Three Wishes (published on The Differential)

The following is a post I wrote during medical school.


Questions are powerful. They stimulate thought. They encourage discussion. And sometimes, they do so much more.

During my time on the Adolescent Psychiatry unit, one of my favorite questions to ask my patients was “if you had 3 wishes, what would you wish for?” or some variation thereof.

It’s not an exact science. But I felt like the question gave me a little bit of an insight into their minds. I had frequently heard the child psychiatrists ask this question of the tiny tots. I didn’t hear them ask this of the adolescents. I’m not sure why.

I remember one patient telling me that one of his 3 wishes included destroying the place we were in. As far as I could tell, I took this answer in stride. I asked him why and he admitted that he didn’t feel like the facility was very helpful. He just wanted to get out of there and go home. A couple days later, when I asked him again, I was glad to hear him say that he had changed his mind. He realized that value of the psychiatric unit and didn’t want it torn down and destroyed anymore.

Another patient told me of her wish to buy her mother a big house. It’s probably safe to assume how and why a wish like this would begin to take hold in the mind of a young person. Other teens also voiced their own desires for material items.

Regardless of the wish, big or small, I felt like it was a backdoor into understanding a little bit more about my patient. And in psychiatry, you take whatever you can get — at least that’s how I felt about it.

What happened to me, though, was that I began to look introspectively. I would like to think this sort of thing happens more often than not to students rotating through psychiatry. I began to think about what I would wish for if I were given 3 wishes. In fact, I was pretty much forced to think about it for myself when one of the patients turned the question back on me after he had answered the question himself.

If I remember correctly, I think I answered that I wished 1) to be done with my schooling and 2) for a lot of money. I told him I’d save the 3rd for later. He thought it was clever. But in looking at my first two wishes, I realize that I’m not that much different than the patients I was seeing. I seem to want physical and financial freedom just as much as they do. I just word it a little bit differently.

And that’s how one little question helped me feel closer to the patients I was seeing each day.


A Test Taking Tip

The other day I was doing one of the online quizzes for my Psychiatry clerkship. I don’t remember the question, but the answers looked something like this:

A. None of the above
B. Answer 1
C. Answer 2
D. Answer 3
E. Answer 4

My test taking, deductive reasoning quickly concluded that the answer could not possibly be A. You follow my reasoning, right? I mean if the answer option says “None of the above” and there is no other answer above it, then it cannot be true.

That makes sense, no?

So, folks, remember this the next time you are taking a quiz/exam and the question writer tries to pull this little trick over you.


Re: Major Depressive Disorder (MDD)

This morning I posted the following on my tumblr1 account (link to original post):

MDD is associated with a mortality rate of 15% — suicide.

50% of people with MDD receive no treatment.

What other disease has a 15% mortality rate, yet we do so little to get them help?

It was subsequently reblogged by myvonne with her “rant” (her words). Here is the link to her full response, unadulterated by my annotations.

Now, I don’t know myvonne at all. It appears she reblogged me through another reblog. So she may or may not ever read this response. But if she does, I want her to know this:

  1. I understand that your own personal life experiences have shaped whatever strong views you hold that must have fueled that rant.
  2. If we, the medical profession, have wronged you or your loved ones, I am sorry. That probably means nothing coming from a stranger over the Internet who hasn’t even graduated medical school yet, but still… I’m sorry. The profession isn’t perfect. We have made mistakes. And too many of us are socially awkward enough that we might not always communicate very effectively. I have strong opinions about they way doctors communicate with their patients. Quite frankly, I think that we have done a poor job.
  3. Please don’t take this response personally. I don’t mean to attack you in any way. My response is to the words you wrote. If we were sitting across from each other, talking face-to-face in a patient-doctor conversation, I probably wouldn’t disagree with you at all — at least not for a while. Because I’d sit there and ask questions about what makes you feel the way you do. But the context is different here. And again, I don’t even know if you will ever read this.

With that being said, I felt compelled to respond to a few things I read in the reblog of my original post. The quoted sections below will be from the post mentioned above.

I’m just gonna say. I HATE labels like this… I wish doctors and psychologists would stop labeling a people as something that they feel they have to live with forever.

Love them or hate them, labels aren’t going away. In fact, I believe that labels are essential to our success as human beings. Childhood learning is full of labeling. We label, we categorize, we generalize. It helps us learn. We look at a ball learn about it. The next time we come to a spherical object, we assume it has similar properties with the first ball we saw. Labeling helps us learn.

In this case, I assume that you are referring to “Major Depressive Disorder” when you say that you “HATE labels like this.” But labeling things like this helps physicians who are treating a patient. I will be the first to say that I am not the biggest fan of the DSM-IV, affectionately known as the Bible of Psychiatry. Sometimes the labels make no sense. But more often than not, in medicine and psychiatry, labels help to dictate the next step in the management of a patient.

We don’t label for fun. We don’t call someone “obese” to be mean. Statistically, those over a certain BMI have an increased risk of unhealthy consequences down the line. We don’t differentiate between pre-hypertension, stage I hypertension, and stage II hypertension because we are bored. Knowing what kind of hypertension a person has will direct the therapy of that individual. Ideally, the delineations like these are there to help guide treatment.

A second reason for these labels is insurance purposes. But I only mention this to acknowledge it. I believe that labeling is important for the reason I’ve written above.

If you are THAT unhappy, there is someone in your environment causing it. You may even have a physical illness (undiagnosed). People will stay in the most horrible situations or with people who are constantly belittling them in some way and not see that as a source of or part of the problem. Sometimes the depressed person is doing something that he knows is wrong … or doing something someone else SAID was wrong… with the resultant self-loathing. To get up, get some balls and actually do something about one’s life takes courage and I know that when you’ve been beaten down for a long time courage is hard to come by.

Sure, there are many reasons a person might be depressed. You are correct that a physical illness can be the cause. There is a diagnosis in the DSM for that — Mood disorder due to a General Medical Condition (DSM-IV 293.83). We also have other diagnoses like “substance-induced mood disorder” or “minor depressive disorder” or “mood disorder not otherwise specified.”

But I will disagree with a blanket statement saying that if someone is “THAT unhappy” then there is “someone in your environment causing it.” It may contribute to the depression for some, but I wouldn’t call it the cause.

There are many theories as to how depression comes about. But one thing is clear — there are definite differences in the brain of a person suffering from depression. There is decreased metabolic activity and PET scans show decreased blood flow. The endocrine system is also affected; depressed patients seem to have specific dysregulation in certain hormones. This is not explained by just “someone” in the environment. There are biological differences.

I wish I could tell the depressed patients I see to grow a pair and DO something. But I can’t because it doesn’t work. Depressed people hear pleas to DO something all the time. Sometimes people need more help than a pep talk.

Life is a battle at worst and a fun game at best. Either way, it takes courage and skill and a willingness to fight or play with all your might. Change of venue, change of friends, change of husband or wife, change of attitude is much more beneficial than a label!

I agree. Life is a battle. There are ups and downs. And a change of venues/friends/spouse just might do the trick. But sometimes, change just cannot happen right away.

The last few weeks I have been on the Adolescent Psychiatry unit. What do you tell a child who is depressed and suicidal due to their own traumatic events? There are kids who have been abused. Kids who don’t have healthy parental support around them. You can’t tell them to just get up and make a change.

Life sucks. Sometimes you can’t make the changes you’d like change. And these depressed patients often need to learn coping skills to deal with the situation they find themselves it.

If you have just lost both legs in Iraq or your child has died or some other genuine horror has befallen you, then okay, I’ll give you some longish time to come to terms with it…otherwise… whatever.

I don’t know what is considered to be a “longish” time. I’ll forego putting into words my initial response to this paragraph; it wouldn’t be helpful. But Iraq was brought up. During my time at the VA, I saw old men who suffered from PTSD. These were hardened, combat veterans. Tough guys. But 30 years later, they still suffer from flashbacks, nightmares, avoidant behavior, hyper-vigilance. Labeling these proud men with PTSD is the first step in getting them the help they need. Ignoring it can be disastrous.

So you don’t like your job or you just ‘feel sad’, go to work, work hard, do something that interests you, run a marathon, create a some art but don’t label yourself and then be that the rest of your life. I know this sounds harsh but the whole label thing really bugs me.

Okay, I’m done with my rant.

Finally, if someone were only “feeling sad” and able to run a marathon, create art, and do things that are enjoyable to them… well, then by definition, that wouldn’t be Major Depressive Disorder. MDD affects a person’s daily living. Anhedonia (or lack of interest in things they used to find enjoyable) is present in nearly all adults with MDD. They don’t find anything interesting.

Now, are there people who are incorrectly diagnosed as MDD? Sure. Diagnoses evolve as we learn about a patient. And yes, I’m sure there are patients who will take their diagnoses of MDD (whether correctly or incorrectly given) and use it as a crutch. They use it as an excuse for themselves or their inactivity in life. However, I don’t think this is a problem of “labeling.” In my view, it is a problem with defense-mechanisms or coping skills. They are basically using avoidance to get out of something they find uncomfortable.

Also, and I feel bad for sticking this in at the end, I think there is a confusion with the diagnosis of MDD. A person who has one major depressive episode can technically be diagnosed with MDD. But a major depressive episode can last for as little as 2 weeks. After that time, they can be back to normal and fully functional. Others, though, will have recurrent episodes of major depressive episodes that last for months (or longer) at a time.

This has been quite the lengthy post. But essentially my points are:

  1. MDD is real. We need to be more vigilant in getting help to those who need it.
  2. Labels like MDD are useful because they help us decide on treatment. It can be quite an effective tool.
  3. Many people with true MDD will benefit from treatment.
  4. Some people do use their diagnosis as a crutch to avoid things, but the problem is not the label. The problem is poor coping skills.
  5. MDD does not mean someone always has a depressed mood. It only means they have had periods (or episodes) of major depression.

If anyone would like to add their $0.02, please feel free to do so via the Contact Me link or in a comment below. You don’t have to agree with me. And I know that some of the people I follow have battled with depression. If your experiences have been totally off, please tell me. Hearing your views will only help me be a better doctor someday.

  1. My tumblr account is usually pretty silly. It is where I post light, non-medical related posts. []

Studying Quirks

I’m trying to get through the PreTest — Psychiatry. The format of the series divides each clerkship into chapters based on topics. There are questions in the beginning of the chapters with answers and explanations at the end of each chapter.

I keep telling myself to read through and answer all the questions first, then read through the explanations. But I keep giving in to the urge to check answers almost immediately after circling my answer.

I feel like I am slowing myself down. Can’t decide which is a better method. But it’s frustrating because I can’t stick to the method that I want to use!

But what probably is slowing down most of all is that I am taking the time to blog about it….


Phone Calls, Puppies, & Babies

I don’t mind talking on the phone. That is, of course, as long as the person on the other end actually has something to say. But phone calls have been one of my least favorite parts of this week on Adolescent Psychiatry.

Whenever we have a new patient, the we are supposed to learn everything about the patient that we can. For these new patients, there are three sources of information: 1) the nursing admission note, 2) the patient, and 3) the parent/guardian.

Usually, by the time the patient becomes “ours,” the patient is already situated in the unit. The nursing note has already been done. Our job, then, is to read the nursing note to get a sense of what happened, and then find out what the story is from the patient and their parent/guardian.

The patient/guardian is a phone call away. And these phone calls often take quite a while. I suppose it is expected, though, with situations that often involve seriously disturbing relationships and circumstances. We have to discuss the current situation and the events that led up to the hospitalization. And then we discuss the patient’s history in detail.

But what I find much worse than the phone calls is what I learn from them, and what I learn as I get to know the patient more each day. As the story unfolds, I have to watch myself. I sometimes get so mad and frustrated. I find myself in disbelief at the atrocities that “my” kid has had to endure. There are stories of 7 year olds who get started on drugs and alcohol. Seven year olds! Who gives a kid drugs and alcohol?!? We have to hear about kids who were abused in every way imaginable by people who were supposed to help protect them. We talk to kids who tell us they see and hear things. We have to daily ask them if they are thinking about hurting themselves or other people — because it is a very real issue for many of them.

And I find myself disgusted that it is harder to adopt a puppy than it is for a person to become a parent. It’s ridiculous. And it sucks.


Addiction Week

I have been on the Psychiatry service for almost 3 weeks now. This week I was assigned to the Addictions unit. It has been quite the eye-opener. It has been filled with meeting people at various stages of recovery. I have sat in on Al-Anon , AA, NA, and other group meetings.

They have been filled with stories. Sad stories. Tearful stories. Stories filled with despair. And stories filled with hope and inspiration.

The biggest thing about this week is the realization that addiction is a disease that does not discriminate. There were successful professionals. There were homeless members. There were women and men. There were people like me. And that scared me. Because I realized that if I could be sitting in one of those chairs and telling one of those stories.


On the Wards – (Child) Psychiatry

I stood at the end of the hallway looking out through the large windows. Outside the sky was gray, the blacktop was damp, and the trees were dripping. It was a stark contrast to the interior. Here, where I stood, the walls were brightly colored, cartoonish faces squinted, frowned, and smiled, and random quotes encouraged readers to share and play nice.

Less than ten feet away from me a doctor was interviewing a patient. I’m not sure how the interview went. I wasn’t paying too much attention. I knew of this patient, though. The young pre-teen had been admitted because she had reported thoughts of killing herself. One might think that this bit of information might be betraying the patient’s identity. But sadly, many of the patients I have been seeing in the child psychiatry unit have/had suicidal ideations.

In a place like this, the patient population seems to have more in common with the dreary weather outside than the bright, cheerful surroundings inside. I’ve spent three days on the unit, and it has been — well, shocking. I have found it all quite interesting. I will definitely not cross Psychiatry off my “list.” But if I had to describe what I’ve seen in one word, that word would be “sad.”

When people hear that I am spending time in the Child Psychiatry unit, I often get asked if the patients look different. Maybe they think these patients have “crazy eyes” or some other telltale sign of craziness. If there are, then I certainly don’t know what the signs are. But to me, these patients look like any other child you might find playing in a schoolyard playground. Except that a number of them are very depressed. And they look sad. But if they were happy, I could picture them laughing and hanging from a jungle gym set or fast and high on a swing set. My point is that visually, these kids wouldn’t stand out if you put them in a lineup with other children.

Abuse is common, though. So are hallucinations — if I can call them that. I’m not sure what the doctors are calling them, but a number of the kids report seeing or hearing things others don’t see or hear. I guess the staff will need to determine if they are truly hallucinations. One patient sees demons at night. Another sees ghosts without any limbs. Others hear voices that tell them to hurt themselves or other people.

When I found out I had been assigned to psychiatry, I thought it would be really fun. I imagined having adult patients telling me outlandish stories that would make me laugh. Then I found out I was assigned to Child Psych. Most of the patients I’ve seen here have made me cringe. Their stories are heart wrenching. It was shocking for me to see some of the things I saw. And as far as the cases of abuse, I wondered, what kind of society do we live in that produces children so mentally damaged by physical, sexual, and emotional abuse?

I have about a week and a half left in Child Psych. I’m sure it’ll be memorable.