Knowledge is good but...

Posted by Kristen Gardner at Friday, August 31, 2012

Tomorrow concludes Rotation 3: Inpatient Psychiatry.

This week was fabulous because I was afforded the opportunity to lead the medication education groups for both the adult mood/anxiety patients as well as the adult schizophrenia patients here at the NIMH (side note: NIH= National Institutes of Health is composed of various institues, one being NIMH or National Institute of Mental Health. Although I am at the NIH Clinical Center, the behavioral units in the building are under the umbrella of the NIMH...hopefully this makes sense).

With the mood/anxiety patients I had planned to discuss chronic fatigue- both causes (lifestyle, medical conditions, medication induced) and possible management strategies per the request of one patient whom suffers significantly. However, the agenda is set by the patients. If they have questions about their medications or clinical care, that comes first! It so happened that they were chatterboxes this week. There were many good questions, particularly related to effectiveness of psychotropic drugs.

A few questions posed and summary of response:

1. Does it make sense that a medication would work in the beginning and then stop working after several weeks? Their definition of stop working was either no more improvement or falling back to baseline symptom presentation. We discussed it could be due to several factors: large degree of improvement followed by more gradual decreases, to see more improvement the dose may need to be increased, the disease is cyclical and frequency, intensity, and nature of symptoms can change, and there are psychosocial stressors that substantially contribute to response which is why adjunct therapy with medications is valuable.
2. How would the team choose between valproic acid and lithium to treat bipolar disorder? We discussed history of prior within the family (if applicable), drug-drug interactions, the way the drug is eliminated by your body (liver or kidney and if patient has co-morbidites which would complicate this, e.g. hepatitis or renal impairment), side effect profile/patient intolerances, patient allergies, and type of manic episode (valproic acid has more evidence for rapid cyclers and mixed episodes vs. lithium as the mood stabilizing agent) to name a few. 
3. What is the difference between SSRIs and stimulants? Discussed different neurotransmitters- serotonin vs dopamine. These patients are quite sophisticated! They understand talk of neurons, cells, receptors, what SSRI vs. SNRI vs. DNRI (e.g. bupropion) vs. TCA mean, firing of cells, receptor down regulation, reuptake blockers, etc. It is amazing what a little education can do! And they LOVE knowing this information because it makes them understand, objectively, the importance of treatment and why a certain agent may be chosen over another.

The second medication education group I led was with the adult patients with schizophrenia. This group was VERY different from the mood/anxiety patients. The level of detail needed to be drastically pulled back, they needed to do the majority of the talking (posing questions was absolutely essential as a lead in to any topic or point you wanted to make), and they needed to be consistently redirected because we have some very sick patients displaying tangential thought, pressured speech, laughing and smiling to themselves during group, extreme difficulty understanding basic information. For these patients I really wanted to empower them to monitor their illness more closely, be on the lookout for side effects, and advocate for themselves. We had a great discussion- all were engaged (some more than others), all asked questions, and shared their personal experiences.

Now, the entire rotation was not always this fabulous for me. I struggled for the first few weeks in this rotation because I came in expecting that the site would still be providing a platform/opportunity to develop my clinical skills. As I mentioned in earlier posts, the research nature makes this site very unique; this is definitely not an acute psych rotation although they are admitted to the unit. When I realized this was not the case, I had a rough time since this was my expectation- I was so excited to build off my current knowledge and practice what I had been reading about for the past 3 years. BTW- rough time is code for emotionally charged conversation with one of my mentors at our College to help process my emotions followed by emotionally charged discussion with preceptor. Also, emotionally charged conversation = on the verge of crying or crying at times. For real. Simultaneously, I was also dealing with being homesick as I have been away from my husband (and dogs!) for the past 10 weeks- this was harder than I thought it would be. And not just because he cleans and cooks for me. While this situation was really hard to process, I became much stronger as a result, and ultimately, extremely grateful for what this site did provide.

What I came to really appreciate by the middle of the rotation was that there was still learning to be done. A different type of learning called gaining perspective! This appreciation coincided with the increased one-on-one patient interaction and emotional processing/reflecting.

I gained a tremendous amount of insight and perspective from the patients. They taught me SO MUCH! My counseling skills were enriched, my interviewing skills were developed, and my ability to process contextual cues/make observations to adjust how I interact with a patient on a second-second basis was sensitized. I am become more adept at quickly developing rapport with patients, empowering/encouraging them, and conveying my passion and sincerity.  These patients have a keen sense and can easily detect someone who does not trust them, is not sincere, and will not follow-up with their concerns (persistence is important with them!). Most of these patients also assume these things until you show them otherwise as paranoia, suspiciousness, and withdrawal are common attributes. I am confident I will be a better clinician because now I can weave a little subjectivity with my objectivity when providing patient care.  Knowledge is good but....it is more than that.

At the end of the group session today with the patients with schizophrenia, a few told me they were going to miss me! This gesture made this whole rotation worthwhile. To hear patients that have struggle with the negative symptoms of schizophrenia describe and convey such an emotionally charged statement was so touching. I am going to miss the patients on the unit, but I will keep the lessons learned from them forever!

Next up: Inpatient Pediatrics/Infectious Disease. Buckle up.