A Day in the Life of a Psychiatrist Part I

Today I started at 8:00 am with morning rounds.

The setting is a room full of medical students, interns, and residents.

We start with the overnight on-call intern going over the list of patients he saw during his 5:00 p.m. to 8:00 a.m. shift. Mostly, these would be Emergency Room consults: people who are seen in the ER with a variety of psychiatric complaints. Some of these patients get admitted, others are sent home with recommendations for follow up. I choose a case, which the intern then presents for 15-20 minutes, leaving us another half an hour for a group discussion about the psychiatric interview, mental status exam, formulation, and plan.

Green interns (meaning those who just started their psych) tend to present their cases as loosely organized collections of symptoms. They talk about what brought the patient to the hospital (the chief complaint) and usually offer some explanation of why that might be: "I had a lady who cut her wrists because she was trying to make herself feel better, then a 15-year-old girl who tried to run away from home as she hates her parents, then this very sad elderly gentleman who is no longer able to care for himself; he told a friend that he doesn't care much for living."

Fresh interns usually present their cases using man or woman or boy or girl for gender, instead of the generic male or female with an associated age tag that is preferred by more senior residents. They also tend to add some very palpable human qualities to the essential demographics: "33-year-old woman, she looked as if she's been through a lot," "25-year-old guy looking wasted," "16-year-old young girl but looking much younger than that, too young, and with this palpable sadness about her, heartbreaking, I don't know why."

They are often interested in the patient's story; they assume, most times correctly, there should be something out of the ordinary that happened to this person to make him come to the psychiatric hospital in the wee hours of the night.

At the same time, they are less apt to gather the precise quantities and duration of symptoms required by the standard diagnostic classification to make a diagnosis.

They also look for explanations. Like most people, they think ex nihilo nihil fit (nothing comes of nothing). Granted, the explanations they get are often superficial ("got mad at parents," "boyfriend cheated on her," "wanted to impress his fiancee"). However, there is at least an attempt to explain distress in terms of a psycho-social dimension of sorts.

In other words, they usually behave similarly to anyone out there encountering another human being in pain and who would care enough to find out how they can help. Interestingly, these basic folk psychology characteristics of functioning often disappear in junior residents, as the process of acculturation in psychiatry takes place, and then reappear in a more refined form in senior residents as they approach graduation.

Back to fresh interns. At this stage of their training, a relatively rudimentary diagnostic logic indicates that if anything looks like something, then the chance is that it is precisely that (if it looks like depression, then depression it is).

During morning report, it is my job to respond to this in a way that's going to move this common-sense, folk-psychology type of thinking, into more evidence-based, clinical decision-making.

So what do I do? I listen, then listen some more, and then, only after they are done explaining, I say:

"Really?"

It's a deceptively simple but in fact loaded question.

The trainee will, of course, defend his diagnosis. And I need to find a way—not by telling them directly but by guiding them to discover—that a major depressive episode is not quite major depressive disorder.

Or, I simply raise my eyebrows at their diagnosis of major depression when after the required two weeks only four criteria are met or, alternatively, when all the nine criteria are met but they fell short of the required two weeks duration requirement. At this stage of training, the goal is to get them to start appreciating the importance of precise knowledge, which is the sine qua non of effective communication in psychiatry.

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And that is the problem. Fresh interns, partly due to their lack of knowledge, tend to withdraw into the big picture, so it is my job to get them to pay equal attention to details. This process of grounding is the same with the real-life process of following an instruction manual (DSM in psychiatry) instead of figuring it out by yourself.

How about the occasional intern who in response to my scholarly discussion of diagnostic criteria might say... "Really?"

Hasn't happened yet. But there were a few times when my diagnostic preaching was followed by an unusually long pause and then:

"So, are you saying that this is not major depression (or panic disorder, or schizophrenia, or [you name it])?" i.e, questions that challenge my pedantic insistence on precise numbers for quantifying sets of symptoms and duration.

I called those "Questioning the DSM Questions" (QDQs) as they attack the very essence of our diagnostic system. Young psychiatrists asking such QDQs tend to experience a fair amount of cognitive dissonance, which explains a slightly bewildered appearance that routinely precedes the asking of the questions.

"I have a patient who looks depressed, complains of depression, the patient's presentation made the air in the room feel thick with depression. I say this is depression. But DSM says this is not depression. DSM is the most expert consensus about diagnosis, isn't it? So the experts must have it right, but I have it right too. Then, who is right? We can't all be. Or can we?"

And the poor intern feels as if his mind is going to blow his head wide open.

Unfortunately, the QDQs don't get asked nearly often enough. So, most of the mornings, we simply review more or less arbitrary diagnostic criteria according to current psychiatric classification. Maybe a map of an elusive reality, but the only one we have at this time.

And our morning rounds are then a preliminary training in the fine art of map reading and interpretation, while remembering that the map is not the territory.

© Copyright Adrian Preda, M.D.