Medical School 2020, Year 3, Week 33 (Psychiatry, Week 3)

After a 45-minute drive, I arrive at 8:30 am for paperwork at the local Veterans Administration (VA) hospital. Unfortunately, due to my short time here, I won’t get access to their electronic medical record system. I am joined by a podiatry resident, an internal medicine resident, and a medical student from a different school. After 2.5 hours of picture-taking and forms, we have our ID cards and are ready to experience the largest healthcare system in the United States.

Tuesday was a typical day: Arrive at 8:20 am for the first patient at 8:30. He is a no-show and the psychiatrist says that the no-show rate is roughly 50 percent. We chat about various psych topics while he does calf and neck stretches. One topic is the difference between ego-syntonic and ego-dystonic. “Both terms have fallen out of favor,” he said. “In DSM-3, homosexuality was considered ego-syntonic because it was a behavior that did not go against a person’s ego. This is compared to the dystonic behavior of obsessive-compulsive disorder in which the patient knows these compulsions are interfering with his/her life.” He explain the components of a mental status exam, including identifying common cognitive distortions, such as all-or-nothing thinking, emotional reasoning (equating transient feelings to reality), and overgeneralization (assuming one negative outcome results in inevitable failure of that goal)

I saw 2-4 patients per day, each for a 30-minute visit (workload would have been 4X at our home institution). When a patient arrives, I begin the interview and the psychiatrist interjects with clarifying questions and counseling regarding medication changes. I leave at 4:00 pm.

[Editor: As of 2019, a VA psychiatrist could get paid up to $320,000 per year. If we assume 3 patients per day for outpatient work, plus a full 40-hour week once/month on inpatient duty, that’s 1000 hours per year (if we assume 30 minutes of paperwork after every 30-minute visit) and $320/hour plus pension and other benefits bringing total compensation to $500/hour?]

As in civilian psychiatry, the typical diagnoses are anxiety and depression. Most patients were in the military for only two or three years and were never deployed abroad nor served in combat. 

I see a 45-year-old who worked at a Pentagon desk for 10 years as an intelligence officer. She presents for follow-up on generalized anxiety disorder. Although the majority of wealthy white women voted for Trump, she is not among them. When asked how she has been doing since her last visit, she responds with a discourse on Donald Trump’s racism and sexism. How much of her day was spent thinking about politics? “A few months ago, it was 75 percent of my day. I’d say it is now only 25 percent.” What coping mechanisms had she implemented? “I watch MSNBC only once per day.” She then explains that another 20 percent of her worry is about the recent remodel of her house.  “We just got these custom-ordered massive glass pane windows. One of them is trapezoidal, and it has several streaks on them.” She gets up on a ladder every day to scrub these and then calls the glass vendor.

[Editor: This proves my general rule that people who rent are a lot happier and have more mental space to think about interesting things than homeowners, constantly burdened with their amateur property management tasks.]

A 38-year-old medically discharged Air Force pilot presents for follow-up on generalized anxiety disorder with panic attacks well-controlled on Prozac and Ativan. He had flown the C-130 in Afghanistan and Iraq. There was an explosion due to mechanical malfunction that left him with damage to his arena postrema (vomit zone in the brain) and asthma from chemical inhalation. He described the weekly intense bouts of nausea that come out of the blue. “All my buddies are now pilots for the airlines, but I’m not allowed to because of my asthma.” His biggest current stressor is finding a job that is meaningful and pays well. “Even with my disability payments and my wife’s earnings as a secretary, money is tight with two small children.”

A 27-year-old overweight white male describes his experience as a flight engineer in the Navy. He was bullied and did not fit in. His team was being investigated for a spy in their midst who was allegedly sabotaging equipment on behalf of China. “At first they thought it was me,” he said. “You don’t know what it’s like to have everyone looking over your back. When I left, they still hadn’t caught the spy. There was never any evidence that it was our team. I never had anxiety before this ordeal.” He had been dishonorably discharged, but was now trying to get that changed to a medical discharge for major depressive disorder and generalized anxiety disorder. He described symptoms that could have come straight from the DSM-5. If we supply the requisite documents to change his status, he will get 100 percent tuition, housing, and books for his computer science studies. Ultimately, we tailor the note to say that his symptoms began during and as a result of his service, so he should be on track for a taxpayer-funded college degree.

[Editor: It seems that a dishonorable discharge is a bar to receiving most VA benefits, but a veteran can still be seen at a VA facility for “disabilities determined to be service connected.”]

There are workshops for the five VA psychiatry residents at lunch, led by an attending. I told them I was still waiting to see psychosis or mania. The chief resident responds: “Oh you’ll see that at the state mental hospital.” A graduate of an Iranian medical school now doing her residency here interjects: “No, no, if you really want to see mania or psychosis, go to Iran. Only about 10 percent of patients in state hospitals are legitimately psychotic. In Iran, it is 100 percent. You only get into a hospital psych bed if you are truly psychotic.” What about those who suffer from depression or anxiety? She laughed: “That’s life. Deal with it.” What was her psych rotation in Iran like?: “Everyone was telling me they are Jesus, Moses, or Muhammad. One asked me, ‘Have you ever spoken with God?’ When I said no, the patient responded, ‘Well you are now.'”

The chief resident describes the challenge in choosing between a position at a state mental hospital versus at the VA. “The state mental hospital job is a two-year contract with the government contractor that staffs the state hospital. There are no guarantees at the end of the contract and the work is intense. The VA offers more money and stability for much less work, but I think that I have too much energy for the VA, I want to change things.” He explained his plans to take the state hospital job and supplement that income with part-time work for a telemedicine psych company.

[Editor: An FAA employee told me, “I was unhappy in this job until I accepted that I was never going to accomplish or change anything.”]

The VA has implemented a new program in which a psychiatrist goes to the VA’s primary care clinic for consults with veterans who were flagged for mental illness by the primary care docs. This eliminates the waiting period from primary care to psych appointments. I see a 50-year-old former intelligence officer who is presenting for depression and anxiety. Her immediate concern is that the state is trying to euthanize her pit bull after the animal attacked a neighbor’s child. The psychiatrist decides to set an appointment up for her to come see him before and after the upcoming court hearing.

[Editor: Our Florida neighborhood, for a radius of about 1 mile, is entirely pit bull-free due to homeowner association rules.]

We then walk to the inpatient psychiatry unit to cover for an attending who has to leave for a family emergency. We admit a 65-year-old who served in the infantry during Vietnam. His diagnosis is polysubstance abuse, primarily crack cocaine. He was recently paroled after 15 years in prison for drug-related offenses and has been working as a mechanic, but was tripped up with a positive test for cocaine on a routine drug screen. The parole officer gave him the option of voluntarily admitting himself to inpatient psychiatry instead of going back to jail. We screen him for depression. He describes feeling that he has nothing to live for. His wife divorced him, took all of the joint assets, and now receives the lion’s share of his veteran’s pension. He lost touch with his daughters while he was in prison and they don’t want to reconnect. “I know I am going to kill myself if I keep using. Can you help me?”

On Friday afternoon, I say farewell to the VA and attend a required lecture on motivational interviewing (“MI”) led by a child psychiatrist. Primary care physicians can now deal with addiction easily if they can remember “SBIRT”: Screen, Brief Intervention, Referral to Treatment. We watch William Miller, a founder of MI, in video interviews with addicts. He gives us another acronym, OARS: open-ended questions, affirmation, reflexive statements, summary/synopsis. “There should be a 2:1 ratio of statements to questions. Once the patient begins talking, don’t interrupt him/her with a targeted question, but instead make an affirming or reflective statement.”

After the prepared PowerPoint ends, we do live practice. He goes into role as Johnny, a 10th-grade pothead taking several AP classes and maintaining a 4.3 GPA. He adds, “Weed is the number one cause of outpatient referrals. From now on, I am not myself, so I don’t want anyone writing me up on evaluations for what could be said.”

As a group we practice MI. What brought you in today, Johnny?” Johnny: “My father and I used to build cars and hang out. Now he is on my back about school and smoking pot. I used to not have any friends, but now I actually hang out with people. Smoking pot hasn’t impacted my grades, it’s just my dad is butthurt. I’m a parent’s wet dream!” We continue to practice responding with statements, and not questions. Bad: “Do you miss spending time with your dad?”; Good: “It must be challenging to balance spending time with your dad and with your new pot-head friends.” The goal of motivational interviewing is to make the patient reflect on the benefits and costs of a bad behavior, e.g., smoking. Do they actually like smoking, or do they smoke because of some other stressor? 

After the conclusion of the exercise, he becomes animated on the subject of marijuana. “I will come out and say that I support legalization,” says the child and adolescent psychiatrist who just told us that marijuana leads to demand for adolescent mental health services. “I think the war on drugs has proven time and time again that locking up nonviolent pot smokers is not the answer, and overall is not effective in addiction treatment. The answer is education and awareness about the real harms of marijuana, especially THC and cannabinoids. There is quite convincing evidence that adolescent pot smoking can lead to harmful impact on depression, anxiety and development of psychosis.”

[Editor: … but a beneficial impact on the incomes of psychiatrists….]

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Stopped by Gentle Greg’s house for his birthday party. Several physical therapist (PT) students attend.

The rest of the book: http://fifthchance.com/MedicalSchool2020