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Bridging The Psychiatric Divide

By Chelsea Slade

I was standing outside of the exam room door, palms sweaty, my voice suddenly feeling very gone. My mentoring physician had just poked his head into the patient’s room to say that he was going to have his medical student ask some questions first, if that would be all right. “It is not all right!” the patient had shouted. “This is my first time here and I need to see the doctor!”  But my mentor had closed the door and handed me the patient’s chart anyway. This was the first time I would be seeing a patient by myself as a medical student, ever.
I knocked and pushed the exam room door open to a strong smell of sweat. My patient was standing – standing – on the exam table, shirtless and hyperventilating. I tried to present a composed face, desperately trying to remember the few tips we’d learned about interviewing patients.  Those tips had all been designed for… calmer patient interviews.  But I began: “Hello, Mr. P, I’m a medical student working with Dr. K.  Please, have a seat, and tell me what has brought you in today?”

Mr. P remained standing on the table and launched into a monologue about how all of the muscles on the right side of his body had disintegrated. “Gone!” he shouted.  He was no longer able to walk using his normal muscles, he insisted - he had to use his neck muscles to control his legs. I listened wide-eyed, scribbling notes, struggling to understand his accent, and feeling very small and very panicked by this man standing on the table yelling at me. I eventually managed to coax him into a sitting position and ask him more. Finally, after examining every piece of skin thrust at me to show me that his muscles had disappeared, I said I believed that his problem was not musculoskeletal, nor did it appear to be neurological. I didn’t know how to say the last part, that I believed his problem may be psychiatric.  I excused myself and said I would return shortly with the doctor.

After leaving the room, I realized I felt close to tears. Why couldn’t my very first patient have just been a nice old lady with high blood pressure?

Later that year, as a first-year medical student at George Washington University, I took a course on psychopathology, which helped me learn how to interview, interact with, and treat patients with psychiatric conditions.  We got a thorough overview of how psychiatrists speak with these patients and manage their conditions.  We learned that it is often difficult for primary care practitioners, who refer to psychiatrists in the first place, to have to say to patients without offending them that their conditions are more likely psychiatric in nature than medical.  We observed video-recorded interviews with patients, and also had the opportunity to observe our professor interview one of his patients in front of our class.  All of this was useful. What we didn’t get to do, however, was practice how to actually have the first conversation with a psychiatric patient presenting to primary care.

Although I know I will receive more extensive training in psychiatry during third year and beyond, I felt wholly unprepared to interact with Mr. P.  This intimidates me, because though I find myself more and more drawn to a career in primary care, I am aware that primary care doctors see so many people who need help for psychiatric conditions. I feel unprepared for that conversation where I have to say, “I believe these things you are suffering may stem more from stresses in your life than from a physical ailment; that you may need treatment for depression rather than for your bowel problems and headaches.”  How can I be prepared to recognize patients in need of psychiatric assistance, and how can I tactfully address this with them and overcome the stigma of mental health care?  We ought to be better prepared, from first year, to have these kinds of interactions.

I believe that I and other future primary care physicians can be more prepared to care for such patients if two major steps are incorporated into our medical educations.  First, medical students should continue to be required to shadow primary care physicians, as we are at GW.  My experiences working with Dr. K and other primary care physicians have let me, as an observer, view the patient-doctor interaction from both sides: I can understand how a physician would become frustrated by a patient with no apparent organic cause for their symptoms, where no lab values are off-balance and nothing is “wrong”; I can also understand how a patient would feel hurt and saddened by a physician who dismissed their suffering as “all in your head,” and did not offer further care.  Shadowing primary care physicians while still a student allows me to reflect on these interactions and consider how I will perform when I am the face behind the stethoscope, the face that has to say with love and concern that, “Mr. P, you may need a different kind of service than the medical care I can provide.”

The second aspect of preparing primary care physicians to recognize and care for patients with psychiatric conditions is to allow medical students to practice having that conversation – that uncomfortable, perhaps even offensive, “I think your problem may be more mental than somatic” conversation.  I have read the stories where a patient complains of odd symptoms and is incorrectly diagnosed as having some somatoform disorder, when in fact they have some rare and strange medical condition; the stories where their primary care physicians are described as “so incompetent” and “cold-hearted.”  Such stories, and the general stigma around mental health care, can make it difficult to bring up suspicions to a patient. 

Medical students could become more prepared to have this conversation by practicing with each other or with standardized patient actors as part of their medical education.  Of the over 150 medical schools in the United States, only around 40 use certified standardized patients as part of their curriculum. At George Washington University’s medical school, we are fortunate to be able to practice firsthand with standardized patient actors. As second-year medical students, we have been taught how to normalize the need for mental health care, and what specifically we can say to help patients lessen the stigma and understand our concerns that they need care in a different dimension of health.  We have also had the opportunity – once – to practice these techniques by interviewing a standardized patient as he presented to primary care with a psychiatric problem (depression). 

I am grateful for this opportunity. However, I know I am still not quite ready to meet a patient like Mr. P again.  Certainly, I will gain exposure to huge numbers of patients, with wide varieties of somatic and mental afflictions, throughout my medical training and career.  However, how immensely helpful it might be to practice staying composed and confident in front of standardized patients with psychiatric issues, rather than feeling embarrassed and shocked when confronted with the real thing, as I felt standing in front of Mr. P, holding a clipboard and wearing a white coat that suddenly seemed too large.  We as medical students need more opportunity to practice this type of interview in a safe setting.

Mr. P was fortunate to eventually receive the care that he needed, as the result of a psych consult in the emergency room, where he presented later that evening when his “heart muscles disintegrated.”  It was unfortunate that he did not initially receive a referral for appropriate care from his primary care practitioner.  Allowing medical students to shadow primary care doctors as they encounter patients in need of psychiatric care, and requiring medical students to practice the type of conversation they would have with such patients while still in school, will help the next generation of primary care doctors have fewer conflicts with their patients and be prepared to skillfully and lovingly assist their patients in receiving the kind of care they need.  Feeling more prepared to interact with psychiatric patients will help me feel more confident in choosing a career in primary care.

Chelsea Slade is a second-year medical student at George Washington University.  She grew up in Washington, DC, attended BYU, and resides with her husband in Arlington, VA.  Chelsea has a strong interest in family medicine, though her interests range everywhere from neurology to ER, and she plans to make international medical service an important part of her career.

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Posted by Alex Folkl on Feb 28, 2012 10:07 AM America/New_York
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