All sorts of bread crumbs

Hot on the heels of Monday's assessment of our physical exam skills was yesterday's assessment of our interviewing skills. All semester long, in addition to our bimonthly physical skills sessions, we also had weekly interview sessions, in which a group of students dressed up, sat around a table, and tried their best to elicit a coherent history from a paid local Dominican patient. We used very specific interview sheets, complete with all of the questions we needed to ask, but the goal of the sessions was to teach us how to elicit a broad spectrum of information while subtly guiding and funneling the conversational contents in such a way as to develop a succinct story of the patient's illness, complete with their psychosocial, personal, family, and medical history. Typically, one student per week would take point, and everyone else would add in questions at the end. It wasn't the best practice for the test, for several reasons.

First, we had 2 hours at our disposal to make sure we collected every detail from the patients - however, the graded practical was a 10-minute sprint. Also, many of us don't have that much experience interviewing anyone, and of the 10 or so sessions, we only had a facilitator twice - the blind led the blind the rest of the time.

That being the case, Nicole and I decided to do our best to replicate the interviewing style that would be graded - we researched various interview rubricks, and condensed them down to a few alphabetic mnemonics, to make sure we covered all pertinent aspects of the history (ex: ABCDE - arthritis, high Blood pressure, Cancer, Diabetes, Epilepsy; OPQRST - onset, palliative factors, quality and quantity, radiation, severity, timing; HAS TOLD ME - hobbies, alcohol, sexual activity, other drugs, living conditions, diet, medications, education, etc). So we figured out a quick method of questioning - next came the practice. That we had fun with - Nicole pretended to be a womanizing banker with ED, a football player with G6PDH deficiency (her best one, I think), and a drunk party girl. I pretended to be a carpenter with leukemia, a pregnant medical student, and, my piece de resistance, a bookseller going through a manic phase. We practiced tailoring our questions to the presentation while still collecting possible pertinent information - all, ideally, within 10 minutes.

There's a bit of a disconnect with the interviews - almost all of the rubricks available center around pain. Logically, the first few questions are concerned with describing the pain - "What brings you in today?" "When did you first notice it?" "Is there anything that makes it better or worse?" "Please describe the pain for me." "Does it radiate anywhere?" However, this particular section of our education is run by the behavioral sciences department - full of therapists and Ph.Ds, whose first instinct is to ask "How's your life?" Now, that's an important question, but I'm not about to let someone ramble on and on when I've got ten minutes; even though they praise the utilization of open-ended questions, for the purposes of this test, I tried to minimize them. I just knew that the BS department would pull something, so I wasn't surprised in the least when the presenting complaint was "I can't sleep".

We were all sequestered in a classroom next to the BS department, so as to minimize cheating, while we waited for our names to be called. I was towards the end, but when my time came, I went and greeted the interviewer and the student-pretender-patient, and go down to business.

"Good afternoon Mrs. Jane Doe, my name is Farley Neasman, I'm a second-year medical student, and I'll be interviewing you today. I just want to let you know that everything said here is confidential, unless there's something that I feel could be a danger to yourself or to someone else, in which case, I'll have to notify someone. Now what brings you in to see us today?"

"I can't sleep."

That threw me for a loop initially. Out of the window went all the questions about rating it on a scale from 1-10, as well as those about radiation and quality. However, as things went on, I realized it was a psych case. Inside, I was greedily rubbing my hands together; I knew I was about to rock this. I teased apart the threads of the pretend history that were pertinent, diagnosed a major depressive disorder (utilizing the lovely little SIG E CAPS mnemonic), and, even provided a little counseling. The facilitator actually looked rather surprised when all was said and done; she'd said that I'd hit all of the main points while being incredibly empathetic, and even provided a bit of consultation. I think I did well. I realized that, whereas MCQ (multiple choice questions) utilize my cluster-bridge model, actual medicine is more like detective work - you're gathering clues and putting them together to form a coherent disease picture. Somewhere in between, though, was the interview practical - someone laid down a trail of bread crumbs, and like Hansel or Gretel, it was my job to follow them home.

This was one of those things that reminded me of why I was at first drawn to psychiatry; it just seems to make sense to me, and it's exciting. There's nothing that shakes the central pillars of who a person thinks they are like mental illness, and that, in turn, affects everything else. I keep going back and forth on what I'm interested in; Nicole says it changes every day. I was telling her yesterday that I might enjoy surgery; I knew I'd be a very good one, but I probably wouldn't do anything groundbreaking. However, regardless of the relegation to drug management foisted upon psychiatry by insurance companies, I felt that I had a very good chance of making a name for myself in that field. Needless to say, I still don't know what I'm going to do, and I don't intend to decide any time soon. I read an article the other day that essentially said that even the clerkships don't really introduce med students to what actual doctor work is like in those fields - so I'm in no rush to nail it down.

HOWEVER: There was an MSNBC video article the other day about endoscopic surgeries. In addition to allowing much greater control and dexterity for highly trained physicians, minimally invasive surgery allows patients to heal more quickly, and lowers their risk for infection. The thing that got me, though, was that part of the application process involved playing X-box games with the program head - you see, with endoscopic surgery, hand-eye coordination in the setting of adapting a 3-D world to a 2-D representation is very important; it was a screening process to weed out those who couldn't adapt. I'm wondering - would playing Halo with my little brothers count as CME? I can dream.

Yesterday was Thanksgiving - continuing the tradition of trampling on patriotism, we had a test yesterday (last time it was an anatomy practical on the 4th of July). Since there's not a turkey to be found anywhere on this island, Nicole and I made do with what we had - instant mashed potatoes, stove-top stuffing mixed with chicken from the shacks, and some locally purchased veggies. It was the best turkey day possible, all things considered!

When I filled out my paperwork for Ross, one of the things I had to sign was a statement saying that they could use my face in their brochures. Here's why - that's me on page 38, in the anatomy lab. Apparently, all new students are going to see my mug.