ADD + Wards ---> To tell or not to tell??

[Counterpointer]

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I was diagnosed with ADD Inattentive type about 4 years ago. I'm starting my MSIII year now and feel that my ADD is becoming a major hindrance to my ability to take a good History and organize the info into a good presentation. I also have suffered from mild depression and some obsessive tendencies, and I've been in talk therapy and taking medication for the better part of the past 4 years.

So far I haven't told anyone at my school about my ADD/psych history. I was able to get through the first 2 years w/o accomodations, though it was certainly a big struggle and I don't feel I did as well as I could have.

I'm wondering 1)should I disclose my ADD diagnosis and 2) to whom?

My therapist felt it might help some of my preceptors to know what I'm dealing with, particularly since my inattention and obsessiveness makes it very hard to organize information quickly and efficiently.

I agree in a perfect world it might be a great idea to bring this up, but I also don't want to be de-valued or to come off as a complainer or someone making excuses.

Of course, I'm barely 3 weeks into my first rotation (Primary Care) and realize that everyone is going to have a transition period. But perhaps my transition will be additionally rough and challenging. I also feel like perhaps Primary Care is a challenging way to start since time pressures are so great and a refined, efficient H&P (not what I can do at this point) is very important.

I'd really appreciate some opinions in this matter! 🙂

 

[Medstudentquest]

I was diagnosed with ADD Inattentive type about 4 years ago. I'm starting my MSIII year now and feel that my ADD is becoming a major hindrance to my ability to take a good History and organize the info into a good presentation. I also have suffered from mild depression and some obsessive tendencies, and I've been in talk therapy and taking medication for the better part of the past 4 years.

So far I haven't told anyone at my school about my ADD/psych history. I was able to get through the first 2 years w/o accomodations, though it was certainly a big struggle and I don't feel I did as well as I could have.

I'm wondering 1)should I disclose my ADD diagnosis and 2) to whom?

My therapist felt it might help some of my preceptors to know what I'm dealing with, particularly since my inattention and obsessiveness makes it very hard to organize information quickly and efficiently.

I agree in a perfect world it might be a great idea to bring this up, but I also don't want to be de-valued or to come off as a complainer or someone making excuses.

Of course, I'm barely 3 weeks into my first rotation (Primary Care) and realize that everyone is going to have a transition period. But perhaps my transition will be additionally rough and challenging. I also feel like perhaps Primary Care is a challenging way to start since time pressures are so great and a refined, efficient H&P (not what I can do at this point) is very important.

I'd really appreciate some opinions in this matter! 🙂

I would certainly tell the clerkship/site director just in case someone cases that your HP's, presentations are not good, disorganized, etc. Explain to them how this affects you. Also, it might be a problem for shelf exams. I say mention it to the "right" people, not just everyone.

 

[donvicious]

It will absolutely affect your presentation to attendings, but whatever, you'll get through it. I resisted telling my residents I had ADD almost all third year. When I did finally reveal it, I got no sympathy whatsoever. My advice...suck it up!

 

[jdh71]

I was diagnosed with ADD Inattentive type about 4 years ago. I'm starting my MSIII year now and feel that my ADD is becoming a major hindrance to my ability to take a good History and organize the info into a good presentation. I also have suffered from mild depression and some obsessive tendencies, and I've been in talk therapy and taking medication for the better part of the past 4 years.

So far I haven't told anyone at my school about my ADD/psych history. I was able to get through the first 2 years w/o accomodations, though it was certainly a big struggle and I don't feel I did as well as I could have.

I'm wondering 1)should I disclose my ADD diagnosis and 2) to whom?

My therapist felt it might help some of my preceptors to know what I'm dealing with, particularly since my inattention and obsessiveness makes it very hard to organize information quickly and efficiently.

I agree in a perfect world it might be a great idea to bring this up, but I also don't want to be de-valued or to come off as a complainer or someone making excuses.

Of course, I'm barely 3 weeks into my first rotation (Primary Care) and realize that everyone is going to have a transition period. But perhaps my transition will be additionally rough and challenging. I also feel like perhaps Primary Care is a challenging way to start since time pressures are so great and a refined, efficient H&P (not what I can do at this point) is very important.

I'd really appreciate some opinions in this matter! 🙂

Are you medicated?

 

[jennyboo]

Having never been in this situation, I cannot comment on how I would make the decision of whether to tell anyone or not.

However, as a resident, I would tell you that your residents do not need to know. In my experience, clerkship grades are first and foremost dependent upon your shelf exam performance and not on your resident evaluations. You are not expected to take a flawlessly complete history in one sitting (you can fill the gaps by going back five or six times if need be) or to perform a perfect physical exam, nor are you expected to make flawless presentations.

It is expected that your very inexperienced oral presentations and patient H&P and progress notes will improve from the beginning of the clerkship to the end. That is all that's expected. So don't obsess too much over what residents think of you (this has very little impact on your grade unless you are a jerk, and it's very hard for most normal people to be jerks), and don't tell them unless it is a specific situation, such as if you are asking a resident who has ADD how s/he coped.

 

[Medstudentquest]

Having never been in this situation, I cannot comment on how I would make the decision of whether to tell anyone or not.

However, as a resident, I would tell you that your residents do not need to know. In my experience, clerkship grades are first and foremost dependent upon your shelf exam performance and not on your resident evaluations. You are not expected to take a flawlessly complete history in one sitting (you can fill the gaps by going back five or six times if need be) or to perform a perfect physical exam, nor are you expected to make flawless presentations.

It is expected that your very inexperienced oral presentations and patient H&P and progress notes will improve from the beginning of the clerkship to the end. That is all that's expected. So don't obsess too much over what residents think of you (this has very little impact on your grade unless you are a jerk, and it's very hard for most normal people to be jerks), and don't tell them unless it is a specific situation, such as if you are asking a resident who has ADD how s/he coped.

In my school it's the opposite. Shelf is only 30%. Evals are 70%.

 

[donvicious]

I was diagnosed with ADD Inattentive type about 4 years ago. I'm starting my MSIII year now and feel that my ADD is becoming a major hindrance to my ability to take a good History and organize the info into a good presentation. 🙂

You've probably already been told this by your therapist and I'm not accusing you of this, but don't get in the habit of blaming all your shortcomings on ADD. Everybody has shortcomings and that's normal 🙂

 

[PeepshowJohnny]

I'd be careful mentioning it to everyone. Even among medical people, a stigma exists around ADD/ADHD that it's a made up illness. I know there are some doctors out there who if you say "I'm sorry I forgot to ask about allergies in my H&P, I have ADD" they'd laugh in your face or scream at you about accepting responsibilities for your mistakes.

 

[koma]

I'd really appreciate some opinions in this matter! 🙂

I wouldn't tell because it will not resolve your problem and might make it worse.Your grade will not be 'corrected' for your ADD. There's much subjectivity and unfairness ingrained in 3rd year for everyone and it's best to just gently navigate through it without making much of a stir. The only time I would ask for special consideration is if I had a clearly visible medical condition or death in the family. Anyway, as the year goes on, you will get much better at doing H&P just by virtue of constant repetition.

 

[eforest]

Do NOT tell. I have ADD AND Bipolar II (although I'm not sure where the medication leaves off, and where the ADD starts). If I told people, I would still have the same issues and nobody would give me a break on grading. 99% of my classmates know nothing of my situation. The few that do know, don't know the extent of the situation. Although I struggle with attentional issues, hiding the slight mood swings that are left over after medication takes care of the extremes, and hiding the medication, I really can't tell anyone. It seems unfair because having these issues can be like having a full time job, except I'm not allowed to tell anyone.

 

[Counterpointer]

Thanks for the input everyone!

A few follow-up points:

I'm currently taking:
-Concerta 36mg qAM
-Wellbutrin XL 150mg qAM

I'm avoiding coffee at the moment and trying to let the Concerta do its thing. It definitely helps.

I've noticed that a BIG challenge for me is listening to/following multi-step directions. I can't always hold the info in my mind and often need to write the steps down or repeat them. This manifests right now in an inability to listen to a patient's HPI and efficiently categorize the Onset, Timing, Quality, etc.

I agree that I don't want to make excuses or get into the habit of placing all the blame on my psych history, though I'm usually encouraged to give myself a break and appreciate how well I do given my situation.

Still, at this point I'm far more inclined to keep it quiet. I'm in the beginning of the year, and hopefully I'll show great improvement with time. I think if this really keeps up and becomes a problem in another month or two I'll have to see if meds/approach needs to change.

 

[Medstudentquest]

Thanks for the input everyone!

A few follow-up points:

I'm currently taking:
-Concerta 36mg qAM
-Wellbutrin XL 150mg qAM

I'm avoiding coffee at the moment and trying to let the Concerta do its thing. It definitely helps.

I've noticed that a BIG challenge for me is listening to/following multi-step directions. I can't always hold the info in my mind and often need to write the steps down or repeat them. This manifests right now in an inability to listen to a patient's HPI and efficiently categorize the Onset, Timing, Quality, etc.

I agree that I don't want to make excuses or get into the habit of placing all the blame on my psych history, though I'm usually encouraged to give myself a break and appreciate how well I do given my situation.

Still, at this point I'm far more inclined to keep it quiet. I'm in the beginning of the year, and hopefully I'll show great improvement with time. I think if this really keeps up and becomes a problem in another month or two I'll have to see if meds/approach needs to change.

Do you get extra time for shelf exams?

 

[jdh71]

Thanks for the input everyone!

A few follow-up points:

I'm currently taking:
-Concerta 36mg qAM
-Wellbutrin XL 150mg qAM

I'm avoiding coffee at the moment and trying to let the Concerta do its thing. It definitely helps.

I've noticed that a BIG challenge for me is listening to/following multi-step directions. I can't always hold the info in my mind and often need to write the steps down or repeat them. This manifests right now in an inability to listen to a patient's HPI and efficiently categorize the Onset, Timing, Quality, etc.

I agree that I don't want to make excuses or get into the habit of placing all the blame on my psych history, though I'm usually encouraged to give myself a break and appreciate how well I do given my situation.

Still, at this point I'm far more inclined to keep it quiet. I'm in the beginning of the year, and hopefully I'll show great improvement with time. I think if this really keeps up and becomes a problem in another month or two I'll have to see if meds/approach needs to change.

methylphenidate and buproprion . . . I will have to defer somewhat to the psychiatrist, but buproprion can be a bit "tricky" and I've never seen those two given together. Probably not helping the anxiety - is the buproprion for depression or adjuvant to the methyphenidate? Ever tried D-amphetamine? I think your meds will probably need some tweaking and moderating, and if your psychiatrist is not in the area, you should probably find one at the school or area very familiar with treating ADHD.

Although, some of what you may describe is nothing more than NORMAL beginning 3rd year disorganization. HPI is really pretty straight forward and industry standard. Start developing a way that makes sense to you and do NOT divert from your game plan. HPI's come quicker and quicker and you miss less and less if you do them the same every time.

Here's what worked for me . . . I'd grab a piece of blank copy paper. There's always a printer around the units or the ED, open the tray a grab a few sheets. I like to turn it on it's side, but that's obviously not required. Let the patient ramble for a few minutes after the obligatory "my name is . . .", "what brings you to the hospital . . .". I have blanks areas on the paper devoted to HPI, PMH/PSH, FamHx, SocHx, Meds/Allergies - the areas are always the same - and if they ramble off something I think goes there, then I jot it down. After the rambling, I begin the directed questions quality, quantity, etc and that goes into the HPI - past history of similar symptoms goes at the end of the HPI. Now pay attention here . . . pertinent positives and negatives are nothing more than ROS Q's at the end of the HPI. Once I'm done establishing quality, quantity, etc. I ask ROS Q's "above, below, and around" the chief complaint, for example, chest pain you obviously run through the CV ROS but also GI. ROS always needs the constitutional questions: fever, chill, sweats, weight loss/gain. Then the rest of the history is pretty straight forward ask specifically about the PMH/PSH, fam, soc, meds and allergies (if the patient has their meds with them - ALWAYS a large bag if they have it - take the time to write it all down). Do it the same way EVERY time for EVERY patient. You do NOT have to do it my way, but you need to find a way to do it the same everyday.

Until I decided to start doing it the same way every time I struggled with H&P's 3rd year. Hope this helps.

 

[Counterpointer]

A few more follow-ups:

-So far in med school I have not asked for or received extra time on exams. It was my pre-med courses where I was first diagnosed with these issues and asked/received extra time.

Despite getting extra time for class exams I took the MCAT w/o extra time mainly because I didn't want to deal with the hassle of requesting it and the possible discrimination of having schools find out I had extra time (same reasons I didn't opt for extra time for Step1). For Step 1 I was able to "train" intensely with questions, and I benefitted by the computer format since I read a LOT of things on the computer. (was already "in shape" for that)

My Psychologist's testing report clearly states that when I feel a time pressure I get flustered and think impulsively/use trial and error intstead of relying on my (pretty sound) logic. But, since I've gotten by so far, I'm hesistant to make a fuss to get extra time on Shelf exams. (maybe a big mistake or flaw in reasoning) I suppose my feeling is that if I can practice in the same format as the exam (qBank/usmleworld) then I am able to eliminate the stress of not knowing how the test is laid out and am better able to just answer questions and use my knowledge.

-The MPH/Buproprion combo has been in place for about 2 months now. Had previously used MPH basically as-needed at 10-15mg initially with another 5mg 2-3hrs later. Tried a small dose of Adderall once (~10/15mg) and felt it was too strong. The MPH is certainly capable of inducing a slight panic attack/anxiety. I've had that happen a few times but so far not with the Concerta. Buproprion is for Dysthymia (since Depression criteria aren't met).

I'm continuing to see an MD and LICSW locally. I am definitely an anxious person, and it seems like my symptoms are on a continuum between ADD and OCD with the constant low-level depression/dysthymia and anxiety.

JDH-- thanks for the input about HPI and staying organized. In fact this has been my feeling-- that I need to rehearse over and over the order of my questioning so that once I'm in the room I don't have those "uhmmm" moments or a need to keep referring to a pre-made checklist/outline. I need to force myself to rehearse this stuff. I think I've had trouble improving because each time I've interviewed (and attempted PhysExam) it's been variable instead of regimented. Have to learn to crawl before walking, and I tend to want to walk and then run.

To follow-up on my original questions....
My answer for now is to keep it quiet overall. I'm debating whether I should try to get extra time on shelf exams, in which case I'd tell only the people that need to know.

I'm not doing too bad compared to what a lot of us see everyday, and I also realize that attendings/residents could be dealing with their own Psych issues w/o raising a fuss.

 

[DebDynamite]

It will absolutely affect your presentation to attendings, but whatever, you'll get through it. I resisted telling my residents I had ADD almost all third year. When I did finally reveal it, I got no sympathy whatsoever. My advice...suck it up!

I hate to agree with this, but I suspect it's the sad truth. I was diagnosed with ADHD when I was 4, and have never received special accommodations in med school (or any other school, for that matter). I do think it makes certain aspects of third year more challenging, but I 'm glad that I never told anyone (any attendings, course directors, etc) because I think they may have viewed it as whining. I would advise you to hardcore memorize a system that you are going to use when writing up/presenting patients and keep going back to it in your thoughts. ADD people love to mix up the order of an H&P (and I think secretly resent being confined to the typical format expected), but the rest of the world really likes it to be orderly.

 

[AlternateSome1]

Here is the problem, you are never going to get special accommodations after medical school. I don't mean to say "suck it up", but this is the time to learn to deal with your attentional deficits in this setting. I personally get really screwed up when I start trying to present. One of the simple things that helps me out is keeping a card with the basic components of the H&P in my pocket. It is something that most people have down (or seem to) by this point, but if I get into the midst of a presentation, all organization goes out the window. A couple of quick cues from a card really help me to pull it together. I hope you can find strategies that help you get by.

 

[EM2BE]

I have not gone to a dr yet to see if I have ADD, but I'm pretty sure I have it. My problem is that I think things are perfectly organized, and someone that reviews the interview said it was so scattered they were surprised the patient kept up. I just said I would work on it and I have, but no idea if it worked until I have another review again.

 

[MeowMix]

I also would recommend dealing with it with good outside support, and not bringing it up as a way of explaining what you perceive to be poor performance.

#1, all third-year med students are constantly improving on H&P and presentation, as well as organization. Third and fourth years are our transition years so we can figure out how to organize information and manage our workload. I do not have ADD and I still write skeleton notes on each pt at night after work; I have a plan in mind of the order in which I will see people on pre-rounds (going between 2 buildings and 6 different floors); I get up early so I have enough time to pre-round, and I go to sleep earlier so I can get up earlier.

#2, I don't care whether you are dealing with ADD, diarrhea, a sick kid at home, or a disastrous marriage, lots of people have to deal with challenges every day, and as professionals (albeit unpaid) we have to figure out how to manage and get our work done. I've supervised staff members who were dealing with psych issues, domestic abuse, kid problems, and all kinds of other stuff outside work. After a certain point I could not provide the support they needed, they weren't getting their work done, and I wasn't getting my work done. Although we are nice sympathetic human beings, the nature of our work as doctors requires us to give a lot and receive little from our patients; I personally want my coworkers to work with me, not add to my workload.

 

[Counterpointer]

I would advise you to hardcore memorize a system that you are going to use when writing up/presenting patients and keep going back to it in your thoughts. ADD people love to mix up the order of an H&P (and I think secretly resent being confined to the typical format expected), but the rest of the world really likes it to be orderly.

In complete agreement with your post. The completely rote memorization is a necessary step it seems everyone needs to take, perhaps even more important for those with ADD.

In regard to mixing up the order of presentation, I've noticed this scenario a few times:

The attending interrupts my HPI to ask a question about something I have categorized in a different section (maybe SurgHx or Social). Sometimes I try to pick-up where I left off and others I end up jumping to that other section to go ahead and relay the remainder of that section before going back to HPI. Since I'm on Family Med/Outpatient, I often feel like the attendings don't want to hear the whole presentation and are cherry-picking questions to try to save time, which I completely understand and empathize with, but since I'm working with several different people I'm also trying to keep up with their quirks. I'm hopeful that when I get to the inpatient wards I'll have an easier time since they'll truly want to hear the "formal" order of presentation and most of the details.

I also would recommend dealing with it with good outside support, and not bringing it up as a way of explaining what you perceive to be poor performance.

Agreed. I feel like this thread has helped give me direction as to ways to practice and improve, so I have a better sense of how I'm going to deal with this issue. And I think you're right about the spectrum of things that people can be dealing with: kids, abuse, illness, etc and how in the end we've got to all try to transcend to acheive great things, especially as a team.

One other question for people: Has anyone found an on-line or videotape/DVD guide to Physical Exam? I really need to just memorize the different parts of the complete exam so I am comfortable with knowing my next move, and I can see myself doing very well by practicing at home while watching a video to rehearse and imprint at least a preliminary PhysExam into my mind.

I know there are Bates videos, but they are broken-up and kind of slow. Was hoping to find the whole normal findings routine performed "live".

 

[Counterpointer]

Answering my own question....

http://www.conntutorials.com/video.html

The integrative video seems like just what I was looking for.