My History with Nuts (or Psychiatry Training in Medical School)
I did think about becoming a psychiatrist when I headed to medical school. Seemed to me that if you wanted to help people, that may be the best chance to do it. The med school psych department soon disillusioned me.
Our psychiatry teaching came in two parts: first a one hour lecture each week for the entire freshman year, followed by an exam. Then in Junior year we would have a six week psychiatric rotation, monitored by one of the staff psychiatrists.
The freshmen lectures were pretty good: a nice change from gross anatomy and some really good teachers. In a school that was still 2/3 female, with a large psychiatry department, there was only one woman in the psych department and she was a pediatric psychiatrist. This was reflected in our final exam.
Really, a solid year of weekly lectures, with no tests or reviews, and then a 25 multiple choice question final exam? Does that make any sense? Every exam question had one humorous answer that was wrong, but the whole thing seemed so stupid you were tempted to put it. The one I will never forget is:
Electroshock therapy:
1. is a better treatment for schizophrenia than depression (false)
2. was first used because epileptics are rarely schizophrenic (the right answer though not necessarily a true statement, though believed at the time ECT was first used)
3. is the treatment of choice for the cure of masturbation (really? see what I mean?)
The problem was the last question:
When she was little, she wanted to be taken care of. When she grew up she decided to become a physician. This is:
1. a sign of the symptoms of schizophrenia
2. sublimation and repression (forms of neurosis, though I suppose this is the correct answer)
3. absurd, because a woman's place is in the home.
A woman who decides to become a physician is neurotic, psychotic or absurd! Our class went nuts. We wrote essays all over the tests and refused to turn them in but gathered them and took them with a letter of protest to the president of the college. This was, however, medical school; the president simply turned them over to the psych department to be graded.
Still, I remained hopeful for the junior psych rotation. Medical College of Pennsylvania was next door to the Eastern Pennsylvania Psychiatric Institute and most students did their rotation there. I was one of two each session assigned to the small, inpatient psych unit at the medical college hospital, for patients with both medical and psychiatric problems. We were each assigned a supervising psychiatrist and a patient to see every day.
My first patient was a 45 year old woman with Crohn's disease (an intestinal disorder with pain and chronic diarrhea) and depression. She had been divorced for 9 years. She said she was depressed because, with so much foul smelling diarrhea, she couldn't go out or visit friends, and no one was treating the Crohn's disease. My supervisor wanted me to get into more detail about the divorce. The woman wanted some treatment for the diarrhea. To me, she made more sense than he did.
When she left, I was assigned a 25 year old African American woman with a draining wound in her arm and a complicated story.
Shana was one of six children of her mother's first husband. The mother later remarried and had several more children. She and my patient had babies within a few days of each other, so they both had 5 year old sons. More recently, one of her sisters was pregnant. Shana convinced her sister to tell her mother that their step father had raped her. The mother, instead of just throwing her husband out, which was what the older girls thought she would do and wanted her to do, called the police. The husband was arrested, but in court, the sister's boyfriend said "Hey, wait! That's my baby!" and the case was thrown out. The mother took her husband back and threw Shana out.
While on the orthopedic service for treatment for the wound infection, Shana told the ortho residents that she had had to leave her 5 year old son with her mother and that he was being abused, even to the extent of being thrown off a balcony. These two ortho residents, known more for discussing how soon they could afford to buy their ranches and planes than for getting involved with patients, actually did get involved and called Child Protective Services. They investigated and found that the boy was fine, not injured, no evidence of abuse. The ortho residents then decided that this patient had no physical cause for the pain (the draining wound didn't count?) in her arm and transferred her to psychiatry.
With all this history, the patient had several thick charts, and, like a good little medical student, I went through them carefully. The psychiatrist in charge of the patient's care felt that all of behavior above, all of the patient's lying, was due to her problem of having to deal with having cancer. We needed to help her find ways to cope with her diagnosis.
My problem was that I couldn't find a pathology report on this tumor. So, I went to the new head of surgical pathology, who said "Hey, I wondered when someone was going to ask about those slides!". They had been on his desk when he arrived at the department 6 months earlier. The diagnosis was uncertain, so he sent them to the Armed Forces Institute, one of the major labs in the country for review of pathology slides. They said that this was an atypical but benign cartilaginous tumor with clean edges ( meaning all the tumor had been removed). So the patient didn't have cancer after all!
I was really excited and dashed back to the patient's psychiatrist to tell him that the Shana didn't have cancer. He said it was irrelevant. He didn't even want to tell her. He said the patient thought she had cancer and that was all that mattered. We had to help her deal with that. I said "So you're saying truth is irrelevant?" He said, "Yes, of course. Perception is what matters".
Shana was discharged shortly after that. She was told that she didn't have cancer, though I don't know if she believed it at that point. I was assigned a new patient: a 19 year old from a well-to-do family, who had a private psychiatrist and a diagnosis of schizophrenia. I went to see her and she said she wouldn't talk to anyone except her own psychiatrist and got up and walked away.
I reported this to my supervising psychiatrist who said "You just don't know how to deal with patients. I think you are going to have to repeat psychiatry. Come on, and I'll show you how to talk to a patient like this". So we went over to the unit. He sat down, she told him she would only speak to her own psychiatrist and walked away, into her room. He got up and followed her and 30 seconds later, literally came flying out of the room backwards till he hit the wall! He got up all full of indignation. "Who assigned this patient to a student? This patient should never have been assigned to a student? Who is in charge of this unit?"
He still threatened to fail me in psychiatry, but after he read the paper I wrote about Shana, he decided maybe I'd learned more than he thought and gave me a Pass (our grades were Honors, Pass, Fail). I learned a lot from Shana; mostly that I wanted to be a medical doctor, not a psychiatrist.
One more story from the psych rotation: we also had lecture twice a week on this rotation. They were given in a narrow room, just large enough for people to push the chairs back from the table, which seated about 15. I did the rotation in winter, 15 degrees outside and 15 people in this small, overheated room. The professor for this part of the series smoked a pipe. Usually I like pipe tobacco, but the stuff he smoked was awful! So, at the start of this lecture, Sandy, a student sitting next to him said "Sir, I, for one, would really appreciate it if you didn't light that pipe". Well, he threw himself back in the chair, lit the pipe and puffed away in silence for a bit, lighting it two more times and puffing clouds of smoke.
He finally said "Well, things have really changed!"
Sandy asked, "In what way?"
"In my day, we wouldn't have had the balls to ask a professor not to smoke!"
Two simultaneous comments:
Sandy: "Do you think that change is necessarily bad?"
Me: (loud enough to be heard from the other end of the table but not loud enough so he could pick out who said it; I wasn't that crazy) "Just goes to show that Sandy has more balls than you did."
He puffed away a bit longer and said "Anyone who doesn't want me to smoke can leave" and puffed some more, waiting. After all, this was medical school. We all stayed put, opening the window at the far end to the 15 degree air.
There is a sequel to this story. Christmas break came after this, and I went to Vermont and stayed with my cousin. Her roommate and I got to talking one night. Seems Carol had gone to a psychiatrist in Philadelphia, and she was the professors wife. Carol said the husband and wife psychiatrists shared their private office. Carol had the first appointment after the husband was done, and his wife would go around, opening all the windows. She said she hated the smell of his pipe, but she didn't complain about the office, because she wouldn't let him smoke at all at home!
The nuts referred to in the title were not the patients.
Our psychiatry teaching came in two parts: first a one hour lecture each week for the entire freshman year, followed by an exam. Then in Junior year we would have a six week psychiatric rotation, monitored by one of the staff psychiatrists.
The freshmen lectures were pretty good: a nice change from gross anatomy and some really good teachers. In a school that was still 2/3 female, with a large psychiatry department, there was only one woman in the psych department and she was a pediatric psychiatrist. This was reflected in our final exam.
Really, a solid year of weekly lectures, with no tests or reviews, and then a 25 multiple choice question final exam? Does that make any sense? Every exam question had one humorous answer that was wrong, but the whole thing seemed so stupid you were tempted to put it. The one I will never forget is:
Electroshock therapy:
1. is a better treatment for schizophrenia than depression (false)
2. was first used because epileptics are rarely schizophrenic (the right answer though not necessarily a true statement, though believed at the time ECT was first used)
3. is the treatment of choice for the cure of masturbation (really? see what I mean?)
The problem was the last question:
When she was little, she wanted to be taken care of. When she grew up she decided to become a physician. This is:
1. a sign of the symptoms of schizophrenia
2. sublimation and repression (forms of neurosis, though I suppose this is the correct answer)
3. absurd, because a woman's place is in the home.
A woman who decides to become a physician is neurotic, psychotic or absurd! Our class went nuts. We wrote essays all over the tests and refused to turn them in but gathered them and took them with a letter of protest to the president of the college. This was, however, medical school; the president simply turned them over to the psych department to be graded.
Still, I remained hopeful for the junior psych rotation. Medical College of Pennsylvania was next door to the Eastern Pennsylvania Psychiatric Institute and most students did their rotation there. I was one of two each session assigned to the small, inpatient psych unit at the medical college hospital, for patients with both medical and psychiatric problems. We were each assigned a supervising psychiatrist and a patient to see every day.
My first patient was a 45 year old woman with Crohn's disease (an intestinal disorder with pain and chronic diarrhea) and depression. She had been divorced for 9 years. She said she was depressed because, with so much foul smelling diarrhea, she couldn't go out or visit friends, and no one was treating the Crohn's disease. My supervisor wanted me to get into more detail about the divorce. The woman wanted some treatment for the diarrhea. To me, she made more sense than he did.
When she left, I was assigned a 25 year old African American woman with a draining wound in her arm and a complicated story.
Shana had been in an automobile accident six months earlier. She was brought to the ER and had a CXR done. Later, after she was sent home, the radiologist noticed something odd in her arm. She was called back, had more x-rays and was found to have some kind of bone tumor, thought to be malignant. She had surgery and a bone graft. Later she fell and broke the bone graft and had a metal plate put in. This developed an infection, so she had this small, draining wound in her arm.
Shana was one of six children of her mother's first husband. The mother later remarried and had several more children. She and my patient had babies within a few days of each other, so they both had 5 year old sons. More recently, one of her sisters was pregnant. Shana convinced her sister to tell her mother that their step father had raped her. The mother, instead of just throwing her husband out, which was what the older girls thought she would do and wanted her to do, called the police. The husband was arrested, but in court, the sister's boyfriend said "Hey, wait! That's my baby!" and the case was thrown out. The mother took her husband back and threw Shana out.
While on the orthopedic service for treatment for the wound infection, Shana told the ortho residents that she had had to leave her 5 year old son with her mother and that he was being abused, even to the extent of being thrown off a balcony. These two ortho residents, known more for discussing how soon they could afford to buy their ranches and planes than for getting involved with patients, actually did get involved and called Child Protective Services. They investigated and found that the boy was fine, not injured, no evidence of abuse. The ortho residents then decided that this patient had no physical cause for the pain (the draining wound didn't count?) in her arm and transferred her to psychiatry.
With all this history, the patient had several thick charts, and, like a good little medical student, I went through them carefully. The psychiatrist in charge of the patient's care felt that all of behavior above, all of the patient's lying, was due to her problem of having to deal with having cancer. We needed to help her find ways to cope with her diagnosis.
My problem was that I couldn't find a pathology report on this tumor. So, I went to the new head of surgical pathology, who said "Hey, I wondered when someone was going to ask about those slides!". They had been on his desk when he arrived at the department 6 months earlier. The diagnosis was uncertain, so he sent them to the Armed Forces Institute, one of the major labs in the country for review of pathology slides. They said that this was an atypical but benign cartilaginous tumor with clean edges ( meaning all the tumor had been removed). So the patient didn't have cancer after all!
I was really excited and dashed back to the patient's psychiatrist to tell him that the Shana didn't have cancer. He said it was irrelevant. He didn't even want to tell her. He said the patient thought she had cancer and that was all that mattered. We had to help her deal with that. I said "So you're saying truth is irrelevant?" He said, "Yes, of course. Perception is what matters".
Shana was discharged shortly after that. She was told that she didn't have cancer, though I don't know if she believed it at that point. I was assigned a new patient: a 19 year old from a well-to-do family, who had a private psychiatrist and a diagnosis of schizophrenia. I went to see her and she said she wouldn't talk to anyone except her own psychiatrist and got up and walked away.
I reported this to my supervising psychiatrist who said "You just don't know how to deal with patients. I think you are going to have to repeat psychiatry. Come on, and I'll show you how to talk to a patient like this". So we went over to the unit. He sat down, she told him she would only speak to her own psychiatrist and walked away, into her room. He got up and followed her and 30 seconds later, literally came flying out of the room backwards till he hit the wall! He got up all full of indignation. "Who assigned this patient to a student? This patient should never have been assigned to a student? Who is in charge of this unit?"
He still threatened to fail me in psychiatry, but after he read the paper I wrote about Shana, he decided maybe I'd learned more than he thought and gave me a Pass (our grades were Honors, Pass, Fail). I learned a lot from Shana; mostly that I wanted to be a medical doctor, not a psychiatrist.
One more story from the psych rotation: we also had lecture twice a week on this rotation. They were given in a narrow room, just large enough for people to push the chairs back from the table, which seated about 15. I did the rotation in winter, 15 degrees outside and 15 people in this small, overheated room. The professor for this part of the series smoked a pipe. Usually I like pipe tobacco, but the stuff he smoked was awful! So, at the start of this lecture, Sandy, a student sitting next to him said "Sir, I, for one, would really appreciate it if you didn't light that pipe". Well, he threw himself back in the chair, lit the pipe and puffed away in silence for a bit, lighting it two more times and puffing clouds of smoke.
He finally said "Well, things have really changed!"
Sandy asked, "In what way?"
"In my day, we wouldn't have had the balls to ask a professor not to smoke!"
Two simultaneous comments:
Sandy: "Do you think that change is necessarily bad?"
Me: (loud enough to be heard from the other end of the table but not loud enough so he could pick out who said it; I wasn't that crazy) "Just goes to show that Sandy has more balls than you did."
He puffed away a bit longer and said "Anyone who doesn't want me to smoke can leave" and puffed some more, waiting. After all, this was medical school. We all stayed put, opening the window at the far end to the 15 degree air.
There is a sequel to this story. Christmas break came after this, and I went to Vermont and stayed with my cousin. Her roommate and I got to talking one night. Seems Carol had gone to a psychiatrist in Philadelphia, and she was the professors wife. Carol said the husband and wife psychiatrists shared their private office. Carol had the first appointment after the husband was done, and his wife would go around, opening all the windows. She said she hated the smell of his pipe, but she didn't complain about the office, because she wouldn't let him smoke at all at home!
The nuts referred to in the title were not the patients.
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