6 months and counting

“You are only 6 weeks away basically completing your undergraduate training,”

Said Nick Breen, one of our General Practice lecturers

“Your level of knowledge at this time is probably at its peak, as you are fresh from completing almost all of your specialties training,” he continued

Gulp.

He was right. My GP rotation would mark the last specialty-training block in the course. In a mere 6 months, I’d qualify as a fully-fledged junior doctor.

To add to the pressure, the exam dates for the finals as well as the convocation ceremony have already been posted.

Gulp.

Psych was a relative breeze. The OSCEs weren’t too bad in terms of the subjects covered. A few curve balls here and there but nothing exceptionally tough or mind-boggling to say the least.

On to the last rotation of my undergraduate training.

Motivation, where art thou?

Marvellously Mediocre

Round one of exams : Done

Status : Two to go

Emotional status : Apathy

I wonder if it is possible to feel both anxious and confident at the same time?

Aine’ (pronounced onyah) was my examiner for the day. Hardly the scariest of tutors around, yet my nerves were starting to betray me as I walked into the huge conference room in the basement of St Vincent’s University Hospital.

Yet despite my heart threatening to dislocate itself from its connecting arteries, the conscious part of my brain was surprisingly calm, almost confident that there was no way I could inherently screw this up.

I had put a lot of work in perfecting my case, endlessly editing, re-editing, and re-re-editing.

I knew she wanted it to be concise yet detailed. No beating around the bush. It is understandable that after listening to 10-20 people present their cases, one’s concentration would tend to drift. This meant that it was a matter of sentencing and word choice, which would determine a huge percentage of marks this time around.

“You did well, good job,” said Aine’

Applause?

Neh.

I’ve learnt over the years that in UCD, to “do well” means, “Congratulations, you didn’t screw up, but that doesn’t mean you’re getting an “A”. So a C would indeed suffice.

Soldiering on, an MCQ and an OSCE to go.

Rambling on..

I would like to present the history of MRS X, a 55-year-old lady who was admitted four weeks ago due to alcohol dependent syndrome and low mood, with a 10-year history of depression, and a history of hysterionic personality disorder

History of Presenting Complaint

This is her second admission for alcohol dependent syndrome.

MRS X had her 1^st drink at 17, and admitted to “heavy drinking” since her first marriage at 19. She currently drinks 10-30 bottles of beer a day, mostly at night. Her last drink was 2 bottles of beer, the night before admission.

With regards to alcohol dependence symptoms,

She has developed tolerance, needing more than 20 beers to get intoxicated; she only drinks beer, showing a narrowed repertoire of drink. She denies any changed in her alcohol preference. She prefers to drink alone, but does occasionally drink with her friends. She still enjoys gardening and walking her dog. She has never tried to abstain from alcohol, and continues to drink despite the being aware of its negative effects. She admits to have a strong desire and losing control when having a drink. She had a road traffic accident 20 years ago due to drink driving. She does not take any illegal substances, and does not gamble. She has had no hallucinations or seizures.

With regards to her low mood; MRSX has no anergia and no anhedonia. Her appetite and weight is fine. She has sleeping problems, with difficulty falling asleep, and denies any early morning waking or disturbed sleep. Her libido is normal. She also admits to being in financial difficulty.

2 weeks ago she took an overdose of seroxat, and was admitted to SVUH A&E. She described the attempt as an impulsive one, with no prior planning, and with no intention to die. Her reasons for it were to “forget her difficulties” and as “a cry for help”. She immediately notified her family, after taking 20-30 pills. There was no will or suicide note. She felt regret for what she had done, and had no plans to commit suicide.

With regards to personal history

MRs X was abused and hit by her father when she was a teenager. She denied he drank. In terms of education, she got through high school, then married at 19.

Her relationship history reveals an annulled marriage, attributed to her alcohol problems. She has one daughter and currently maintains a good relationship with her.

Mrs X admits to having subsequent unstable relationships with many men throughout her life. She recently broke up with her long-term partner of 22 years, who had been living in Spain for the past 4 years. She feels that it has “somewhat” contributed to her excessive drinking

With regard to employment Mrs X has problems at work. She skipped a “few days” due to alcohol effects. She also has received multiple warnings due to poor performance. She attributes it to the new HR officer who does not like her.

Forensic history. She was arrested once due to drink and driving 8 years ago

In terms of patient insight, MRs X wants to change but NOT WILLING to fully give up alcohol. She is uncertain that abstinence is for her

She feels that her troubled life lead to drinking, and that her drinking has NOTHING to do with her troubled life.

She is willing to enter the rehabilitation programme to help her cut down on her drinking.

Management Plan

Biopsychosocial approach :

Bio : maintain the current medication, seroxat 30mg Daily

History of Depression was not clear, obtain more information, contact GP

Monitor withdrawal symptoms - tremors, seizures etc

Disulfiram/Acamprosate : consider, though patient does not want to completely abstain

Psychosocial

RPU, SMAG

CBT

Monitor emotional symptoms,

Psychoeducation on addiction (insight)

Collateral history from family.

Damn. I hate pysch

Crunch Time

“A good little bit of heat in ‘ere, righ’ lad,” said the naked old man beside me.

It was the archetypal “Irish” way of mentioning the plainly obvious in order to start a conversation. We were after all in the sauna.

It had been a long day. My two-hour session in the library was followed by a two-hour session in the gym.

The over-exertion of both the mind and body was probably a coping strategy for what had happened earlier in the day.

The mark sheet for the formative (ie : useless) MCQ read :

14.5/40

A clear fail.

Whilst the results had no bearing whatsoever on my overall GPA, it was a telling sign that things aren’t all too well in terms of study.

A week to go. And I’m still writing.

PS : No, I don't go into the sauna naked

The Cuckoo's Nest

End of Summer

“Are we ready people?” said Dr Matt Sadlier, our chirpy tutor on the first day of class.

His enthusiasm was met by groans. Summer had ended. Welcome to final med. It’s official.

Ciaran and I were paired up to attach with Dr O’Gara, the addiction team consultant. Yes rugby fans, he is in fact the brother of the legendary full back Colin O’Gara. More about him later.

Psychiatry and the media

Prior to my psych rotation, my perception on what psych really is probably measures up to the general public; crazy people intent on hurting other or themselves. Case and point: Hannibal Lector sprang immediately to mind.

What I found out was that psychiatry deals with a whole load of other “stuff” that are genuinely medically treatable, with both pharmacotherapy and an element of psychotherapy.

My initial first few days in the wards were let down stemming from my over the top imagination on what a psych “facility” should look like. Again I blame the movies.

There wasn’t anyone running around naked. No one set themselves on fire. And they don’t wheel people around in white straps. Overall it has been pretty tame so far. Save for the odd lady who followed me around the hospital because she thought I was a spy. Lol.

Acceptance

The ward rounds in psych are totally different from the medical ones. The patients are interviewed on a one-to-one basis. All cramped in a room consisting of the consultant and his registrars, psychologists, occupational therapist, social worker, nurse, and of course medical students, yeay.

Also different to my previous experiences in medical teams, I actually feel part of the team.

“What just happened in there?” asked Ciaran, looking quite puzzled.

“I’m trying to make sense of it all,” I answered.

“They actually acknowledged us! Oh god, I feel so needed” added Ciaran

Being part of the team really ups your motivation. For a while at least.

My first psych interview

“ I’ve thought about it you know, ending it all,” said PT, who was battling depression

“What do you mean” I asked, taking good care not to put any thoughts into his head.

“I thought about hanging myself. But I never thought I could go through with it” he continued.

The interview went on for almost an hour. We delved into his childhood, relationships, family problems and a whole host of issues that one would never think to share with a stranger. I guess part of the appeal of psych is having that privilege of information, which is why confidentiality is a huge part of it all.

Some of the stuff gets really dark and messed up. For some reason, it affects me more than I’d care to admit.

Suicide in Ireland

Ireland has been a relatively religious country over the last century. Suicide was definitely frowned upon in the old days. In fact ,suicide was a capital offence up to 1993. In other words, if one failed in an attempted suicde, the punishment would be death. I lol-ed so hard. Gotta love the Irish.

“I’m an alcoholic”

MOG was an alcoholic. She didn’t want admit it at first, but the signs were all positive. She even scored 3/4 in the CAGE questionnaire (google it). Throughout our conversation she revealed to me a lot about her torrid past, the abuse she endured as a child and her series of failed relationships with numerous men.

At some level I felt we developed a connection, evidenced by her brutal honesty on what the root of the problem was. Alcohol.

Admitting that you’re an alcoholic is as easy as it is made out to be. It’s a huge first step toward recovery. Most patients take a long time to see that it wasn’t the beatings, or the abuse;or the bullying; or a whole crapload of excuses, until they admit they have a problem with alcohol.

“You know, there must be something about you. I’ve never been so open to anybody before,” admitted MOG.

“You should really consider this as a career,” she added.

I smiled.

Yeah. Right.

Vindication

“Interestingly Dr O’Gara, one of our patients, MOG told me during our one-to-one session that she felt that talking to a certain medical student was more helpful compared to the treatment and counselling she’s been getting during ward rounds with us,” said Roisin the occupational therapist

All eyes focused on me and Ciaran. I looked down not knowing how to react.

“Was it you?” ask Dr O Gara

“Yes I think it was” I answered, still looking down.

“Well ladies and gentleman, I believe someone is starting to show a knack for psychiatry,” he said, winking in my direction.

Old-age psychiatry

I have nothing against the elderly. Let me rephrase that. Excluding family and friends, I feel that I wouldn’t able to tolerate treating old people. If given a choice, I would stay away from any branch of medicine that deals with them.

It’s just simply depressing.

One of the patients, CK, is a 63 year old woman, who just a few weeks ago was swimming in the 40 foot (off the shores of Dun Laghoire), but then developed severe depression due to an unknown cause. Since then, she has regressed to the point of developing hallucinations that she “smells rotten”.

She also has delusions that everyone else is talking behind her back on how smelly she is. I can’t help but feel sorry for the old lady each and every time we meet on the ward. The thing is, for these patients, their experience is undeniably real to them. This means, she wakes up every morning to the stench of rotting flesh; she walks around corridors hearing voices of people talking bad about her. Now how would that make you feel?

Her constant tearful episodes and genuinely sorry state has affected the whole team as well, probably me more than anyone else. Old age psych, another tear jerker.

A conclusion, somewhat

Im in my 5^th week and already feel like a veteran on the wards. With the OSCEs ever so close, it’s a wonder why I haven’t gotten the palpitations I’m so used to by now. The lack of anxiety is proving to be a factor in my general laziness and reduced drive to actually pick a book up to study. Distractions are aplenty and in fact welcomed in order to mask the reality I dread to face each day.

Am I losing the plot? Or is it just the (hopefully temporary) depressive state induced by my time in the psychiatric wards?

I don’t know.