Sunday, December 30, 2012

2012 Reflections: Psychiatry

The year 2012 is coming to an end. It has been a long year, full of joy and discovery, as well as grief and tragedy. Personally notable for this year is that I received my M.D. and began training in a combined family medicine and psychiatry residency program. It has been such an amazing mass of experiences thus far, and it's only just beginning. In this post, I aim to discuss why I feel it is such a fascinating time to be a young psychiatrist.

The field of psychiatry is developing at a breakneck pace. Great strides have been made since the mainly psychoanalytic era of the 1950s, with a much better understanding of the causes of mental illnesses, and the discovery of medications that can help treat them. Schizophrenia is an excellent example of the progress being made. Though there remains much still to be learned about the disorder, many of the dysfunctional neural pathways have been identified, multiple genes associated with its development have been discovered, and a host of very effective medications exist. Similar strides have been made with a variety of other mental illnesses, including major depression, bipolar disorder and PTSD.

As our understanding of mental illness has improved, a need for better conceptualization and classification has arisen. This is reflected in the much anticipated release of the new DSM-V in May of 2013. The DSM, or "Diagnostic and Statistical Manual of Mental Disorders" is the primary book used by psychiatrists to diagnose and classify mental illness. There has not been a full revision of the DSM since the release of the DSM-IV in 1994, though there was an update (DSM-IV-TR or "text revision") made in the year 2000. Work on the DSM-V began in 2010 and many steps have been taken to incorporate the last information on mental illness into its pages. I am thrilled to be in my residency during this exciting transitional period.

Despite these advances, there is a lot that still needs to be done. Why is there still so much untreated or undertreated mental illness? Much of it has to do with stigma. Even though we know so much about the genetic and biologic causes of mental illness, there are many who still think of it as being under the control of the sufferer. I daresay that many people think that those suffering from mental illness just need to "man up" or "cut it out" or "just get over it", though we would recoil in horror if someone used similar language to a person with cancer.

An abhorrent extension of this stigmatization is the so-called "mental health carveout" with health insurance. In many cases, psychiatric treatment is specifically written out of insurance policies. What about the countless mentally ill without health insurance? They fall back upon government funded institutions, whose severely limited funding has even further plummeted in recent years. The single county-funded mental hospital in my city recently had to shut down function of half of more than half its beds because of lack of funding. Gravely disabled patients and those suicidal or homicidal from mental illness sit in the city's emergency rooms for days waiting for placement. It's been a rare day for there to be an empty bed when I've worked on the psychiatric unit of the county jail.

All in all, I'm extremely excited about becoming a psychiatrist. We've learned so much and are continuing to expand our knowledge of mental illness and its treatment. There is so much still to be done in terms of decreasing the stigma and marginalization of mental illness as a weak will or deficiency of character, and so much work to be done in terms of increasing access to care to those who need it so desperately. I'm thrilled to be in the thick of it.

Monday, August 13, 2012

Fragmentation

As I was driving to work this morning, I was thinking about how I wish I had time to exercise more. It's my 7th week as an intern, and I have only gone on a run once in that time (a 2.5 mile run last week in 25:30- pitiful considering that two months ago I was running 8-10 miles at least once a week). I got to thinking about all the patients I have to whom I recommend exercise (an almost literal panacea in terms of health benefits), but tell me they just don't have time for it. How did it come to be that we don't have time for exercise? What's with the explosion in obesity, and particularly childhood obesity?

Then the realization hit me, that all our modern conveniences have created a new way of life where we actually have to schedule time for things like exercise, when it used to be just a part of everyday life. I'm driving to work in my pickup, but people used to have to walk- even if you had a horse to ride, that still took a fair amount of physical effort! So much of our "work" these days is mental, and our bodies suffer as we sit at a computer desk all day long, day after day- something new research shows is devastating to your body, even IF you hit the gym on your way home from work! For most of us, gone are the days of plowing and digging, building your house by hand, picking your own food, and coming up with your own entertainment rather than sitting in front of a screen being passively entertained.

I think our lives have lost a lot of richness due to this fragmentation of our lives. "Exercise" didn't used to be its own entity, because your day was packed with physical activity, from your morning chores, to working in the fields, to walking wherever you had to go, running and swimming and hiking and fishing as a carefree child and dancing the night away because there was no TV to squat in front of all night. Now "exercise" is a dreaded event which must be planned into our schedule, which we usually engage in alone, with only our iPod to keep us company.

Our consumption of food has been divorced from the simple joys of sowing, harvesting and preparing it. We feel hunger, look for the nearest golden arches and load up. Where is the investment? With such easy availability, no wonder we are adding up the pounds. To eat, you used to have to pick it yourself. Pound out the wheat yourself, knead the dough yourself, bake it, mix it...and now it's as simple as "A #1 please!"

The examples abound, of our modern technology making things yes, more convenient, but also robbing us of the joy of the process. Emails are much simpler to send, but where is the joy of carefully planning and penning a thoughtful letter- or receiving one? A text message is convenient to send, but what about sitting down to a cup of tea (or coffee) with your friend? It doesn't get more convenient than television, but what about sitting on the porch, talking about life and watching the kids run around in the yard.

I'm not against technology or our modern advances- to be sure, I probably use them as much or more than the average American. But I can't help but mourn the price that such technology comes with- a fast paced, "convenient" but empty life. Aren't you tired of going through the motions? Make a commitment with me to try to escape the monotonous routine, and take back some of the richness that life can offer. It may not be efficient to stop and smell the roses, but it's essential to a rich life.

Wednesday, June 27, 2012

My First Few Days

I started my internship on Monday. Let me just tell you, I am absolutely loving it. There are so many wonderful aspects to my job, and while I will admit that I'm a bit tired as I write this, I am so thrilled to finally be a doctor. Some of the best things about what I get to do:

>>The patients, both in the hospital and out. I am so honored to be able to care for people in some of their most vulnerable moments. In my current rotation, I am caring for patients with general medical problems in the hospital, and I also have clinic in the afternoon one day a week. I am already seeing such a variety of people, with their diverse personalities and ways of dealing with illness. Yesterday was my first day of clinic, and it was so exciting to actually be seeing people that I am now the primary care physician for. Some of the problems I saw were able to be treated with one visit alone, but one person I saw will be following up with me in two weeks. It is such a rush to be able to schedule someone to follow up with me! It's one of the things I love about family medicine- being able to build relationships with people over time, and take a step by step approach in helping them out.

>>The staff here. Everyone is so good at what they do! I'll admit that my pager has a way of going off every time I finally get to sit down for a second, but the nurses here are exceptional. They are extremely competent and very friendly. The same can be said for the rest of the staff, from program coordinators to discharge planners to pharmacists. It's really a pleasure to work with everyone.

>>My fellow residents. What an awesome group of doctors I get to work with! It is so refreshing to find doctors who are passionate and enthusiastic about what they do. The attending physicians eager to teach, my senior residents have been so helpful, encouraging and patient with all the things I don't know how to do yet ("Is this how you order an ultrasound?"; "Where's the interventional radiology lab?"), and my fellow intern class is really a solid group of doctors. Coming to work is a blast with such great people to work with! It's a privilege to be a part of both the family medicine department and the psychiatry department, because I get to work directly with twice as many incredible people, and both departments have really made me feel at home. The first two weeks of orientation there were so many "Welcome Intern" events that I couldn't even go to all of them!

It's so great to be able to work hard in the hospital and play hard with my kids when I get home. The new work hour restrictions laws only allow interns to be in the hospital for 16 hours at a time, so I'm getting a fair amount of time with my family when I get home, too. After clinic yesterday I went home and took my kids to the swimming pool and spent the rest of the night watching "LOST" with my wife. Granted, I'm on an easier rotation right now, and I'll be a fair bit busier during the two ICU rotations I have next, but I'm not worried about it. I love my job and have a great support system both in the hospital and at home. Life is good :)

Tuesday, June 19, 2012

Global Philosophies on Justice

A few weeks ago, I received my rotation calendar for my intern year. Every three months for the next two years, I will switch back and forth between family medicine and psychiatry rotations, since I am in a program to become board certified in both of these specialties. Anyway, I noticed that in December of this year I will be doing a month of psychiatry at our county jail. In this rotation and others in "forensic psychiatry", as it is known, I will perform psychiatric evaluations of inmates, be a member of the "expert witness" team at trials and propose/implement treatment plans for inmates with mental illness.

I think that my impending up-close involvement in the justice system is one reason that I have lately become more attentive to the system as a whole. One article in CNN today caught my eye for this reason(click here to view). The article highlights the looming implementation of a recently passed law in South Korea which allows the "chemical castration" of convicted serial rapists. At first, I was put off by this notion, but I find that my opinions are changing the more I think about it.

I wish to clarify that in tentatively supporting this idea, I am decidedly not echoing the boorish rants in the comments section below that article. Those comments, crassly suggesting that a serial rapist "deserves" only physical castration, exemplify the very American justice philosophy of revenge. From what I have noticed, the American justice system seems to place a large emphasis on punishment, and the general public seems to think that even the harsh prison sentences and the executions that still do happen in the U.S. are not severe enough to sufficiently punish inmates for their crimes.

In contrast, the South Korean law seems to actually be an attempt to decrease the risk of repeat offense. "Chemical castration", as the article describes it, involves a mandatory injection of some compound (I won't speculate here what the compound might be) which would theoretically decrease the sex drive of the convict, but that is all. Those sentenced under this law would stay under close scrutiny for three years and receive treatment for up to 15 years. As I think about it, in the United States we already use antipsychotic or sedative medications for violent inmates even if they do not consent to treatment. Are sexual offenses all that different? I haven't thoroughly thought through the potential implications of such a move, but it doesn't seem like an unethical leap.

And after all, shouldn't our focus as a society be on rehabilitating criminals with intent to reintegrate them into the fabric of our society, rather than retaining our current system which encourages repeat offenders and establishes a rather large population of citizens who cycle in and out of prison for life? To take an extreme example of a rehabilitation-based system, consider the example of Norway. Last month, I was reading this article about the "World's nicest prison", located on an island off the coast of Norway. I encourage you to read the well-written, if lengthy, composition. It details the Norwegian judicial philosophy, including their short prison sentences and emphasis on teaching convicts how to return as productive members of society, and providing those opportunities.

Such a system doesn't leave the vengeful with much satisfaction, but I ask you to consider, should our focus be on making ourselves feel better about the proper retaliation against an offense, or should our focus rather be on reducing the "recidivism" rate, or risk of repeat offense after a criminal is released? Say what you will about the Norwegian system, the numbers don't lie. The Norwegian recidivism rate at 3 years out is 16-20%. In the U.S.? It's 43-50%. Food for thought.

NOTE: I greatly appreciates responses/discussion, but please keep it civil. Thank you.

Saturday, June 16, 2012

So, I'm a Doctor

A lot has happened since my last blog post. A LOT. My wife, our two kids, two dogs and I have moved cross country in an F-150 pulling a camper trailer full of belongings to our new home in our old hometown. We decided to rent a two bedroom apartment for the first 8 months or so, so we could find a home to buy that we are truly thrilled about and not rushed into. We've been out here for just over a month now, insanely busy but loving every day in the Golden State.

The first few weeks were primarily related to getting settled in to our new apartment. The hustle and bustle of acquiring furniture, unpacking boxes and deciding where everything should go filled our days. Then, last Sunday, I officially became a doctor. I wasn't able to make it all the way back to Ohio for the ceremony, but the graduation for the Class of 2012 came and went, leaving me with the coveted letters of M.D. to place at the end of my name.

Then, this Tuesday, it all started to become intensely real. Every day since has been crammed with orientation, paperwork and meeting people. Most of my orientation events have been with the Family Medicine department of the medical center, since they start a bit earlier than the Psychiatry department. I cannot begin to express how excited I am to be working with these incredible people- the staff all seem to be incredibly organized, efficient and thoughtful, the program directors and faculty seem to be involved and friendly, the "older" residents all seem excited about us joining, and I think my entire intern class is really a solid group of doctors.

Our wonderful Family Medicine department realizes how important it is for the interns to all get to know each other, so they sent us all for a half day at a team building adventure camp. What fun! We learned a lot about each other, and most importantly have learned that we can trust each other, which will be invaluable starting on the 25th, when we actually begin working in the hospital.

Also exciting has been the two days we spent getting certified in resuscitation. We spent one day on "neonatal resuscitation", meaning what to do when a baby is first born and isn't doing so well. There was a sophisticated infant mannequin that would cry, wiggle, turn blue and breath, depending on how well we were doing. Our team really knew its stuff! The following day was adult resuscitation, from BLS (Basic Life Survey) to ACLS (Advanced Cardiac Life Support). Basically, it's the steps of what we all do as a team when a "Code Blue" is called in this hospital. There are a lot of steps involved! But at the end of the 8 hour day, we all passed our "Megacode" simulation test and got certified.

The rest of our time has been filled with equally important but less thrilling events like training on our electronic medical record (really top of the line), and filling out page after page of paperwork. Next week we will get orientation more specifically to what we will be doing in the hospital (and learning our way around it), meet with our faculty mentors to discuss our specific goals and interests, and wind down the week with a pool party for all residents, faculty and families before the big day on June 25. Everyone try to stay safe and out of the hospital for a few weeks while we figure out what we're doing, ok? :)

Monday, April 30, 2012

Family Medicine Honors Project

Hi there! I am four days away from my very last rotation of medical school! It's been a whirlwind of a month, finishing up last minute requirements. One of those things was the longitudinal "Family Medicine Honors" elective that I took. Part of that elective involved proposing and completing a project that involved patient education in some way. It wasn't structured any more than that, which some people enjoy, I hear, but I happen to loathe. After months of trying to decide on a project, I decided to go with something I know, and that is the Patient Centered Medical Home. I have been involved with a project with the Department of Family Medicine at my institution, to create a curriculum to teach the principles of the PCMH to resident physicians for the last year. Because of this, I've learned a lot about the PCMH model, and I'm really excited about it! I realized that, even though all of the family medicine clinics at my school were certified patient centered medical homes, none of the patients seemed to have any idea what it was, or what it meant to them. So, for my project, I created a website to teach the average person what a Patient Centered Medical Home is, and what it means to them. You can view my project at www.pcmh.webs.com I hope you check it out, and I hope you enjoy it!

Friday, April 6, 2012

How Medical School Changed Me

Today was the last day of my penultimate rotation as a medical student. I just have 4 weeks of emergency medicine left, and then I will get my M.D., and I'll be able to remove the quotes around the doctor of "Doctor" Matt :) I have been thinking a lot over the last few weeks about all the many ways that the experience of medical school has changed me.

The most obvious is knowledge. I've drunk from the proverbial "firehose" of information that we experience in medical school, and apparently enough of the facts stuck with me to pass all my exams, and secure myself a residency program back in my homestate of California. I was blessed enough to match last month into a 5 year program, at the end of which I'll be board certified in both family medicine and psychiatry. Significantly different from the pediatrician I thought I was going to be when I started med school, but at least I stuck (mostly) with primary care!

The change in specialty shows another way medical school has changed me. My focus shifted from just providing care for kids, to wanting to take care of the whole family. I discovered a love for truly comprehensive medicine, treating mind and body. I've overcome a lot of preconceived notions/fears of the mentally ill, and find myself led to try to help them, too. I can't just stop at treating the individual, though. The individual patient exists in the context of the family. The family exists in the context of the neighborhood, the county, the state...I have discovered that I'm unable to limit myself in caring for just one or two dimensions that make up my patients' existences. Thus, I find that I've become a social activist.

My political views have certainly changed as part of this. I was raised far-right, and naturally, those were my default views. I didn't do much independent thinking in undergrad either, but I got out "on my own" during medical school, and what I saw changed a lot of how I thought. It started with capital punishment- I'm now against it. I've seen what a lot of ruthless for-profit corporations have done to honest, hard-working people (and also less honest, less hard-working people, too). I'm a lot more sympathetic to the homeless and impoverished. The list goes on, but I find myself a just a bit left of center now. That's a far jump from the staunch conservative I used to be (I voted for McCain/Palin but try to forgive me...I'm voting for Obama in November.)

You'd probably not be surprised to find out that my changing views have disgruntled a few people in my life. When I told my wife that I was against the death penalty a few years ago, her response was, "I didn't marry a Democrat!" My thoughts on for-profit insurance companies, etc, don't always jive with those around me, either. In fact, I've found that many of my experiences in medical school, I can only really share with those who have gone on the journey as well, either with me or before me. I've seen people die. I saw a man shot in the head by a jealous girlfriend. I saw a woman who very nearly died of a heart attack in bed with her husband, but she lived. Children with incurable diseases, young adults with cancer, grandmothers and grandfathers with dementia. My hands have been inside people, I've been covered in their blood, I've worked 36 hours straight, the list goes on and on...

These experiences are hard to just tell other people about, and have them understand. I tried telling someone once about a man who came into the trauma bay with a leg broken and bleeding in many places. My job was to hold his leg still and straight while we moved him from the paramedic board onto the hospital gurney. I was sweating and my arms just felt horribly weak, but I knew I had to stay strong so I didn't hurt this man's leg any more than it was already. I resolved to get more in shape and increase my upper body strength, for him. So I wouldn't have to worry about my physical limitations causing one of my patients pain. The non-medical person I told this story to just didn't understand.

Just last week, someone told me "Doctors just don't care about patients." I hear all the time, "Doctors are stupid"; "They just push drugs (or vaccines) on you"; "They're in the pocket of the drug companies." There's some basis for these statements, of course, but I cringe whenever I hear them. More and more, I feel a close kinship to my colleagues...brothers and sisters in medicine. We've been through a LOT together. We've cried together...tears of joy and tears of sadness. We've sacrificed a LOT to be doctors...time (at least 8 years of education after high school), money (I'm exiting with $300,000 of debt), and immeasurable energy, emotion, care, and missed opportunities because we were working hard. Medical school has changed me a lot, and I hope with all my heart that all my experiences will make me an excellent doctor. We've been through a lot, we've done it together, and, even if we don't always do it well, we've done it with the one main goal of providing excellent care for you.

Thursday, March 22, 2012

Healthcare for the Underserved

I thought I had some coherent thoughts for this blog post, but I can't seem to get them organized, or even find any specific point that I'm trying to convey. However, it's been so long since I posted, that I'm going to go ahead and write something anyway, and see where it ends up.

For the last two weeks, I've been on a rotation called "Healthcare for the Underserved." I've been riding around on a large RV that's been converted into a mobile medical clinic, driving around to the destitute areas of the city, seeking out the homeless and other people with little access to medical care. For some reason, I've run into a lot of things this week that have made me think of the New Testament, specifically the gospels. I thought I'd share them with you.

The first was a man just slightly younger than I am. He hobbled onto the bus with a really bad foot infection. I was asking about his medical history, and he mentioned to me he had been recently given the diagnosis of Hansen's disease. I wasn't familiar with that so I looked it up...it's another name for leprosy! I couldn't believe I was seeing a man who actually had advanced leprosy, which causes loss of sensation in the limbs. Since you can't feel pain in them anymore, you can seriously injure your hands and feet without even knowing it. It's hard to believe that it exists in the developed world anymore, since it's a bacterial infection that is relatively easy to treat. It broke my heart to see this man in such a state. Having seen him, though, helps me visualize the stories in the gospels of Jesus healing the lepers. I wished I could heal this man like Jesus did. Even with the best medical treatment, the best we could do for him would be to defeat his foot infection and treat the infection of "Mycobacterium leprae", so that his areas of numbness wouldn't spread. But we can't undo the damage that's already been done. He'll likely require his big toe amputated at the hospital we drove him to. And we can't fix the nerves that have already been destroyed.

The other things is that I've been washing a lot of feet lately. Trimming nails, paring down horrible callouses and corns, treating ulcers, and scrubbing fungus-infected feet down and slathering them with antifungal ointment. We all need our feet, but none of us perhaps as much as a homeless person, living in a camp off the road, walking to get wherever he needs to get. Yet, almost every single one of them that I've seen in the last two weeks has required a significant amount of foot care. There's something so humbling about scrubbing someone's feet. I can't really explain it. You get a little tub, fill it with warm soapy water, and get to work. Big nail clippers, often a scalpel to cut away all the dead skin. It would take too long to really get down to the new skin underneath the entirety of both feet, so you just take care of the worst areas, and start working on the next person. It's really thought-provoking to consider Jesus cleaning the disciples' feet.

You don't realize how essential your feet are until you start to see people who are missing toes, whose toes are so horribly twisted and ulcerated from shoes that don't fit, with infections and odor and pain. I'm not sure what my point is in sharing all this, but I wanted to share these experiences. Coming from my last rotation, in a dermatology/cosmetic surgery rotation in a wealthy side of town, to seeking out the homeless, has really been a change. Last month, people were coming in and paying thousands of dollars to have their tiny leg veins lasered off. This month, people are so grateful for the most basic care that we provide. It's such a shock.

Again...no real point to what I'm writing, I just hope I have been able to convey some of the amazing experiences that I'm gaining as I finish up medical school. I'm truly honored to be almost a doctor, and to be serving under the Great Physician, who can cure more than physical disease.