psychiatry, introductions

I started my first week of psychiatry today. It is the best way to end my third year, which has been a string of glimpses into different realms of experience. My attending physician keeps letting me go right at things, because I'm at the end of this clinical year and should theoretically well-equipped to do so, but in reality I feel more unprepared for this than for any other rotation. It puts me in a place of true beginning, which has been humbling.

For three weeks I am working at the VA. I've worked here before, for one month of my internal medicine rotation, and I love being back. I think there's an element in it that has to do with being sensitive and aware of a specific population (of veterans), in the same way I liked how ob-gyn paid attention to their specific population of women, how pediatrics is concerned with how to treat kids, as opposed to another type of person. I think this is how adult medicine should be: the general population of people is also a specific population that requires certain thoughtfulness and attention, but people don't think of it that way enough. So whenever a particular quality (age, gender, or in this case military service) makes care providers more aware of who they're treating, I find there is a lot to appreciate.

I'm working in the consult service, which means that we see any patients who are admitted to any other part of the hospital (medicine, hospice, surgery) who have psychiatric concerns. They were not admitted to the hospital for psychiatric reasons, but they have psychiatric needs nonetheless, so our team follows them as patients. So far I've had one patient from the ICU, one from the general medicine service, and one patient from hospice. The VA has a wonderful hospice department; it was the first hospice I'd seen (second year of med school) and it was where I had my first end-of-life patient (third year of med school), so besides the other reasons to enjoy the VA, I'm really glad to have this integration.

I had my first one-on-one conversation with schizoaffective disorder today. This means he has both schizophrenia and a mood disorder. He says that someone inserts thoughts into his mind; it's not a voice, it's a thought. These thoughts are pleasant. They keep him company; he's been alone all his life. The television sends him messages, and he finds it a sign of his significance. He's adamant about getting out of the hospital, talks about this with intense fierceness in his eyes and voice, but if you joke with him his eyes give way a bit unsteadily to crinkly amusement...the transition is sweet in its clumsiness. My attending doesn't see the point in changing his medications to decrease his symptoms. He's comfortable in his psychosis. We often see patients in terms of their limitations, but sometimes they own more than we can call ours.