to New Orleans (N'Awlins) before now, so this externship promised to be an adventure for me. Finding acceptable housing was an issue because Tulane didn't officially confirm my externship until a week and a half before my start date. Life moves at a different pace in this city. I got lucky, though, and found a great housing situation through craigslist. It is a historic landmark built in 1845, located in the Garden District, which is a fancy-schmancy part of town with beautiful mansions in ornate French New Orleans style. I am staying in a flat on the second floor of the house, rented out to me by a real estate professional in his 30's. He is a proper Southern gentleman who offers all the hospitality that comes along with that background. So far, the living situation has worked out very well.

The first two days of the externship, I worked directly with the med/psych program director at her psychiatry clinic. Then I started working at Tulane Hospital with the consult & liason (CL) team. This is basically an in-house psychiatry consult service. For example, doctors in the emergency department may consult the CL service to determine whether a patient meets criteria for placing a 72-hour mental health hold (here in Louisiana called a physician emergency certification, or PEC for short). The CL service is also commonly called in to evaluate delirium and psychosis.

I will likely be spending the majority of my remaining time at Tulane working with the CL team, along with several weekly afternoon med/psych clinics. I will also be attending "Friday School," which is basically required lectures for internal medicine interns. I'm glad to be getting a taste of the didactic training that I would be experiencing myself as a Tulane intern.

Priorities

The annual meeting of the Association of Medicine and Psychiatry (AMP) is being held in Chicago this weekend. This meeting is an excellent opportunity for medical students to network with dually-trained physicians and program directors, current med/psych residents, as well as the handful of other medical students applying to combined training programs. I had been looking forward to this meeting ever since I discovered med/psych earlier this year, but it unfortunately falls on the same weekend as my grandmother's 91st birthday.

The decision wasn't difficult, to skip the meeting and celebrate my grandmother's birthday. How many birthdays and other big family events have I already missed because of medical school, and how many more will I miss during residency? I am still disappointed to forgo all the networking opportunities, especially heading into interview season. But the program director at Davis offered me some reassurance when I told him why I couldn't attend: "There will be meetings every year. Go spend time with your family."

Well-deserved vacation

I finished the Davis externship, and now I'm on my first real vacation since Winter break in December 2011. The two weeks I spent at home last month don't count because I was studying for Step 2. So here I am back at home: nothing to study, no patients to care for, no responsibilities except to relax. It feels great.

Davis: End of the externship

My externship with the Davis combined medicine/psychiatry program ended today. I left the clinic this afternoon with a sense of satisfaction that the experience was all-around positive and that I received encouraging feedback from everyone. I'm sad to be leaving, and I'm eager to return to Davis for the interview; this speaks volumes about my gut-level feeling about the program.

I had two goals when I started this externship. First, I wanted to figure out whether combined medicine/psychiatry is right for me, or whether I might be better served by a pure medicine or pure psychiatry program. Second, I wanted to get a better feel for the UC Davis program, in particular: the leadership, the residents, the strength of the training, and the general environment of Sacramento.

On the first goal:

I am much more certain now than when I started this rotation that I want combined training. I could only feel comfortable coming to this conclusion after gaining first-hand experience in an environment that combines medicine and psychiatry to provide integrated patient care. This rotation leaned heavily toward the psychiatry end of the spectrum, much to my initial disappointment. But this limitation to my experience here at UC Davis provided a contrast that helped me appreciate the satisfaction I feel from treating patients' medical and psychiatric needs together.

Over these past four weeks, I learned why much of my clinic experience was straight psychiatry: MediCal reimbursement rules prevent billing for medical and psychiatric services in one visit. In fact, one of my last patients of this rotation lamented that she would soon have to find a new primary care provider for her medical needs because her insurance was switching over to MediCal. This is a woman with COPD, congestive heart failure, diabetes, and bipolar disorder, all of which my dually-trained attending has been managing well. She would be ill-served being forced to find a new primary care provider who just treats her medical needs. My attending says that changes to MediCal reimbursement rules are in the works to address this problem. This is a poignant lesson, though, of the types of struggles that I will likely face in choosing the combined medicine/psychiatry path.

On the second goal:

Over and over again, I was struck by how friendly and happy people are here at UC Davis. I'm left with the feeling that I would enjoy working with these residents and attendings, an extremely important feeling considering that these would be my colleagues for the next five years. Both the medicine and psychiatry programs, as well as the combined training program, are very strong. And Sacramento itself was a pleasant surprise. It's a small city with not too much going on, which suits my purposes just fine for residency. The heat was not unbearable as I was expecting. And it's close by to many attractions (e.g. San Francisco, Lake Tahoe, the Redwoods). My attending says that Sacramento is a better place to live than visit. I agree.



So, with everything said and done, my mind wanders back to about four years ago when I was visiting different medical schools. I remember walking around Colorado's medical school campus, taking everything in, thinking, "I could see myself happy here." And it turns out that I was. I get that same feeling from Davis. This is a nice starting point to have heading into interview season.

First residency interview offer!

I got my first residency interview invitation this morning! So exciting! The whole thing feels a lot more real, now.

Late Update: My first interview offer was to Iowa's combined medicine/psychiatry program. Exciting!

Residency application: Submitted!

Today is a big day for fourth-year medical students all over the country, the day when we can finally apply for residency programs. This is done through ERAS, the Electronic Residency Application System that aggregates all application materials. The whole process is much simpler than applying for medical school. There are only three parts to ERAS that medical students have any control over: 1) the personal statement, 2) the curriculum vitae, and 3) letters of recommendation.

I did my fair share of freaking out about the personal statement. My perfectionist traits shine brightly when writing an essay that's meant to convey most of who I am and the kind of doctor I want to become, all in less than a page. But beyond that, I've had a surprisingly zen attitude about this new round of applications. It doesn't do to obsess about something that can't be changed. For all the nit-picking over my application this last week, the substance of my application has been settled for quite some time.

Perhaps that's why clicking the "Submit" button this afternoon felt anticlimactic. I celebrated, regardless. How exciting to think about all those program directors out there reading through my application! Nerve-wracking to wait for the interview offers? Yes. But I'm confident in my application and am looking forward to this next step in the long slog of becoming a doctor.

Be a sponge

I had lunch with the med/psych program director for my midpoint evaluation. His feedback was different than any of the feedback I have gotten during other midpoint evaluations, which more often than not are formalities and not all that helpful. "I want you to take a step back," he said. "I want you to absorb everything that's going on around you. Be a sponge."

This advice was especially interesting to me because it echoes something that a close friend told me as I headed off to medical school: "Be a medical anthropologist. Look at what works and what doesn't work in the medical system and think about how you would do it differently." So, throughout medical school, I have been purposefully doing just that. Here at UC Davis, taking a step back and observing as much as possible of my surroundings and the people around me, that is all the more important as I am trying to figure out whether this is the right residency program for me.

Face time with med/psych residents

Last week, the chief resident took me and a few other med/psych residents out for my first recruitment dinner of the interview season. It's a great opportunity to get to know the people who I may be working with closely over the next five years. Do I like them? Would they be easy to work with? No doubt they are asking those same questions about me. This dinner was all the more important, for all of us. Because I have mostly been working with dually-trained attendings and psychiatry interns, I haven't had the opportunity to get to know my potential future colleagues.

Recruitment dinners in general have an interesting dynamic. On the one hand, it's a social event, and everyone should be having fun. I don't want to come across as boring or rigid or anything else negative, but I also don't want to have too much fun. I've heard many stories from current interns about applicants who drink too much alcohol during these recruitment dinners and end up making asses of themselves. Why anyone would do such a thing with so much in the balance is beyond me. Regardless, I did genuinely enjoy dinner and chatting with the med/psych residents.

Then, this weekend, I took a day trip to San Francisco with one of the med/psych interns and a couple of her friends. The whole day was very relaxed and a ton of fun, a showcase of what my days off could be like if I end up at UC Davis.