What I Hear is...

At the end of last year's comprehensive assessment, we had to create an individualized learning plan (ILP) for ourselves. The plan needed to have four academic and one "personal" goal. My personal goal (guess it's not that anymore...) was to finish things early. I have a tendency towards procrastination which works to satisfy my love of chaos. I wonder if my psych preceptor read my ILP (something about psychiatrists makes you paranoid that they are analyzing you) and has decided to help me with that goal. Based on his "suggestions," and you never disagree with an Attending, I will complete all of the required work for this four week clerkship in the next week and a half. The lazy part of my psyche is a bit annoyed because it means less time to blog and read useless facts about weddings I'll never be able to afford. The over-achieving part of my psyche is pumped because someone is finally challenging me like old times. The doctor part of my psyche sees the utility in this approach, that I ought to learn and grow while exhorting my patients to do the same and that the big pay-off of calm studying time at the end of the clerkship will be a huge reward.

So I tackled assignment one today, which was to interview a patient and complete a write-up in the narrative medicine style. Narrative medicine, as championed by Rita Charon at Columbia, is an alternative method for expressing empathy. Rather than expressing empathy towards your patient with canned phrases such as "Uhm hmm" (side note: always say three "uhm hmms" before speaking to encourage a patient to say all that they want to say), "I see," and "that must have been really hard for you," you show the patient how much you understand about them by creating a narrative of their experience, kind of like a collaborative biography of their illness. I've just completed my write-up (early, I'm growing!) which was fun, but I still found this exercise incredibly difficult.

The psychiatric interview is unlike anything in medicine, and I've had so very little practice with it. The goal of an interview is two-fold. First, you rule-in and rule-out diagnoses like the standard medical interview. ("You're depressed now, but has there ever been a time when you needed less sleep, engaged in risky sexual behavior, or spent too much?" to rule out bipolar disorder.) Second, and also like the standard medical interview, you prescribe a treatment, only in the case of a psychiatric interview the patient is the treatment, and the treatment takes a looooong time. I've spent my whole life trying to impress people with my intelligence, to show how I found nuanced connections that others miss, because that's what good students do. But in the psychiatric interview, the connection or eureka moment is blazingly, blindingly obvious, and it takes everything in my power to remember to give the patient the chance to have it. If I have it for them, they won't get better, just as when someone else let me discover that 3 x 5 = 15 when I was 8. Coaxing the Eureka moment out of the psych patient is really hard, because you must use questions and not statements to get them there. And I find good questions hard to come up with.