End of rotation reflection- QHC-PSY
Jinjin Lin
After 5 weeks rotation at psychiatry emergency department at Queens Hospital Center, I learned a new approach to interview patients with mental illnesses. It has a lot of differences from what I learned to interview patients who have medical concerns from Physical Diagnosis class. For interviewing psychiatric patients, I learned that the first sight of patient is very important, for example, is patient disheveled or well-groomed? Is patient agitated or calm? This kind of general survey is very useful and it guides us through the interview. One big difference from medical concerns interview is that for patients with psychiatric problems, we will always need to get collateral information from family members, outpatient psychiatrist, or someone know the patient very well, because we cannot fully rely on what patient told us. For example, patients may minimize their angry outburst to avoid admission or try to overstate their psychiatric history for secondary gains. Sometimes, when we call the family for collateral information and they provide different stories from what patient told us.
At first, writing an HPI and present it to an attending psychiatrist or a PA is very challenging, because there is very different style of writing an HPI for patients with mental illness. For example, they are using different format and some specific phrases to format the HPI. And, with practice and time, I learned how to format an HPI in a way that a psychiatrist will do. Most likely, we will need to describe the basic information of the patient, their behavior, mental status exam, put in collateral information, and decisions that made based on the presentations of the patient. For the HPI, we use quotations a lot to mark down what patients says, and it is very important to put “acute” or “at this time” for patient’s presentations, because when we interviewed the patient, it is only for a short period of time.
Sometimes, it is really hard to interview patients who are angry and agitated. Usually they brought in by EMS because they have arguments or fights with others, and when they are being asked why they involved in these issues, they will keep cursing and say we cannot help them. For these patients, I learned that do not rush to get into questions about why they behave in this way. First, provide them food and water, leave the room and let them calm down a bit. Second, when we come back and approach them with empathy, and start questions by asking them how they feel right now. After patients calm down, they usually need a listener, this is the best time to interview them. In addition, sometimes there are really aggressive patients, for example, they will spit, cursing, break table, banging on the windows and try to get out. We will need to go back to our safe box, activate team code, and order stat medications to calm patients down.
In this five-week rotation, I have seen a lot of funny cases and also depressive cases. I still remember one case that I was doing interview primarily. Patient is a young 23 years old female brought in by EMS due to acetaminophen overdose. She looks guarded, depressed, and tearful. She denies suicidal ideation, and states that she takes whole bottle of Tylenol accidently. After get collateral information from her mother, who states that patient complaints to her about feeling depressed all the time few months ago, and patient is living by herself, we decide to admit patient to CPEP after medically clear for further observation. At that time, patient’s mother asks me is her daughter in danger. I told patient’s mom that patient is not stable, and we are waiting for patient’s lab results, because she takes 30 pills of Tylenol, which is life-threating. Patient’s mother states the patient is 23 years old already and will take care of herself, and she will not come back to New York, because she has an important meeting in Florida. Patient ends up being transferred to ICU, because her liver function declines so badly. Every suicidal patient has a story behind their presentations which make them to harm themselves, and they want someone to hear their voice and understand them.
For my next family medicine rotation, I will try to practice on my medical procedure skills, like intramuscular injection, EKG, and venipuncture, because in psychiatry rotation, I did not get a chance to do procedures, like injections or blood work. I will ask nurse or doctors there to allow me practice on these procedures whenever it is possible. In addition, because I did not get a chance to interview pediatric or geriatric population at psychiatry department, for the following rotations, I will observe how attendings or PAs interact with these patients, and then practice on conducting better interviews with these patients. It is important to learn how to get trust from pediatric patients, and how to deal with geriatric patients with multiple medical concerns.
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