Medical School 2020, Year 2, Week 26

From our anonymous insider…

Psych week. Based upon my M3 mentor, I am using the DSM-5, also known as the “Holy Bible for Psych” and the First-Aid psychiatry chapter to study. Straight-Shooter Sally: “I’m surprised we have only one week of psychiatry. Mental health has become a prominent national issue.” Lanky Luke: “Doesn’t surprise me. Step 1 doesn’t give much weight to psych.”

A quirky spaced-out 60-year-old psychiatrist introduces basic psych terminology and substance abuse disorders. He joked about the number of psych drugs. “There is a website that tests you on if a name is a drug or a Pokémon. Our former residency director is proud of getting 60 percent. Get ready ladies and gentleman for psych week!” The psychiatrist emphasized the diagnostic criteria for psychosis: presence of a delusion, hallucination, or disorganized thought. A delusion is a fixed, false belief. He gave several examples: “I’ve had patients who think they have Michael Jackson’s baby or are the president. Somewhat more common is a referential delusion. While they drive, they believe a billboard is speaking about them, or a TV is speaking to them directly.” Lanky Luke: “Is #NotMyPresident considered a psychosis?”

He began the substance-use disorder lecture by playing a BBC video of vervet monkeys getting drunk off stolen liquor from unsuspecting tourists on the beach in St. Kitts. “Among adults, 8.5 percent qualify as alcohol dependent or abusers. Think about that when you drive home tonight.” He continued: “Why do we have 10 percent of our human population with [genetic] phenotypes that make them susceptible for this dependence?” Students responded: “Alcohol is important in certain cultures to build social interactions”. Another student added, “Mating ritual.” The psychiatrist added, “I do not think I would have met my wife without alcohol. I have terrible social anxiety meeting new people. Alcohol certainly helps!”

“What about heroin? Did the poppy seed hijack the reward pathway to disseminate its euphoric seeds around the world or was it coincidental? Cocaine, amphetamines, heroin, fentanyl, and coca leaves all activate the dopamine reward system. The Incas built an empire on drugs. Mail carriers chewed on coca leaves for more energy while traveling across the 1000-mile empire. Why did they not knock down and steal coca from ancient 7-11s?” Students responded: “They did not make coca illegal”; “It was not purified”; “It was chewed through saliva.” He continued, “Right. Cocaine was purified in the 1880s. Sigmund Freud still has the best pharmacodynamics measurements for cocaine. When I was in medical school, they tried to replicate his experiments. They asked four volunteers to do cocaine and monitor blood levels for $500. Ninety-six people volunteered, but unfortunately I was not selected.”

He digressed on the history of drug use in America. “In 1970s cocaine was $100 for a gram… so about $50 to get high. Then we developed crack in the early 1980s and a rock was about $5. This spread like wildfire among the urban poor. With good intentions we tried to stamp down on it, but the result was mass incarceration. It’s tough to get a job after incarceration, so these former inmates are on disability with psych issues now.”

[Editor: Who has better mental health, the person who goes to school for 28 years and takes on $500,000 in debt in hopes of getting a job as a doctor, or the person who gets monthly SSDI checks without working?]

He continued, “We are seeing a similar transformation in opioids. You need poppies to make heroin so it gets expensive when the supply is reduced at the poppy farms. Fentanyl is completely synthetic; you can make it in your basement if you have basic understanding of chemistry for a lot cheaper. People are dying now from fentanyl, not heroin.”

He continued: “When you come to my floor your job is to understand the mindset of an addict. Most of you guys plan about five years in advance. You imagine a family, a house with a picket fence. A heroin addict can plan only a week in advance. Someone on methamphetamine plans nine hours ahead. Good luck getting a meth addict to come for a follow-up appointment in two days.”

He concluded, “We see that addiction spreads in culturally demoralized communities. I worked for two years on an Indian reservation, part of my penance for being an aging white male and therefore partly responsible for the introduction of alcohol in North America. What you quickly realize is the Navajo community has relatively low alcoholism compared to the Sioux because of their economic and cultural cohesion. With the decline of the coal industry, you see the same pattern in Appalachia versus the rest of the U.S.”

[Editor: Appalachian coal shipments to China are up in 2017 and 2018, but Americans still love their opioids just as much!]

Straight-Shooter Sally: “I wish we had a Drug Use 101 lecture. Terminology, ways to use it, cost, demographics, etc.. This was close, but no cigar.”

A tall 45-year-old child psychiatrist with a slight Eastern European accent briefly introduced Conduct Disorder. This is essentially the same as “sociopath” (also known as antisocial personality disorder), but the profession refuses to apply that label to anyone under 18. She spent the rest of the 100-minute lecture on attention-deficit hyperactivity disorder: “ADHD is a developmental disorder of inattention and impulsivity. They have task-irrelevant motor/verbal behaviors and delays in motor inhibition. A common observation from teachers is that the child will get derailed by any disturbance outside of the classroom, such as a squirrel climbing a tree or a cell phone ringing. Most kids will notice and get distracted, but they refocus on the task at hand.” If teachers can pick the ADHD kids out of the class, what is the role of the psychiatrist? “My job is to look beyond the obvious. There are a lot of disorders that have attention deficits. Individuals with ADHD frequently have other development delays such as language and social interactions. Classic case is a patient with ADHD and oppositional defiant disorder [ODD, cognitively inflexible child that deliberately annoys others and cannot think of compromise out of dilemma].” Persevering Pete whispered, “ODD sounds like a fancy way to call a kid a brat.”

She showed a slide with CDC data: 11 percent of school-age children and 20 percent of high school age boys have been diagnosed with ADHD. This is a 16-percent increase since 2007, and a 41-percent rise in the past decade.

She briefly described an emerging theory about ADHD. “ADHD patients whose mother smoked have a tuned-down dopamine reward system. They are hardwired to search for new things because the world around them is not interesting to them. These were the explorers of new worlds in the era of cavemen. When we force the child with ADHD to listen to boring lectures all day, they find it impossible to focus. However, when they find a passion, they can focus without difficulty. Stimulants such as Adderall [amphetamines] and Ritalin increase dopamine signaling causing them to be more interested in the dull activities.”

[Editor: Are there vats of Adderall and Ritalin sufficiently large to get Americans interested in computer programming? And maybe we all need Adderall and Ritalin during tax filing season.]

Once a patient has begun stimulant treatment for ADHD, they have regular check ups to assess attention, sleep, appetite, headaches, and mood changes. “We do drug holidays every two years. This usually happens when the child is learning to drive. When you ask children how they are doing, they will always say okay. Ask their parents how they are driving. People with ADHD [off the meds] have a much higher rate of car accidents.”

Pinterest Penelope asked why the United States treats way more ADHD than any other country. “I’ll try not to be too blunt. It’s several reasons. First, I think we have a greater demand for attention than we used to. I have parents and young adults come to me saying they need to pay attention for 16 hours per day [e.g., school plus music lessons then homework or a college student with an evening job]. It’s just not going to happen. Attention is a finite resource. Second, we do not train our children to delay any sort of gratification. The French use very strict schedules. Eat at this time with no snacks between. Third, other cultures are less willing to call this a disorder. The willingness of parents to give medications to young children astounds me.”

( “The worldwide prevalence of ADHD: is it an American condition?” (Faraone, et al. 2003; World Psychiatry) concluded that ADHD symptoms are actually just as common among children in other countries, though diagnoses may differ.)

My small group waited 10 minutes for IT to come deal with our projection difficulties. Type-A Anita used the downtime to ask if we watched the State of the Union speech, which she characterized as “disgusting.” Adrenaline Andrew, an aspiring EM physician whose family immigrated from Kurdistan: “I thought Trump was hypocritical. He was touting all these immigrants that he brought in, but he wants to keep them all out.” Straight-Shooter Sally commented on the Arizona policeman and wife who adopted a child from a heroin-addicted mother. “Oh my God! You do not know if that baby will be f***ked up. I could never do that.” Jane had watched some highlights on Facebook: “It was mostly a celebration of America, just a lot of patting ourselves on the back. I am not quite sure why we are celebrating so much.”

We changed the subject when Fashionable Fiona walked in late, waving a beautiful diamond ring, to announce her engagement to an MBA two years her senior. We all congratulated her. Type-A Anita announced, “I have to be the primary breadwinner before I get married.”

[Editor: Congratulating Fiona would have been considered a terrible faux pas in the 1950s; one congratulates the groom, not the bride, so as to avoid the implication that the woman was desperate to find a man. Separately, given that physicians have much longer careers than MBAs, let’s hope that she reads Real World Divorce and settles in a state that won’t offer her spouse the opportunity to tap her for a lifetime of alimony!]

Our small group facilitator is a brilliant personable EM physician married to a head and neck surgeon. She has been out of clinical practice for three years while taking care of two young children. “Don’t do the double doctor thing. It ends with one supporting the other.” She has to recertify her boards two years from now, and enjoys facilitating to prepare for her studying. “It is amazing how much more you guys have to know. All these genes, drugs.”

She recounted her medical school quest to get right-to-privacy rules altered in the state of New York. “When I was in residency in New York, we were not allowed to get a HIV or hepatitis test on a patient to see if we were exposed by a needle stick. We would have to weigh the risk of the patient to decide if we should go on these serious antiviral drugs. Imagine being on those drugs while doing residency. Fatigue. It was crazy. California and New York had these crazy antiquated laws. We lobbied [successfully] to get that changed. If you were exposed you could require a patient to get blood drawn to test for virus.”

Thursday morning, our last lecturer for the week is a 65-year-old psychiatrist who became blind after medical school. “Most specialites have diagnostic imaging and tests. Psychiatry doesn’t, with the exception of some new expensive functional imaging. Think of psych disorders like trying to treat heart or kidney disorders 100 years ago. We barely understand them. We are in the Caveman age of psych drugs. We are just beginning to tap into the mechanisms of the brain disorders.”

He described anxiety disorders: “The frontal cortex and amygdala are at war with each other. The amygdala is the old part of the brain, tens of millions of years old versus 1.5 million for the cortex. New always loses to the old. Our brain is wired to assess if something is trying to harm you. It’s not wired to feel good about yourself. I have lots of patients that park their cars next to the ED when they’re going to sleep because they are so afraid of these attacks.” (Their treatment might stay within our lecturer’s family: “I tried to be flexible with my son and let pursue his own dreams. I told him, ‘You can do any psych residency that you want.’ He ended up choosing EM. The problem is he now has more interesting stories that I do!”)

Thursday afternoon, 16 of us visit the inpatient psychiatric wing of the hospital. “We did not have to prepare because we always have a few schizophrenics and bipolar patients admitted to our service,” explains the attending as we arrive. The psych wing is in an old part of the hospital. My favorite retired trauma surgeon pointed out that the wealthy love to donate money to put their names on new pediatric wings, not for geriatrics and apparently not for psych. The hallways are a muted grey with occasional peeling chips of paint. Many of the sliding doors are glass so that staff can see inside. We divide further into groups of four to sequence through two or three patients, 5-10 minutes at a time, with a psych resident.

Our first patient has her face touching a wall of her room as she attempts to walk through it. The resident instructs Gigolo Giorgio to ask her something. “Hello, Meredith. Are you okay?” No response. She explains, “This patient has catatonic depression. Her neighbor brought her in yesterday. When she first came in she had her right arm raised above her head for two hours.”

Our next patient is hospitalized for a hypomanic episode. “Just ask him what brought him here,” chuckled our resident, “He’ll do the rest.” Ambitious Al: “What brought you here today, Gregory?” Gregory responds, “Well, let me tell you from the beginning. I’ve had bipolar disorder for seven years. I do not take any medications. I’ve been bounced around different hospitals, but this place is great. They got all my medications in order. I just want to be able to talk to my family. They are so sick of dealing with me. Every time they ask me something, they can’t shut me up!” Students head home from the session at 7:00 pm.

Friday morning is our patient case: Sarah, a 25-year-old bank teller with a history of depression and anxiety since the age of 12. She presents to the ED for uncontrollable crying, a lack of energy, and a plan for suicide. The previous month, she felt “amazing,” though she slept less than 3 hours per night for 3 weeks straight. Her boyfriend accompanied her to the ED and reports that she recently cleaned the house from top to bottom, and cooked tremendous amounts of food for her extended family and neighbors. She scores 20/30 on the MME (mini mental status exam; not the challenging Montreal Cognitive Assessment on which President Trump purportedly scored a perfect 30!). She is not oriented to place or time, is unable to subtract serial sevens, and can’t recall three words from the beginning of the encounter. She agrees to be admitted to the psychiatric ward for Bipolar Type 1 disorder.

This turns out to have been a watershed moment for Sarah, who had previously been bounced around among multiple psychiatrists and multiple drugs, few of which were appropriate for bipolar disorder. Antidepressants can exacerbate the swings of mania and depression for patients with bipolar disorder and thus, during the seven-day admission, Sarah is taken off her antidepressant and started on a mood stabilizer.

Over the next two years, she tries 11 different medications to control her mood, finally settling on a three-drug cocktail. Sarah, now a skinny 29-year-old boasting long dyed red hair with streaks of purple, is well controlled. She told her own story: “My father committed suicide when I was 14. From what I remember, my depression started then.” (She was hospitalized for an attempted suicide at age 14.) Pinterest Penelope asked about other relatives with psychiatric disorders, such as depression, bipolar, or schizophrenia. Sarah responds, “Yes, my father, my cousin, and my aunt. All on my father’s side.”

The psychiatrist added, “You will quickly realize psych disorders run in families. We don’t know exact mechanisms, but it is both genetic and environmental exposure. How difficult is it for a mother or father to fear the child might suffer from their own disease?” Sarah’s mother, a portly 58-year-old with a wide smile and gregarious laugh, nodded her head: “As a mother you want to see your children reach their potential. I have son who is a computer science professor at a university and a daughter who has bipolar disorder. I am proud of both of them. My daughter holds a job. My daughter is independent. My daughter has built meaningful relationships. She is a functioning member of society. My daughter recognizes the impact her choices have on others. You should have seen her growing up. The change is unbelievable. When she was in high school, I had to wrestle her to the ground with all my strength. She had cut herself horizontally with a knife, and was threatening to finish herself off with a vertical cut.”

What advice did she have for us? Sarah: “Tell your patients they can get to normal if they really try with an invested psychiatrist. It might be different than other people’s normal. But you do not always have to be a homeless alcoholic substance-abuser. You can have a job… and not be on disability.”

Sarah continued, “From a young age, my dream was to be a mother. Dreams die. I have to respect myself, and respect those around me. If I were to have a baby, I would have to come off my drugs before and during pregnancy [her meds would interfere with a baby’s brain development]. Also, after if I want to breastfeed. I do not know if the meds would work again because my hormones would be all whacky. I recognize that there is a high likelihood that my child would be taken care of by my mother, boyfriend, or husband. It has taken me a long time, but I cannot do that.” Straight-Shooter Sally asked if Sarah had considered adoption. Sarah responded that she did not consider her condition sufficiently stable to take on the responsibility for a child, even without the pregnancy.

Type-A Anita asked for Sarah’s view on abortion. Sarah paused, then answered, “I believe in God. But if I become pregnant I will not be having the child. I do not care what you believe about abortion, if I get pregnant, I will not keep the baby.” (Sarah is unlikely to be a Planned Parenthood abortion customer due to the fact that she is currently “in a relationship” with another woman.)

Gigolo Giorgio ask Sarah’s psychiatrist how he persuaded patients to continue taking their medications despite serious side-effects. “I tell them to treat their psych problems just like any other disease. Would you stop taking your blood pressure medications because they make you have orthostatic hypotension [lightheadedness when you stand up]?”

Afterwards at lunch in the common area, Gigolo Giorgio commented: “You can tell she is drugged up. She would pause for a long time responding to each question.” The table agreed, and then moved on to an abortion debate. Jane: “Although Sarah is a unique case, and most women do not have similar reasons for why they can’t be pregnant, this is a good argument for legal abortion.” Type-A Anita: “To all those far-right deplorables, this is an example that disproves their anti-abortion views.” Lanky Luke: “Look, I agree with you, but you don’t hear the pro-choice people agreeing to allow abortion for these cases and prior to say 25 weeks, but not after that.” Straight-Shooter Sally: “Oh, please! 99 percent of abortions after the first trimester are for medical necessity. That’s such a bogus argument.”

After lunch a Step 1 panel was held with four M3s and four M4s. Next week will be our last week of lectures in M2. After that there will be a week for block exams and then a six-week individual study period before the Step 1 test. Lanky Luke whispered, “Our tuition is the same as last year even though we are not in school for six weeks?”

The eight panelists explained that most students used Pathoma, First Aid and a question bank to study for Step 1. Three of them had taken all eight of the NBME practice exams at a cost of $60 each. A fit M3 joked, “I’ve never been in better shape than studying for Step 1. I would get up in the morning, cook a luxurious breakfast of eggs or pancakes, then head off to the library from 9:00 am until 1:00 pm. I would get lunch then switch to Starbucks for another 4 hours.” What is your advice about the day of the exam? “Bring lots of coffee. If you do not want to pee between breaks, bring 5-hour energy or caffeine pills.” The panel explained that Step 1 is a one-day test with seven one-hour 40-question blocks. You can take a total of one hour of break in between the blocks, e.g., 30 minutes for lunch and a few 5-minute restroom breaks.

I spoke afterwards with two M4s, one applying to Gen Surg (general surgery) and one to Ob/Gyn. The aspiring Gen Surg resident is somewhat of an outlier in her class, enjoying hunting and skeet shooting. Any advice for rotations? The huntress responds: “Ob/gyn can be tense. The residents became cautious a few years ago when a [female] medical student wrote up a [female] resident. The resident spent 30 minutes teaching the student how to do a fetal ultrasound, then asked the student to do the next one. The student freaked out, and the resident went off on her. Two weeks later, the resident was called into the Chief’s office for a reprimand. You do have to demonstrate competence and then chill out. They do curse a lot in Ob/gyn, which is kind of surprising given their job of delivering cute babies. Just don’t be offended.”

The Ob/Gyn: “I loved Gen Surg. Internal medicine is a lot longer hours, it drains you. My best advice is to separate the people from the profession. You’ll do some rotations with amazing attendings and residents, and you’ll do some rotations with people that do not click with you. For example, I loved the people in Gen Surg, and they almost convinced me to become a surgeon.” Why didn’t she do it? “I realized that I don’t want to do that stuff. The smell is terrible when you open the abdomen.” The huntress giggled, “See I love that stuff.”

Aziz Ansari’s dating habits have been in the news and classmates are commenting. Type-A Anita posts the original Babe.net article featuring a description of a Manhattan date:

“It was white,” she said. “I didn’t get to choose and I prefer red, but it was white wine.”

Jane: “Well, that is just rude.” [Editor: White wine? Ansari identifies as a woman?]

Jane and Pinterest Penelope thought that the article was positive for our culture and agreed that non-religious American women in this day and age would likely have had a similar experience while “hooking up with a guy”. Penelope elaborated, “You do not want to be mean or insult the other person, so you just freeze and go cold when you’re not having any more of it. It’s not realistic to justify this behavior and say, ‘Well the woman should have just left.’ It would have been even harder to leave a celebrity.” Jane: “Whether or not it is true or justified, people will be more cognizant because of this article.”

Type-A Anita’s introduction to the article on Facebook:

TW [Trigger Warning]: sexual assault, rape

@ people who think I “hate all men,” when I talk about how hard it is for me to trust men or add new men to my friend group:

It is so exhausting trying to figure out which men are “the good ones,” and which will require a ton of energy on my part to discuss with them and educate them about how what they’re saying/doing is sexist/misogynistic/reinforcing rape culture… Can men take a second to read this and appreciate that a lot of people, particularly survivors of sexual assault, looked up to Aziz as a guy who “gets it.” It’s a sad realization that so many survivors have had to experience over and over again in their own relationships and friendships, and I am tired tired tired.

Statistics for the week… Study: 18 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: Burgers and Beers with Mischievous Mary and Lanky Luke. Mary gleamed as she recounted her day. She scrubbed in on an open heart surgery in the morning and spent the afternoon in the cardiac care unit (ICU for heart patients). She heard a pericardial rub (inflammation of the heart lining that produces a “walking on fresh snow” sound) with her stethoscope.

More: http://fifthchance.com/MedicalSchool2020