A Day in the Life of a Psychiatrist - Part I

Today I started at 8:00 am with morning report.

The setting is a room full of medical students, interns and residents.

We start with the overnight on-call intern going over the list of patients he saw during his 5:00 pm - 8:00 am shift. Mostly, these would be Emergency Room consults: people who are seen in the ER with a variety of psychiatric complaints. Some of these patients get admitted, others are send home with recommendations for follow up. I choose a case, which the intern then presents over 15-20 minutes, leaving us another half an hour for a group discussion about psychiatric interview, mental status exam, formulation and plan.

Green interns (meaning who just started their psych) tend to present their cases as loosely organized collections of symptoms. They talk about what brought the patient to the hospital (in technical terms the chief complaint) and usually offer some explanation of why that might be. "I had a lady who cut her wrists because she was trying to make herself feel better, then a 15 year old girl who tried to run away from home as she hates her parents, then this very sad elderly gentleman who is no longer able to care for himself, told a friend that he doesn't care much for living". Fresh interns tend to present their cases using man or woman or boy or girl for gender, instead of the generic male or female with an associated age tag which is preferred by more senior residents. They also tend to add some very palpable human qualities to the essential demographics: "33 year old woman, she looked as she's been through a lot", "25 year old guy looking wasted", "16 year old young girl but looking much younger than that, too young, and with this palpable sadness about her, heart breaking, I don't know why". They tend to be interested in the patient's story - as they assume, most times correctly, there should be something out of ordinary that happened to this person to make them come to the psychiatric hospital in the wee hours of the night, and are less apt to gather the precise quantities and duration of symptoms required by the standard diagnostic classification to make a diagnosis. They also tend to look for explanations as they think, like most people, that ex nihilo nihil fit (nothing comes of nothing). Granted, the explanations they get tend to be superficial ("got mad at parents", "boyfriend cheated on her", "wanted to impress his fiancee"), however, there is at least an attempt to explain distress in terms of a psycho-social dimension of sorts.

In other words, they tend to behave similarly to anyone out there who would encounter another human being in pain and would care enough to find out how they can help. Interestingly, these basic folk psychology characteristics of functioning tend to disappear in junior residents, as the process of acculturation in psychiatry takes place, and then reappear in a more refined form in senior residents as they approach graduation.

Back to fresh interns. At this stage of their training their relatively rudimentary diagnostic logic goes along the line that if anything looks like something, then the chance is that it is precisely that. Eg: If it looks like depression, then depression it is.

During morning report, it is my job to respond to this in a way that's going to move this common sense, folk psychology type of thinking, into more evidence-based clinical decision making.

So what do I do? I listen, then listen some more, and then, only after they are done explaining to me how decided what is what, I say:

"Really?"

It's a deceptively simple but in fact loaded question.

The trainee will of course defend his diagnosis. And I need to find a way - not be telling them directly but guiding them to discover - that a Major Depressive Episode is not quite Major Depressive Disorder.

Or, I simply raise my eyebrows at their diagnosis of Major Depression when after the required two weeks only four criteria are met or, alternatively, when all the nine criteria are met but they fell short of the required two weeks duration requirement. At this stage of training, the goal  is to get them to start appreciating the importance of precise knowledge, which is the sine qua non of effective communication in psychiatry.

And that is the problem. Fresh interns, partly due to their lack of knowledge, tend to withdraw into the big picture, so it is my job to get them to pay equal attention to details. This process of grounding is the same with the real life process of following the instruction manual (DSM in psychiatry) instead of figuring it out by yourself.

How about the occasional intern who in response to my scholarly discussion of diagnostic criteria might say...

"Really?"

Hasn't happened yet. But there were a few times when my diagnostic preaching was followed by an unusually long pause and then:

"So, are you saying that this is not Major Depression (or Panic Disorder, or Schizophrenia, or [you name it])?" ie, questions that challenge my pedantic insistence on precise numbers for quantifying sets of symptoms and duration.

I called those "Questioning the DSM Questions" (QDQs) as they attack the very essence of our diagnostic system. Young psychiatrists asking such QDQs tend to experience a fair amount of cognitive dissonance, which explains a slightly bewildered appearance that routinely precedes the asking of the questions.

"I have a patient who looks depressed, complains of depression, the patient's presentation made the air in the room feel thick with depression. I say this IS depression. But DSM says this is NOT depression. DSM is the most expert consensus about diagnosis, isn't it? So the experts must have it right, but I have it right too. Then, who is right? We can't all be. Or can we?"

And the poor intern feels as if his mind in going to blow his head wide open.

Unfortunately, the QDQs don't get asked nearly often enough. So, most of the mornings, we simply review more or less arbitrary diagnostic criteria according to current psychiatric classification. Maybe a map of an elusive reality, but the only one we have at this time.

And our morning report is then a preliminary training in the fine art of map reading and interpretation, while remembering that the map is not the territory.

Further reading:

Of Two Minds: An Anthroplogist Looks at American Psychiatry

© Copyright Adrian Preda, M.D.