Thursday, July 14, 2016

3/4: A Psychotherapist in Training

I’m back at Our Lady Of An Undisclosed Location hospital now as a final-year resident. You wouldn’t think a year would make so much difference, but it does.

Identifying residents by their year is easy. The first-years walk around, deer-in-the-headlights look to them, impossible to confuse with anybody except maybe a patient having a panic attack. The middle-year residents are a little more confident. And then the final year residents, leading teams, putting out fires, taking attendings’ abuse in stride.

(True story – last week an attending yelled at me for not knowing some minor detail about uraemic encephalopathy. Later I couldn’t find the detail he’d mentioned, so I asked for a reference, and he said it had been discovered by one of his friends at the big university hospital where he used to work, but the friend had died before he could publish his findings. I think the attending realized as he was talking that it might have been unreasonable to expect me to know a fact whose discoverer took it to the grave with him, but he didn’t apologize.)

It’s only sort of a facade. 99% of things that happen in a hospital are the same things that happened yesterday and the day before, so if you hang around long enough you can learn what to do, or at least which consultant you can call to make it not your problem anymore. On the other hand, Actual Pathology is still a gigantic mystery. I’m not sure this ever changes. One in every X patients with symptoms won’t have any of the things that could possibly be causing those symptoms, won’t respond to any of the treatments that are supposed to cure those symptoms, and you’ll still have family members and hospital administrators demanding that you fix it right now (and in psychiatry, X is probably a single digit number). All you can do is keep up the facade, put your skill at taking attendings’ abuse in stride to good use, and start learning necromancy so you can summon the one big university hospital researcher who studied it but never got a chance to publish their findings.


Two of the most important things I learned during my third year were “Tell me more” and “[awkward silence]”.

“Tell me more,” works for every situation. Part of the problem with psychotherapy is that you’re always expected to have something to say. As a last resort, that thing is “Tell me more”. It sounds like you’re interested. It sounds like you care. And if you’re very lucky, maybe the patient will actually tell you something more, as opposed to their usual plan to stonewall you and hide all possibly useful information.

I saw something on Tumblr the other day which, despite being about a 9-1-1 operator, perfectly sums up being a doctor too:
my bf has many interesting stories and observations from his new job as a 911 operator

my favorite is how meandering people are, even in the midst of a terrible emergency 
they respond to “what is the emergency” with “well, the thing is, four weeks ago–” 
and then he’s like “WHAT IS THE EMERGENCY RIGHT NOW” 
and they’re like “so what happened this morning was, i said to my wife, i said–” 
“oh i’m having a heart attack”
my second favorite is how specific he has to get sometimes

like, “what is your emergency?” 
“i’m sitting in a pool of blood.” 
“… is it… your blood?” 
“yes i think so” 
“do you know where it’s coming from?” 
“probably the stab wound” 
“have you been stabbed?” 
“oh yah definitely”
Psychiatry is like this, except it’s all very vague, and your patients are really suggestable, and people are always afraid that if you just ask specific questions like “Are you depressed?” then they’ll say yes to make you happy and won’t talk about how the real problem is their anxiety or something. So instead, the patient says something like “I’m sitting in a pool of blood”, and I say “Tell me more…”. They say “Well, it’s my blood.” I say “Tell me more…”. After repeating this process a couple of times, we finally get to the stabbing, and the patient doesn’t feel like I railroaded over their chance to tell their story.

Or it helps you figure out what’s important to the patient. If someone said “I hate my husband so much,” my natural instinct might be to ask “Why?”. But maybe why isn’t the question the patient cares about. Maybe what she really wants to talk about is how guilty she feels about hating their husband, and if I asked her why then we’d get on a tangent about what the husband is doing that never addresses her real problem. Maybe she’s agonizing every moment about whether or not to divorce him, and losing sleep over it, and coming to me for a sleeping pill. Maybe she’s just hatched a plan to kill him and wants to check it over with me to see if I can find any flaws. In any case I should probably figure out why they hate him eventually, but if their real issue is whether or not I approve of their murder plot then we should probably get to that first.

So instead, it’s “I hate my husband so much.” “Tell me more.”

“I’m feeling depressed.” “Tell me more.”

“Sometimes I think life isn’t worth living.” “Tell me more.”

“Listen, if you don’t give me a prescription for Adderall right now I swear to God that I will stab you right here in this office!” “Tell me more.”

This has seeped into my personal life. I was on a date with a girl earlier this year, and whenever she started telling me about her life I would just say “Tell me more”, and it worked.

And then there’s [awkward silence]. I learned this one from the psychoanalysts. Nobody likes an awkward silence. If a patient tells you something, and you are awkwardly silent, then the patient will rush to fill the awkward silence with whatever they can think of, which will probably be whatever they were holding back the first time they started talking. You won’t believe how well this one works until you try it. Just stay silent long enough, and the other person will tell you everything. It’s better than waterboarding.

The only problem is when two psychiatrists meet. One of my attendings tried to [awkward silence] me at the same time I was trying to [awkward silence] him, and we ended up just staring at each other for five minutes until finally I broke down laughing.

“I see you find something funny,” he said. “Tell me more.”

by Scott Alexander, Slate Star Codex |  Read more:
Image: uncredited