Tuesday, July 31, 2007

Grand Rounds, Killer Biostats, and Clinic

Yesterday morning I went to the Neuroscience Grand Rounds. I don't normally go to that one, but this talk was being given by the same guy who did one of our Dean's Dinners last year, and I was hoping to hear more about a drug he told us about called natalizumab. Unfortunately, he spent most of the time talking about how the immune system surveys the central nervous system (brain and spinal cord), and he just gave a very brief mention at the end about natalizumab. I'd already heard it all, so I left for class feeling kind of disappointed.

Speaking of class, the last couple of days in biostats have just been insane. First of all, there is no way to really do more than just skim the reading. But this is medical school, and I'm already more or less used to that kind of insanity by now. The worst part is that the classes themselves feel like being in the Twilight Zone. I never thought two hours of my life could possibly go by this slowly. It has to be some kind of new warping of time and space.

This afternoon I went to longitudinal clinic. We don't normally have clinic over the summer, but I'm doing some extra sessions. I was going to do them anyway since I said I would in my portfolio last year. (That was my plan to try to improve my speed and comfort level with the clinical skills.) But now it's even more important that I'm doing it because I am going to miss the fall OSCE in October. (OSCEs are those clinical exams that we have to take to prepare us for Step II CS.)

My first two patients today were not terribly exciting, but the third one kind of got to me. She has a chronic, debilitating disease and she was feeling really depressed and worried about her finances. I was in the room with a resident and her, and the resident kind of moved on to other physical symptoms after the patient had said she was depressed. So while we were waiting for the doctor, I went back in and asked the patient whether she was thinking about hurting herself. She started just crying like crazy and telling me about how she was alienated from her family and didn't really have any friends in Cleveland even though she had lived here for a long time. I felt really bad and also totally powerless to do anything to help her. I also didn't know how to end the conversation, because it was obvious she wanted to keep talking to me about her problems. When my preceptor finally came in, we wound up spending like another 45 minutes with this patient trying to help her come up with a plan to improve her symptoms enough that she could go back to work and not have to worry about her finances. I don't know if we really did anything to help, but she seemed to feel better when she left. I am totally exhausted now though. I think emotional patients are even more exhausting than physically sick patients, and god help you if the person is both!


Anonymous said...

Isn't there some sort of a stern policy that prohibits one from disclosing any type of patient info?

I probably have a skewed understanding of the actual confidentiality policy- feel free to enlighten me!

CCLCM Student said...

You are talking about the privacy rule of the HIPAA laws. Here's an explanation about HIPAA from Wikipedia: http://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act

This is a fine line to walk. I clearly may not tell you any information that allows you to know a specific patient's health status or health care history. For this reason, I generally only describe my patients in broad, generic terms that cannot be used to readily identify them. In addition, I sometimes change specific details about a case to protect the patients' privacy.

Mysteries in the mind said...

Well,I just read this post though you have written it a long time.It clearly shows the view held by Psychiatrists that psychological and mental illnesses and disorders are more common than people think and that the average Physician or Surgoen usually don't recognise them.Your resident obviously did not recognise them!Your patient would have been better refered to a Psychiatrist.

CCLCM Student said...

Maybe so, but it's a fine line to walk. Many patients resist getting psych referrals and can refuse to get help altogether if you push the point too hard. I think we can both agree that depression treatment by the long-time PCP who knows the patient well is infinitely better than no treatment at all. And I definitely agree with you that depression is highly under-diagnosed and under-treated. An awful lot of our patients walk into the clinic with medical complaints when what they really need is someone to talk to or a shoulder to cry on.

We are actually studying psych right now (October 2007), and I just finished reading an article that suggested uncomplicated first major depressive episodes should be handled by the PCP, while depressed patients with comorbidities (other psych diagnoses, substance abuse issues, multiple depressive episodes, etc.) should be referred to psych. Seems reasonable to me.