Wayfaring MD

I am a family medicine resident who likes to highlight the hilarious in medicine as I write about patients, medical school, residency, medical missions, and whatever else strikes my fancy.

HIPAA is for reals, folks. All of my "patient stories" have been changed to protect patient privacy. I will change any or all identifiers, including age, location, race/ethnicity, sex, medical history, and quotes. Also, I am an anonymous internet person. Why should you trust an anonymous internet person to give you medical advice? Don't ask me, ask your doctor!
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Posts tagged "psychiatry"
I was wondering if you have much experience with mental health patients, and if you do, what was it like? (:
wayfaringmd wayfaringmd Said:

Oh yeah. I did a psych rotation in med school (all inpatient psych) and will do another one this year in residency (all outpatient). Plus I see patients with psychiatric conditions on a daily basis in the family medicine office. Whether you’re treating psychiatric disorders or not, you will deal with psych issues and patients with mental health problems all the time. Remember the old saying “crazy people get sick too”. 

Working with mental health issues can be very rewarding when your patient makes progress, but can also be extremely frustrating when they don’t (check my “depression” and “psychiatry” tags for stories). The frustration is definitely compounded by the inefficient and insufficient state of our country’s mental health systems and by our shortage of psychiatrists.  Because of these deficiencies in our system, primary care docs end up managing a lot of mental illness (and not necessarily well). 

Asker Anonymous Asks:
I am debating on majoring in psychiatry because I hear how difficult med school is, and I do not think I am that I would be accepted into one because certain areas of science aren't my strong points. I was curious if you know anyone on Tumblr who is studying psychiatry, or do you have an advice and/or tips on someone who is undecided on majoring in it?
wayfaringmd wayfaringmd Said:

Do you mean psychology or psychiatry?

Psychology would be the undergrad major.

Med schools do not have majors. Everyone learns the same thing and trains in their specialty in residency. 

So if you wanted to be a psychiatrist, you’d have to go to medical school still.  And you could major in psychology or whatever else you wanted to in undergrad. 

The only psychiatrist I know on tumblr is shrinkrants. Maybe he can offer some answers for you?

Asker Anonymous Asks:
Can you give any advice on getting an adult family member to seek help for depression when they have a huge stigma against mental health problems? The person in question's quality of life is going downhill, but they think that counselors/psychologists/psychiatrists are quacks, and that most mental illnesses don't actually exist.
wayfaringmd wayfaringmd Said:

Convincing someone that they need help when they don’t see that they have a problem is tough. Might I suggest you try a bit of motivational interviewing, as we do when we are trying to convince smokers or alcoholics to quit? 

You say this person’s quality of life is going downhill. Engage them in a conversation about it. Ask them what they think is causing that decline, or if they even recognize the decline. If they don’t recognize it, suggest it to them and let them know what you and other loved ones have observed. Let them know that you care about them and just want to see them live a better life. Usually with some nudging people are able to come up with some reasons.

Find out what this person is doing to help work on these issues. Encourage them to think about how effective those methods have been thus far. What do they think they are missing? Maybe they will see that their efforts haven’t been enough and that they could use some more help. This is the part where you ask them to let you help them.  

Acknowledge the fact that depression, or this issue, whatever you wanna call it, is likely multifactorial. This person doesn’t believe in mental illness? Ok, don’t fight it. But maybe they do understand that social stressors or physical issues can cause some change in emotions. And depression can also be considered a physical issue. Explain to them that some people exhibit problems with sleep, sex, concentration, and energy when they are dealing with emotional stress or depression. Ultimately, the brain (an actual physical thing!) is where emotions come from. Changes in the chemical makeup of the brain can change emotions much in the same way that changes in blood chemistry can show up as liver disease, diabetes, kidney disease, etc. 

If this person had diabetes, would they want it to be treated? Probably so. So why not treat another medical problem that could also zap his energy (and potentially his life)?

You can’t force someone to get help that they don’t want or think that they need. But you can at least introduce the idea to them that they have a problem. It may take ten conversations before they begin to budge. In the meantime, let them know you are concerned about them and offer to help in any way you can.  You may be the only counselor this person ever sees. 

Asker Anonymous Asks:
What do you think of Psychiatrists now considering nonconformity a mental illness?
wayfaringmd wayfaringmd Said:

1) never heard of such

2) sounds like the media have stretched a definition of oppositional defiant disorder or gender dysphoria so they can have some news to report on.

3) psychiatrists must really hate hipsters.

Dear WayfaringMD, I was wondering if you know anyone who has a bit of social anxiety first going into medicine. I’m a shy and timid person and I hate it. I can study well but I feel like unless I do something about my timidity/shyness/social anxiety I’m not ready for the medical world. Is there anything else I can do to overcome social anxiety? Do you know any doctor who had this problem and was able to overcome it? – anon

Yo, one of my best friends in med school had near crippling social anxiety. As far as I can tell with her, it hasn’t really affected her interaction with patients. It did make med school a little harder for her though. She made a real effort to try to participate in events and go out with people occasionally, but she also didn’t apologize for the times she didn’t go out, which I can definitely appreciate.

Also remember that you don’t have to be a social butterfly to be a great doctor. There are plenty of quiet, shy, even timid docs out there. But don’t use that as a reason to not deal with your anxieties. 

Medical school, especially the clinical years, is a nerve-wracking endeavor for anyone, social anxiety or not. We all have to work to overcome our anxieties. Some are just faster than others at it.

Here are some suggestions for you to work on your social anxiety:

  1. Start small. Don’t jump right in to the thing that scares you most. Start out with little interactions that you can become comfortable with and build on. Maybe for you the step is just asking patients how they are doing or asking a coworker how their day was. After you get more comfortable with one step, move on to a bigger one.
  2. Recognize and challenge your negative thoughts. Don’t assume that you know what others think of you or how they’ll react to your conversation. Don’t believe that everyone around you is focused on you and what you’re doing and saying. And don’t jump to the worst conclusion in every situation.
  3. Take a second to collect your thoughts. Don’t sit and plan out every word you’re going to say, but if you’re nervous about an interaction, take a second, take a few deep breaths, tell yourself it’s going to be fine, and then proceed. I have to do this myself before I go into patient exam rooms if I think the interaction is going to be particularly uncomfortable for me.
  4. Find a group of people with similar interests as you. Take a class in something you’re interested in, hang out at a dog park with your furbaby, or volunteer for a cause you believe in. Shared interests make conversation much easier.
  5. Consider counseling or medication. A trained counselor can help you figure out which situations are scariest for you and can help you come up with ways to approach them. Counseling is the jam.

Several of the docs I work with recommend The Anxiety and Phobia Workbook to their patients with anxiety who are not able to afford counseling (or who are too anxious to even seek help from a counselor!). It’s a great place to start and you can work through it at your own pace.

 Hope this helps, anon!

Resident: Ms. P is back to her usual sunny self. She says she thinks she’s been a little out of it lately but now she feels fine. However, she was a little suspicious of her peanut butter this morning so I’m not so sure about her mental status. 

Attending: Were you trying to kill yourself?

Patient: Yes.

Attending: Have you tried to kill yourself before?

Patient: Yes.

Attending: Would you like some help?

Suicide Prevention Lifeline ( 1-800-273-TALK  in the US)

Folie a deux: French for “a madness shared by two”.  Also known as shared psychotic disorder or shared delusions, this  is a disorder in which one individual passes on a delusional belief to another person. Usually the initiator of the delusion has an underlying psychotic disorder, while the second person is usually not psychotic when left alone. If separated, the delusions generally resolve in the second person without medication. This condition is separate from folie simultanee, where two separately psychotic people adopt and play off of each other’s delusions. 


Recently I was scheduled to see a patient in clinic who had a long history of delusions of parasitosis. As I reviewed the patient’s chart, I found that his PCP had already examined “samples” of these parasites, which were found to be sloughed skin under microscopic exam. Luckily for me the patient missed his appointment and had to be rescheduled. And luckily for you, reader, my desk was close enough to the front desk that I got to witness this unfold: 

Mr. Ekbom to front desk: I have to see a doctor today. It’s an emergency. Worms are coming out of my skin again and they’re itching me like crazy! See? (shows scabs from picking his skin). My wife saw one come out of my mouth!

Front Desk: Well, you missed your appointment this morning so we will need to reschedule for after lunch.

Mr. Ekbom: No, I need to be seen now! The CDC says this is a parasite they’ve never seen before and there’s no possible treatment! I need to see my doctor!

Front Desk: Sir, according to your chart, this has been fully worked up already and no parasites have been found. Your doctor is not here today and the one you were scheduled to see is now full for the day.

Wife, Mrs. Ekbom: Look lady, I saw the worms coming out of his mouth! And I got ‘em right here in this baggy (holds up bag with a few scabs and skin pickings)! I seen ‘em crawl through his skin. They’re killing him!

Panic attacks are worst in 2 places: church and Wal-mart. If it happens at church, it can take 6 months to get the patient back in church. If it happens at Wal-mart, then they’ve won at life and don’t ever have to go back to Wal-mart.

Psychiatrist lecturer extraordinaire

If you could have the answer to any question you can think up, up to and including the meaning of life, what would you ask? -anon

I think I’ve pretty well got the meaning of life figured out, but I do have some questions I’d like to ask God. I’d like to ask him to explain mental illness to me. There’s so much we don’t understand about it—what causes it, how to treat it, etc. We don’t really understand how the mind, body, and the spiritual interact. 

Dr. C: Did she mention the fleas today?

MM: No, thank goodness, we didn’t go into all that today.

Me: ?? 

Dr. C: the patient thinks fleas are infesting her and are responsible for her liver failure… So what’s the plan for her, M?
MM: plan is to D/C home on Frontline. Maybe Advantage. Depends in her insurance.

Asker Anonymous Asks:
Were you taught any particular ways to encourage patients who are having a tough time coping with ongoing illness and might appear to be depressed? Is this something that you think is your responsibility to notice/question or does it fall outside your duty (and in the hands of perhaps a psychologist)?
wayfaringmd wayfaringmd Said:

We don’t have any set technique that we learn in med school. We’re just taught to be aware that your patient may have issues beyond the physical. But in general I would encourage patients to talk about their difficulties coping and would encourage them to seek counseling of some sort, whether formally in a series of visits with me or a trained counselor, or informally through a pastor or friend. 

It is absolutely my responsibility as a doctor to notice a patient’s change in mood and worsening depression. Mental illness affects physical health and well being. Plus, I’d add that the majority of patients suffering with mental illness do not seek help from a psychologist or psychiatrist first. They usually go to their family doctor about it. And many patients either don’t realize that they’re depressed, or they are unwilling to recognize it in themselves. That’s when we family docs, who have the benefit of continuity of care and know our patients well, can step in and be a big part of helping a patient heal physically and mentally. 

It took me 4 years of psychiatry residency to learn how to sit on a couch and not say a word.

Staff psychiatrist shares the wisdom of listening

why do you dislike borderline pd patients? - anon

I don’t dislike them. They can be very nice people. But often I find it harder to deal with them than other patients. 

People with personality disorders show an “enduring pattern of inner experience and behavior the deviates markedly from the expectations of the individual’s culture” (definition taken from the DSM-IV). So if a patient’s personality deviates heavily from societal norms, they can be hard to deal with. 

Borderline Personality disorder (as described by the DSM-IV) is presented here without further comment. Italicized are my explanations:

A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. (clingy behavior)

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. (splitting people into black and white “good” and “bad” categories without wiggle room)

3. Identity disturbance: markedly and persistently unstable self image or sense of self.

4. Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex, substance abuse, reckless  driving, binge eating). 

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood,e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days. (ie mood swings)

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms. (they frequently feel victimized, persecuted, or targeted after a minor ego insult)