Maggie's Farm

Ed. note: We will post each of the 3 parts daily.

These posts are bits from a short series of presentations which I give to medical students during their required Third Year Psychiatry rotations. Which is to say, it is more or less directed to the general public but oriented towards general-physicians-to-be.

(Very few of these medical students will choose Psychiatry as a career, given all of their choices. More of them will chose Radiology than Psychiatry - wherein they will have plenty of fun and much to learn but never even have to talk to a patient at all - or Dermatology, wherein they will never have to be on call for the hospital. However, most will select Internal Medicine for their internships, which itself is a path to other specialties. FYI, all American-trained Psychiatrists do internships which include Internal Medicine or Pediatrics, plus Neurology, and get Board certification from the American Board of Psychiatry and Neurology.)

My presentation is not about making specific diagnoses (that comes from other Profs) - it's about the preliminaries: how all Docs can think about their patients, if they want to, and how shrinks think about their patients.

It's partly meant to be a corrective to the often-stated idea that the DSM is any gold standard of diagnosis, and it is meant to encourage young docs to think about their patients' lives, not just about their diagnoses - whether psychiatric or otherwise. And if I can interest them in the sorts of things shrinks think about, and gain some appreciation for what shrinks do, so much the better.

My presentation is based on the idea that, in the end, the job we shrinks get paid to do is to figure out what interferes with a person's ability to make a reasonably mature and effective adjustment to life if they wish to do so, and to try to reduce pathological mental pain, impairment, and anguish (but not healthy pain, worry, and anguish, like guilt, regret, sadness, realistic anxiety, or grief).

It's not to try to make people "normal," because "normal" doesn't really apply. People are wonderfully different, each with his own unique fingerprint of strengths, weaknesses, neuroses, interests, abilities, ego strength profile (about which more later), etc. In fact, unusual characters are a fine addition to the fabric of life.

I usually end my first session with a case example, for example, of a 42 year-old patient with hypertension coming in for a routine follow-up with his internist or GP. He has been prescribed 20 mg of Coreg/day for a month, and his systolic BP is 170 (had been 180 at his last visit).

I do my rapid-fire Socratic shtick. I ask them "So, Doctor, what do you want to know about this guy?"

"Is he compliant with the meds?" somebody wonders.

"Compliant!" I say. "What is he, your servant?" "Isn't the right question whether he is concerned enough about it to take the pills every day? Whether he can afford the meds? Does he need your free samples? Whether his life is too disorganized to do it? Whether it's the right medicine or the right dose? Or whether he even cares?"

We go on like this for around ten or fifteen minutes, and end up constructing a picture of a middle-management sales guy who is recently unemployed, divorced with two kids, mildly depressed, worried about money and alimony and child support, living in a small rented condo with rental furniture on take-out junk food and Chinese food, with some tendency for denial because he feels overwhelmed, with some deterioration in his self-care since his divorce made worse by the lack of structure and discipline in his unemployed life. His BP is the least of his concerns, but he does want to maintain a good relationship with the Doc, who he views as a friend and as a caring emotional support.

You rapidly move past the notion of A Case of Hypertension to the uniquely human and individual. It's good fun for all of us, and a good break for them from the fascinating but mechanistic details of caring for the renal functions of unconscious gomers in the ICU. It's about the art of doctoring, not medical science. You cannot do medicine "by the book," because each patient is his own book.

Then I tell them that they have just made a first step towards Real Psychiatric Diagnosis - and the real practice of clinical, office medicine as opposed to our equally wonderful technological medicine. It's about wondering "Who is this person who is asking me for help?" and not just about "What ails them?" After all, hypertension is painless, and doesn't really "ail him" at all. If you want to help this guy, all of this information about him might be useful to you.

In conclusion, I warn them that the same thing applies to Psychiatric diagnostics. Some people with Schizophrenia - a dread and incurable disease - have more satisfactory lives than some addicts - a sort-of fully curable problem. People are complicated, and so, often, are their lives.

Then I command the students to read MacKinnon and Michels' The Psychiatric Interview  as their first of several readings for my series. A Psychiatric interview isn't much different from any other medical consultation with a new Internist or Family Doc, really - except no physical exam other than that of the well-informed medical eyeball (which can detect a lot).

Yes, I will interrogate them on their readings just as the Surgical Profs do with their text on the examination of the abdomen, or Neurologist Profs do with the diagnosis of stupor and coma (or, as we termed it in medical school, the Diagnosis of Stupor, Coma, and Death. Funnily enough, the diagnosis of death isn't always so easy).

Parts 2 and 3, and maybe 4, later. Why am I posting this? To help me collect my thoughts and to improve my presentations.

Photo is Dr. Emil Kraepelin, father of modern Psychiatric diagnosis who, among many other things, distinguished Manic-Depression from Dementia Praecox (Schizophrenia).