09.i try to channel you in hopes that i could steer you back.

[Nicki Minaj - Dear Old Nicki]

[Album: Pink Friday]

"maybe you died 'cause everybody asked me where you at."

Our Shelf Exams last week marked the End of a Rotation...and as with all ends it also marked a new Beginning. From OB/GYN I have moved on to Psychiatry and the two fields couldn't be more different.

My first impression of Psychiatric practice has me convinced that this specialty represents the purest form of Patient Interaction and exhibits the most intimate Rapport Building in the entire Profession. The Medicine part is at a minimum, at least what we conventionally think of as Medical Practice -- medications, and physical exams, and procedures.

Through conversations and the most careful of observations Psychiatrists must somehow unravel and decode what I consider the most complex entity ever created: the Human Mind.

I admit I have always judged this book by its cover...and not always in the most positive manner. By book I mean the Diagnostic & Statistical Manual of Mental Disorders (DSM). And by the DSM I mean the field of Psychiatry in general. But I also admit that my judgement of Psychiatry stemmed mostly from ignorance and a lack of awareness as to what Psychiatric Physicians and Psychiatric Patients face on, at times, a near constant basis.

Disease is Disease, and Psych is no different.

My first impression of Psych has me convinced that First Judgements 

are only guesses and assumptions at best. 

With that, I think my selection of a Nicki Minaj song is so appropriate for this entry. I don't know a contemporary artist more judged and ridiculed than Dear Old Nicki. Whether we like it or not she is as perfectly imperfect as the rest of us...and admit it: 

You like that Super Bass.

Book covers are meant more for protection anyways right?

"but i needed to grow, and i needed to know.

were there some things inside of me that i needed to show?"

crate -- 

:::The Mental Status Exam

This is the backbone of Psychiatric Evaluation -- the Mental Status Exam (MSE).

It is the Psych equivalent of a conventional Physical Exam that nearly every other specialty performs. Yet instead of shining blinding lights into each eye and hammering on miscellaneous tendons -- both to elicit and assess some sort of reaction -- when performing an MSE one would, alternatively, just have a conversation. Questions are kept at a minimum.

Ideally, a 5 minute conversation starting with "How was your day?" should and could lead to all the answers a Psychiatrist seeks.

The goal doesn't differ though. We are still attempting to elicit and assess some sort of reaction...where any and all reactions are welcome.

But the MSE is a Crate after all, and as such it does have concrete parameters and very tangible aspects. As a mental exercise as well as an informative gesture the following are the broad categories being assessed during an MSE:

Appearance

Speech

Mood

Affect

Thought Process

Thought Content

Perceptions

Sensorium/Cognition

Insight/Judgement

And so the MSE Crate contains quite a lot. Appropriate, as our Patients often have a lot to say whether they realize it or not.

"you told me you'd come when i needed you.

and you said it so sweetly, i believed you."

Whether it takes the aforementioned ideal of 5 minutes or a few hours or even a series of days Psychiatric Evaluations are designed to hone in on our most Human aspects. It's not bleeding, or coughing, or growing tumors that are in focus with the Psychiatrist's lens. That is, unless you are referring to the slow bleed of Depression that decimates those afflicted from the inside out. Or the malignant panic of someone suffering from debilitating Anxiety or Post-Traumatic Stress -- metastasizing towards the depths in us that we hold so close and dear.

Disease is Disease, and Psych is no different.

I have been, unfortunately, quick to Judge otherwise.

~~~~~

Like most things in Medicine, I have found, it is the Patients and Experiences that have taught me best and have left the most lasting impressions. I have spent this past week on the Psychiatric Inpatient Service where we spend all day meeting and talking with our Patients...often 10-12 Patients -- 10-12 different Stories -- in a single day.

Each and every Patient had a cover...a facade. Some by deliberate choice but most had absolutely no say in the matter -- Powerless or Clueless or Both. What I came to realize is that these 'fronts' served the same role as those around books...they are protective. 

Defensive. 

And by no means do they represent what lies inside.

"but you was underground, and i was mainstream.

i live the life now that we would daydream."

"my only wish is you come enjoy it with me."

hippo -- 
:::The My Status Exam

The MSE scratches at the surface, but it is the surface of an iceberg that is larger and more encompassing than any Hippo you'll ever see.

It's a little unnerving to realize that parameters like body posture, word cadence, and thought progression can act as canaries -- indicators -- of thoughts and feelings that lie much deeper within the mineshaft of our consciousness.

I know every Patient is different. That is common sense and emphasized to the maximum in Medicine -- especially now at the advent of the Personalized Medicine movement. Yet, more often than not, we still refer to groups of Patients, mostly for efficiency's sake. You have "the hypertensives" and "the diabetics," for example, (both of which are unfortunately very common) and we have more or less set regimens to deal with such situations.

As the most naive Medical Student in the history of Medical Students I walked into Psychiatry on Day One thinking we could similarly corral Patients into "the schizophrenics" or "the bipolars"...and I couldn't be more wrong.

It worked on OB/GYN where the treatment plans depended less on a person's upbringing and state of mind. Yes, Patient Preference and Compliance are paramount and will of course factor into final decisions. But the intimate details that make each of us unique are not critical to the specific anti-hypertensives used or the dosages of insulin administered. When it comes to Psychiatry, however, our personal stories are not only critical but extremely crucial to a good outcome. This is the Mind after all -- the human aspect that makes us perfectly imperfect...and no two Minds are identical.

"and tell me that you comin' back and you just took a break.

maybe i blamed you for everything that was my mistake."

The Hippos yelled at me in anger this week for my naiveté. I realized that those Hippos -- those human intangibles -- that I so readily defend and spout about can be elevated further than I've ever thought possible.

I have always relished personal stories and emotional well-being but have usually treated those aspects of Patients as a means to build rapport and ensure comfortability -- building a human connection. I have never been so attentive and sensitive to them, however, as a ways and means to diagnose and treat and change the course of a life-or-death situation.

~~~~~

We had a Patient this week who suffered from repeated auditory and visual hallucinations -- often seeing footsteps in the shadows and hearing sounds that were not present. She could not work or function...let alone sleep for that matter...out of fear for the unknown.

Don't judge this book no matter how much you want to I told myself. She was young, dropped out of high school, had an extensive history of substance abuse and was rather unpleasant in conversation. It's tempting to let one's mind wander towards certain assumptions.

"i had to make them changes, i hoped you understood.

you see for every bad, i did a ton of good."

I'm thankful for keeping my perfectly imperfect human judgement in check. Yes the cover of this book -- this Patient -- was not the most attractive...according to society's most widely accepted conventions, but I later learned why. 

Covers really are meant for protection over everything else.

Medical treatments were not effective for this Patient. Repeated Psychiatric admissions in a series of institutions were not effective. Behavioral Therapists and Social Workers were perplexed and at a loss. I had three meetings with the Patient throughout the week and the last one was with my Attending -- who is the best Hippo-ologist I have met thus far.

The Patient, as aforementioned, was not the most pleasant. She was very guarded and soft-spoken. She verbally denied any abuse or substantial trauma -- physical or otherwise. The only clue we could get was an extreme aversion to 'moving shadows' and 'footsteps' and 'sounds trying to get her,' especially at night.

The gut reaction is a diagnosis of Paranoid Schizophrenia, 

but what good does that do for the Patient if she is not getting better?

After meeting with the Patient this 3rd time my Attending turned to me and asked if I ever slept with a nightlight. I replied, yes when I was little. He then asked "Why?" to which I replied I was worried that something would come into my room and eat me. For reals.

He then asked me what I would do if something actually did come into my room when I was younger. I replied I have no idea. My Attending told me that the Patient, too, had no idea what to do. Boom.

Not just a Mental Status. This was a My Status.

She was repeatedly and traumatically abused...to the point that she had no idea. To the point that she denied it and truly believed nothing had happened. There are no Medications or Procedures that are definitive enough for something like this. There is only the personal healing that could come from gradual realization, a core acceptance, and the most wonderfully intimate/intrusive of human connections that Psychiatrists have mastered.

She had come so close to killing herself multiple times. She never knew why until now.

At that point she made eye contact for the first time. She said she felt better.

Mind Blown.

"in hindsight i loved your rawness and i loved your edge.

'cause it was you who talked me down from jumping off the ledge."

~~~~~

It was quite a First Week on the Psychiatry Service. I may have just found the natural habitat of Hippos within the world of Medicine. Intangibles are everything here.

Gut reactions and Judgements may be inevitable as humans but they can not be the end all, be all...I realize. In dramatic fashion I've seen how much each Patient has to say, again, whether they realize it or not.

Disease is Disease, and Psych is no different.

Above all I have seen just how many and how potent the 

Defenses we have erected around ourselves can be. 

We are all Books, ready to be read.

But the Cover is not there to be an indicator of who I am.

It's there to keep me safe.

"but im standing here calling, i cant see you.

but i am holdin' you, holdin' you, holdin' you 

to that."