Is a physician allowed to diagnose a student?

[dreambig2night]

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This has been bothering me for a few days, so I thought Id ask the Psych community,

Is a physician allowed to diagnose a student?

My preceptor recently had a one-on-one, 15 min, uncalled for consultation with me, his student, on what he thought I had, and have been suffering from and needs to be taken care of.

He thinks I have ADD and that I masked it well enough to this point in my education. He thinks I can be an even better student if I take care of it soon. As you can imagine, I was completely taken aback by his comments. Anyway, I completely disagree with him for several reasons.
1) For false assumptions he made about me
2) He only knows me for 2 weeks.
3) Why does his evaluation of me strike me as very bizarre rather than ring a bell?
4) I never had any problems as a kid.
5) Several more reasons, but wont bore you

What do you guys think?

I dont want to read too deeply but he either thinks Im a genius who was held back to mediocre things like medical school or a dumb nitwit who just barely passed 2 yrs of medical school but had to come up with some excuse for my dumbness.
The second excuse would be out of place because so far all my preceptors have had positive things to say about me for the most part and I also did well in my first 2 years.

On a positive note, he is a great educator and I have been getting along well with him...it may also be because I dont let his criticism get to my head.

oh...and he's a psychiatric physician.

please give me advice, opinion/s, anything! 😕

 

[billypilgrim37]

What do you guys think?

I think your impression that this "consultation" was inappropriate was spot-on.

As to the accuracy of his opinions, that we can't comment upon.

 

[Kazema]

Seems like a violation of professional and personal boundaries for me. It would be one thing if you asked for his opinion, but this is quite another.

 

[Doc Samson]

This impromptu opining is indeed a boundary violation - if he has concerns for potential impairment there are appropriate protocols to follow. As far as the diagnosis - not having trouble as a kid is not necessarily indicative of not having ADHD, esp in a high-functioning patient. If you're curious about the diagnosis, then I'd seek independent evaluation.

 

[dreambig2night]

I think your impression that this "consultation" was inappropriate was spot-on.

As to the accuracy of his opinions, that we can't comment upon.

I dont care much about his opinion...I was only trying to be funny.

But it was shocking to listen to him tell me I have something wrong with me.
I kinda feel like telling him I dont appreciate his opinions and that it is unnecessary.
Isnt the preceptors sole responsibility to teach the student?
Since when were they given authority to diagnose the students they teach?
I wonder if anyone else experienced something like this...and how they responded to the situation if they did? Would my school be able to intervene on my behalf?
It doesnt bother me too much because that just my nature...but I hope he doesnt carry this habit on to other students and diagnose them.
He might not be as lucky with another student.

 

[whopper]

Hmm, sounds inappropriate. He sees you for 2 weeks and thinks you have ADHD? and then he tells it to you as if you're a patient.

At the most extreme, him giving you a diagnosis on you, he's made you his doctor, and now you have a patient/doctor relationship. I'm saying that's the most "extreme" but that could hold up in a court of law, and in fact it has.

Its hard to judge and I will not do so. He may have meant only positive things by his comments. What you mentioned happened could be interpeted in several ways, good, neutral or bad.

Are you with him alone for extended periods of time? I've noticed sometimes when students shadow attendings, if the 2 have personalities that don't go hand in hand, it can sometimes cause friction between the 2.

 

[Tradewind]

I had a psychiatry attending likewise tell me things about myself, when I never asked for his opinion about myself. It was rather annoying, particularly because he was off the mark and yet had this smug look on his face like he thought he was right. And he wasn't joking. It was like being forced into psychotherapy. I heard that that attending may not have a license anymore. That wasn't my doing. I'm glad I'm not alone and that others think this sort of behavior is just plain weird.

 

[JacobSilge]

Wouldn't he only be able to diagnose ADHD if he had information regarding your behavior in multiple settings, not just on the clerkship with you?

 

[billypilgrim37]

Wouldn't he only be able to diagnose ADHD if he had information regarding your behavior in multiple settings, not just on the clerkship with you?

Since he's obviously such a rigorous diagnostician 😉

 

[kugel]

The story as you've told it is bad.
Regardless of the accuracy of the diagnosis, there is an issue of consent to the evaluation. If there were something serious and acute in this ("you know you might want to have that red pus-filled thing looked at"), it might be forgivable, even reasonable.

Please consider telling it to your school's clinical coordinator or whomever supervises all your clerkships.

 

[whopper]

It was rather annoying, particularly because he was off the mark and yet had this smug look on his face like he thought he was right.

I've seen this in a few doctors when working with residents or attendings. The medical education heirarchy is often one of obedience & subservience on the part of the people lower than the attendings. Some attendings exploit this, and use it to feed their already massive egos.

Of course students & residents do need to respect the chain of command with attendings, but attendings should also act as educators in good faith.

 

[OldPsychDoc]

I've seen this in a few doctors when working with residents or attendings. The medical education heirarchy is often one of obedience & subservience on the part of the people lower than the attendings. Some attendings exploit this, and use it to feed their already massive egos.

Of course students & residents do need to respect the chain of command with attendings, but attendings should also act as educators in good faith.

I doubt that this applied to the OP's situation, but as attendings supervising medical students and residents, there are also times when we are called upon to point out where there are deficiencies that extend beyond lack of knowledge and/or skill in a field. Especially in mental health, where unfortunately some trainees who "just don't fit in" can be shunted, there are times when we need to have a heart to heart about someone with Axis I or II problems preventing them from doing an adequate job. I've seen situations where a resident had either such REALLY bad social phobia, or more likely outright Asperger's vs residual schizophrenia, that they had to be told--"you can't do this , you're making the patients uncomfortable!" 🙁 So it's not always an ego-driven attending abusing his power to put an uppity student in their place!

 

[Anasazi23]

I agree with OPD. I'm not saying that it was appropriate for this psychiatrist to "diagnose" you, but it seems there is likely more to the story.

If I had to guess, this was his way of telling you that you're not performing satisfactorily in your rotation, and is 'softening' it for you by telling you that you're too distracted or unfocused. Or, the two of you were having a casual discussion about such a topic, and he may have noticed some qualities in you that rang.

 

[dreambig2night]

I agree with OPD. I'm not saying that it was appropriate for this psychiatrist to "diagnose" you, but it seems there is likely more to the story.

If I had to guess, this was his way of telling you that you're not performing satisfactorily in your rotation, and is 'softening' it for you by telling you that you're too distracted or unfocused. Or, the two of you were having a casual discussion about such a topic, and he may have noticed some qualities in you that rang.

I thought about this....its a good possibility....but I dont know yet. Ill know soon.

If my dissapointing performance is a recurring theme, then I would have to agree with OldPsychDoc. But I've had no problems in my other rotations and no mention of ADD like behavior from my other preceptors.

But he does seems nice and polite. But I know I can be polite to a ******* as well. Who knows!!!

 

[loser]

As far as the diagnosis - not having trouble as a kid is not necessarily indicative of not having ADHD, esp in a high-functioning patient. If you're curious about the diagnosis, then I'd seek independent evaluation.

I believe one of the diagnostic criteria is that symptoms that cause impairment have to be present before age seven. No impairment, no illness. The OP made it through med school. It is impossible to make it through med school with undiagnosed ADHD unless you are a super genius with an IQ that makes Einstein look stupid. An IQ like that would be able to compensate for the deficits of ADHD.

Sorry for nitpicking. I actually have ADHD so I hate it when doctors or teachers try to diagnose everyone with ADHD or when college/university students suddenly claim that they have ADHD! It's VERY demeaning to people who actually have ADHD. I remember an old thread about a student who was diagnosed while she was in dental school! Give me a f-ing break and stop insulting the REAL ADHD sufferers!

Oh, and to answer the OP's question, I agree that the doctor was inappropriate.

 

[error404]

OP, that's completely out of line, for all the reasons people have already mentioned (and probably a few we've forgotten.)

Has anyone else had experiences with absolutely bat-f$%ck insane psych attendings? I've done a few extra psych electives, where everyone has been delightful. But my first psych attending ever....

--Was a splitter. I was on the rotation with my friend, and he went out of his way to treat us very differently, to "see if it would cause strain." Would praise one of us and insult one of us continually for a week, and then switch. Ultimately gave us grossly different grades for no reason.
--Would tell us, "Well, you never know if one of you will have a psychotic break tomorrow."
--Would do things that seemed like attempts at initiating very personal conversations. ("Error, you seem down today. Would you like to tell me what's going on in your life?" "Other student, how's your dating life?")
--Required us to take dictations in his clinic
--Rumor has it, was fired for a sexual relationship with a patient.

Those were some of the hardest weeks of medical school for me. I guess this wasn't a useful post, unless you count it as commiserating. Sorry to hear what you're going through.

 

[Zock]

.

 

[Regnvejr]

As you describe it, clearly out of order. He could have mentioned some examples of ADHD symptoms as seen in you (we all have some), as a teaching tool for you to grasp it better, but what you described went way beyond that.

He might also have ADHD himself and being excited about "sharing" in some discrete way. You will find that if you are quiet, people will have plenty to say to fill the void. When you interview patients, you will notice that the best interviews are those where the other person does 75% or so of the talking. With silence, people do eventually feel compelled to talk.

Now, if he presents it as a problem rather than a neutral observation, then there is clearly a problem. I f.ex. don't see ADHD as a problem but more as a different style of learning, where the brain is quite good at sucking in information for up to 15 min but not doing so well in a 50 min classroom. But once people are done inputting (learning) and start outputting, then they're able to output more than the humdrum regular brain. Ask the CEO of Sun Microsystem (Java software), he directly attributes his ADHD with being able to come up with so many new ideas.

I always tell parents and kids to never see ADHD as an illness (at least by itself), but rather as treatment needed to fit the learning style into an unyielding school system to make the good grades that gives jobs with control, where those skills can really blossom. I see nothing wrong with ADHD, and it is possible that the attending has that same view.

Any other attendings here with views about this?

 

[Regnvejr]

Has anyone else had experiences with absolutely bat-f$%ck insane psych attendings? I've done a few extra psych electives, where everyone has been delightful. But my first psych attending ever.....

My wife is a Psychologist and she has a theory about this.

The students hit college and have to take a social science class. "Oh, wait, interesting class in the catalog, 'Abnormal psychology,' maybe I can find out what's wrong with my family/me." Then get hooked on the subject and stays in the field. She feel this is a huge reason why so many psychology programs are so interpersonally dysfunctional. And a hefty dose of other therapists and psychiatrists as well. I have personally known 2 psychiatrists who had bipolar and occasionally took breaks from teaching/attending.

The field as a whole, however, does OK. And the intakes are still more interesting than in any other field. Compare them to the "have you had your bowel movement today" stories of medicine. I LOVE Psychiatry.😍

 

[whopper]

Especially in mental health, where unfortunately some trainees who "just don't fit in" can be shunted, there are times when we need to have a heart to heart about someone with Axis I or II problems preventing them from doing an adequate job.

True.

Its all really a matter of perspective. If that same psychiatrist were to explain why he did what he did, we could be having a different opinion.

On the surface it sounds pretty inappropriate. We might not be hearing enough of the story. I've seen as many cases where the attending was out of line as much as the resident or student, however we are only hearing one side of the story.

I have my own horror story of someone with a very strong Axis II disorder, possibly an Axis I in my residency program who caused quite a hurricane of disasters. She was removed (justifiably--she was putting patient's lives in danger). Her own version of the story I'm sure doesn't exactly detail how she caused 3 code blues and medicated a pregnant patient with Depakote without verifying this with the attending.

 

[Tradewind]

Thank you, Whopper. (I'm so excited, I was quoted, and not in a bad way! 😛) I agree that a little hierarchy and respect go a long way.

Error, I think you and I had the same attending! To his credit, he was highly knowledgeable and I learned a lot. Still ended up going into psychiatry and haven't regretted it since. Haven't had any major problems with attendings in person since then, which was years ago.

For the OP, you may very well get a good evaluation... It's hard to say. In my experience, sometimes, the more negative oral feedback attendings give, the better the evaluations. (Reaction formation? Avoidance? ) But either way, I hope this one incident doesn't color your view of psychiatry too negatively.

 

[michaelrack]

I\ The OP made it through med school. It is impossible to make it through med school with undiagnosed ADHD unless you are a super genius with an IQ that makes Einstein look stupid. An IQ like that would be able to compensate for the deficits of ADHD.

\.

The OP hasn't made it through med school yet, he's only a 3rd year student. I think it is possible to make it through the preclinical years with undiagnosed ADHD if the student is smart (in the top quartile of IQ's for med students) and if he has developed some ADHD coping strategies along the way.

 

[DebDynamite]

Wouldn't he only be able to diagnose ADHD if he had information regarding your behavior in multiple settings, not just on the clerkship with you?

Precisely.

I was diagnosed with ADHD when I was four. As someone who made it through medical school medication free, I'll tell you it can be done. I can't imagine being unaware that you've got ADHD, but I suppose it's possible.

I was mad when I found out that tons of my classmates where popping ritalin just to pull all nighters. But then I just let it go. After all, I could have taken it myself.

Sitting in class to "learn" and then going home to study were virtually impossible for me during the pre-clinical years. I studied at home, where I could walk around and read out loud to myself. Literally, I turned my notes into note cards and walked around the block, over and over while reading them. I had to do all sorts of things like this just to pay attention (to information that I thought to be, well.. boring route memorization). If a particular course had dynamic lectures (micro, path, etc), that would be the one (only one) I would attend for the day. If you had undiagnosed ADHD/ADD, you'd probably suspect it by the end of your pre-clinical years. Not to mention your surgery rotation, where you are expected to actually stand in one place for hours.

Maybe your attending picked up on your boredom and confused it with distraction. Regardless, I think in this day and age it is inappropriate to point out traits in a student... unless of course there is concern it will have impact on patient care.

 

[BobA]

Can some of the more experienced folks help me with this?

While there are clearly defined criteria for diagnosing ADHD such as inattention, difficulty with concentration, present in multiple settings, onset before age of 7, etc, my understanding is that ADHD (like many psych diagnosis) is more of a symptom cluster than a true disease.

If we're really treating a cluster of symptoms and not a disease, do we really need strict criteria for diagnosis and treatment? Couldn't a prescriber weigh the risk/benefit ratio of writing for a stimulant for that particular patient and go from there?

I'm not advocating indiscriminate use of stimulants, but rather trying to elevate the discussion beyond "I have ADHD" and "you do not have ADHD". It's not like "I have a wound infection"/ "you do not have a wound infection".

Or do we need the strict criteria to prevent over prescription of stimulants?

 

[error404]

Error, I think you and I had the same attending! To his credit, he was highly knowledgeable and I learned a lot. Still ended up going into psychiatry and haven't regretted it since. Haven't had any major problems with attendings in person since then, which was years ago.

Based on the fact that your attending turned out to be knowledgeable and inspiring, I would guess we didn't have the same guy. 🙂

But like I said, everyone else I've worked with (except that one nurse who always told me about the latest changes to her zoloft dosage) = 👍

 

[sonofthesouth]

i haven't read everyone's posts in this thread (too ADHD to have done so), so excuse me if i repeat what someone said or even contradict someone completely. anyway, dreambig2night, i am so glad someone brought this up. i had an almost identical situation happen to me. i had made it through the entirety of 1st, 2nd and 3rd year of med school with very few problems. my only problem in the first 3 years (which caused me to fail my family medicine rotation) was that i totally spaced out once while observing a physician interview a diabetic patient--on 2 separate occasions. i failed the course on account of professionalism because i (and i quote) "wasn't paying attention" on 2 occasions. my psychiatry rotation was the last one of my third year. at the end of the 6 weeks at my final one-on-one evaluation, the main attending (who had worked with us only 2 days a week X 6 weeks) said he was pretty thoroughly convinced that i had ADHD. he asked me about past history and i told him i had a lot (ok, ALL) of the symptoms of primarily inattentive ADHD. so he set up a formal evaluation (for "free"... see below) with him and the psychologist that he works with. the psychologist evaluated me and gave me a mind-numbing TOVA (Test of Variables of Attention) test. then after that, i saw the doctor. well, it was a no-brainer. i had ADHD, and according to them, it was pretty "severe," although admittedly i know very little about the TOVA test. they started me on adderall. it worked really well, but i hated the side effects. then vyvanse. same story. oh and btw, after the initial evaluation, i had to pay for every visit. so much for "free." but he didn't tell me that up front. now, i haven't gone back because i'm pissed it wasn't free (even though i am grateful to be getting help), coupled with the thought that "well, i've lived with it this long, so i must've developed some decent coping strategies."

as for the "genius" stuff, i didn't do very well on my SAT's (1300 by the old ranking), MCAT (28), or USMLE (212 Step 1 and 214 Step 2) and have never been formally IQ tested. But shorter, more informal IQ tests have put me in the range of the high 130's, low 140's. does that mean i'm a genius? cuz i sure don't feel like one. sure, my dad studied physics at CalTech (where this "Einstein" guy taught... not joking), but i'm in the bottom quartile of my med school class, and as i mentioned, even failed one course (although it wasn't for academic stuff).

other random thoughts... i always had a hunch i was ADHD but my parents were in such denial they never had it checked out. they were CONSTANTLY being called in for parent-teacher conferences about my careless mistakes on assignments, impulsiveness, disruptiveness, lack of listening skills, organizational difficulties, losing things, forgetfulness, etc. yet they STILL never considered it. apparently, my teachers were pretty uneducated about it too because (according to my parents), they never used the word "ADHD" (actually "ADD" back then) when describing this behavior.

oh, and for the record, i do not go to harvard, yale, duke, or anywhere of the sorts. just an average med school.

sorry this post is so incoherent. it's just good to hear that someone else had a similar situation.

please feel free to comment on ANYTHING in my post. i don't even really know where to begin with questions... well, yeah i do...

1) was ANYTHING my attending did right? or was it all pretty much whack? he's a pretty nice guy and i feel like he was trying to help. was i duped?

2) i know this sounds silly, but am i really a genius? what IQ level is typically considered genius? or is there such a thing?

 

[whopper]

what IQ level is typically considered genius?

Over 140.

Though IQ should not be the end all be all of intelligence testing. For example, and I don't remember the documentary I saw...there were quite a few people who for some strange reason just didn't do well on those tests (e.g. put them in the area of severely mentally ******ed) but they did well in college. On interviews you can clearly tell they are not ******ed (good grammar, held a job, were able to do ADLs on their own, seemed like everday normal people).

And as a colleague of mine-a psychologist mentioned, no matter how low the person's IQ, he's seen the most mentally ******ed of people be experts at manipulation on chronic, long term units. He mentoined he even believes a manipulation IQ should be considered as a separate test but no one's made one up yet.

1300 by the old ranking

That actually is a very good SAT score by the old system. That's good enough to get to one of the lower level 5 star schools, or upper level 4 star schools by Barron's standards.

 

[Lurkielurk]

I am assuming you are female, and he is male, because this whole scenario seems somewhat sexual to me. It is inappropriate as hell, and in my experience doctors often use their MD authority/control to deal with sexual feelings. By INAPPROPRIATELY diagnosing you, a student, randomly and within the span of 15 minutes, in his mind you are less a human/potentially threatening sexual being and you become a patient, someone he has a measure of control over. And, furthermore, as someone who he now has control over (because he has diagnosed you with something, thus he has access to your mind and perceptions perhaps even greater than you do), the opportunity exists for him to potentially pursue anything he wants.

If you are male, and he is male... maybe he is gay?

 

[OldPsychDoc]

i haven't read everyone's posts in this thread (too ADHD to have done so), so excuse me if i repeat what someone said or even contradict someone completely. anyway, dreambig2night, i am so glad someone brought this up. i had an almost identical situation happen to me. ....
1) was ANYTHING my attending did right? or was it all pretty much whack? he's a pretty nice guy and i feel like he was trying to help. was i duped?

What WAS done right here, in contrast to the OP, was that he at least scheduled you for "real" clinical time, and referred for appropriate testing. Turning it into a referral for ongoing care, essentially without your consent, was fairly shady though. Would've been better to refer you to a colleague.

 

[Shalom77]

The OP made it through med school. It is impossible to make it through med school with undiagnosed ADHD unless you are a super genius with an IQ that makes Einstein look stupid.

This is just false. I would agree that it is impossible to make it through med school without showing any signs of impairment if one has ADD since by definition one has to have signs of impairment since childhood - BUT it certainly is possible to make it through without being diagnosed. Diagnosis depends connecting with the right clinician who is able to connect the dots and make the diagnosis. Really smart kid with ADD inattentive type (add some anxiety/depression to make it more complicated) from an anti-psychiatry family could easily escape diagnosis.

And the surgery rotation isn't a good test - there is that hyperfocus aspect of ADD - surgery in my opinion is an "add friendly" field.

As for the original question - it's hard to judge without knowing the framing of the conversation - saying you think someone might have ADD and recommending evaluation - is not the same as diagnosing them - more of an encouragement to be evaluated.

Actually I think the second case is much shadier and in my opinion more inappropriate - it's one thing for an attending to tell someone their impressions and recommend evaluation - student can take it or leave it and decide what to do about the opinion. It's another to take someone's history and end up self-referring (in the context of being the person who grades them - how can true consent take place here?)

The first approach is much less coercive and invasive and much more appropriate assuming s/he didn't say something like "you have ADHD" as opposed it seems based on my observations/impressions of you over the past 2 weeks that you might have ADD and it could really help you/your career to have it evaluated and treated.

 

[janisjoplin]

I honestly think these scenarios sound almost downright criminal. There are proper channels for conveying almost any concern an attending may have about a medical student, and that includes a concern about the medical student's mental health. The proper way, if the concern is serious enough, would be via the Dean of Students' Office. To "diagnose" the student in this informal manner on rounds or some other point during the rotation is just stupendously inappropriate if you ask me. You really have to wonder when you hear about these things happening.

Would an IM or OB/gyn attending or a surgeon get involved with their clerkship students in this way? I doubt it. As a med student who got sick myself during rotations, I never once had one of those attendings try to "diagnose" me. They expressed concern and told me to go to the ER or wherever but had they gone overboard and pulled out their own stethescope that would have been extremely weird. If the student needs urgent treatment that different, but that's going to be very, very rare for a medical student on a psych rotation. I feel very sorry for these students whose psych attendings are overly intrusive and feel they can "diagnose" a student in a setting which they are not even a patient but yet are in a subservient role to begin with so they cannot be properly evaluated in any circumstance.

By the way there are other reasons besides ADHD why the student may not have been "paying attention" on rounds. What knowledge did that attending have of the student's medical and neurological history? Any?

 

[Shalom77]

They expressed concern and told me to go to the ER or wherever but had they gone overboard and pulled out their own stethescope that would have been extremely weird.

How did they express concern? That's why I think the first case which in theory could be an expression of concern (although seemingly inappropriately formulated from the info we have here) is more appropriate than case 2 which is clearly wrong. Attendings should not be taking histories and treating their students. However, there may be concerns which do not rise to the level of notifying the dean (wouldn't you prefer hearing directly about it first than having someone offer unsubstantiated impressions to your dean?) but which the student might benefit from hearing about directly. Clearly tactful and careful formulation is the key.

 

[janisjoplin]

How did they express concern? That's why I think the first case which in theory could be an expression of concern (although seemingly inappropriately formulated from the info we have here) is more appropriate than case 2 which is clearly wrong. Attendings should not be taking histories and treating their students. However, there may be concerns which do not rise to the level of notifying the dean (wouldn't you prefer hearing directly about it first than having someone offer unsubstantiated impressions to your dean?) but which the student might benefit from hearing about directly. Clearly tactful and careful formulation is the key.

Yeah I would agree that a clear and tactful private personal discussion is better than an attending notifying the dean. And I mentioned the Dean of Students as opposed to the academic dean. I'm just saying that I think an attending who is inclined to "diagnose" a clerkship student probably is a rogue to begin with and their "concerns" might be so off base that anything they would convey, even if tactfully and privately, should be suspect.

My situation is different since it was medical and was totally obvious to all involved. I will tell you though that not being healthy medically even if it's relatively temporary can destroy your confidence as a medical student on rounds because you feel like a patient. But what I appreciate looking back was that these other people around me did NOT add to this by offering their "diagnosis." You're asking how they expressed concern and I don't want to be too specific because it gets into what happened but it's just the normal way you help someone who isn't dying instantaneously but obviously needs to get some help. Anyway, I just don't like the idea of attendings (or residents) putting clerkship students in the "sickly" role if it's a medical scenario or the "crazy" role if it's on a psych clerkship. I think that is rogue behavior. That's why I'm saying if an attending REALLY questions the mental status of a medical student, to the point where they are thinking "diagnosis," it may be time to go to the dean. Or at least pull the student aside, but in that situation be very careful what is said. The attending could be completely wrong. If it's a trait or a personality quality on the other hand, that can go in the student's evaluation. What I don't understand is why it should be any less serious or inappropriate than a surgeon who is not YOUR doctor saying "i think you have appendicitis" +/- "and look I have my scalpal right here with me."

 

[Shalom77]

It's not clear that the attending in the first case - made a formal diagnosis - as opposed to sharing his impressions. In any case he clearly didn't take a history or perform any treatments - just shared his impressions and made the recommendation - "you should get it taken care of" I don't really see that as any different than someone who says to a student whose been complaining of nausea/epigastric pain that's now moved to the RLQ - seems like you might have appendicitis - you should go to the ER and get that checked out and taken care of.

In neither case did someone take out a scalpel and start to operate or the psychiatric equivalent. I agree it's impossible to make a "diagnosis" of ADD without a careful history - so obviously the attending could be completely wrong. On the other hand - I think it's better to share one's impressions and encourage someone to be formally evaluated than to start to take a formal psychiatric history which I do think crosses the line.

Now the second case - that's a different story and I've already written that I think that was wrong and inappropriate.

 

[janisjoplin]

It's not clear that the attending in the first case - made a formal diagnosis - as opposed to sharing his impressions. In any case he clearly didn't take a history or perform any treatments - just shared his impressions and made the recommendation - "you should get it taken care of" I don't really see that as any different than someone who says to a student whose been complaining of nausea/epigastric pain that's now moved to the RLQ - seems like you might have appendicitis - you should go to the ER and get that checked out and taken care of.

In neither case did someone take out a scalpel and start to operate or the psychiatric equivalent. I agree it's impossible to make a "diagnosis" of ADD without a careful history - so obviously the attending could be completely wrong. On the other hand - I think it's better to share one's impressions and encourage someone to be formally evaluated than to start to take a formal psychiatric history which I do think crosses the line.

Now the second case - that's a different story and I've already written that I think that was wrong and inappropriate.

I agree, they seem different, but why was it appropriate for the attending in the first scenario to share "impressions" about the student to begin with? If he isn't satisfied with the student's level of attention on rounds, he can say so in the student's course evaluation. I disagree that it's appropriate to share "impressions" with anyone who happens to appear to have some degree of a psychiatric symptom on some day of the week while being in the same room as a psychiatrist. I'm just a med student, but if you ask me, that is why a lot of people get freaked out by psychiatrists. Yeah, the first attending could simply want to help this student. I just think there are more professional ways to do it.

By the way, would this attending share the SAME impressions with their department chair if they had similar impressions of THEM? No. They should give the medical student the same level of respect.

Nausea/epigastric pain can be urgent, and sending someone to the ER can be absolutely obvious and necessary, especially if the student seems to be soliciting some help. By contrast I don't see how pointing out ADD, unsolicited, is important enough to be warranted. (If the student appears psychotic that might be different). Even if the attending is spot on about ADD, it's none of his business. How does he know the student isn't already receiving treatment for it?

Like I said, a note saying the student should pay more attention in the evaluation would be kosher. Or he could pull the student aside and say, kindly, "looks like you need to pay more attention." I could even see saying something like "there are many reasons why people have trouble paying attention, and there are ways to address them." If the student finds it difficult to PAY attention, he/she can then seek their own consultation for that. If it's a lifelong pattern dating back to childhood, I bet the student will know.

But I agree with you that the 2nd case is shadier.

 

[Shalom77]

Here we'll have to agree to disagree. I would much much prefer an attending to address their concerns directly with me than to write them in an evaluation or send a letter to the dean of students. From the story told here it sounds like he made a suggestion - but left the student alone to take it or leave it and to follow-up on it as was his/her choice. Personally I see directly addressing it with the student as more respectful of the student than not addressing it directly and putting it in an eval or just sending a letter to the student's dean.

My mentor is allowed to criticize me in ways that I would never think of criticizing him. That's because he's in the power position and the one whose job it is to teach and guide me - not because he doesn't respect me. Sometimes he does give me advice that really isn't appropriate - but I know he does it with the best intentions and means well. He does it non coercively and privately so I just ignore it when it is way off the mark.
A mentor who talks to a program director (or dean, etc) behind one's back on the other hand is deadly and not to be trusted.

It doesn't actually matter whether the attending is right or not or whether the student was already receiving treatment or not. If s/he was - then self reflection about whether the treatment is working would be in order. Otherwise - figuring out what behaviors/attributes are leading someone to think that the student has ADD and fixing the negative ones would be the way to most benefit from this unsolicited advice. Really it's actually better to be given a heads up about the impression one is making on other people particularly mid rotation (not end of the rotation - when it's impossible to improve) even if it makes you uncomfortable. Perhaps being treated for ADD (which the student might not have) isn't the right way to fix the problem - but at least the student knows there is a problem. The alternative for example of being constantly told one is doing a great job - but then being slammed in an evaluation - is far worse from a learning perspective. Well I guess the attending could have assumed the student isn't interested in the subject, inherently disorganized, late, lazy or whatever instead of assuming the student has a fixable problem and trying to be helpful.

I just used appendicitis because it was your example. But in my experience when someone is noticibly ill even in non life-treatening ways it's common to receive encouragement to get it taken care of, encouragement that is often accompanied by an assessment of what could be wrong. It's not just doctors who do this - lay people do this too.

 

[janisjoplin]

I actually agree with what you are saying. I too would rather be told of something than have it appear out of nowhere in my evaluation, or have the dean be informed behind my back. It's just that I don't see why this had to escalate into a "health" concern so quickly, especially when the attending barely knew this student. A "health" concern seems quite serious to me, either something where you do tell someone to go to the ER or you are so concerned you might, in fact, alert the dean.

A concern about the impression the student is making on the clerkship is different. That can be addressed without resorting to "diagnoses." I'm just saying I think even a psychiatrist can talk and act like a normal human being and approach their trainees like trainees, as opposed to patients, and get the important points about improvement across. Maybe we disagree a bit here but I don't think it's all that much. I too would want that feedback. If the attending knows the student/resident well, I can see more acceptability for suggesting "ADD" or whatever; but in this case, they were almost strangers.

And let's say it were a pregnancy that the attending were suspecting. Would they blurt out to the student or resident "Are you pregnant? Because it looks and seems like you might be." I suspect not, for a variety of reasons, although that pregnancy might VERY well affect the student's performance on the clerkship. I think a student's mental health issues should be as confidential as their reproductive health issues. Unless it's clearly documented and clearly interfering with their performance (like the student actually can't DO the job) I would think a more tactful and less intrusive approach could be found. And the attending who does not even bother to look for it, that's what I wonder about.

I do agree that it's in a student's interest to tell them what things they can improve upon, including if those things resemble symptoms of a psychiatric illness.

 

[Therapist4Chnge]

he asked me about past history and i told him i had a lot (ok, ALL) of the symptoms of primarily inattentive ADHD. so he set up a formal evaluation (for "free"... see below) with him and the psychologist that he works with. the psychologist evaluated me and gave me a mind-numbing TOVA (Test of Variables of Attention) test. then after that, i saw the doctor. well, it was a no-brainer. i had ADHD, and according to them, it was pretty "severe," although admittedly i know very little about the TOVA test.

While I'm not going to comment on the relational situation....

In general, a clinical interview, pt history, and a TOVA aren't sufficient to properly diagnose ADHD...at least I wouldn't do it. I've done ADHD research, and unfortunately most Dxs are woefully insufficient because people often "want" a reason and/or do not want to go through a full battery of tests.