Psychiatry Miniboard

Each rotation culminates in an NBME (National Board of Medical Examiners) miniboard exam, so that we can be somewhat standardized (you know, so people can't open up their own Billy Bob's School of Medicine and start churning out inadequate doctors.)

This is a useful outline that the NBME provides to help you figure out how much weight each subject carries on the exam for each discipline, and includes a few sample questions. Here's the psych miniboard outline:

• General Principles - 5-10%
• Promoting Health and Health Maintenance - 1-5%
• Understanding Mechanisms of Disease - 10-15%
• Mental disorders usually first diagnosed in infancy, childhood, or adolescence - 5-10%
• Substance-related disorders - 5-10%
• Schizophrenia and other psychotic disorders - 5-10%
• Mood disorders - 5-10%
• Anxiety disorders - 5-10%
• Somatoform disorders - 1-5%
• Other disorders/conditions - 5-10% (this probably includes personality disorders, because there was some of that)
• Applying Principles of Management - 20-25%
• Diseases of the Nervous System and Special Senses - 10-15%

The NBME also exists to be the bane of medical students' existence (I picture them all to look like Mr. Burns from the Simpsons - sitting around being animated, rubbing their palms together and going, "Yesssssss ...") The psychiatry miniboard, incidentally, wasn't bad at all. Other than reading a little throughout the rotation for our every-other-week quizzes, and doing further reading about a few major patients that I wrote up, I only studied hard(ish) for a day or two. I am a compulsive book-buyer, and I used Lange Psychiatry Q&A 9th edition, Blueprints Psychiatry, and First Aid for the Psychiatry Clerkship. I don't think there was anything that I couldn't answer by using these books, had I studied a little more (I looked up items that I didn't know later. As Christy says, I may be the only person on earth who studies more AFTER the exam that I do before it. Heh.)

Most rotations require a score at the 11th percentile to pass the exam (except OBGYN, which I think is 22nd percentile, and Family Medicine, which is somewhere around the 5th percentile because it includes surgery and OB questions, which are separate rotations that the student may or may not have had yet. The Family Medicine department gives its own exam in addition to the NBME one.)

So, I really liked psychiatry. Not just because the hours were really good or because the material wasn't beat-your-head-against-the-wall hard, but because it was interesting. I had a great group of fellow students to work with, too. I'm going to miss them when I start Internal Medicine tomorrow! I'm thinking of doing some time in psych as an elective next year, because no matter what your specialty is, you're going to deal with psychiatric patients and psychopharmacology. I would like to actually have a little extra training (seeing how I'm planning on a primary care residency) instead of just giving my patients whatever antidepressant that is written on my ink pen! (Not that primary care providers do that - I'm not insinuating that.)

A hairy situation

One of the most interesting cases that I saw during my psych rotation (which, by the way, ended on Friday with the NBME miniboard*) was a pediatric patient who presented with abdominal pain and an episode of vomiting. Some sort of scan (not sure if it was a CT or MRI) revealed a mass that was about the size of two footballs, which could be easily felt when palpating the abdomen. The size could be estimated by percussing and by using the scratch test, too.

When they figured out what it was, they consulted us in our psychiatry dungeon (psych & behavioral health is in the basement of the hospital.) It was HAIR. The patient's scalp had a few bald spots, and questioning revealed that she was pulling out her hair and chewing on it. Rapunzel syndrome at its finest. They told us about bezoars (glorified human hairballs) in GI pathology last year, and then followed up by telling us that we'd never ever see one. The surgeon that removed this patient's bezoar hadn't seen one. And the images that were taken after surgery were amazing - the patient's stomach was so full of hair that the bezoar looked like a cast of a stomach made of hair after it was removed. Her intestines had to be scoped 70 feet to remove all of the strands.

I went on a consult with the child psychiatrist, when the patient was a few days post-op, and we couldn't find any other OCD-type behaviors, so I don't know what was going on. And I expected her to look malnourished, because she had been doing this for at least two years and, judging by the size of the resected hairball, should have definitely had obstruction problems (she didn't until the week she came to the hospital.) She said that she drank 1 gallon of chocolate milk every day, which provided her with enough calories, I guess - but milk also curdles and adds to the mass. Nice, huh?

There's some pictures and other interesting information on trichotillomania (hair pulling) here - I don't want to post the pictures, lest I make someone spew on their monitor!

*Each rotation culminates in an NBME (National Board of Medical Examiners) miniboard exam - which I'll talk about in a separate post, because the hairball? Deserves to stand on its own.

The Psychiatry Stuff That I Was Too Lazy To Post the Other Day

Now that I'm on my last week of my rotation, I guess I should talk about it a little bit. Sorry I've been so scarce - I've been moving (more on that later) and just busy and tired.

Anyway, I'm in psychiatry for 8 weeks - and our schedules are split into "primary" and "secondary" assignments. The primary assignment is the one that we do in the mornings, and it changes every 2 weeks. The secondary one is our afternoon stuff, and it stays basically the same throughout the 8 weeks. So for the first two weeks, I was at the "main hospital" (the one that is closely associated with the medical school) in the mornings, and we did/observed outpatient therapy and med checks for both adults and children, and covered psych consults for the hospital (along with the attending and/or the resident, of course.) The outpatient stuff work was slow, because most of the doctors and therapists were on vacation, and patients also tend to cancel appointments. But the consults were interesting - I saw a case of delirium (which I think was brought on by both a head injury and withdrawal from a bunch of substances) in a guy who had been in an ATV accident (without a helmet, of course.) I think it would help the whole "Don't be an idiot, wear a helmet when you're on an ATV" campaign if they just showed a clip of this poor guy thrashing around in his bed. He was so sad. And we saw a couple of cases of delirium, and that was about it for my consult experience so far. (I should mention that they keep our rotations "standardized" by giving us a list of procedures we're supposed to either observe or do, and patient encounters that we're supposed to have, and we have to have a certain percentage of them signed off before we can pass the rotation. So patient encounters for psychiatry are things like, ADHD-adult; ADHD-child; Anxiety Disorder; Bipolar Disorder; Conduct Disorder; Delirium, Dementia, Domestic Violence; Eating Disorder; Major Depressive Disorder; Mental Retardation/Developmental Delay - adult; Mental Retardation/Developmental Delay - child; Obsessive Compulsive Disorder; Oppositional Defiant Disorder; Panic Disorder; Personality Disorder(s); Schizophrenia; Substance Abuse/Dependence; Tourette's, etc. And for procedures, we have to do some Mental Status Exams, Substance Abuse Assessment, attend an Alcoholics Anonymous meeting, Psychological Testing, Electroconvulsive Therapy, etc.) For the rest of those mornings for the first two weeks, I observed some child therapy, some play therapy, adult med checks, and watched some DVDs of those patient encounters (like The Teachings of Jon for MR/DD Adult, or Thin for Eating Disorders, or The Basketball Diaries for Substance Abuse/Dependence.) In the afternoons, I have lectures on Monday and Friday, see my Hospice patient on Wednesday, see patients in Student Clinic on Thursday, and Tuesday afternoon I have off.

For the second two weeks, I went to a private inpatient hospital for my morning assignment. That's where things started to get interesting, because that's where I started to see schizophrenic patients, patients with psychosis, that sort of thing. We (Todd and I) would get to the hospital around 9 (okay, he would get there at 9, I'd get there circa 9:15), see a couple of patients and write SOAP notes/progress notes, and when our attending got there at 9:30 or 10, we'd see some patients with him or get a mini-lecture from him on, say, Borderline Personality Disorder, if we'd seen a patient with it that morning. This was where I started having my "I can't believe they're letting me do this!" moments - when I was grabbing charts and writing notes (in BLACK INK, for the love of all that's good and pure - I wrote in blue ink exactly once, and it was such a BAD THING that I might as well have pricked the patient's finger and written with their blood) and also talking to patients and asking them personal questions, and they'd actually TELL ME. Signing my progress notes with my name followed by "MS-III" IS fun, I have to admit. I'll bet MS-IV will feel even better, if I make it to that point. I had two really interesting patients at that hospital - one was bipolar and had been really manic for about 5 days, not sleeping at all during that time. At the end of this lack of sleep, he got one of those Nigerian scam emails, and had a little bit of a psychotic break, and believed it. He became delusional about having millions of dollars in various international banks, and insisted that he was a descendent of the ruler of a country in Africa. I got to follow him almost the entire time he was a patient there, and it was great to get to see him get better with the mood stabilizer meds. He also had an episode of acute dystonia after they started him on Zyprexa (which is muscle spasm in the neck and shoulders) - and I learned that you treat that with Benadryl, of all things. It's the anticholinergic properties of Benadryl that fix it. And then there was another patient with schizophrenia who believed that people could hear him think. He said that he was "allergic to photos" - that if he looked at a picture for too long, he would "fill it up" and that the people who could hear him think would die. I looked forward to seeing how he was doing every morning.

And then for the next two weeks, I was at a different inpatient hospital, with some very, very sick folks. At the end of my two weeks there, even these patients - who were terribly delusional and psychotic at admission or committment - are showing some improvement. That's really rewarding, even though I had nothing to do with it. :-) For the last two weeks, I'm back at the first hospital - the outpatient stuff and the consults. Yesterday I had my oral exam (on an adolescent patient in a 30-day inpatient program at one of the hospitals - on which I got a 97, woo! Thank the Lord.) Friday I have my miniboard exam, and that will be all for psychiatry.

If I think of anything else interesting from the past eight weeks that I left out (and I'm sure I will, because something interesting happens every day) I'll post about it ... well, sometime.

These Are Your Heels On A Psychiatry Rotation. Or, Jessica Simpson Causes Large Fluid-Filled Lesions.

I haven't said nearly enough about my foray into the sleepy, "I can't believe they're letting me do this!" world of clinical medical education. Now, this has been entirely different from the first two basic science years of medical school. First and most imporant, we have to dress up every day (blah blah blah professionalcakes) instead of looking like we just woke up four minutes before. And unfortunately, I'm too fat for most of my "professional" clothes, so I had to buy a bunch of new stuff (that's not the unfortunate part - the unfortunate part is that I'm quickly approaching the size of a small house.) I had to be careful in top selection - cap sleeves must be avoided at all costs, because a shirt with cap sleeves might as well say, "Look at me! I have sausage arms!" They're worse than sleeveless, even. And then we move on to shoes. Since safety requirements dictate that we wear shoes that are completely closed-toe, and comfort requirements dictate that I can't wear much of a heel or anything like that - I pretty much look like I'm sharing shoes with my great-grandmother. The very first day, I wore this cute pair of Jessica Simpson wedges (ballet flats with a wee heel - the marriage of cute and comfortable. Or so I thought.)

At the end of the day, I had blisters as big as my head (and that's BIG.) I later managed to rip the skin off of the blisters by dutifully walking a couple of laps around the park in my orthopedic-looking-but-very-comfy-and-functional Masai Barefoot Technology shoes from Bliss. Check out my scary blisters, and my cracked heels which I cannot fix despite the 1,023,872 heel creams I've tried. And when those suckers crack, they HURT - a lot more than something that small should hurt. I have a crack on the bottom of each heel right now, and I have developed this odd walk-on-my-toes mechanism, which makes me look like I might be cognitively impaired. Anyway, the blisters:

And the next day, I still had to wear shoes, because barefoot student doctors are generally frowned upon. So I ended up buying TWO sets of not-at-all-fashionable shoes with toes - a regular pair in a couple of different colors and a backless pair in those same colors. (I love shoes, though, so I can't really complain. I just wish my shoes in current rotation could be could be cuter.) I actually like being dressed up, though - I feel like a real grownup going off to work or something. (Ha ha, I'm so not a real grownup, though.)

As you know, I'm on the psychiatry rotation, which is known for being the easier one. This was a good one for me to start with, since I don't adapt to change well and it takes me a little while to get used to new routines and such. So it's better that I don't have 4:45AM-8:00PM days (see "Surgery") right off the bat. Eeeeugh, 4:45AM. I really don't know how I'm going to manage that, y'all. I have a hard time rolling out of bed at 6:30. And I've learned that my psychiatry preceptors (i.e., the psychiatrists) are not unlike me. One of them told me that he hates morning. A couple of them don't roll into the hospital until around 9:30 or 10. That's AWESOME. I might consider going into psychiatry solely for that reason. Just kidding. Although I do think this rotation has been really interesting, particularly the inpatient stuff. I'm learning a lot from my patients.

And now I'm tired. To be continued. I also need to tell y'all about my Pain Clinic experience.

Dreams, psychiatry, and future blogging

Y'ALL! I've missed you. I don't know why I'm not writing more - it's not like I'm at the hospital 24/7 or anything (I'm on psychiatry, for crying out loud!) I guess I'm just not feeling creative or something. Although I do have a lot to write about - speaking of that, here's the thing about HIPAA and patient talk. HIPAA, as I understand it, means that I can't talk about patients in any way that would allow them to be identified. So I can tell you about the patient who equates West Virginia with Egypt:

Me (doing a mini mental status exam): Do you know what state [current city] is in? (I was expecting a correct answer, because she did get the city right.)
Patient: West Virginia.
Me: That's corr-
Patient: You know, Egypt.
Me: -rect? Okay.

And you would have no idea who that patient was. You could even go onto the floor at the hospital where I'm currently working and still not be able to pick her out based on that. So I will not discuss patients in a way that allows them to be identified, but I may discuss them if I'm talking about a particular concept in psychiatry, or something that deeply affected me, or whatever. [/obligatory HIPAA statement, because I signed approximately 10^3 forms stating that I won't violate it or else they'll kill my kitty cats and let the air out of my tires. Oh, and chop off my big toe.]

With that said, I can't stop dreaming about my rotation. Seriously. I either dream about psychiatry, psychiatric patients, the other students on this rotation with me (which, despite popular-but-ridiculous belief, I have NO CONTROL OVER and it does not mean that I want to jump their bones in any way, shape or form), or marriage. For instance, I recently dreamed that Scott and I got married and moved to Australia, where I had to take Step One again (the horror!) and Scott's personality changed so that he was a completely different person. He was also wearing yellow capri pants, which was very disturbing. And then last night I dreamed that every person I talked to exhibited an inappropriate affect. This is when someone laughs as they tell you about the death of a person close to them, or smiles at strange points in the conversation - it also applies for crying or being sad at weird times as well. So everyone in my dream had an inappropriate affect, and I would point at each one of them and declare, "Inappropriate affect!" I don't think I'm right in the head, y'all.

Re: Future blogging - I bought a book called The Book Of Myself - A Do-It-Yourself Autobiography in 201 Questions, and I think I'll answer some of the questions here from time to time. Because y'all want to know me better, right? And I want to do a better job of chronicling my past and my thoughts about things. The questions are things like this:

• This is the profession that I often considered as a teenager and how I learned about it
• I was very hurt by this person I counted as a friend
• If I had any trouble with my mother/father when I was young, it was in this area
• This is how I met my sweetheart and fell in love

Just stuff like that. What do you think? Do you think that type of thing would make for interesting posts? Give me some feedback, please. I really wish that each of my parents would fill out one of those books for me. I love hearing about their childhood and early years together, and stories about family members - not just genealogy - I like the narratives.

All right, I'm off to a substance abuse lecture. Whee!

No Internet For You!

My internet access has been screwed up all week, and Comcast is on my LIST, y'all. I'm currently in the library at the hospital waiting for a monsoon to pass over, so I thought I'd let my faithful reader(s?) know why I've been silent all week. And I really had lots that I wanted to say, too - I felt like writing. Oh well. I'm going home this weekend, where the Inter-webz abounds, and I will talk your ears off. Maybe.

Psych is going well, and I found out yesterday that my next rotation is Internal Medicine. Yay! With Christy! Yaaaaaaay! For Medicine, I've heard that we work in pairs, and I hope to goodness that I don't get paired with an undesirable person.

That's all for now.

I'm not dead y'all.

I'm just busily intermittently seeing patients while sometimes doing nothing, and also trying to keep up with my fake medication regimen (more later).

There's much to tell*, but my brain, it has shut down for the night. I just wanted to say hi. I missed you, faithful readers. Let's see, is there anything I can tell you real quick? Oh yes, a little exchange between Scott and me while we were at dinner at Logan's the other night.

Me: So I was supposed to have clinic, but Dr. Psychiatrist-Who-Was-Covering-Student-Clinic was out of town and there was no clinic, so I was just there for consults.
Him: I think it's funny that you say "CON-sults".
Me: What am I supposed to say?
Him: It's con-SULTS.
Me: No it isn't - I've never heard anyone say it that way when they're using it as a noun.
Waiter: Do you need a refill?
Me: Yeah, thanks. (I drink diet cola like a fish. A fat fish.)
Him: That doesn't mean it's right. It's like how everyone says trans-alkyl something, when they're talking about that one thing, and it's really supposed to be blahdeblah and ghosh instead of trans, because of single bonds and something-or-other. (I love him, but I just don't always know what he's talking about - and sometimes I forget the actual words so I have to make them up.)
Me: Oh.
Him: Yeah. Like that.
Me: Well, they say CON-sults on House. And ER. And in real life.

So I looked it up. It turns out that you CAN pronounce it "CON-sult" if you're using it as a noun, but it's the second pronounciation after "con-SULT". Well, that's just stupid. Nobody says it that way. Isn't it sad that Scott and I have settled numerous arguments with a dictionary? We're such giant dorks.

By the way, I PASSED THE FREAKING USMLE STEP ONE! Yaaaaay! More on school stuff later.

*Risk management people or whoever you are, stop looking at me! I'm not going to violate HIPAA, okay? As usual, it's going to be all about meeeeeeee.