Monday, May 17, 2010

Mood Disorder NOS

It's 3PM, May 13 2010. I'm in a medical examination room inside an outpatient pediatric office located on the East Side Suburbs of Cleveland sitting across from my attending psychiatrist, Dr. Mike, thinking about a couple of things. First, I'm hungry. I'm always hungry. Second, this is so much cooler than studying. Third, in a two incredibly short years, I'll have similar responsibilities as the guy on the other side of the table. As I begin to daydream Dr. Mike asks me, "what's your differential?" Without even thinking I respond, "ADHD combined type and Mood Disorder NOS."

Two very short years of pre-clinical training brought me here to my first ever clinical rotation. The last time I posted an entry was December of 2008. At that time, I was a first year medical student. Everything was new to me. 18 months has transpired since that time and I still feel like everything is new to me. Only this time, I'm not so concerned about anatomy, IQ groups or taking tests. Now, I actually get to deal with real patients, their families, physicians, and other health professionals. It's pretty cool.

Here's a run down of everything that has transpired since my last post:
  • Completed Block 3: biochemistry and GI (I thought it was fun)
  • Completed Block 4: cardiovascular, pulmonary, renal systems and general pharmacology (I thought this was fun too)
  • Completed Block 5: microbiology and other stuff (total hell)
  • Completed Block 6: neurology and psychiatry (most fun I've had in med school)
  • Officially graduated with my Masters in Public Health in January 2010
  • Spent 5 weeks studying like mad
  • Ditched studying for 3 days to hang out with my friends in Houston
  • Took a 7 hour test in a little booth under closed circuit surveilance.
  • Reaped the rewards of 5 weeks of studying like mad
  • Flew to Cambridge University in England to present a poster
  • Drove to Philadelphia to present another poster
  • Walked across the street from the med school to present another poster, and won $100 for the poster.
  • First author of a paper pertaining to off-label uses of psychotropic medications (I know, no one cares)
  • Mourned the deaths of two good people
  • Celebrated a few births (in the extended family)
  • Flew to India to visit my relatives after a 6 year hiatus
  • Switched from a Blackberry to iPhone
  • Played 30 rounds of golf at about 25 different courses in 4 different states (Ohio, Alabama, California and Florida)
  • Witnessed another Cleveland sports disappointment
  • Began my first clinical rotation

After finishing up Block 6 in March, I took 5 weeks to study for Step 1 of the USMLE. For those who don't know what that is, it's a big bad exam that all med students freak out about. Most go into hiding for a certain time period, then re-emerge once the exam is over. Most usually pass and life goes on. High scores generally help when it comes time to applying to residencies. I achieved a score that was higher than what I was expecting, so no complaints here. Glad that it is over. To celebrate completion of boards, I spent 3 days golfing in Alabama with one of my friends. Upon returning from my golf trip I did absolutely nothing the next 10 days. And by nothing, I organized my room, cleaned my car, went hiking with my dogs until they were sick of me, worked out 3 hours a day, played more golf, caught up on research work, read more journal articles, yelled at the TV as the Cavaliers showed no effort or desire, and finally booked my trips to New Orleans (this weekend for American Psychiatric Association Annual Meeting) and Las Vegas (no fancy conference here, just hanging out with some good friends from Rice).

At Case SOM, third year consists of three core rotations (called Core 1, Core 2, and Core 3) and a 4 month research block, affectionately known as vacation-unless you take your research seriously. I placed out of the research block since I spent a substantial time during my first two years finishing up my MPH, which included a scholarly project that took more time than the allotted 4 months for the med school research block. After boards, I'm scheduled to be on 2 months of my research block, followed by core 1, followed by the remaining 2 months of research, followed by Core 3 in January, and Core 2 in March. Since research block does not exist for me, I can theoretically do whatever I want during this time. Having Obsessive Compulsive Personality Disorder, I'm on top of my game. I have decided to use this time to take clinical electives that can be used towards med school graduation credits. This way, I can either defer my four months of vacation to the end of fourth year, or I can decide to use that time later for research since I like research and will probably engage in some other scholarly activity before I graduate (next year's APA conference is in Hawaii...).

So I am officially starting off third year with three 2 week rotations: child psychiatry, family medicine at the free clinic and cardiology consults at the VA. My idea is to pick fields that I find interesting and to work my way towards a more intense inpatient experience that will get me ready to hit the ground running for Core 1 in July, which consists of internal medicine and surgery.

I chose child psychiatry because of all the psychiatry didactics we had in Block 6, I found the child stuff to be the most fascinating. Furthermore, the faculty were really supportive. It also helps to have a father who is a child and adolsecent psychiatrist. So far, I think I made a great choice. Some might think I'm interested in psychiatry because my dad is a psychiatrist. My dad's a smart guy, but not the best test taker in the world. The only reason he's a psychaitrist is because it was the only field he could into. Good for him because he absolutely loves what he does. Part of me wants to see what the hype is about, but honestly I'm interested in psychiatry because I am fascinated by behavior. Child psychiatry makes sense to me because it is a perfect opportunity to intervene early on when psychopathology begins to manifest in individuals predisposed to mental illness. It kind of fits with the public health side of me in that sense. Furthermore, psychiatry as a whole interests me because not much is known about it. Epidemiology is key to research into phenomenology and treatment. While not a whole lot is known about psych compared to other fields of medicine, child psychiatry is basically in its infancy. There are a ton of questions out there waiting to be answered. This kind of fits with the research side of me. Definitely not a bad way to start third year.

So far the elective has been great. It's mostly observational, but I do get a few minutes during each patient interaction to ask the patient (the kid) and his/her parents questions. The attendings are very supportive and go out of their way during the patient interview to highlight key areas in the patient presentation/history that they feel are good learning points. The patients I've come across are amazing. Kids in my opinion are so much more fun to work with than adults. The challenge though are the parents. Not always, but sometimes. The apple doesn't fall too far away from the tree, as they say. Sometimes it's tough to fix the kid when it is the parent with the serious psychopathology. It's so interesting seeing the type of personality disorders the parents have. I never thought I would see so many cluster B personalities (people with relationship problems generally). Lots of narciscism, lots of borderline behavior.

A common misconception in child and adolescent psychiatry is that a given practice consists of all ADHD, and all psychiatrist do is just push pills. ADHD does consist of a decent proportion of the patient population, but you'd be surprised to see how much substance abuse and mood disorders are present. Lots of kids have bipolar. Since not much is known about pediatric bipolar, and since psychiatrists don't like to give kids labels, especially so young in life, pretty much every patient is slapped with the disorder "Mood Disorder NOS." The NOS stands for Not Otherwise Specified. A tip for those of you ever rotating in child psych: if you want to score points on your differential, just blurt out Mood Disorder NOS. And about the pill pushing: in a 30 minute follow-up evaluation, 5 minutes is spent managing the medication while the other 25 is generally spent counseling the patient and his/her parents.

What's amazing is seeing the improvements that kids make. Having spent time in the past working in adult outpatient and adult inpatient psychiatry, I've kind of grown accustomed to taking solace in small victories. Unlike adults, many kids go from manifesting serious problems to doing well at school, and meeting developmental milestones. Early intervention can literally change the course of a kid's life. There is nothing better than seeing a kid who was failing school and getting into all sorts of trouble come back to the office with a huge smile on his face reporting that school is going well, they are making friends and things at home are going well. It's not glamorous like surgery, and it doesn't provide an adrenaline rush like dealing with trauma in the ER, but if that isn't saving a life, then I don't know what is.

The job does come with its challenges. First, you have to be willing to deal with uncertainty. Psychiatry is vague, ambiguous and is not rooted in strict biomedical science (not yet that is). It really is more of an art than a precise science. Psychiatrists have done a great job in the past of observing behavior and categorizing those behaviors that are perhaps problematic into sets of "disorders." In order to help treat psychopathology there are two main tools available: drugs and talking. The arsenal drugs at a child and adolsescent psychiatrist's disposal include anti-depressants, anti-psychotics, mood-stabilizing agents and stimulants. Equally as important is talk therapy (psychotherapy, CBT etc.). No one knows why these things work, but they do. Everyday new research is coming out to fill in the blanks. The biggest explosion of medical knowledge over the next 50 years will be in the neurosciences and in particular, mental health. If you don't like the fact that ADHD can't be explained as simply as lobar pneumonia can, then this isn't your field. Second, you have to have patience...a lot. Parents can be demanding, and often rightfully so because they have to put up with their children all the time whereas you the physician deal with them for fifteen minutes. You have to be calm, and reassuring. Third, your job does not start and end with medical science. There are times where I wish I can just order a lab test, or look at an image. And yes, it is frustrating at times. In the end though, you treat the whole patient. This includes talking with teachers, counselors and parents to see how the patient is functioning in all aspects of their lives. Medical school doesn't teach you this. Life does. Being a good caring person goes a long way.

The other day, a 8 year old girl came into the office with her mom. Poor thing was suffering from some bad OCD. She came into the office and told me everything that was wrong with her in the past. She wasn't able to touch doors, shake hands, or even open her school desk. Kids at school were making fun of her, she had no friends. Life sucked. Six months of SSRI treatment and counseling 3x week resulted in dramatic improvements. She loves school, she has friends, things are good. Before she left, she gave me a gift:







I still have a long ways to go before I decide on a field, let alone a subspecialty. I'm going to wait until I experience everything third year throws at me before I make up my mind, but I can say that child and adolescent psychiatry is something I can definitely see myself doing in the future. I can see why dad loves his job.

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