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Psychiatry and medical education.

We had completed our didactics. It was now time to embark on our third-year clerkship in surgery and psychiatry: two rotations considered to be on polar ends of the medical spectrum.

In surgery, we routinely scurried from room to room in the early morning hours caring for patients. Soon, we discovered that those long days without rest were molding our psyches into those of surgical robots whose primary responsibilities were providing wound care and surgical assistance, identifying surgical illness, and of course, completing student-oriented surgical scut work with a smile.

Twelve weeks later, we began our psychiatry rotation on a unit that could be entered and exited only with a key. We expected the same kinds of intense stressors we had already experienced, but a new set of stressors quickly began to emerge.

The morning rounds came and went--without scurrying for supplies or getting flustered by esoteric questions. We were spared the physical hardships of surgery, but we learned that the many gray areas in psychiatry make working in this specialty challenging and frustrating in other ways.

While working the inpatient psychiatry unit during our initial interviews, we realized that patients did not always present within the confines of any single DSM-IV criterion. The criteria appeared at times too simplistic; many patients seemed to present with characteristics of multiple disorders. We struggled with the proper placement of these patients on Axes I-V within the DSM.

As time passed, we began to understand that many of these patients lacked the skills needed to function well in society. Some of them required hospital care, intense psychiatric care, medicinal regimens, and psychosocial support systems. Yet, all the while, a specific label that defined their illness was often lacking.

Halfway through our rotation, we had an epiphany about our own shortcomings: Having a specific psychiatric diagnosis appeared to be only the proverbial tip of the iceberg. The knowledge we were acquiring was far more useful than knowledge of a diagnostic label. Learning how to apply such knowledge in a clinical setting was even more valuable than knowledge rooted in didactics. To our surprise, patients presented with a working diagnosis that could change within the first few days of admittance. In a matter of hours, a patient diagnosed with paranoid schizopbrenia could morph into one labeled as having bipolar disorder with paranoid delusions.

This open-minded thinking was quite different from that required during our surgical rotation. After all, as medical students, we had thought that every question yielded a specific answer. But our work in psychiatry made it clear that when presented with overlapping illnesses or ambiguous personalities, a philosophically gray explanation was all we could expect.

Adding to the complexity, we witnessed two cases of patients with schizophrenia that illustrate the kind of open-ended thinking required in psychiatry. In both cases, the patients were failing their medicinal regimens. We soon realized that these two patients probably differed in their neurochemical mechanisms, which in turn, may have been the basis for tailoring their treatments differently.

What took us aback was our realization that years of experience had endowed the psychiatrist with a keen sense of inference that allowed her to discern a patient's disorder. We began to see that in psychiatry, the wisdom of open-ended clinical judgment could replace diagnostic studies.

Neither of us has determined which path we will take, but this psychiatric rotation has given us the tools of empathy and understanding that we will use throughout the rest of our medical careers.

MR. HAZIN and MS. WEBSTER are third-year medical students at New York College of Osteopathic Medicine, Old Westbury.


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Author:Hazin, Moustafa Imran; Webster, Toni
Publication:Clinical Psychiatry News
Article Type:Drug overview
Geographic Code:1USA
Date:Dec 1, 2005
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